- Email: [email protected]
Using a Virtual Journal Club for Sharing Evidence-Based Practice Recommendations in Critical Care Registered Nurses
Teaching and Learning in Nursing xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses1,2 Ruth Ann LaMar, DNP, MSN, RN ⁎ Ball State University School of Nursing, Cooper Nursing Room 418, 2111 West Riverside Avenue, Muncie, Indiana, United States 47306
a r t i c l e
i n f o
Article history: Accepted 19 August 2016 Available online xxxx Keywords: Virtual journal club Evidence-based practice Registered nurse
a b s t r a c t Objective: Registered nurses must remain current with evidence-based practice knowledge to meet job demands in an evolving health care climate. This pilot study's purpose was to investigate a virtual journal club's effect on satisfaction, knowledge, and practice. Background: On-line learning is used to convey information while meeting diverse learner needs, and journal clubs are used to disseminate and discuss evidence-based practice knowledge. Combining the 2 concepts into a virtual journal club creates an opportunity to meet learner needs while discussing information that promotes evidence-based practice knowledge and implementation. Setting/Population: Sixteen critical care nurses from one midwestern teaching hospital's intensive care unit. Methodology: Researchers used the Kirkpatrick Learning Evaluation Model in a 4-week-long, mixed methods pilot study. Researchers presented 1 article about sepsis in an on-line discussion forum. Nurses took a pretest before participation and a Likert-type satisfaction survey and posttest after participation. Two weeks following journal club participation, researchers sent participants e-mails asking if/how nurses applied knowledge to practice. Researchers analyzed pre−/posttest results using McNemar's Test. Results: Sixteen nurses actively participated. Ten nurses took satisfaction surveys, choosing mostly 4 s (agree) and 5 s (strongly agree), reflecting statistically significant satisfaction. Sixteen nurses took pre- and posttests and demonstrated improvement in knowledge; however, only answers to 2 questions demonstrated statistically significant improvement. Eight nurses responded to the evaluation surveys with comments surrounding increased confidence in caring for septic patients and increased awareness of symptomology, testing, and treatments. Two nurses noted that their practice was not impacted by participation. Practice Implications: Choose relevant articles and make hard copies of the article available for easy access. The virtual journal club discussion forum should promote ease of use and be moderated by someone well positioned to participate frequently and knowledgably. In addition, consider offering continuing education credits to encourage participation. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction and Background Registered nurses (RNs) must be integral in applying current research to practice with constantly evolving health care knowledge affecting treatments, patient satisfaction, and patient outcomes; thus, innovative professional development strategies are needed that are flexible with health care workers' schedules and that facilitate nurses' learning and implementation of new evidence (Bilodeau, Pepin, & St-Louis,
1 Research Project Completed in Partial Fulfillment of Doctorate of Nursing Practice Degree, Indiana University School of Nursing, 1111 Middle Drive, Indianapolis, Indiana, United States of America 46202. 2 Research Project completed at Indiana University Health Ball Memorial Hospital, 2401 West University Avenue, Muncie, Indiana, United States of America 47303. ⁎ Corresponding author. Tel.: +1 765 489 5599. E-mail address: [email protected].
2012). On-line learning is one strategy that is meeting this need with its asynchronous, self-paced, and self-directed format (Dovi, 2014; Morente, Morales-Asencio, & Veredas, 2014). On-line learning may meet the needs of learners who receive and assimilate information in diverse ways (Cottrell & Donaldson, 2013; Morente et al., 2014), can reach more health care workers at one time without limitations of time/place restrictions (Morente et al., 2014), and offers interaction experiences that might not be available otherwise (Carter, Rukholm, & Kelloway, 2009). In addition, some health care organizations may view on-line professional development as a more cost-effective approach for presenting information to a large number of people (Sortedahl, 2012). Therefore, on-line education is being used in health care as an effective method of conveying knowledge and overcoming time, class attendance, diverse learner, communication, and financial barriers. (See Tables 1 and 2.) Journal clubs have been used within health care for many years as a way to share and discuss evidence-based practice (EBP) knowledge
http://dx.doi.org/10.1016/j.teln.2016.08.006 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
2
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
with the added benefit of a greater understanding of research methodologies (Steenbeek et al., 2009). Combining on-line learning and journal clubs opens the door for interactive learning experiences through a virtual journal club (VJC) wherein knowledge is shared and discussion is encouraged so that learning takes place and evidence can be put into practice (Lehna, Berger, Truman, Goldman, & Topp, 2010). Literature Review The author searched several databases from October 3 to 7, 2014 to obtain research articles: CINAHL through EBSCO, Cochrane Library, ProQuest, Medline through Ovid, Web of Science, Medline through EBSCO (using different search terms than CINAHL/EBSCO search), and PubMed. A variety of search terms and combinations were used: virtual journal club, journal club, on-line education, web-based learning, e-learning, knowledge, understanding, comprehension, practice, skills, application, impact, affect, influence, registered nurses, nurses, and RNs. After obtaining relevant articles, the author combed through reference lists and forward searched in an effort to capture all applicable research. The literature search resulted in 37 studies. Excluded studies were more general with a focus on on-line, Web-based, and/or e-learning. Also excluded were the systematic reviews that included the nine articles that made the final cut for critical appraisal. Study outcomes revealed that, while no researcher has actually observed practice change or improved patient outcomes as a result of journal clubs, nurses, nursing students, and medical doctors reported satisfaction with journal clubs and an increase in practice and research knowledge. Some studies went a little further. McLeod, MacRae, McKenzie, and Brasel (2009) compared moderated face-to-face journal clubs and on-line journal clubs and found that participants scored better on critical appraisal tests in the face-to-face clubs as opposed to the Internet journal club, demonstrating that informative comments and free give-and-take interaction in-person may be valuable to increasing knowledge and need to be considered when using the on-line format for learning. Kawar, Garcia-Savan, Baker-Genaw, Drake, and Kaatz (2012) presented evidence that enthusiasm about and involvement with the new club may wear off after the first few months, so members may require incentives to participate (Sciarra, 2011). Kean (2013) offered valuable information about using an embedded librarian in a VJC, especially for nurses who may not be aware of the resources medical librarians have to offer. Lastly, several authors reported that study participants experienced an increase in understanding interpretation of research methodologies. Local Problem Currently, the hospital under scrutiny continues to provide some EBP education to nursing staff through in-class instruction, requiring nurses to come in on days off and receive an hourly wage during the training (Youngblut & Brooten, 2001). This method of education incurs substantial cost to the institution and requires nursing staff to come in on unscheduled work days, creating problems with attendance. While face-to-face education maintains staff accountability and is ideal for evaluating learning outcomes, it is not the most efficient use of time and resources for both employees and the Table 1 Satisfaction (N = 10) Question
Mean scores
1 2 3 4 5 6
4.3 4.3 3.9 4.3 4.2 4.2
Table 2 Knowledge (N = 16) Question
Pretest correct responses (#,%)
Posttest correct responses (#,%)
Difference (+/−)
P
1 2 3 4 5
6 (37.5%) 9 (56.25%) 12 (75.0%) 9 (56.25%) 8 (50.0%)
13 (81.25%) 16 (100.0%) 12 (75.0%) 10 (62.5%) 10 (62.5%)
+43.75% +43.75% 0.0% +6.25% +12.5%
0.0196 * 1 0.7055 0.5271
organization. A viable alternative is required whereby nursing staff is held accountable for learning, new knowledge can be gained and learning can be evaluated, new skills and knowledge can be effectively implemented, and patient outcomes can benefit as a result, without the extra cost for and time spent in face-to-face training. Intended Improvement With the establishment of a VJC through an on-line collaboration portal in our study, nurses independently can access and read a current research article and interact with other members in an on-line forum, overcoming classroom attendance barriers (Lizarondo, Kumar, & Grimmer-Somers, 2010). The VJC's facilitators are the hospital's nurse researcher and the author of this article. The research article choice was based upon a current area of interest in the intensive care unit (ICU) and upon recommendations from the unit leaders and unit-based council. For the purpose of this small pilot study, only one article was used for VJC evaluation. To incentivize RNs to participate, we gave $5 Subway gift cards to participants and one massage gift certificate to the participant chosen in a drawing. Another incentive was that VJC participation could be included in yearly evaluations. Study Question In ICU RNs, what is the effect of VJCs on satisfaction, knowledge, and practice? Ethical Issues This small pilot study was deemed a performance improvement project and, therefore, did not need institution review board approval. Because of the nature of the project, the identities of participants were known. However, the responses to evaluation tools were confidential to the researcher who collected the data because names were removed. The nurses were informed in unit meetings prior to the study that participation was not required and that no form of punishment would be given to those who did not participate. Setting The pilot study took place within the ICU of a teaching hospital in Midwestern Indiana. The ICU was chosen through recommendations from the ICU manager, clinical nurse specialist (CNS), and nurse researcher who believed that ICU staff would benefit the most because they are a relatively young team in terms of years of experience and have, traditionally, been open to learning opportunities. To participate in the VJC/study, nurses had to work in the ICU as a unit or float staff nurse on a supplemental, part-time, or full-time basis. Methods For the author's project of developing interventions to implement a VJC, intervention mapping (IM) was a helpful tool to ensure that all necessary components of the process were included. Step Zero of IM is conducting a needs assessment. Rationale for the project was that
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
the VJC was a means of promoting nurse reading and application of EBP. The author and nurse researcher met with other groups within the same hospital network that had completed similar projects to investigate what worked and what did not work within their VJCs. The author and nurse researcher met with the EBP committee, unit-based council, ICU manager, and CNS to investigate what they believed was needed for the project, as well. Four needs were identified: determining key stakeholders and building relationships with them, finding or building an appropriate forum for discussion that was easy to locate and use, developing a strategy for selecting and obtaining appropriate articles, and developing strategies for encouraging participation. Step One in IM is reviewing behavioral outcomes and specifying learning objectives by creating a matrix of performance objectives and determinants for each behavior (Tortolero et al., 2005). A matrix of behavioral outcomes with associated determinants, learning objectives, and relevant theory principles is found in Appendix A, and the matrix for VJC performance objectives and determinants is found in Appendix B. Step Two in IM is the selection of theory-based, practical methods and strategies (Tortolero et al., 2005). A conceptual theory guides identification of appropriate intervention strategies and is a supporting technique that influences change in the determinants identified in Step One. Because the learners in the VJC are adults and exhibit adult learning behaviors, the author chose Malcolm Knowles' Adult Learning Theory. Knowles identified six principles of adult learning: adults are internally motivated and self-directed, adults are goal oriented, adults bring life experiences and knowledge to learning experiences, adults are relevancy oriented, adults appreciate respect, and adults are practical. The learning objectives in Step One are supported by principles of the adult learning theory (Mitchell & Courtney, 2005). Step Three in IM was designing and developing the VJC in such a way that participants are most likely to meet learning objectives. The nurse researcher met with the chief nursing officer and ICU manager in the beginning to obtain approval and support for the project, which was necessary to ensure that staff nurses had the education and time they needed to be able to adequately participate in the program. Keeping the learning objectives in mind, the author, nurse researcher, and two nurses from staff education worked together to make the VJC as user friendly as possible, knowing that adult learners are practical and appreciate respect for themselves and their time. The resulting VJC was easily accessed through the hospital's intranet system with which the nurses were familiar and utilized an easy-to-use discussion forum format. Step Four of IM is adoption and implementation. The purpose of the VJC was to create a forum whereby nurses could independently access the journal club, read the assigned article, and interact with other members asynchronously in order to learn new EBP information. Performance objectives and determinants were reviewed to ensure that the implementation of the VJC would promote performance objective attainment. The four performance objectives were (a) inform and invite nurses to join, (b) participate in VJC, (c) actively discuss/employ strategies to apply new knowledge to practice, and (d) demonstrate application to practice (Appendix B). Keeping the personal and external determinants in mind, the author and nurse researcher planned implementation in such a way as to overcome most, if not all, determinants that can present obstacles. The author and nurse researcher used a 4-month planning period to design the intervention with the last 2 weeks focusing on communication of VJC information and instructions. Communication occurred at unit meetings, through informational e-mails and flyers and through face-to-face contact with staff nurses known to have been important champions in the past. The nurses were informed that participation in the discussion forum was encouraged but not required because later attendees might find that their comments had already been stated. The nurses were given contact information in case of software errors or other questions so that time would not be wasted. The author and nurse researcher believed that, in order to meet learning objectives, sufficient time should be allotted for VJC involvement, so it was decided
3
that 1 month would be given. Based on the adult learning theory principle that adults are internally motivated and self-directed, the author and nurse researcher decided to leave the application of evidence to practice up to the nurses' judgment, although any application to practice had to be consistent with the hospital's existing policies and procedures. The discussion forum took place within an eLearning Module System typically administrated by two staff development members with special training, so they were made aware of VJC dates and were involved in the entire process because they were responsible for initiating and terminating ICU nurse access to the journal article and for helping with any software issues specifically involving eLearning Module System. Step 5 in the IM process is the development of an evaluation plan. In the process and effect evaluations, it is necessary to determine if the intervention was or was not successful (effect evaluation) and why the intervention was or was not successful (process evaluation; Tortolero et al., 2005). The evaluation plan used for this pilot study was based on Kirkpatrick's Four-Level Evaluation Model and measured whether performance objectives were met using mixed methods (both quantitative and qualitative). Kirkpatrick's four levels are designed as a sequence of ways to evaluate educational programs, and as one proceeds through each of the levels, the evaluation becomes more difficult and requires more time. In practice, then, it is common for trainers to evaluate Levels 1 and 2 and never proceed to Levels 3 and 4, where the most useful data exist (Kirkpatrick & Kirkpatrick, 2007). The four levels of Kirkpatrick's evaluation model are as follows: reaction – what participants thought and felt about the training (satisfaction level); learning – the resulting increase in knowledge and/or skills (evaluated using a knowledge demonstration or test); behavior – transfer of knowledge, skills, and/or attitudes from classroom to practice (evaluated observation or surveys/questionnaires); and results – the final results that occurred because of participation in a training program (performance based and may involve change in customer outcomes). Level 4, effect on patient outcomes, was the only level not evaluated for this pilot study because of too many other factors affecting outcomes. For instance, the article participants read was on the subject of sepsis, and coinciding with the sepsis article was the planning of a brand new sepsis bundle implementation. Therefore, it would be very difficult to attribute improved patient outcomes solely to the reading and discussion of sepsis in the VJC. Analysis Level 1 evaluation in Kirkpatrick's model (evaluating satisfaction with the educational offering) was accomplished using a 6-item survey with Likert-type responses given after VJC participation. The possible responses were 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), and 5 (strongly agree). Ten of the nurses (62.5% response rate) completed the satisfaction survey. Seventy percent of respondents gave the first statement, “I will be able to use what I learned from reading this article,” a 4 (agree). Statement 2 was, “I am able to learn in an on-line, asynchronous format like this journal club.” Again, 70% of respondents gave this statement a 4 (agree). For statement 3, “Discussion with colleagues was helpful to further understand the content of this article,” 90% of respondents chose 4 (agree). Statement 4 was, “The VJC was easy to use.” Forty percent of respondents chose 5 (strongly agree), and 50% chose 4 (agree). Statement 5 was, “I will participate in the VJC again when offered.” Forty percent of respondents chose 4 (agree), and 40% chose 5 (strongly agree). Last, Statement 6 was, “Participating in this journal club was a good use of my time.” Forty percent of respondents chose 4 (agree), and 40% chose 5 (strongly agree). Therefore, respondents were overwhelmingly positive about the VJC and agreed that they would participate again when it is offered in the future. Level 2 evaluation in Kirkpatrick's model was accomplished using pre- and posttests in order to measure knowledge increase. The preand posttests were exactly the same with five questions offering
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
4
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
multiple choice responses and were given directly before and after VJC participation. Two of the questions had more than one correct answer. Paired t tests were used to analyze each item, and P values were obtained to find out if each item yielded statistical significance. Sixteen of the VJC participants completed the pre- and posttests. The first question required only one answer and yielded statistically significant improvement in knowledge (P = 0.0196). *The second question had more than one correct answer, and all 16 participants answered correctly in the posttest, making it impossible to obtain a P value. However, this result is certainly statistically significant. In question 3, 12 respondents answered correctly in the pretest and in the posttest, creating a P value of 1, which is not statistically significant. Question 4 had several correct answers, and only one more participant answered correctly in the posttest than in the pretest, yielding a P value of 0.7055, which is not statistically significant. Finally, Question 5 had only one possible correct answer. Only two more respondents answered correctly in the posttest as opposed to the pretest. This yielded a P value of 0.5271, which is not statistically significant. Therefore, only Questions 1 and 2 yielded statistically significant results, and Questions 3–5 did not. Nevertheless, no decrease in correct answers was noted from pretest to posttest, and mild improvement was noted in Questions 4 and 5. Level 3 evaluation in Kirkpatrick's model was accomplished using a qualitative survey given 2 weeks after the close of the VJC and was used to investigate application of knowledge to practice. Six VJC participants answered the two questions. The questions were as follows: 1. Fill in the blank with a number to indicate how many, “Since participating in the journal club, I have provided care directly or indirectly for ___________patients with sepsis?” 2. How did what you learn in the VJC influence your care or decisions for patients with sepsis or for patients whom you suspected had sepsis? An average of 2.8 patients with known sepsis were cared for by the nurses responding to the survey (N = 8), and qualitative responses demonstrate how nurses felt the VJC impacted practice. The most common comments were associated with considering laboratories or other treatment options for the patient. Further, four comments were made by nurses who noted increased confidence in his or her care of sepsis patients and in awareness of sepsis symptomology. Two comments were associated with actual action being taken, and two comments were from nurses who reported that the VJC participation did not promote change in their care of sepsis patients. Results The VJC started on February 16, 2015 at 8 am and ended on March 16, 2015 at 8 am. The author was on the unit on the first day of the VJC pilot to answer questions and encourage participation and then visited four more times throughout the VJC pilot on day, night, weekend day, and weekend night shifts to answer questions and encourage participation. During these visits, several nurses and the nurse manager noted more patients with higher acuity than normal during the VJC pilot. In the last week of the VJC pilot, the nurse manager added information about the VJC to the shift huddles in case anyone had missed it. At the end of the pilot, 16 participants had actively taken part in discussion, although more nurses reported reading the forum and choosing to not post anything because comments had already been stated. Discussion was rich and centered around new information available in the article about recommended treatments and blood tests for patients with sepsis. Ten nurses took the VJC satisfaction surveys and were overwhelmingly positive about the VJC, the article discussed, and about future plans to participate in the VJC again. The most common scores of 4 (agree) and 5 (strongly agree) reflected comments made to the author of this article during unit rounds. It is unknown why only 10 nurses completed the satisfaction survey when the VJC had 16 participants, but because the pop-up reminder about the satisfaction survey only appeared following article access, it is assumed that the nurses simply did not see it.
Sixteen nurses took the pre- and posttests evaluating learning for a 100% response rate. All posttest results demonstrated improvement in knowledge. However, only Questions 1 and 2 demonstrated statistically significant improvement. Reading the article thoroughly was necessary for answering the questions correctly. A couple of possible reasons for not reaching statistical significance exist: the nurses were very busy with high acuity patients at the time and were not able to give full attention to the article and/or the article content was misinterpreted or conflicted with current practice, causing confusion. However, even without reaching statistical significance, all questions on the posttest demonstrated improvement in knowledge, which is promising for future VJC endeavors. The qualitative survey evaluating application to practice was distributed to all VJC participants by e-mail exactly 2 weeks after the close of the VJC, and only eight nurses responded (50% response rate). Not all nurses check e-mail promptly, which may have impacted response rate. Four of the respondents stated that the VJC did have an impact on their practice, and four nurses noted an increase in confidence in caring for patients with sepsis or in awareness of symptomology and treatments. It is difficult to quantify or describe how increased confidence and awareness may affect a patient, but it could be argued that these feelings may improve nurses' prioritization and/or might prompt them to take action more quickly. Three comments focused directly on how the nurse considered different blood tests and treatment options, and one comment focused on how a nurse took action more quickly and had the patient transferred from a medical floor to a critical care bed on presentation of sepsis symptomology. Another comment noted that an actual practice change involving ventilated patients on fentanyl infusions had occurred on the floor following the VJC pilot. Two comments were made by nurses who noted no change in his or her practice in caring for patients with sepsis. Therefore, of the eight categories of themes derived from the eight qualitative responses, only two comments related to care decisions not being impacted by VJC participation. The rest of the comments were positive about the VJC impacting care decisions, and some respondents provided specific examples of how care decisions were changed. Limitations A limitation to this small pilot study was that a small sample size was used in a specialized setting. To generalize this study's findings, future research should focus on a larger sample size across practice settings. In addition, study instruments were developed for this study and need further testing for validity. Lastly, researchers did not evaluate patient outcomes as a result of nurse participation in the VJC. Discussion Implementing the VJC in an ICU where the leadership and nurses welcome learning opportunities was a practical choice for introducing the VJC and may have promoted participation (Duffy, Thompson, Hobbs, Niemeyer-Hackett, & Elpers, 2011). Nurses reported high satisfaction with VJC participation and demonstrated that a VJC impacts knowledge. Being able to obtain qualitative information about how the nurses were able to apply the new knowledge was of particular interest and demonstrated that application to practice was, indeed, possible, even without changing policies and procedures to fit article recommendations. The results of this study corroborated studies' findings in the literature review, although none of those studies evaluated application to practice. Recommendations for future VJCs include offering CEUs to increase participation and using staff-chosen relevant articles, if possible. In addition, future VJC facilitators should consider distributing hard copies of the article to be discussed (or allow the article to be printed) so that nurses do not feel pressured to read article content too quickly and potentially miss important information. Last, the chosen discussion moderator should be knowledgeable about article content and available to engage in on-line discussion. The person most well positioned for this
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
role is the CNS because of his or her clinical knowledge and expertise, awareness of current practice policies and procedures, familiarity with staff and environment, and access to current EBP recommendations. Future research should evaluate journal club's impact on practice and patient outcomes because the majority of journal club studies merely evaluate satisfaction. According to the literature and this small pilot study, journal clubs impact satisfaction, knowledge, and practice and, therefore, have potential to impact patient outcomes. Contributions I would like to thank Sue London, librarian for Indiana University School of Medicine, for reviewing my search process and offering additional help with choosing articles for critical appraisal. In addition, I would like to thank my mentor, Dr. Renee Twibell, and my adviser, Dr. Mary Beth Riner, for providing insight into all aspects of my project and offering instruction and support as needed. Last, I appreciate Jingwei Wu's contributions during the statistical analysis portion of this study. The entire project would have been impossible without the help of these valued professionals.
5
(continued) Behavioral outcomes
information might be used on the unit
Determinants – Personal and external factors that influence a desired outcome.
Learning objectives – created by crossing performance objectives for each behavior by determinants for that behavior. At the end of the VJC pilot, the nurse will have performed the following activities:
(Personal)
practice. Adults bring life experiences and knowledge to learning experiences (adult learning theory) Reported at least one attempt to apply the EBP. Adult learners like to be respected (adult learning theory)
6. Nurse will report Time to trial new on attempts to put practice. (Personal) EBP in place on unit.
Declarations of Interest I am not financially involved with any entity associated with this research study. No funding was needed or obtained for this study. Study participation incentives were paid for by the author of this article. Appendix B
Differences Between Protocol and Review Initially, the author started out with more studies for the literature review, but most articles were not directly related to journal clubs or VJCs, focusing on more general terms, such as online learning. The resulting literature review of nine articles pertain only to journal clubs as an intervention within health care disciplines, which relates directly to the intervention and population.
Performance Personal objective determinant (participants Knowledge must do)
Determinants – Personal and external factors that influence a desired outcome.
1. Nurse will agree to participate in VJC.
Past experience with journal clubs. (Personal) Familiarity with VJC software and navigation skill
2. Nurses will read article for VJC.
Access to computer with virtual club material during shift. (External) Time to read (external) Time to reflect on article during shift. (external)
3. Nurse will share what he or she learned from the article.
4. Nurse will discuss EBP with colleagues 5. Nurse will share how article
Learning objectives – created by crossing performance objectives for each behavior by determinants for that behavior. At the end of the VJC pilot, the nurse will have performed the following activities: Accessed program during one shift Adults are internally motivated and selfdirected (ADULT LEARNING THEORY) Read the article Adults are goal oriented (adult learning theory)
External determinant Organizational practice/ policy/support Hospital is supportive and provides time to inform and recruit nurses Hospital is willing to allow nurses to stay over or come in early if needed to complete VJC requirements Hospital is willing to support procedure/ policy change with regards to evidence application in practice
Familiarity with VJC and study being conducted
Demonstrates Agree to join interpersonal VJC communication that promotes VJC enthusiasm
Participate in VJC (at least read article and access discussion forum)
Familiarity with how to use the VJC article and discussion forum and rewards of use
Demonstrate ability to use computers and hospital's intranet
Demonstrate acceptance/ accepting attitude of VJC
Actively discuss/ employ strategies to apply new knowledge to practice
Provide examples of how nurses may apply knowledge in practice
Demonstrate effective communication with multidisciplinary team members to discuss ways to apply new knowledge to practice
Demonstrate application to practice
Familiarity with how application to practice may affect patient and change outcome
Demonstrate strategies that promote application of knowledge to practice
View willingness to negotiate how knowledge may be applied to practice within team as useful method of achieving results and as respecting one another Be willing to change practice to reflect evidence
Posted in discussion forum on what he or she learned from the article.
Adults are practical (adult learning theory) Time to discuss Discussed the article Willingness to discuss Adults are relevancy oriented (adult learning theory) Reflection on how to take Shared with others about action – praxis. application of evidence to
Personal determinant Attitude
Inform and invite nurses to join VJC
Appendix A Behavioral outcomes
Personal determinant Skill
Hospital is willing to support procedure/ policy change with regards to evidence application in practice
(continued on next page)
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
6
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
References Bilodeau, I, Pepin, J, & St-Louis, L (2012). Journal club in a critical care unit: An innovative design triggering learning through reading and dialogue. Dynamics: The Official Journal of the Canadian Association of Nurses, 23(1), 18–23 (Retrieved October 6, 2014 from ProQuest database). Carter, L, Rukholm, E, & Kelloway, L (2009). Stroke education for nurses through a technology-enabled program. Journal of Neuroscience Nursing, 41(6), 336–343 (Retrieved October 6, 2014 from Web of Science database). Cottrell, S, & Donaldson, J (2013). Exploring the opinions of registered nurses working in a clinical transfusion environment on the contribution of e-learning to personal learning and clinical practice: Results of a small-scale educational research study. Nurse Education in Practice, 13(3), 221–227 (Retrieved October 6, 2014 from Medline through EBSCO database). Dovi, G (2014). Empowering change with traditional or virtual journal clubs. Nursing, 44(10), 51–53 (Retrieved October 6, 2014 from Medline through EBSCO database). Duffy, J, Thompson, D, Hobbs, T, Niemeyer-Hackett, N, & Elpers, S (2011). Evidencebased nursing leadership: Evaluation of a joint academic-service journal club. JONA: The Journal of Nursing Administration, 41(10) (Retrieved October 6, 2014 from Medline through Ovid database). Kawar, E, Garcia-Savan, E, Baker-Genaw, K, Drake, S, & Kaatz, S (2012). Journal Club 102: Enhancing evidence-based medicine learning using a virtual journal club. Journal of Graduate Medical Education, 4(1), 116 (Retrieved October 5, 2014 from Medline through Ovid database). Kean, E (2013). Assessment and impact of a new role as an embedded librarian in nursing online journal clubs. Journal of the Medical Library Association, 101(4), 335–338 (Retrieved October 6, 2014 from ProQuest database). Kirkpatrick, D, & Kirkpatrick, J (2007). Implementing the four levels. San Franciso, CA: Berrett-Koehler Publishers. Lehna, C, Berger, J, Truman, A, Goldman, M, & Topp, R (2010). JONA: The Journal of Nursing Administration, 40(12), 522–528 (Retrieved October 5, 2014 from Medline through Ovid database).
Lizarondo, L, Kumar, S, & Grimmer-Somers, K (2010). Online journal clubs: An innovative approach to achieving evidence-based practice. Journal of Allied Health, 39(1), 17–22 (Retrieved October 6, 2014 from Medline through Ovid database). McLeod, R, MacRae, H, McKenzie, M, & Brasel, K (2009). A moderated journal club is more effective than an internet journal club in teaching critical appraisal skills: Results of a multicenter randomized controlled trial. Journal of the American College of Surgeons, 211(6) (Retrieved October 5, 2014 from Medline through Ovid database). Mitchell, M, & Courtney, M (2005). Improving transfer from the intensive care unit: The development, implementation and evaluation of a brochure based on Knowles' adult learning theory. International Journal of Nursing Practice, 2005(11), 257–268. Morente, L, Morales-Asencio, J, & Veredas, F (2014). Effectiveness of an e-learning tool for education on pressure ulcer evaluation. Journal of Clinical Nursing, 23(13–14), 2043–2052 (Retrieved October 5, 2014 from Web of Science database). Sciarra, E (2011). Does journal club membership empower practice? Nursing Management, 422(1), 17–18 (Retrieved October 6, 2014 from Medline through Ovid database). Sortedahl, C (2012). Effect of online journal club on evidence-based practice knowledge, intent, and utilization in school nurses. Worldviews on Evidence-Based Nursing, 9(2), 117–125 (Retrieved October 5, 2014 from Medline through Ovid database). Steenbeek, A, Edgecombe, N, Durling, J, LeBlanc, A, Anderson, R, & Bainbridge, R (2009). Using an interactive journal club to enhance nursing research knowledge acquisition, appraisal, and application. International Journal of Nursing Education Scholarship, 6(1), 1–8 (Retrieved October 6, 2014 from Medline through Ovid database). Tortolero, S, Markham, C, Parcel, G, Peters, R, Escobar-Chaves, S, Basen-Engquist, K, & Lewis, H (2005). Using intervention mapping to adapt an effective HIV, sexually-transmitted disease, and pregnancy prevention program for high-risk minority youth. Health Promotion Practice, 6(3), 286–298. Youngblut, J, & Brooten, D (2001). Evidence-based nursing practice: Why is it important? AACN Clinical Issues, 12(4), 468–476 (Retrieved February 15, 2015).
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses1,2 Ruth Ann LaMar, DNP, MSN, RN ⁎ Ball State University School of Nursing, Cooper Nursing Room 418, 2111 West Riverside Avenue, Muncie, Indiana, United States 47306
a r t i c l e
i n f o
Article history: Accepted 19 August 2016 Available online xxxx Keywords: Virtual journal club Evidence-based practice Registered nurse
a b s t r a c t Objective: Registered nurses must remain current with evidence-based practice knowledge to meet job demands in an evolving health care climate. This pilot study's purpose was to investigate a virtual journal club's effect on satisfaction, knowledge, and practice. Background: On-line learning is used to convey information while meeting diverse learner needs, and journal clubs are used to disseminate and discuss evidence-based practice knowledge. Combining the 2 concepts into a virtual journal club creates an opportunity to meet learner needs while discussing information that promotes evidence-based practice knowledge and implementation. Setting/Population: Sixteen critical care nurses from one midwestern teaching hospital's intensive care unit. Methodology: Researchers used the Kirkpatrick Learning Evaluation Model in a 4-week-long, mixed methods pilot study. Researchers presented 1 article about sepsis in an on-line discussion forum. Nurses took a pretest before participation and a Likert-type satisfaction survey and posttest after participation. Two weeks following journal club participation, researchers sent participants e-mails asking if/how nurses applied knowledge to practice. Researchers analyzed pre−/posttest results using McNemar's Test. Results: Sixteen nurses actively participated. Ten nurses took satisfaction surveys, choosing mostly 4 s (agree) and 5 s (strongly agree), reflecting statistically significant satisfaction. Sixteen nurses took pre- and posttests and demonstrated improvement in knowledge; however, only answers to 2 questions demonstrated statistically significant improvement. Eight nurses responded to the evaluation surveys with comments surrounding increased confidence in caring for septic patients and increased awareness of symptomology, testing, and treatments. Two nurses noted that their practice was not impacted by participation. Practice Implications: Choose relevant articles and make hard copies of the article available for easy access. The virtual journal club discussion forum should promote ease of use and be moderated by someone well positioned to participate frequently and knowledgably. In addition, consider offering continuing education credits to encourage participation. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction and Background Registered nurses (RNs) must be integral in applying current research to practice with constantly evolving health care knowledge affecting treatments, patient satisfaction, and patient outcomes; thus, innovative professional development strategies are needed that are flexible with health care workers' schedules and that facilitate nurses' learning and implementation of new evidence (Bilodeau, Pepin, & St-Louis,
1 Research Project Completed in Partial Fulfillment of Doctorate of Nursing Practice Degree, Indiana University School of Nursing, 1111 Middle Drive, Indianapolis, Indiana, United States of America 46202. 2 Research Project completed at Indiana University Health Ball Memorial Hospital, 2401 West University Avenue, Muncie, Indiana, United States of America 47303. ⁎ Corresponding author. Tel.: +1 765 489 5599. E-mail address: [email protected].
2012). On-line learning is one strategy that is meeting this need with its asynchronous, self-paced, and self-directed format (Dovi, 2014; Morente, Morales-Asencio, & Veredas, 2014). On-line learning may meet the needs of learners who receive and assimilate information in diverse ways (Cottrell & Donaldson, 2013; Morente et al., 2014), can reach more health care workers at one time without limitations of time/place restrictions (Morente et al., 2014), and offers interaction experiences that might not be available otherwise (Carter, Rukholm, & Kelloway, 2009). In addition, some health care organizations may view on-line professional development as a more cost-effective approach for presenting information to a large number of people (Sortedahl, 2012). Therefore, on-line education is being used in health care as an effective method of conveying knowledge and overcoming time, class attendance, diverse learner, communication, and financial barriers. (See Tables 1 and 2.) Journal clubs have been used within health care for many years as a way to share and discuss evidence-based practice (EBP) knowledge
http://dx.doi.org/10.1016/j.teln.2016.08.006 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
2
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
with the added benefit of a greater understanding of research methodologies (Steenbeek et al., 2009). Combining on-line learning and journal clubs opens the door for interactive learning experiences through a virtual journal club (VJC) wherein knowledge is shared and discussion is encouraged so that learning takes place and evidence can be put into practice (Lehna, Berger, Truman, Goldman, & Topp, 2010). Literature Review The author searched several databases from October 3 to 7, 2014 to obtain research articles: CINAHL through EBSCO, Cochrane Library, ProQuest, Medline through Ovid, Web of Science, Medline through EBSCO (using different search terms than CINAHL/EBSCO search), and PubMed. A variety of search terms and combinations were used: virtual journal club, journal club, on-line education, web-based learning, e-learning, knowledge, understanding, comprehension, practice, skills, application, impact, affect, influence, registered nurses, nurses, and RNs. After obtaining relevant articles, the author combed through reference lists and forward searched in an effort to capture all applicable research. The literature search resulted in 37 studies. Excluded studies were more general with a focus on on-line, Web-based, and/or e-learning. Also excluded were the systematic reviews that included the nine articles that made the final cut for critical appraisal. Study outcomes revealed that, while no researcher has actually observed practice change or improved patient outcomes as a result of journal clubs, nurses, nursing students, and medical doctors reported satisfaction with journal clubs and an increase in practice and research knowledge. Some studies went a little further. McLeod, MacRae, McKenzie, and Brasel (2009) compared moderated face-to-face journal clubs and on-line journal clubs and found that participants scored better on critical appraisal tests in the face-to-face clubs as opposed to the Internet journal club, demonstrating that informative comments and free give-and-take interaction in-person may be valuable to increasing knowledge and need to be considered when using the on-line format for learning. Kawar, Garcia-Savan, Baker-Genaw, Drake, and Kaatz (2012) presented evidence that enthusiasm about and involvement with the new club may wear off after the first few months, so members may require incentives to participate (Sciarra, 2011). Kean (2013) offered valuable information about using an embedded librarian in a VJC, especially for nurses who may not be aware of the resources medical librarians have to offer. Lastly, several authors reported that study participants experienced an increase in understanding interpretation of research methodologies. Local Problem Currently, the hospital under scrutiny continues to provide some EBP education to nursing staff through in-class instruction, requiring nurses to come in on days off and receive an hourly wage during the training (Youngblut & Brooten, 2001). This method of education incurs substantial cost to the institution and requires nursing staff to come in on unscheduled work days, creating problems with attendance. While face-to-face education maintains staff accountability and is ideal for evaluating learning outcomes, it is not the most efficient use of time and resources for both employees and the Table 1 Satisfaction (N = 10) Question
Mean scores
1 2 3 4 5 6
4.3 4.3 3.9 4.3 4.2 4.2
Table 2 Knowledge (N = 16) Question
Pretest correct responses (#,%)
Posttest correct responses (#,%)
Difference (+/−)
P
1 2 3 4 5
6 (37.5%) 9 (56.25%) 12 (75.0%) 9 (56.25%) 8 (50.0%)
13 (81.25%) 16 (100.0%) 12 (75.0%) 10 (62.5%) 10 (62.5%)
+43.75% +43.75% 0.0% +6.25% +12.5%
0.0196 * 1 0.7055 0.5271
organization. A viable alternative is required whereby nursing staff is held accountable for learning, new knowledge can be gained and learning can be evaluated, new skills and knowledge can be effectively implemented, and patient outcomes can benefit as a result, without the extra cost for and time spent in face-to-face training. Intended Improvement With the establishment of a VJC through an on-line collaboration portal in our study, nurses independently can access and read a current research article and interact with other members in an on-line forum, overcoming classroom attendance barriers (Lizarondo, Kumar, & Grimmer-Somers, 2010). The VJC's facilitators are the hospital's nurse researcher and the author of this article. The research article choice was based upon a current area of interest in the intensive care unit (ICU) and upon recommendations from the unit leaders and unit-based council. For the purpose of this small pilot study, only one article was used for VJC evaluation. To incentivize RNs to participate, we gave $5 Subway gift cards to participants and one massage gift certificate to the participant chosen in a drawing. Another incentive was that VJC participation could be included in yearly evaluations. Study Question In ICU RNs, what is the effect of VJCs on satisfaction, knowledge, and practice? Ethical Issues This small pilot study was deemed a performance improvement project and, therefore, did not need institution review board approval. Because of the nature of the project, the identities of participants were known. However, the responses to evaluation tools were confidential to the researcher who collected the data because names were removed. The nurses were informed in unit meetings prior to the study that participation was not required and that no form of punishment would be given to those who did not participate. Setting The pilot study took place within the ICU of a teaching hospital in Midwestern Indiana. The ICU was chosen through recommendations from the ICU manager, clinical nurse specialist (CNS), and nurse researcher who believed that ICU staff would benefit the most because they are a relatively young team in terms of years of experience and have, traditionally, been open to learning opportunities. To participate in the VJC/study, nurses had to work in the ICU as a unit or float staff nurse on a supplemental, part-time, or full-time basis. Methods For the author's project of developing interventions to implement a VJC, intervention mapping (IM) was a helpful tool to ensure that all necessary components of the process were included. Step Zero of IM is conducting a needs assessment. Rationale for the project was that
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
the VJC was a means of promoting nurse reading and application of EBP. The author and nurse researcher met with other groups within the same hospital network that had completed similar projects to investigate what worked and what did not work within their VJCs. The author and nurse researcher met with the EBP committee, unit-based council, ICU manager, and CNS to investigate what they believed was needed for the project, as well. Four needs were identified: determining key stakeholders and building relationships with them, finding or building an appropriate forum for discussion that was easy to locate and use, developing a strategy for selecting and obtaining appropriate articles, and developing strategies for encouraging participation. Step One in IM is reviewing behavioral outcomes and specifying learning objectives by creating a matrix of performance objectives and determinants for each behavior (Tortolero et al., 2005). A matrix of behavioral outcomes with associated determinants, learning objectives, and relevant theory principles is found in Appendix A, and the matrix for VJC performance objectives and determinants is found in Appendix B. Step Two in IM is the selection of theory-based, practical methods and strategies (Tortolero et al., 2005). A conceptual theory guides identification of appropriate intervention strategies and is a supporting technique that influences change in the determinants identified in Step One. Because the learners in the VJC are adults and exhibit adult learning behaviors, the author chose Malcolm Knowles' Adult Learning Theory. Knowles identified six principles of adult learning: adults are internally motivated and self-directed, adults are goal oriented, adults bring life experiences and knowledge to learning experiences, adults are relevancy oriented, adults appreciate respect, and adults are practical. The learning objectives in Step One are supported by principles of the adult learning theory (Mitchell & Courtney, 2005). Step Three in IM was designing and developing the VJC in such a way that participants are most likely to meet learning objectives. The nurse researcher met with the chief nursing officer and ICU manager in the beginning to obtain approval and support for the project, which was necessary to ensure that staff nurses had the education and time they needed to be able to adequately participate in the program. Keeping the learning objectives in mind, the author, nurse researcher, and two nurses from staff education worked together to make the VJC as user friendly as possible, knowing that adult learners are practical and appreciate respect for themselves and their time. The resulting VJC was easily accessed through the hospital's intranet system with which the nurses were familiar and utilized an easy-to-use discussion forum format. Step Four of IM is adoption and implementation. The purpose of the VJC was to create a forum whereby nurses could independently access the journal club, read the assigned article, and interact with other members asynchronously in order to learn new EBP information. Performance objectives and determinants were reviewed to ensure that the implementation of the VJC would promote performance objective attainment. The four performance objectives were (a) inform and invite nurses to join, (b) participate in VJC, (c) actively discuss/employ strategies to apply new knowledge to practice, and (d) demonstrate application to practice (Appendix B). Keeping the personal and external determinants in mind, the author and nurse researcher planned implementation in such a way as to overcome most, if not all, determinants that can present obstacles. The author and nurse researcher used a 4-month planning period to design the intervention with the last 2 weeks focusing on communication of VJC information and instructions. Communication occurred at unit meetings, through informational e-mails and flyers and through face-to-face contact with staff nurses known to have been important champions in the past. The nurses were informed that participation in the discussion forum was encouraged but not required because later attendees might find that their comments had already been stated. The nurses were given contact information in case of software errors or other questions so that time would not be wasted. The author and nurse researcher believed that, in order to meet learning objectives, sufficient time should be allotted for VJC involvement, so it was decided
3
that 1 month would be given. Based on the adult learning theory principle that adults are internally motivated and self-directed, the author and nurse researcher decided to leave the application of evidence to practice up to the nurses' judgment, although any application to practice had to be consistent with the hospital's existing policies and procedures. The discussion forum took place within an eLearning Module System typically administrated by two staff development members with special training, so they were made aware of VJC dates and were involved in the entire process because they were responsible for initiating and terminating ICU nurse access to the journal article and for helping with any software issues specifically involving eLearning Module System. Step 5 in the IM process is the development of an evaluation plan. In the process and effect evaluations, it is necessary to determine if the intervention was or was not successful (effect evaluation) and why the intervention was or was not successful (process evaluation; Tortolero et al., 2005). The evaluation plan used for this pilot study was based on Kirkpatrick's Four-Level Evaluation Model and measured whether performance objectives were met using mixed methods (both quantitative and qualitative). Kirkpatrick's four levels are designed as a sequence of ways to evaluate educational programs, and as one proceeds through each of the levels, the evaluation becomes more difficult and requires more time. In practice, then, it is common for trainers to evaluate Levels 1 and 2 and never proceed to Levels 3 and 4, where the most useful data exist (Kirkpatrick & Kirkpatrick, 2007). The four levels of Kirkpatrick's evaluation model are as follows: reaction – what participants thought and felt about the training (satisfaction level); learning – the resulting increase in knowledge and/or skills (evaluated using a knowledge demonstration or test); behavior – transfer of knowledge, skills, and/or attitudes from classroom to practice (evaluated observation or surveys/questionnaires); and results – the final results that occurred because of participation in a training program (performance based and may involve change in customer outcomes). Level 4, effect on patient outcomes, was the only level not evaluated for this pilot study because of too many other factors affecting outcomes. For instance, the article participants read was on the subject of sepsis, and coinciding with the sepsis article was the planning of a brand new sepsis bundle implementation. Therefore, it would be very difficult to attribute improved patient outcomes solely to the reading and discussion of sepsis in the VJC. Analysis Level 1 evaluation in Kirkpatrick's model (evaluating satisfaction with the educational offering) was accomplished using a 6-item survey with Likert-type responses given after VJC participation. The possible responses were 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), and 5 (strongly agree). Ten of the nurses (62.5% response rate) completed the satisfaction survey. Seventy percent of respondents gave the first statement, “I will be able to use what I learned from reading this article,” a 4 (agree). Statement 2 was, “I am able to learn in an on-line, asynchronous format like this journal club.” Again, 70% of respondents gave this statement a 4 (agree). For statement 3, “Discussion with colleagues was helpful to further understand the content of this article,” 90% of respondents chose 4 (agree). Statement 4 was, “The VJC was easy to use.” Forty percent of respondents chose 5 (strongly agree), and 50% chose 4 (agree). Statement 5 was, “I will participate in the VJC again when offered.” Forty percent of respondents chose 4 (agree), and 40% chose 5 (strongly agree). Last, Statement 6 was, “Participating in this journal club was a good use of my time.” Forty percent of respondents chose 4 (agree), and 40% chose 5 (strongly agree). Therefore, respondents were overwhelmingly positive about the VJC and agreed that they would participate again when it is offered in the future. Level 2 evaluation in Kirkpatrick's model was accomplished using pre- and posttests in order to measure knowledge increase. The preand posttests were exactly the same with five questions offering
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
4
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
multiple choice responses and were given directly before and after VJC participation. Two of the questions had more than one correct answer. Paired t tests were used to analyze each item, and P values were obtained to find out if each item yielded statistical significance. Sixteen of the VJC participants completed the pre- and posttests. The first question required only one answer and yielded statistically significant improvement in knowledge (P = 0.0196). *The second question had more than one correct answer, and all 16 participants answered correctly in the posttest, making it impossible to obtain a P value. However, this result is certainly statistically significant. In question 3, 12 respondents answered correctly in the pretest and in the posttest, creating a P value of 1, which is not statistically significant. Question 4 had several correct answers, and only one more participant answered correctly in the posttest than in the pretest, yielding a P value of 0.7055, which is not statistically significant. Finally, Question 5 had only one possible correct answer. Only two more respondents answered correctly in the posttest as opposed to the pretest. This yielded a P value of 0.5271, which is not statistically significant. Therefore, only Questions 1 and 2 yielded statistically significant results, and Questions 3–5 did not. Nevertheless, no decrease in correct answers was noted from pretest to posttest, and mild improvement was noted in Questions 4 and 5. Level 3 evaluation in Kirkpatrick's model was accomplished using a qualitative survey given 2 weeks after the close of the VJC and was used to investigate application of knowledge to practice. Six VJC participants answered the two questions. The questions were as follows: 1. Fill in the blank with a number to indicate how many, “Since participating in the journal club, I have provided care directly or indirectly for ___________patients with sepsis?” 2. How did what you learn in the VJC influence your care or decisions for patients with sepsis or for patients whom you suspected had sepsis? An average of 2.8 patients with known sepsis were cared for by the nurses responding to the survey (N = 8), and qualitative responses demonstrate how nurses felt the VJC impacted practice. The most common comments were associated with considering laboratories or other treatment options for the patient. Further, four comments were made by nurses who noted increased confidence in his or her care of sepsis patients and in awareness of sepsis symptomology. Two comments were associated with actual action being taken, and two comments were from nurses who reported that the VJC participation did not promote change in their care of sepsis patients. Results The VJC started on February 16, 2015 at 8 am and ended on March 16, 2015 at 8 am. The author was on the unit on the first day of the VJC pilot to answer questions and encourage participation and then visited four more times throughout the VJC pilot on day, night, weekend day, and weekend night shifts to answer questions and encourage participation. During these visits, several nurses and the nurse manager noted more patients with higher acuity than normal during the VJC pilot. In the last week of the VJC pilot, the nurse manager added information about the VJC to the shift huddles in case anyone had missed it. At the end of the pilot, 16 participants had actively taken part in discussion, although more nurses reported reading the forum and choosing to not post anything because comments had already been stated. Discussion was rich and centered around new information available in the article about recommended treatments and blood tests for patients with sepsis. Ten nurses took the VJC satisfaction surveys and were overwhelmingly positive about the VJC, the article discussed, and about future plans to participate in the VJC again. The most common scores of 4 (agree) and 5 (strongly agree) reflected comments made to the author of this article during unit rounds. It is unknown why only 10 nurses completed the satisfaction survey when the VJC had 16 participants, but because the pop-up reminder about the satisfaction survey only appeared following article access, it is assumed that the nurses simply did not see it.
Sixteen nurses took the pre- and posttests evaluating learning for a 100% response rate. All posttest results demonstrated improvement in knowledge. However, only Questions 1 and 2 demonstrated statistically significant improvement. Reading the article thoroughly was necessary for answering the questions correctly. A couple of possible reasons for not reaching statistical significance exist: the nurses were very busy with high acuity patients at the time and were not able to give full attention to the article and/or the article content was misinterpreted or conflicted with current practice, causing confusion. However, even without reaching statistical significance, all questions on the posttest demonstrated improvement in knowledge, which is promising for future VJC endeavors. The qualitative survey evaluating application to practice was distributed to all VJC participants by e-mail exactly 2 weeks after the close of the VJC, and only eight nurses responded (50% response rate). Not all nurses check e-mail promptly, which may have impacted response rate. Four of the respondents stated that the VJC did have an impact on their practice, and four nurses noted an increase in confidence in caring for patients with sepsis or in awareness of symptomology and treatments. It is difficult to quantify or describe how increased confidence and awareness may affect a patient, but it could be argued that these feelings may improve nurses' prioritization and/or might prompt them to take action more quickly. Three comments focused directly on how the nurse considered different blood tests and treatment options, and one comment focused on how a nurse took action more quickly and had the patient transferred from a medical floor to a critical care bed on presentation of sepsis symptomology. Another comment noted that an actual practice change involving ventilated patients on fentanyl infusions had occurred on the floor following the VJC pilot. Two comments were made by nurses who noted no change in his or her practice in caring for patients with sepsis. Therefore, of the eight categories of themes derived from the eight qualitative responses, only two comments related to care decisions not being impacted by VJC participation. The rest of the comments were positive about the VJC impacting care decisions, and some respondents provided specific examples of how care decisions were changed. Limitations A limitation to this small pilot study was that a small sample size was used in a specialized setting. To generalize this study's findings, future research should focus on a larger sample size across practice settings. In addition, study instruments were developed for this study and need further testing for validity. Lastly, researchers did not evaluate patient outcomes as a result of nurse participation in the VJC. Discussion Implementing the VJC in an ICU where the leadership and nurses welcome learning opportunities was a practical choice for introducing the VJC and may have promoted participation (Duffy, Thompson, Hobbs, Niemeyer-Hackett, & Elpers, 2011). Nurses reported high satisfaction with VJC participation and demonstrated that a VJC impacts knowledge. Being able to obtain qualitative information about how the nurses were able to apply the new knowledge was of particular interest and demonstrated that application to practice was, indeed, possible, even without changing policies and procedures to fit article recommendations. The results of this study corroborated studies' findings in the literature review, although none of those studies evaluated application to practice. Recommendations for future VJCs include offering CEUs to increase participation and using staff-chosen relevant articles, if possible. In addition, future VJC facilitators should consider distributing hard copies of the article to be discussed (or allow the article to be printed) so that nurses do not feel pressured to read article content too quickly and potentially miss important information. Last, the chosen discussion moderator should be knowledgeable about article content and available to engage in on-line discussion. The person most well positioned for this
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
role is the CNS because of his or her clinical knowledge and expertise, awareness of current practice policies and procedures, familiarity with staff and environment, and access to current EBP recommendations. Future research should evaluate journal club's impact on practice and patient outcomes because the majority of journal club studies merely evaluate satisfaction. According to the literature and this small pilot study, journal clubs impact satisfaction, knowledge, and practice and, therefore, have potential to impact patient outcomes. Contributions I would like to thank Sue London, librarian for Indiana University School of Medicine, for reviewing my search process and offering additional help with choosing articles for critical appraisal. In addition, I would like to thank my mentor, Dr. Renee Twibell, and my adviser, Dr. Mary Beth Riner, for providing insight into all aspects of my project and offering instruction and support as needed. Last, I appreciate Jingwei Wu's contributions during the statistical analysis portion of this study. The entire project would have been impossible without the help of these valued professionals.
5
(continued) Behavioral outcomes
information might be used on the unit
Determinants – Personal and external factors that influence a desired outcome.
Learning objectives – created by crossing performance objectives for each behavior by determinants for that behavior. At the end of the VJC pilot, the nurse will have performed the following activities:
(Personal)
practice. Adults bring life experiences and knowledge to learning experiences (adult learning theory) Reported at least one attempt to apply the EBP. Adult learners like to be respected (adult learning theory)
6. Nurse will report Time to trial new on attempts to put practice. (Personal) EBP in place on unit.
Declarations of Interest I am not financially involved with any entity associated with this research study. No funding was needed or obtained for this study. Study participation incentives were paid for by the author of this article. Appendix B
Differences Between Protocol and Review Initially, the author started out with more studies for the literature review, but most articles were not directly related to journal clubs or VJCs, focusing on more general terms, such as online learning. The resulting literature review of nine articles pertain only to journal clubs as an intervention within health care disciplines, which relates directly to the intervention and population.
Performance Personal objective determinant (participants Knowledge must do)
Determinants – Personal and external factors that influence a desired outcome.
1. Nurse will agree to participate in VJC.
Past experience with journal clubs. (Personal) Familiarity with VJC software and navigation skill
2. Nurses will read article for VJC.
Access to computer with virtual club material during shift. (External) Time to read (external) Time to reflect on article during shift. (external)
3. Nurse will share what he or she learned from the article.
4. Nurse will discuss EBP with colleagues 5. Nurse will share how article
Learning objectives – created by crossing performance objectives for each behavior by determinants for that behavior. At the end of the VJC pilot, the nurse will have performed the following activities: Accessed program during one shift Adults are internally motivated and selfdirected (ADULT LEARNING THEORY) Read the article Adults are goal oriented (adult learning theory)
External determinant Organizational practice/ policy/support Hospital is supportive and provides time to inform and recruit nurses Hospital is willing to allow nurses to stay over or come in early if needed to complete VJC requirements Hospital is willing to support procedure/ policy change with regards to evidence application in practice
Familiarity with VJC and study being conducted
Demonstrates Agree to join interpersonal VJC communication that promotes VJC enthusiasm
Participate in VJC (at least read article and access discussion forum)
Familiarity with how to use the VJC article and discussion forum and rewards of use
Demonstrate ability to use computers and hospital's intranet
Demonstrate acceptance/ accepting attitude of VJC
Actively discuss/ employ strategies to apply new knowledge to practice
Provide examples of how nurses may apply knowledge in practice
Demonstrate effective communication with multidisciplinary team members to discuss ways to apply new knowledge to practice
Demonstrate application to practice
Familiarity with how application to practice may affect patient and change outcome
Demonstrate strategies that promote application of knowledge to practice
View willingness to negotiate how knowledge may be applied to practice within team as useful method of achieving results and as respecting one another Be willing to change practice to reflect evidence
Posted in discussion forum on what he or she learned from the article.
Adults are practical (adult learning theory) Time to discuss Discussed the article Willingness to discuss Adults are relevancy oriented (adult learning theory) Reflection on how to take Shared with others about action – praxis. application of evidence to
Personal determinant Attitude
Inform and invite nurses to join VJC
Appendix A Behavioral outcomes
Personal determinant Skill
Hospital is willing to support procedure/ policy change with regards to evidence application in practice
(continued on next page)
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006
6
R.A. LaMar / Teaching and Learning in Nursing xxx (2016) xxx–xxx
References Bilodeau, I, Pepin, J, & St-Louis, L (2012). Journal club in a critical care unit: An innovative design triggering learning through reading and dialogue. Dynamics: The Official Journal of the Canadian Association of Nurses, 23(1), 18–23 (Retrieved October 6, 2014 from ProQuest database). Carter, L, Rukholm, E, & Kelloway, L (2009). Stroke education for nurses through a technology-enabled program. Journal of Neuroscience Nursing, 41(6), 336–343 (Retrieved October 6, 2014 from Web of Science database). Cottrell, S, & Donaldson, J (2013). Exploring the opinions of registered nurses working in a clinical transfusion environment on the contribution of e-learning to personal learning and clinical practice: Results of a small-scale educational research study. Nurse Education in Practice, 13(3), 221–227 (Retrieved October 6, 2014 from Medline through EBSCO database). Dovi, G (2014). Empowering change with traditional or virtual journal clubs. Nursing, 44(10), 51–53 (Retrieved October 6, 2014 from Medline through EBSCO database). Duffy, J, Thompson, D, Hobbs, T, Niemeyer-Hackett, N, & Elpers, S (2011). Evidencebased nursing leadership: Evaluation of a joint academic-service journal club. JONA: The Journal of Nursing Administration, 41(10) (Retrieved October 6, 2014 from Medline through Ovid database). Kawar, E, Garcia-Savan, E, Baker-Genaw, K, Drake, S, & Kaatz, S (2012). Journal Club 102: Enhancing evidence-based medicine learning using a virtual journal club. Journal of Graduate Medical Education, 4(1), 116 (Retrieved October 5, 2014 from Medline through Ovid database). Kean, E (2013). Assessment and impact of a new role as an embedded librarian in nursing online journal clubs. Journal of the Medical Library Association, 101(4), 335–338 (Retrieved October 6, 2014 from ProQuest database). Kirkpatrick, D, & Kirkpatrick, J (2007). Implementing the four levels. San Franciso, CA: Berrett-Koehler Publishers. Lehna, C, Berger, J, Truman, A, Goldman, M, & Topp, R (2010). JONA: The Journal of Nursing Administration, 40(12), 522–528 (Retrieved October 5, 2014 from Medline through Ovid database).
Lizarondo, L, Kumar, S, & Grimmer-Somers, K (2010). Online journal clubs: An innovative approach to achieving evidence-based practice. Journal of Allied Health, 39(1), 17–22 (Retrieved October 6, 2014 from Medline through Ovid database). McLeod, R, MacRae, H, McKenzie, M, & Brasel, K (2009). A moderated journal club is more effective than an internet journal club in teaching critical appraisal skills: Results of a multicenter randomized controlled trial. Journal of the American College of Surgeons, 211(6) (Retrieved October 5, 2014 from Medline through Ovid database). Mitchell, M, & Courtney, M (2005). Improving transfer from the intensive care unit: The development, implementation and evaluation of a brochure based on Knowles' adult learning theory. International Journal of Nursing Practice, 2005(11), 257–268. Morente, L, Morales-Asencio, J, & Veredas, F (2014). Effectiveness of an e-learning tool for education on pressure ulcer evaluation. Journal of Clinical Nursing, 23(13–14), 2043–2052 (Retrieved October 5, 2014 from Web of Science database). Sciarra, E (2011). Does journal club membership empower practice? Nursing Management, 422(1), 17–18 (Retrieved October 6, 2014 from Medline through Ovid database). Sortedahl, C (2012). Effect of online journal club on evidence-based practice knowledge, intent, and utilization in school nurses. Worldviews on Evidence-Based Nursing, 9(2), 117–125 (Retrieved October 5, 2014 from Medline through Ovid database). Steenbeek, A, Edgecombe, N, Durling, J, LeBlanc, A, Anderson, R, & Bainbridge, R (2009). Using an interactive journal club to enhance nursing research knowledge acquisition, appraisal, and application. International Journal of Nursing Education Scholarship, 6(1), 1–8 (Retrieved October 6, 2014 from Medline through Ovid database). Tortolero, S, Markham, C, Parcel, G, Peters, R, Escobar-Chaves, S, Basen-Engquist, K, & Lewis, H (2005). Using intervention mapping to adapt an effective HIV, sexually-transmitted disease, and pregnancy prevention program for high-risk minority youth. Health Promotion Practice, 6(3), 286–298. Youngblut, J, & Brooten, D (2001). Evidence-based nursing practice: Why is it important? AACN Clinical Issues, 12(4), 468–476 (Retrieved February 15, 2015).
Please cite this article as: LaMar, R.A., Using a virtual journal club for sharing evidence-based practice recommendations in critical care registered nurses, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.08.006