Rachael Beard, PhD, EdD, RN, EBP-C, Susan Boyle, BSN, RN, CCRP, EBP-C, Cynthia Dortch MPH, BSN, RN, CPHQ, EBP-C

At VA St. Louis Health Care System (VASTLHCS), nursing excellence is part of a culture of continuous improvement that integrates evidence-based practice and professional development.¹ As part of this philosophy, the Evidence-Based Practice & Research Council was tasked by senior nursing leadership to undertake an evidence-based practice project to determine how best to establish a system-wide nursing journal club. The Evidence-Based Practice & Research Council team followed the seven steps of the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model of Evidence-based Practice Methodology² to accomplish this goal.

Steps of Evidence-based Practice³

Step 0: Cultivate a spirit of inquiry

Step 1: Ask clinical questions in PICOT format

Step 2: Search for the best evidence

Step 3: Critically appraise the evidence

Step 4: Integrate the evidence with clinical expertise and patient preferences and values

Step 5: Evaluate the outcomes of the practice decisions or changes based on the evidence

Step 6: Disseminate evidence-based practice results

The Background: Evidence-based Practice and Nursing Journal Clubs

In the current climate of value-based care, emphasis is placed on outcomes, while reimbursement depends on the quality of services delivered. Consequently, successful healthcare organizations must employ innovative strategies to deliver high-quality, evidence-based care. Melnyk et al., define evidence-based practice as a problem-solving approach to delivering health care that integrates the best evidence with clinician expertise and patient preferences and values to improve outcomes.⁴ Evidence-based practice competencies for practicing registered nurses and advanced practice registered nurses (APRNs) include the ability to critically appraise, evaluate, and synthesize research evidence to determine relevance to practice.⁵ Nursing journal clubs are an effective way to fulfill this evidence-based practice competency. Typically, a nursing journal club session consists of individuals who read a pre-selected article and then participate in a facilitator-led discussion.

While the medical establishment has used journal clubs for decades in education and professional practice, nursing journal clubs are a more recent phenomenon in the healthcare setting. They are proving to be an effective professional development tool, keeping nurses up to date, disseminating knowledge, and bridging the gap between research and practice.

Furthermore, Gardner et al. reported that nurses’ committed participation in a journal club was used to develop and support evidence-based practice.⁶

Significance to Cardiovascular Nurses

Cardiovascular nurses and APRNs are on the cutting edge of many advances in treating cardiovascular disease. They must keep abreast of new research developments and continually update their knowledge and skills. Nursing journal clubs with a cardiovascular focus can facilitate such learning. The following examples illustrate how nursing literature supports journal clubs for cardiovascular nurses.

• In 2015, the Rocky Mountain chapter of the PCNA sought to increase engagement by members and nonmembers by piloting a journal club.⁷ After several successful sessions, the chapter leadership and planning committees, with the support of the PCNA national office, decided to offer the journal club on a biannual basis to complement the Annual Cardiovascular Nursing Symposium.⁸
• The Society for Vascular Nursing Research Committee published a well-articulated guide titled “Practical Tips for Starting a Journal Club.”⁹
• A teaching hospital established a journal club in the ICU to keep nurses up to date on cardiac surgery post-operative care.¹⁰ The journal club was well attended and viewed as a positive learning experience with subsequent hands-on application.

Step-by-Step Methodology

The Covid-19 pandemic caused an interruption in this project at VASTLHCS. Some workgroup members were assigned to other duties, and the journal club project was put on hold for approximately one year. Once vaccinations were readily available and operations began normalizing, staff resumed their regular job assignments. This enabled the team to address the journal club project in earnest.

Step 0 – Cultivate a Spirit of Inquiry

A spirit of inquiry was the foundation of the evidence-based practice journal club project at VASTLHCS. The team identified a system-wide gap in nurses’ ability to translate research to practice via searching and critically appraising the literature.

Step 1 – Formulate a PICOT Question

The PICOT question is an essential step to guide one’s search for answers in the literature, where:

• P – Patient, Population, Problem
• I – Intervention
• C – Comparison
• O – Outcome(s) (measurable)
• T – Time (optional)

The VASTLHCS PICO Question

For nurses at VASTLHCS (P), does participation in the nursing journal club (I), compared to standard practice (C), foster evidence-based practice skill development and participation in quality improvement, evidence-based practice, and Research (O)?

Step 2 – Literature Search

The workgroup enlisted the help of the VASTLHCS Medical Librarian, who conducted a systematic search using PubMed. Search terms included nursing, journal club, hospital, evidence-based practice, and relatable terms. Filters applied included English language, human subject, adult 19-44 and 65 plus years. In addition, the Evidence-Based Practice & Research Council workgroup searched databases/platforms readily available online, including Elsevier Clinical Key for Nursing, Sigma Theta Tau Repository, Joanna Briggs, and Wolters Kluwer Health. The time period for articles encompassed 2002-2019. Search results yielded 24 articles, and after title and abstract review, 17 “keeper” articles were identified.

Step 3 – Critical Appraisal of the Keeper Articles

The workgroup divided the 17 articles among the workgroup, carefully analyzing and inputting key information into an Evidence Table developed by the local Evidence-Based Practice & Research Council leadership.¹¹ The purpose was to determine the level of evidence, design/aim of the study, quality, credibility, and clinical relevance to practice at the VASTLHCS organization. Many of the keeper articles were categorized as Level V evidence.

VASTLHCS Nursing Journal Club Levels of Evidence Table (Only use the table appropriate for your evidence)

Next, the workgroup completed an Interventions Synthesis Table.¹² This allowed the team to compare the appraised articles for common themes in purpose/aim/interventions. Most of the interventions fell into two categories: how to develop and implement a journal club and general guidelines and practical tips for implementing a journal club.

Interventions Synthesis Table

The final part of the critical appraisal was to complete an Outcomes Synthesis Table.¹³ The VASTLHCS team used critical thinking skills to identify and evaluate the stated outcomes in each article and group them by a common theme. Most outcomes fell into two categories: promote new knowledge and a better understanding of the research process through reading and dialogue and advance nursing practice using evidence.

Step 4 – Integrating the Best Evidence with One’s Own Experience and Expertise  

During the course of the project, a great deal of valuable information was obtained from a critical appraisal of the literature, noting recurring themes and similar recommendations among study authors. The workgroup considered the VASTLHCS organizational culture and contextual factors that might influence the acceptance of the ideas. The Evidence-Based Practice & Research Council journal club team was optimistic that many key aspects of the organizational infrastructure would result in widespread approval for the project. These key aspects include:

• Engaged and committed senior nursing leadership
• Well-developed shared governance structure
• Active Evidence-Based Practice & Research Council with trained and certified evidence-based practice mentors
• Adoption of an organizational framework (ARCC Model)
• Full-time nurse scientist
• Onsite medical librarian

Based on the evidence synthesis, the workgroup formulated written recommendations for establishing a nursing journal club. Detailed descriptions of the following categories were included in the report:

• Journal Club Purpose and Goals
• Suggested Format and Design
• Learning Objectives and Expected Outcomes
• Roles and Responsibilities of Key Stakeholders
• Roles and Responsibilities of the Journal Club Facilitator
• Data Collection and Measurement

Initially, the journal club platform was envisioned as a train-the-trainer concept. Representatives from each unit would attend a quarterly virtual journal club session facilitated by an Evidence-Based Practice & Research Council member. The participants would then reproduce the journal club session at the unit level. The Evidence-Based Practice & Research Council discussed the finer points of the proposed format and decided their role should be that of facilitator/evidence-based practice champion. The responsibility for journal club participation and sustainability would rest with the individual nursing units.

The revised plan was presented and received by the nurse executive board and nursing shared governance councils. From there, the workgroup developed an educational PowerPoint and SBAR (Situation-Background-Assessment-Recommendation) elevator speech to disseminate the project further.

Step 5 – Evaluate Outcomes

The workgroup was eager to initiate the nursing journal club and hoped to roll it out during Nurses Week. The group wasn’t expecting to encounter barriers to the proposal. Such barriers are commonly cited in the evidence-based practice literature and can include a lack of leadership engagement, infrastructure, cost, time limitations, staffing levels, and burnout.¹⁴

The specific feedback that the workgroup received centered on organizational reluctance to proceed due to the impact of COVID-19 on managers, staffing levels, and burnout. The workgroup understood that the timing was unsuitable for a system-wide initiative such as a nursing journal club during a pandemic.

Step 6 – Dissemination

The COVID-19-related turn of events provided a new appreciation for the complexity of change, so the workgroup concentrated on making the project work on a smaller scale. They partnered with groups just starting journal clubs and those with an established department-level interdisciplinary journal club. The workgroup offered to mentor and support new clubs and joined established clubs to learn new techniques and strategies that could be applied at VASTLHCS.

As a result, the workgroup gained a greater understanding of incremental change, and the group continued to identify creative ways to move their agenda forward. Key learnings include:

• Learning from experts in the field how to plan for implementation and sustainability.
• Identification of facilitators and potential barriers unique to the VASTLHCS organization

Findings were disseminated (an essential aspect of evidence-based practice) as an evidence-based practice poster during the Veterans Health Administration Office of Nursing Service virtual poster session for Nurses Week 2022. As evidence-based practice leaders and scholars, the workgroup ignited their own “spirit of inquiry”15 through their journey of discovery into the realm of evidence-based practice and establishing a nursing journal club.

In summary, evidence suggests that nurses are more receptive to evidence-based practice when they engage in journal club activity. Cardiovascular nurses and clinicians can benefit from participation in journal clubs to enhance professional development and evidence-based practice competency, gain access to scientific literature they might not be aware of, acquire and disseminate new knowledge, and implement evidence-based care to improve patient outcomes. Perhaps they can also learn from the team’s experience at VASTLHCS as they work to undertake their own journal club activity related to cardiovascular nursing.

This material is the result of work supported with resources and the use of facilities at the VA St. Louis Health Care System.

References

1. VA St. Louis Health Care System Nurse Practice Model
2. Melnyk, B., Fineout-Overholt, E., Gallagher-Ford, L., & Stillwell, S. “Evidence-based practice: step by step: sustaining evidence-based practice through organizational policies and an innovative model”. American Journal of Nursing, 2011;111(9): 57- 60. doi:10.1097/0.1NAJ.000040563.97774.0e
3. Melnyk, B., Fineout-Overholt, E., Stillwell, S., & Williamson, K. “Evidence-based practice: step by step: the seven steps of evidence-based practice”. American Journal of Nursing, 2010;110(1):51-53. doi:10.1097/01.NAJ.0000366056.06605.d2
4. Melnyk, B., Fineout-Overholt, E., Stillwell, S., & Williamson, K. “Evidence-based practice: step by step: igniting a spirit of inquiry”. American Journal of Nursing, 2009;109(11):49-52. doi:10.1097/01.NAJ.0000363354.53883.58
5. Melnyk, B., Gallagher-Ford, L., Long L., Fineout-Overholt, E. “The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs”. Worldviews Evidence Based Nursing 2014 Feb; 11(1):5-15. doi:10.1111/wvn.12021
6. Gardner, K., Kanaskie, M., Knehans, A., Salisbury, S., Doheny, K., & Schim, V. “Implementing and sustaining evidence based practice through a nursing journal club”. Applied Nursing Research, 2016;31: 139-145.
7. Himmelfarb, C. “Letter from our president”. Journal of Cardiovascular Nursing, 2016 May- Jun;31(3): 195-197. doi:10.1097/JCN.0000000000000338
8. Himmelfarb, C. “Letter from our president”, 195-197.
9. SVN Research Committee. “Practical tips for starting a journal club”. Journal of Vascular Nursing, 2009 Mar;27(1): 18-19. doi:10.1016/j.jvn.2008.12.002
10. Bilodeau, I., Pepin, J., St-Louis, L. “Journal club in a critical care unit: an innovative design triggering learning through reading and dialogue”. Dynamics, 2012 Spring;23(1): 18-23. PMID: 22533097
11. VA St. Louis Healthcare System Evidence-Based Practice and Research Council.
12. Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. “Evidence-based practice, step by step: critical appraisal of the evidence part III”. American Journal of Nursing, 2010;110(11): 43-51. doi:10.1097/01.NAJ.0000390523.99066.b5
13. Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. “Evidence-based practice, step by step: critical appraisal of the evidence part III”, 43-51.
14. Alqahtani, J., Carsula, R., Alharbi, H., Alyousef, S., Baker, O., & Tumala, R. B. “Barriers to implementing evidence-based practice among primary healthcare nurses in Saudi Arabia: A cross-sectional study”. Nursing Reports, 2022 Apr 28;12(2): 313-323. doi:10.3390/nursrep12020031
15. Melnyk, B., Fineout-Overholt, E., Stillwell, S., & Williamson, K. “Evidence-based practice: step by step: igniting a spirit of inquiry: an essential foundation for evidence-based practice”, 49-52.