Applied Nursing Research 31 (2016) 139–145
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Clinical Methods
Implementing and Sustaining Evidence Based Practice Through a Nursing Journal Club☆ Kevin Gardner Jr., BSN, CCRC a,1, Mary Louise Kanaskie, PhD, RN-BC a,2, Amy C. Knehans, MLIS, AHIP b,3, Sarah Salisbury, BSN, RN a, Kim K. Doheny, PhD, NNP-BC b,4, Victoria Schirm, PhD, RN a,⁎ a b
Penn State Hershey Medical Center, Department of Nursing, Hershey, PA. USA, 17033 Penn State University College of Medicine, Hershey, PA. USA, 17033
a r t i c l e
i n f o
Article history: Received 13 October 2015 Revised 29 January 2016 Accepted 13 February 2016 Available online xxxx Keywords: Journal club Nursing Evidence-based practice
a b s t r a c t Background: The outcomes based emphasis in nursing and health care delivery requires identification of best available evidence in order to produce quality, safe, and effective patient care. Finding, critiquing, and ultimately implementing the best available evidence for practice is a formidable task for many clinical nurses. Development and implementation of a nursing journal club (NJC) became one organization's successful attempt to help clinical nurses better understand and use best available evidence in actual practice. Methods: The process and structure for the NJC evolved from an additional activity scheduled outside of work to a fully established endeavor of Nursing Research and Evidence Based Practice Council (NR&EBP). The Nursing Professional Practice Model was foundational to establishing the NJC as a formal component within the NR&EBP Council shared governance structure. Efforts to embed the NJC included taking advantage of resources available at an academic medical center and incorporating them into the council structure. Results: Successful outcomes of the NJC include a quarterly schedule, with topics selected in advance that are based on nursing department as well as organizational driven goals and initiatives. The structure and process in place has eliminated frequently mentioned deterrents to evidence based practice such as not enough time, lack of knowledge, or no immediate application to practice. Conclusions: Incorporating the NJC as a component of NR&EBP Council has provided clinical nurses time away from clinical care that supports scholarship for nursing practice. Committed leadership and garnering of available resources have been key factors for success. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Bringing research to the bedside through evidence based nursing practice has been a refrain used at this Academic Medical Center to embed the concepts into the culture as well as to engage clinical nurses in actual implementation of both research and evidence. The mantra, although well intentioned, has had the unforeseen consequence of obscuring the distinction between research and evidence based practice (EBP) for many nurses. Interlinking the terms was one way to overcome the trepidation that clinical nurses frequently have toward research. The approach also served as an invitation to all levels of nursing regarding the importance they have in promoting scholarly practice for the benefit ☆ The authors declare no conflicts of interest. ⁎ Corresponding author. Tel.: +1 717 531 4289; fax: +1 717 531 0766. E-mail addresses:
[email protected] (K. Gardner),
[email protected] (M.L. Kanaskie),
[email protected] (A.C. Knehans),
[email protected] (S. Salisbury),
[email protected] (K.K. Doheny),
[email protected] (V. Schirm). 1 Tel.: +1 717 531 6508. 2 Tel.: +1 717 531 8348. 3 Tel.: +1 717 531 8630. 4 Tel.: +1 717 531 1332. http://dx.doi.org/10.1016/j.apnr.2016.02.001 0897-1897/© 2015 Elsevier Inc. All rights reserved.
of patients. Effectively incorporating evidence into clinical practice requires that nurses have knowledge and resources to identify, appraise, and summarize the available research. Such skills often vary among clinical nurses and the situation is further compounded by institutional barriers whereby EBP or research is deemed secondary because priority is given to patient care (Cadmus et al., 2008). Broadening nurses' understanding of what constitutes evidence and the relationship to research; and distinguishing between the two concepts without diminishing the quality of the scholarship present obvious challenges in the clinical setting (Boucher, Underhill, Roper, & Berry, 2013; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012; Wilson, Kelly, Reifsnider, Pipe, & Brumfield, 2013). Duffy et al. (2015) acknowledged that the gap existing between research knowledge and translating EBP into practice requires creative professional development solutions beyond didactic education. Others (Wilson et al., 2013) have described resourceful academic–service partnerships that provide relevant strategies to engage practicing clinicians in EBP and research. A common theme and frequent conclusion among the reports is that executive nursing leadership plays a significant role in promoting both research and EBP within an organization. However, the enduring question remains how nursing leaders can best determine the balance
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in nurse time away from the bedside for EBP and research learning activities versus clinical care. These reports provide context for understanding the common challenges faced in advancing EBP in the clinical setting; and offer background for constructing a pragmatic solution to sustain EBP within an organization. This presentation is one organization's journey in development and evolution of a nursing journal club (NJC) that engages nurses in giving attention to evidenced based nursing practice. Highlighted are the structure and process for implementing an NJC and the resulting outcomes in developing nursing scholarship and enhancing patient care. 1.1. Journal Clubs and Evidence Based Practice Journal clubs have been a formal part of academic nursing and medical education programs as well as embedded into scholarly clinical practice activities as a way to keep up-to-date, understand, and apply advances in knowledge to actual patient care. Results from a systematic literature review on effective journal clubs suggest a dearth of nursing literature on journal clubs compared to what is available in the medical literature (Deenadayalan, Grimmer-Somers, Prior, & Kumar, 2008). The fact that many medical education and physician residency programs have a formal process and requirement for journal club participation may contribute to this difference. More prevalent in the nursing literature are descriptions of technical aspects of journal club activities and generalizations about the educational benefits, including developing critical appraisal skills, increasing research awareness, and promoting evidenced based nursing practice (Thompson, 2006). The attention to EBP has intensified efforts to bridge the gap between merely understanding new knowledge and meeting the expectation to implement best practice interventions at the point of care. The elements of EBP training that successfully overcome the divide between accumulated evidence and application to actual practice are elusive. Results of a systematic review of EBP training for allied health professions concluded that any training improved knowledge, skills, and attitudes (Dizon, Grimmer-Somers, & Kumar, 2012). Recommendations such as creating a culture of inquiry and scholarship, presenting education workshops, engaging experts, or providing firsthand experience have been advocated as ways to assist clinical nurses in applying EBP at the bedside. Organizational commitment and an infrastructure to promote clinical nurse participation in research utilization through application of EBP has been recognized as a key ingredient for culture change (Melnyk et al., 2012; Newhouse & Johnson, 2009; Yoder et al., 2014). Interestingly, reports in the literature have touted journal clubs as an instructive and practical way for clinical nurses to apply research evidence in practice; although, the early reports used the term “research utilization” as the intent of journal club participation (Fink, Thompson, & Bonnes, 2005; Goodfellow, 2004; Rich, 2006) or emphasized critical appraisal of research (St. Pierre, 2005). In contrast to these early reports, more recent literature and the related follow-up suggestions about journal clubs focus more specifically on clinical nurse involvement in EBP implementation. For example, Patel et al. (2011) reported using a hospital wide journal club to specifically engage clinical nurses in employing EBP in decision making for direct patient care. Journal club topics included clinical care such as feeding tubes, chlorhexidine bathing and infection rates, safety huddles, and tracheostomy care. Nurses participating in the journal club were assisted by experienced leaders to make recommendations for practice changes. Sciarra (2011), likewise, used a journal club to empower and increase clinical nurses' participation in EBP. Although conducted with only seven participants, results of this institutional review board approved study suggested that clinical nurses were better able to discuss and apply evidence to nursing practice in an intensive care setting following journal club participation. Pfenning (2011) also reported similar positive results in attitudes, knowledge, and use of EBP by 26 nurses after participation in a unit-based journal club.
Other reports in the literature offer additional rationale for journal clubs as an important venue for enhancing application of EBP by clinical nurses. More importantly, these reports place emphasis on journal clubs as a practical way to connect best available evidence to actual clinical practice (Lehna, Berger, Truman, Goldman, & Topp, 2010). And when implemented in the context of quality improvement cycles, a journal club enables clinical nurses to critique and explore evidence that leads to appropriate practice changes (Staveski, Leong, Graham, Pu, & Roth, 2012). This evidence suggests that an NJC can be useful in fostering skill development and promoting nurses' participation in EBP activities. At the same time, the question remains how to balance nurse time away from the bedside to engage in EBP projects, and learn and use the requisite research related skills. Clearly, a supportive organizational culture is necessary to overcome barriers in order to implement and promote EBP knowledge and skills at all levels of nursing (Melnyk et al., 2012). 2. Methods The Nursing Professional Practice Model (PPM) and Care Delivery System provided the basis for Nursing Research & Evidence Based Practice (NR&EBP) Council as the shared governance entity best suited to implement the NJC at this Academic Medical Center. In the larger context of nursing care, the PPM is the central framework for practice and illustrates the way nurses practice, collaborate, and communicate in providing quality patient care that is evidence based (American Nurses Credentialing Center [ANCC], 2014). The PPM incorporates the four components of the ANCC Magnet Model: transformational leadership, exemplary professional practice, structural empowerment, and new knowledge. NR&EBP Council activities focus on the latter component by emphasizing education and skill development related to EBP and research, with the ultimate goal of making linkages to clinical practice. The PPM foundation also supports NJC topic selection congruent with nursing care delivery and the organization's mission, vision and values. Initially, the NJC was promoted by NR&EBP Council as a useful way to assist busy clinical nurses to advance EBP and gain an appreciation of nursing scholarship. The first NJCs were hosted off campus with the intention to allow nurses to attend outside of scheduled work. Topics were selected based on relevant clinical issues and included Pressure Ulcer Prevention, Back to Basics Nursing Care, Workplace Incivility, Pain Management, and Palliative Care. Off campus attendance was modest and led council leadership to problem solve and develop an NJC process and structure that would fit with the reality of nursing practice and not be perceived as adding another activity to already busy professional and personal schedules. 2.1. Creating the Structure Topics and information discussed at the first series of NJCs were disseminated through the NR&EBP Council newsletter and by those in attendance. Despite sparse attendance, this informal sharing influenced practice in visible ways. The Pressure Ulcer Prevention NJC resulted in wound-ostomy nurses maintaining their recommendation to use a single product line for pressure ulcer care rather than promoting several options. The Back to Basics Nursing Care topic stimulated discussions about the importance of nurses' presence at the bedside; and offered support to ongoing work to streamline charting and documentation. Discussions at the NJC on Workplace Incivility resulted in sharing evidence with the Nursing Quality of Worklife Council, thereby empowering the membership to address specific medical center workplace issues. The articles presented at the Pain Management and Palliative Care NJCs, likewise, offered new insights and created a better understanding among participants how they could readily translate evidence into practice. Those attending expressed more confidence about the nurses' role in advocating better pain management for patients and in initiating discussions with other care providers about palliative care consults.
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Council leadership, realizing that a fledgling NJC could impact nursing practice, began discussions with members to create a structure that would engage a larger audience of clinical nurses. Subsequently, transitioning the NJC from an off-campus gathering to planned time during NR&EBP Council was put into motion. This integration was congruent with council's overall responsibility for translating and incorporating new knowledge into clinical practice. Council members created the guidelines displayed in Fig. 1 to serve as ground rules for the NJC; and developed a quarterly schedule, allotting time for discussions at the beginning of NR&EBP council meetings. This formal structure established principles for enhancing nursing scholarship and for translating and integrating best available evidence and new knowledge into clinical practice.
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blended educational approach of self-directed reading and appraisal, and participation in group discussion (McGee & Reis, 2012). The ANCC Commission on Accreditation (2015) guidelines for continuing nursing education followed by the state nursing association as an approved provider were used to create the education activity with contact hour credit that meets re-licensure and recertification requirements for nurses. Session objectives are that learners will be able to (a) appraise research based on levels of evidence; (b) summarize findings based on levels of evidence; and (c) translate evidence based findings into practice. Requirements for participants include completing journal article readings and a Levels of Evidence Table (Fig. 2); attending the 1 and ½ hour session; and evaluating the activity. Participants receive 2 contact hours that includes the live session and prerequisite requirements. The NJC session is from three to four groups of 5 to 10 participants conducted simultaneously. Although the theme of each NJC differs, discussion follows a similar format and reflects the Evidence Table categories of study purpose and framework; design/method; sample/setting; variables and measurement; analysis and major findings; and implications. The Melnyk and Fineout-Overholt (2011) levels of evidence categories is used to rate each article. Members of the council leadership facilitate discussions, and each group provides both a verbal and written report. This summary report becomes part of the NR&EBP Council record and follow-up recommendations are presented to appropriate entities in the organization.
2.2. Developing Education Strategies The new knowledge component of the PPM model was foundational to the NR&EBP Council journal club planning group as they moved forward to help nurses integrate evidence into clinical practice. The team identified that many nurses have had limited instruction or practice in appraising research and interpreting levels of evidence, skills that are essential for clinical application. The team, led by a nurse educator, developed a
Nursing Journal Club Guidelines Purpose: Nursing Research and Evidenced Based Practice Journal Club strives to introduce pertinent nursing research to develop and support staff's research skills that ultimately enrich nursing practice. Goals: •
Enrich knowledge of research and evidence-based practice.
•
Enhance ability to critically appraise and evaluate published nursing literature.
•
Create an awareness of current nursing research studies.
•
Assess current practice using evidence-based nursing results.
•
Share information with other nursing staff members.
•
Motivate participation in evidence-based practice and/or nursing research projects.
•
Align and impact nursing goals and organizational goals.
Desired outcomes: Enhance nursing practice related to: •
Documentation
•
Patient Satisfaction
•
Delegation
•
Patient/Family Centered Care
•
Patient Education
•
Interprofessional Collaboration
Assignments: Links to the journal articles for review will be sent via email and be posted in the Learning Management System. Participants are requested to complete the Evidence Table and come prepared to discuss articles: What is the relevance of the article to nursing practice? Are there practice and/or policies that should be changed based on the evidence? What are quality improvement and clinical implications? Fig. 1. Nursing journal club operational guidelines.
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Nursing Journal Club Evidence Table and Levels of Evidence
Citation
Purpose of
Design
Study &
Method
Sample/Setting Measurement Analysis
Framework
Notes on
Description
& Major
Quality &
(Major
Findings
Clinical
variables and
Implications;
definitions)
Level of
Instruments
Evidence
Level
Evidence
1
Systematic review & meta-analysis of randomized controlled trials; clinical
(Strongest) guidelines based on systematic reviews or meta-analyses 2
One or more randomized controlled trials
3
Controlled trial (no randomization): quasi-experimental
4
Case-control or cohort study
5
Systematic review of descriptive & qualitative studies
6
Single descriptive or qualitative study
7
Program evaluation, research utilization, QI projects, case reports (JC sentinel event), benchmarking studies (NDNQI data, UHC reports) or non-research based clinical practice guidelines
8
Expert opinion/authorities and/or reports of expert committees, textbooks, clinical
(Weakest)
product guidelines. Fig. 2. Levels of Evidence Table. Adapted from Melnyk and Fineout-Overholt (2011).
2.3. Connecting With Other Resources
3. Results
The learning management system is used for preregistration, to post articles, to obtain follow-up evaluation, and to provide the continuing education credit certificate. The evaluation of NJC is conducted via a Survey Monkey (www.surveymonkey.com) questionnaire. This summative evaluation (Billings & Halstead, 2012) assesses achievement of learning objectives, effectiveness of the instructional strategies, and facilitation of the learning process. The evaluation specifically requests participants to rate perceived ability to appraise the research based on levels of evidence; summarize research findings; and translate findings into practice by identifying quality improvement and clinical practice opportunities that enhance patient outcomes. Participants also rate the extent of satisfaction with the education activity, perceptions regarding changes in knowledge or attitudes, and perceived value of the activity. A 5-point Likert scale of very low (1), low (2), moderate (3), high (4), and very high (5) is used. The health sciences librarian as an active member of NR&EBP Council locates articles, creates permalinks to articles, and participates in appraisal and discussion sessions. The PICO (population, intervention, comparison, outcome) format is used to develop the question to design and execute the search strategy. Council members are responsible for developing the NJC topic and work with the librarian to frame the PICO question. This guidance helps focus the PICO question to clarify and formulate relevant search terms. The search is not exhaustive like one would do for a systematic review; and is not necessarily replicable but it is well thought out and organized. The NJC planning group usually selects seven to eight final articles. One article that has been deemed central to the topic is assigned to all participants; and the remainder are divided among each of the groups.
3.1. Translating Evidence Discussions Into Practice Descriptions of several NJCs illustrate the process and education strategies in action. The first NR&EBP Council sponsored Journal Club on Healthcare-Associated Infections reviewed articles on hand hygiene, catheter associated urinary tract infections (CAUTI), and central line associated blood stream infections (CLABSI). This combination of topics enabled participants to critically analyze the literature and engage in meaningful discussions about CAUTI and CLABSI prevention strategies that include hand hygiene as an integral component of an evidencebased bundle. The discourse resulted in an exchange of ideas for improvement and prevention strategies as well as identification of barriers to compliance across the organization. Recommendations were shared with nursing colleagues and infection prevention specialists. The NJC on Alarm Fatigue was prompted in part by The Joint Commission (2013) national patient safety goal on clinical alarm management and safety. Anecdotal reports from nurses indicated considerable desensitization due to alarms, with occurrence of “near misses” making the topic pertinent and timely. One nurse shared that the NJC discussion “provided insight and introspection into an issue that I thought little could be done to change”. Nurses also became aware of the existence of a hospital Alarm Fatigue Task Force created in response to The Joint Commission initiative. One nurse journal club participant that had patient assignments on several units conducted a count of the numerous alarms encountered across the various units. The subsequent detailed report relating the variety of alarms across units resulted in an invitation to become a member of the Alarm Fatigue Task Force.
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3.2. Nursing Journal Club Evaluation Tables 1 and 2 display participants' evaluations of four NJCs: professional image, alarm fatigue, quiet hospitals, and nurse communication. Mean scores show that participants rated positively NJC learning activities of appraising research based on levels of evidence, summarizing research findings, and translating findings into practice. The evaluation of the journal club was also highly rated for overall satisfaction, extent to which knowledge or attitude changed, and perceived value of the activity. Some participants offered comments that further affirmed the value of the NJC, saying “I am loving the journal club in this format”, “I gained greater depth into EBP, research, and understanding of how to evaluate an article”, and “Very informative, valuable for practice implementation.” At the same time, one participant wrote that an orientation is needed for the NJC, saying “This was my first journal club. I found it very informative and a great exercise; however I felt unprepared to fully participate due to lack of comfort with the research terms and levels of evidence.” Additional evaluation of the NJC was conducted by NR&EBP Council to determine ways to increase participation by other nurses and colleagues from across the organization. Council members analyzed the situation by conducting a root cause analysis. Results from using quality
Table 1 Nursing Journal Club Participants Evaluation of Skills in Appraising Research and Evidence. Nursing Journal Club Participants Evaluation of Skills in Appraising Research and Evidence 5.0 4.5 4.0 Mean Score
Another clinically relevant topic, Quietness of the Hospital and Promoting a Healing Environment, became an NJC subject because of an organizational wide “quiet campaign”. Overall performance results for patient satisfaction HCAHPS scores (Hospital Consumer Assessment of Healthcare Providers and Systems) prompted this topic. Journal club participants compiled a list of noise culprits on their respective units and assessed the likelihood of successfully implementing recommendations into actual practice. Additionally, the director of support services attended this NJC and heard nurses' comments on specific noise culprits that could be easily remedied by the support department. Another topic derived from a review of HCAHPS scores was Nursing Communication with Patients and Families: Perceptions and Evidence. This NJC topic was selected during council time while reviewing the institution's quality dashboard for patients' ratings of overall satisfaction with the hospital. This review concluded that an obvious need existed regarding activities in nurse/patient communications that are likely to promote patients' overall hospital experience. The literature search concentrated on locating articles on nursing communication strategies that contribute to patient satisfaction. Results identified bedside shift report, purposeful rounding, and scripted communication as nursing care activities associated with enhancing patient satisfaction with not only nursing care but also impacting HCAHPS scores. Reports by attendees at this NJC demonstrated an increased awareness of nurses' direct contribution to HCAHPS ratings as well as a better understanding of evidence that supports nursing interventions that optimize the patient and family experience. The evidence table was disseminated at unit councils, and shared with the patient and guest experience director and the patient satisfaction team. One NJC was prompted by the chief nursing officer (CNO) seeking input into strengthening the professional image of nursing within the organization. This topic initiated an all-encompassing discussion on personal appearance, professionalism, and dress code policy revisions. The CNO request put in motion the creation of Professional Image Taskforce to identify elements of a best organizational nursing image. The taskforce used the evidence to formulate recommendations for policy development. The NJC discussions and completed Evidence Table were presented at other shared governance council meetings. In addition, the evidence became the focal point of a Nursing Grand Rounds on Professional Image and Dress. The accrual of evidence from the literature was supported by Family Advisory Council reports of family and patient observations about the inability to distinguish nurses from other caregivers. Ultimately, this accumulation of evidence influenced redesign of name badges for the institution.
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3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Appraises Research Based on Levels of Evidence
Summarize Research Findings
Translate Findings into Practice
Professional Image (N=28)
4.32
4.25
3.93
Alarm Fatigue (N=23)
3.96
4.04
3.91
Quiet Hospitals (N=25)
4.28
4.20
4.20
Nurse Communication (N=21)
4.38
4.43
4.29
Journal Club Session
improvement techniques of fishbone diagramming and the problem solving technique of asking the “5 Whys” (Five Whys Tool, n. d.) revealed that scheduling time to attend, lack of skills appropriate for participation, and minimal information about the purpose were obstacles. Results of the analysis determined that giving advance notice about the topics and times would produce more involvement in the NJC and allow staff to better accommodate within their schedule. Probing via the “5 Whys” also demonstrated the need to refine NJC Guidelines; and clarified the importance of using the Levels of Evidence Table as a working tool within the discussion groups as well as a means for disseminating practice recommendations. 4. Discussion 4.1. Lessons Learned and Outcomes Achieved The NR&EBP Council continues to work successfully in moving current knowledge to actual practice in a timely manner via the NJC. A quarterly schedule is in place and topics are selected in advance, with focus given to nursing practice issues that are aligned with organizational initiatives. This structure and process overcome many of the barriers that are frequently identified as deterrents to implementing EBP into clinical practice (Boucher et al., 2013; Cadmus et al., 2008). Findings also suggests that NJC activities are providing nurses with practical tools that make evidence relevant to practice (Jeffs et al., 2013). Embedding the NJC as an educational component of NR&EBP Council allows busy nurses time away from clinical care. Clearly, this allotted time when viewed as nonproductive time (as opposed to direct patient care time) can be expensive and considered uneconomical. Committed leadership is essential to enabling and supporting a process that requires time away from the bedside. Such support was evident through the CNO's request that the NJC explore the available research on dress codes and professional image in the hospital setting; and then disseminate the findings by means of a Nursing Grand Rounds presentation. Leadership within the council has been an advocate for NJC as well. The NR&EBP Council chair and co-chair developed the initial offcampus NJC; and pressed diligently for ways to create a better forum for participation. Council leaders, including nursing directors and educators, guided and helped design a formal structure congruent with the mission, vision, and values of the Nursing Professional Practice Model. Accessing evidence and knowledge building for EBP have also been achievements of the NJC. Especially successful has been the involvement of the library liaison as a member of NR&EBP Council, thereby creating a win–win partnership (Urquhart, Turner, Durbin, & Ryan, 2007). The
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Table 2 Nursing Journal Club Participants Evaluation of Nursing Research and Evidence-Based Practice Journal Club.
Mean Score
Nursing Journal Club Participants Evaluation of Nursing Research and Evidence-Based Practice Journal Club 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
Journal Club Session
Satisfaction with Educational Activity
Extent Changed Knowledge and Attitude
Value of Educational Activity
Professional Image (N=28)
4.21
4.00
4.11
Alarm Fatigue (N=23)
4.35
4.22
4.26
Quiet Hospitals (N=25)
4.40
4.04
4.32
Nurse Communication (N=22)
4.59
4.23
4.45
librarian provides specialized expertise and collaboration that overcomes nurses' lack of time for finding and retrieving evidence. This situation of the librarian actively participating in NJC is unique in that library support usually focuses on consultation and literature search assistance, with minimal or no participation in journal club discussions (Kean, 2013). This participation not only offers additional education on the EBP process of searching and evaluating literature, but also raises awareness of library resources and services. At the same time, the librarian gains understanding of the needs of nurses for information and how they approach pursuing evidence for patient care. This shared understanding of the hierarchy of evidence needed to impact patient care places both the nurse and the librarian on the same page to ask and answer important clinical questions. Involvement by a librarian has been identified as an important attribute of successful journal clubs (Honey & Baker, 2011). As nurses engage in the process of examining the existing evidence on a topic of concern for an issue that has direct relevance to their practice, they become eager to develop the requisite skills and knowledge to critique clinical studies. The NJC offers the opportunity for practical application directed toward enhancing nursing practice related to documentation, delegation, patient education, patient satisfaction, and patient and family centered care. It is our experience that when the process is facilitated by nurse scientists, clinical educators, and librarians, clinical nurses are supported and eager to attain such skills. Through participation in the activities of critiquing research studies and determining the level of empirical evidence on a topic, nurses overcome knowledge deficits regarding EBP and are able to make appropriate and immediate application to clinical practice. Identifying the structure and processes and overcoming common barriers to implementing EBP in the clinical setting were imperative to the success of our NJC. Promoting a culture of inquiry and scholarship through the NR&EBP Council, presenting education workshops, and engaging experts with clinical research experience were utilized as ways to assist staff nurses in applying EBP at the bedside. In addition, the involvement and advocacy of these activities were supported by a visible CNO who provided an organizational commitment and an infrastructure to promote a culture for clinical nurse participation in EBP activities. 5. Limitations Promoting interest and gaining more participation in the NJC from staff other than NR&EBP Council members remain a challenge. This
limitation in participation deters broader dissemination of relevant evidence for practice. In addition, the annual change of NR&EBP Council membership creates an ongoing need to keep new members apprised of the elements needed for efficient running of the NJC. Such disruptions in continuity require the ongoing education related to EBP and research methods that are often repetitive for seasoned members. Use of the learning management system has assisted in overcoming some barriers to education; and has facilitated registration, evaluation, and access to credit certificates. At that same time, system workarounds have been required to provide materials for wider distribution pre and post each NJC session. Ongoing work is aimed at removing these barriers in order for the NJC to be an important strategy for sustaining an environment for nursing research and EBP. Another limitation is the inability to demonstrate directly via linkages to quantitative data how the NJC enhances quality care and patient outcomes. Even a modest association between NJC topics and selected patient outcomes would offer support for continued investment of nursing time to attend during regularly scheduled work time. As Burman, Robinson, and Hart (2013) note, incorporating patient preferences to promote better patient outcomes is the component of the EBP triad that is frequently omitted. Our NJC has done a reasonable job of empowering nurses to implement the two EBP components of best available evidence and clinician expertise. Ongoing efforts continue to complete the triad and to make valid connections to patient outcomes.
6. Conclusions Development of an NJC by NR&EBP Council has created a structure and process to remove common barriers that hinder clinical nurses from integrating EBP into practice. The NJC Club provides nurses and colleagues essential skills in critically appraising literature that has potential impact on practice. Nurses' active participation in a journal club that aligns topics with organizational goals has become a method to advance and sustain evidence-based practice throughout the organization.
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