Purpose: The purpose of this integrative review was to determine whether a journal club (JC)

feature article Transferring Research Into Practice An Integrative Review JULIA L. ROGERS, MSN, RN, CNS, FNP-BC Purpose: The purpose of this integrative review was to determine whether a journal club (JC) is a successful medium to bridge the research-to-practice gap and more specifically to answer the question: Do JCs increase research knowledge, dissemination of the knowledge, and implementation of evidence into practice? Background: Although substantial advancements have been made to increase awareness and utilization of evidence-based practice (EBP), the implementation of evidence into practice has its limitations. Theoretical Framework: The Promoting Action on Research Implementation in Health Service framework was used as the theoretical base for this review. Review Methods: An integrative review, as described by Ganong, was conducted. The search generated 28 articles, 10 of which met the inclusion criteria. Data were interpreted and evaluated using a data summary sheet influenced by the Ganong approach. The findings were summarized into 4 categories: understanding, circulation, implementation, and facilitation. Data sources: CINAHL, MEDLINE, Cochrane, Athens, Google Scholar, and Academia Premiere. Outcome: Journal clubs improved research-critiquing skills and increased the dissemination of research findings, but lacked the ability to integrate the evidence into practice. Facilitators of a successful JC were leaders in reviewing, developing, and implementing EBP. Conclusion: The 3 elements of the Promoting Action on Research Implementation in Health Service framework, context, evidence, and facilitation were supported by the findings. Implications: A JC promotes change, stimulates professionalism, and provides the opportunity to improve practice through understanding, utilization, and implementation of EBP. KEY WORDS: evidence-based practice, journal club, knowledge translation, nursing, research utilization Through the process of inquiry, the profession of nursing has gained momentum in the dissemination, translation, and implementation of research knowledge. Nurse leaders worldwide are searching for innovative means to bring research into practice to improve the quality, effectiveness, and safety of healthcare delivery. As evidence-based practice (EBP) in nursing care is becoming nationally recognized, the identification of a medium to bridge the research-to-practice gap has gained popularity. The Agency for Healthcare Research and Quality (2007) reports a span of 10 years or more between the availability of research evidence and its integration into practice; based on this report, it Author Affiliations: Porter County Pulmonary and Critical Care Medicine, Valparaiso; Purdue University North Central, Westville; and LaPorte Regional Health System, Indiana. Corresponding author: Julia L. Rogers, MSN, RN, CNS, FNP-BC, 1101 E. Glendale Suite 103 Valparaiso, IN 46350 (juliarogersnp@gmail.com). Clinical Nurse Specialist A Copyright B 2009 Wolters Kluwer Health Lippincott Williams & Wilkins 192 CLINICAL NURSE SPECIALIST A

is evident that innovative concepts that are also expeditious need to be initiated into healthcare. Previous researchers have documented the barriers and influences to using research within nursing practice. Montgomery et al identified that Barriers include a lack of knowledge among nurses of the research process and the inability to understand research reports. 15(p125) Few research studies have been conducted on successful interventions used to overcome these barriers for research dissemination and implementation of research to occur. Journal clubs (JCs) have been previously described in the literature as a powerful tool for research utilization and education by providing experience in locating, appraising, and implementing research to practicing nurses under the guidance of an experienced mentor. 9 A journal club is not an avant-garde idea in the world of medicine. In fact, JCs have been used in medicine for educational purposes dating back to 1875. Today, JCs are still thriving in medical schools, but have made little expansion into nursing. Clinical nurse specialists (CNSs) have been instrumental in the creation of more JCs in healthcare facilities and thereby narrowing the research-to-practice gap. The CNS role as a researcher is a vital component to improving patient care through the development and utilization of empirical research. PURPOSE While substantial advancements have been made to bridge the gap between research and practice through increasing awareness and utilization of evidence. The implementation of research findings into practice has its limitations. Therefore, the aim of this integrative review was to determine whether a journal club is a successful medium to bridge the research-to-practice gap, more specifically to answer the question: Do journal clubs increase research knowledge, dissemination of the knowledge, and implementation of evidence into nursing practice? SEARCH METHODS Design An integrative review was conducted using the guidelines described by Ganong. 4 The sample was collected through informal, primary, and secondary phases. The informal phase consisted of peer sharing among nurses who attended journal club meetings at LaPorte and Porter Hospitals. During the primary phase, the libraries at Valparaiso University, Purdue University North Central, and LaPorte Hospital were used to review journal articles. The secondary phase was performed via searching the following databases: CINAHL, MEDLINE, Cochrane, Athens, Google Scholar, and Academia Premiere. Multiple combinations of the key words journal club, nursing, research utilization, evidence-based practice, and knowledge translation were used during the database search. Sample Although the literature contains a plethora of information regarding journal clubs, much of the information is based on opinion and not empirical research. A decision was made initially to include original research that was published in nursing journals and written in English between the years 2000 and 2007 because these kinds of articles were thought to have the most current research on EBP. However, it soon was apparent that the initial inclusion criteria were too stringent and that more evidence was needed to maintain the validity of the review. Therefore, the inclusion criteria were augmented to include studies involving health professionals from other disciplines. Furthermore, the time span was expanded to include articles published as far back as 1995. This increased the sample to 28 abstracts. These 28 abstracts were reviewed to verify that the inclusion and exclusion criteria were met. Next, duplicate abstracts, nonresearch abstracts, and literature reviews were removed, which left 16 empirical research abstracts. Full-text articles of the 16 abstracts were obtained and read. Of these, 10 articles were found to be relevant to the research question. Analysis Ten articles were read in their entirety, examined on an individual basis, and compared with the other articles to determine reliability and validity. Data were interpreted and subsequently evaluated using a data summary sheet. The author created a summary table resembling the format advocated by the Ganong 4 approach (Table 1). Once each study was summarized appropriately, the author compared data among the 10 studies to determine commonalities and extract themes. RESULTS After data were synthesized, it was found that participation of nurses in journal clubs can increase research knowledge, dissemination of the knowledge, and implementation of evidence into practice. Four major themes emerged: understanding, circulation, facilitation, and implementation. These 4 themes represent basic processes that are needed to initiate and maintain a successful journal club. Understanding According to Montgomery et al, 15(p126) An understanding of how to read the literature is crucial; furthermore, a lack of awareness of current research results represents a loss of potential for improving patient care. Six articles 1,6,7,14,16,20 in the review discussed an increase in the nurses skills regarding critiquing and evaluating research. Jolly 6 reported that nurses attitudes toward research and development were poor before any involvement in a program that assisted them to fully understand how to read and critically appraise research articles. Karkos and Peters 7 established that nurses approaches to research utilization and implementation should focus on critiquing research articles and implementing research into practice. Milne et al 14 discussed the increased ability of participants to generate questions that are meaningful to practice, as well as the ability to perform research in a rigorous manner. Rajpal et al 16 revealed that critical appraisal of research is a fundamental goal of a journal club. VOLUME 23 NUMBER 4 193

Table 1. Integrative Review Format Citation Purpose Theoretical Framework McQueen et al 13 (2006) Explore the potential impact participation in a specific journal club had on knowledge of evidence for practice and actual clinical practice Clifford and Murray 2 (2001) Explore ways of facilitating the use of research in nursing and midwifery practice Camiah 1 (1997) Milne et al 14 (2007) Describe the extent to which nursing research was being used in practice and the degree of nurses awareness of current research findings relevant to their daily work Demonstrate a potential approach to the challenge of ensuring that practice is evidence based Rajpal et al 16 (2007) Determine resident perceptions of journal clubs, factors that make JCs successful, and identifying variables for improving JCs Method Design Sample Variables Instrument Analysis Findings Exploratory study Convenience sample of 7 occupational therapists Qualitative Convenience sample of 473 nursing and midwifery staff in the trust Involvement Attitude Pre/post questionnaire Research Utilization Questionnaire Qualitative content analysis to identify key themes Qualitative content analysis to identify key themes Quantitative parametric tests Journal clubs increase confidence, knowledge, and skills in research. Journal clubs promote changes in professional practice, staff attitudes, and increase awareness of evidence base practice information for patient interventions. Overall positive attitudes toward research. Nurses lack the knowledge required to use research in practice. Professional journals are the medium where nurses are obtaining research information. Qualitative Convenience sample of 34 second-/third-year nursing students and 36 key informants; second sample was purposive of 30 practitioners employed in 2 different settings Cross-sectional qualitative Descriptive electronic survey Convenience sample of 120 nurses and allied health professionals Convenience sample of 763 resident members of the Congress of Neurological Surgeons Attendance at journal club Individual and group interviews Qualitative content analysis to identify key themes Survey Qualitative content analysis to identify key themes Research awareness and utilization are poor and have high resistance to improve. Changes could improve both by working together to promote research in practice through facilitation, support, encouragement, role modeling, consistency, and application in clinical practice. The program was worthwhile and beneficial to everyday practice. A critical appraisal and research utilization program has benefits of building confidence, knowledge, and skill acquisition and for the organization in terms of provision of evidence-based care and quality and safety. Questionnaire Perceived primary goal of JCs is keeping current with literature and the dissemination of information. Students increased skills in critiquing and evaluating research articles. 194 CLINICAL NURSE SPECIALIST A

Wilson and Collins 21 (2005) Fink et al 3 (2005) Encourage the use of the video journal club as part of a professional education program; explore the factors that contribute to the sustainability of the present video outreach journal clubs Examine the effects of multifaceted organizational strategies on registered nurse s use of research findings to change practice Karkos and Peters 7 (2006) Identify barriers to research utilization for nurses within a Magnet community hospital. Jolly 6 (2002) Determine nursing needs for developing research awareness Rogers Diffusion of Innovations Behavioral theory Retrospective audit Descriptive cross-sectional survey Descriptive, quantitative Descriptive, qualitative Convenience sample of 20 outreach journal clubs Convenience sample of 880 registered nurses Convenience sample of 275 staff nurses. Convenience sample of 42 gynecology staff nurses at Queen s Medical Center Activity Attendance Type of journal used Change in practice Registered nurses employed on the inpatient unit at a Magnet facility Nurse Setting Research Presentation Log: Journal Club Review Form BARRIERS to Research Utilization Scale and Research Factor Questionnaire t tests, chi square, and association were used to analyze data. Themes were identified BARRIERS scale Factor analysis, Scheff2 test Survey/ questionnaire Content analysis to identify key themes Influence of journal club activity on education and change in practice is difficult to quantify. Outreach journal clubs have a high probability to change practice. There is a link between video journal club and increased patient care. Using evidence-based literature in the journal club can change practice. Results lend support to Rogers Diffusion of Innovations theory. The journal club increased awareness of research and promoted a positive attitude regarding nursing research. Nurses have a better understanding of evaluating and implementing evidence-based research. Nurses beliefs and attitudes about research can be improved through organizational commitment to the use of research in practice. Nurses have a firm interest in learning to understand research articles, having the opportunity to discuss research, and be involved in research opportunities that relate to their clinical practice. A journal club increases awareness, access, and understanding to use research Journal clubs encourage the reading of research, discussion of research, risk taking to implement new ideas, and mentoring. Application of research into practice is encouraged through attendance at a gynecologic journal club. A journal club is useful in learning to critique and present research. Facilitation of a journal club should be provided by APNs. continues VOLUME 23 NUMBER 4 195

Method Design Sample Variables Instrument Analysis Findings Four significant sources emerged: direction and understanding in analyzing evidence, blending research, technology, and experience for usefulness. Research knowledge transfers through human circulation. Human sources of information for practice were the most useful in reducing uncertainties. It is not research knowledge that drives clinical decisions of nurses but the media through which it is delivered. The facility most associated with this role is a CNS and associated roles. Q sort themes, content analysis Interviews, observations Documentary audit Q methodological modeling Convenience sample 108 nurses at 3 large acute-care hospitals in northern England Cross-case analysis, qualitative Thompson et al 20 reported the need to provide nurses with the necessary skills and knowledge to locate, appraise, and implement research knowledge. In 5 articles, 1 3,13,14 authors discussed improved attitudes toward research. The nurses became more positive about implementing change based on research findings, as well as having increased confidence in practicing at the bedside based on evidence. 1 3,13,14 Camiah 1 found that respondents in her research study felt more positive about using research in practice after applying strategies identified. Clifford and Murray 2 conducted research that concurred with the findings of McQueen et al 13 reflecting positive attitudes toward research following an intervention such as the use of JCs, which allowed participants to have a better perception of the concepts involved in research. Fink et al 3 conducted a study to identify changes in nurses attitudes toward the utilization of research and discovered that nurses who participate in research activities such as JCs are more likely to use research evidence in practice because of the increased confidence in understanding research. An evident change in confidence levels was noted in the study performed by McQueen et al. 13 There was an apparent increase in confidence when incorporating changes into practice based on research. Milne et al 14 found that clinicians became more confident in using EBP in the delivery of care after they received appropriate education on how to appropriately disseminate research findings. Some researchers discussed the importance of nurses having an increased knowledge about research. 3,6,7,14 Fink et al 3 reported that 65% of nurses had an increased awareness of research findings. Jolly 6 concurred with Fink et al 3 and determined a significant link between research attitude and understanding the processes of research utilization. Karkos and Peters 7 determined that nurses who have an increased interest in research have the desire to increase their knowledge about research, and Milne et al 14 acknowledged in their study that the respondents benefited through increasing research awareness and knowledge. One nurse participating in an interactive JC had this to say: We have learned that nursing research can be understandable, useful, and interesting to read and review. 18(p1236) Table 1. (continued) Theoretical Framework Citation Purpose Examine sources of information that nurses find useful for reducing the uncertainty associated with their clinical decisions Thompson et al 20 (2001) Circulation Circulation of evidence from journal articles was discussed in 2 articles. 3,21 Fink et al 3 determined that JCs had a high participation rate which allowed for greater dissemination of research information. Wilson and Collins 21 discussed the initiation of an online journal club for a rural healthcare center that was interconnected with a larger facility in another city. Information became easily accessible and exchanged through the process of posting journal articles over the Internet. Authors also discussed circulation of evidence through dissemination of research knowledge. 16,20 Rajpal et al 16 explained the positive impact on dissemination of research knowledge through the assistance of journal club meetings. The meetings allotted time to circulate ideas about changing care based on the evidence presented. Thompson et al 20(p692) found that Interpersonal contact may play a pivotal role in knowledge diffusion and utilization. 196 CLINICAL NURSE SPECIALIST A

Implementation The CNS can augment patient outcomes through improving patient care and staff development through the implementation of EBPs. The study done by Grol and Grimshaw 5 revealed positive effects from actively participating in a small-group interactive educational activity. The researchers also found that Change is possible when a well-designed intervention is used. 5(p1227) In all 10 articles, either the application or promotion of evidence into the practice setting was discussed. 1 3,6,7,13,21 During the research conducted by Camiah, 1 new policies were drafted and circulated for implementation into practice. Respondents also acknowledged taking a fresh look at the way in which they practice care. Clifford and Murray 2 revealed that nurses felt able to change practice through reading journals that provided new research findings that affected their practice. Fink et al 3 found that 48% of respondents used research findings as a direct result from participating in research activities. Karkos and Peters 7 affirmed implementing evidence-based changes into practice with the assistance of advanced practice nurses (APNs) and healthcare organizations. Jolly 6 reported nurses having a lack of knowledge of how to implement change into practice based on research evidence. According to McQueen et al, 13 JCs are providing the bridge between research and practice through promoting research in the clinical setting. In fact, Wilson and Collins 21 reported that letters to journal editors have been published based on JC activities and contend that evidence-based literature can change practice. Facilitation Burrows [1997, p401] conducted a concept analysis on facilitation and arrived at the following definition: Facilitation is a goal-oriented dynamic process in which participants work together in an atmosphere of genuine mutual respect in order to learn through critical reflection, this definition shows that the role of a facilitator is to work with groups of people toward change. 20(p694) Kartes and Kamel 8 suggest that, The person leading the journal club needs to be familiar with how to conduct a literature search, how to critique an article, and be familiar with policies and procedures in the facility, the article continues, An advanced practice nurse, such as a CNS may be best suited for this role. 8(p265) Four researchers discussed the use of an APN as the JC facilitator. 1,6,7,20 Camiah 1 explained that poor research awareness could be remedied by proper facilitation and role modeling. Jolly 6 also reported that the key nurses in facilitating research awareness need to act as role models. Thompson et al 20 went on to state that the CNS is able to provide useful resources of information, and nurses trusted the advice provided by nurse specialists. Two authors 3,7 discussed organizational support as a key in facilitating research dissemination and implementation. It was noted within the study conducted by Fink et al 3 that a barrier to research utilization is the organizational culture. According to Karkos and Peters, 7 supporting nurses to use research can assist in advancing nursing practice and enhance the quality and efficiency of care provided. The hospital within the study of Karkos and Peters 7 began a monthly research study group to cultivate interest in research knowledge. Individuals in the role of facilitator need advanced experience in translation, synthesizing, and contextualizing research for a variety of users. They also need strong communication skills, networks, and credibility within their own organization and to be involved in linking users and creators of knowledge. 20 The CNS seems to be the key element in facilitating a successful journal club. The CNS acts as a liaison between the 2 fundamental elements of facilitation, the nursing staff and the administration. DISCUSSION This integrative review was restricted by the limited number of empirical studies on nursing JCs. Another constraint was the weak designs used in the studies. However, this integrative review advances nursing knowledge by showing that successful JCs ascertain 4 processes: understanding, circulation, facilitation, and implementation. It is evident from the findings that the CNS role is critical in each of these processes. The 4 processes identified have similarities to the Promoting Action on Research Implementation in Health Service (PARIHS) framework. The framework, initially developed by Kitson et al 10 and revised by Rycroft-Malone et al, 17 has 3 essential elements that are key to successful implementation of evidence into practice. The 3 elements of the PARIHS framework are context, evidence, and facilitation. Context is used to refer to the environment or setting in which the proposed change is to be implemented. 17(p176) This fits with the themes of circulation and implementation. Evidence is scientifically robust and matches professional consensus and patient needs. 17(p174) The theme that coincides with this element is understanding. Facilitation is a technique by which one person makes things easier for others. 17(p177) In EBP, this is thought to promote individual and organizational change. 17(p177) This links closely with the theme of facilitation. The elements of the PARIHS framework were supported by the findings. Clinical nurse specialists can use the PARHIS framework as the platform in which to build a bridge linking research to practice. To further understand how a journal club bridges the research-to-practice gap, this author has created a model for visual interpretation (Figure 1). The Bringing Research Into Diverse Groups Effectively (BRIDGE) model s foundation to bringing research into practice is the PARIHS theoretical framework. The 3 constructs of the framework, context, evidence, and facilitation, support the structure of the bridge. The model begins with individual clinical expertise, evidence, and patient experiences as a representation of 3 important roads leading to bridging the gap between research and practice. The bridge starts with research, and a journal club is formed to create a change in practice through utilization of the 4 processes illuminated within this article: understanding, circulation, implementation, and facilitation. Once the research has been implemented into practice, the road is filled with improved patient outcomes, nursing excellence, and EBP. The model illustrates how JCs have the capability of transitioning research findings into best practices. Research conducted by nurses, disseminated to broad populations of healthcare VOLUME 23 NUMBER 4 197

Figure 1. BRIDGE Model. providers, and then used by nurses who provide direct care to patients, represents the ideal triad of research-based clinical practice. 15(p124) Nurses with increased awareness in research are more apt to apply research findings into practice. Journal clubs improve research understanding, increase the circulation of research knowledge, promote practice change, and require facilitators who are leaders, role models, and change agents, such as a CNS, to overcome the innate ability lacking to implement the evidence into practice. IMPLICATIONS Rewards of a journal club include increased passion about research and excitement about what is happening in nursing and healthcare. 12(p101) There is a need in nursing to continuously improve the quality of healthcare; the challenge is to find ways to overcome the barriers through utilization of innovative mediums. Exploration into JCs and other avenues to increase research utilization, dissemination of knowledge, and implementation of research into practice is warranted. Nurses need to increase their awareness of research to improve current practices, stimulate professionalism, and increase the quality of patient care, all of which can be accomplished with a well-developed JC. Lawson 11 acknowledges that EBP encourages examination of nursing rituals and traditions and, when justified, allows implementation of new practices that are grounded in scientific research. However, to implement change, nurses must first know the basics of research utilization. Montgomery et al 15 clearly identifies that, to make research utilization possible, nurses in all specialties must be educationally prepared on how to locate research findings. CONCLUSION Empirical research studies need to be conducted on JC accomplishments including implementation of the evidence into nursing practice. Clinical nurse specialists must be vigilant in conducting research that uncovers the most advantageous methods used to bridge the research-to-practice gap. Future research could be conducted on specific constructs of the framework. For example, research could be conducted solely on the CNS role in understanding research or being the facilitator of a journal club. Research must also be incorporated into nursing programs across the world for future nurses to understand, appreciate, use, and implement research. One way to begin is through the initiation of a journal club. The PARIHS framework along with the BRIDGE model can be used to initiate or transform a journal club. As APNs, we need to look toward the future of nursing, and EBP is a necessity in defining nursing as a profession. As hospitals seek to promote evidence-based nursing practice and improve the quality of bedside nursing care, formation of a nursing journal club can be one strategy to accomplish both goals. 19(p390) References marked with an asterisk (*) indicate studies included in the integrative review. References 1. *Camiah S. Utilization of nursing research in practice and application strategies to raise research awareness amongst nurse practitioners: a model for success. J Adv Nurs. 1997; 26:1193 1202. 2. *Clifford C, Murray S. Pre- and post-test evaluation of a project to facilitate research development in practice in a hospital setting. J Adv Nurs. 2001;36:685 695. 3. *Fink R, Thompson CJ, Bonnes D. Overcoming barriers and promoting the use of research in practice. JONA. 2005;35(3): 121 129. 4. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10:1 11. 5. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet. 2003;362:1225 1230. 6. *Jolly S. Raising research awareness: a strategy for nurses. Nurs Stand. 2002;16(33):33 39. 198 CLINICAL NURSE SPECIALIST A

7. *Karkos B, Peters K. A magnet community hospital: fewer barriers to nursing research utilization. JONA. 2006;36:377 382. 8. Kartes SK, Kamel HK. Geriatric journal club for nursing: Aaforum to enhance evidence-based nursing care in long-term settings. JAMA. 2003:264 267. 9. Kirchoff KT, Beck SL. Using the journal club as a component of the research utilization process. Heart Lung. 1995;24: 246 250. 10. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care. 1998;7(3):149 158. 11. Lawson P. How to bring evidence-based practice to the bedside. Nursing. 2005;35:18. 12. Luby M, Riley JK, Towne G. Nursing research journal clubs: bridging the gap between practice and research. Medsurg Nurs. 2006;15:100 102. 13. *McQueen J, Miller C, Nivison C, Husband V. An investigation into the use of a journal club for evidence-based practice. Int J Ther Rehabil. 2006;13:311 316. 14. *Milne DJ, Krishnasamy M, Johnston L, Aranda S. Promoting evidence-based care through a clinical fellowship programme. JClinNurs. 2007;16:1629 1639. 15. Montgomery KS, Eddy NL, Jackson E, et al. Global research dissemination and utilization: Recommendations for nurses and nurse educators. NLN. 2001;22(3):124 129. 16. *Rajpal S, Resnick DK, Baskaya MK. The role of the journal club in neurosurgical training. Neurosurgery. 2007;61:397 403. 17. Rycroft-Malone J, Kitson J, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care. 2002;11(2):174 180. 18. Speers AT. An introduction to nursing research through an OR nursing journal club. AORN. 1999;69:1232, 1235 1236. 19. St. Pierre J. Changing nursing practice through a nursing journal club. Medsurg Nurs. 2005;14:390 392. 20. *Thompson GN, Estabrooks CA, Degner LF. Clarifying the concepts in knowledge transfer: a literature review. J Adv Nurs. 2006;53:691 701. 21. *Wilson SF, Collins N. Video outreach journal club [electronic version]. Rural and Remote Health. 2005. http:rrh. deakin.edu.au. Accessed September 15, 2007. This is your life. When patients trust their acute care to you, staying up to date on advanced clinical nursing specialties isn t an option, it s a commitment. This is your website. Clinical Nurse Specialist Online The all-new electronic journals platform from Lippincott Williams & Wilkins is loaded with personalized options you can tailor to your information needs, multimedia content, improved search options, better article readability, and more tools to help you manage content that s vital to your patient care. Register online at cns-journal.com Not a subscriber? Visit cns-journal.com to subscribe and find out more. VOLUME 23 NUMBER 4 199