Professional consciousness and pride facilitate evidence‐based practice—The meaning of participating in a journal club based on clinical practice reflection

Abstract Aim An evidence‐based approach should permeate clinical nursing practice, but many nurses lack confidence in applying relevant research evidence to clinical practice. Journal club participation can increase evidence‐based practice knowledge and skills while facilitating positive attitudes among participants. Thus, the aim was to describe the experience of nurses in participating in a journal club based on a curriculum derived from their practice narratives. Design The study employed a phenomenological hermeneutical approach. Qualitative data from six focus groups with 19 nurses were interpreted in a three‐step process influenced by the French philosopher Paul Ricoeur. Methods Influenced by narrative pedagogy and critical reflection through problem‐based learning, a journal club named Reflexivity was facilitated in three 2‐hourly workshops over eight weeks and evaluated together with nurses across three clinical departments. Results Three themes are identified: (a) professional reflections are an oppressed aspect of daily nursing; (b) revealing nursing from the hidden; and (c) emerging consciousness in nursing. The study concludes that Reflexivity has the potential to integrate evidence‐based knowledge and increase professional consciousness by reflection on clinical questions in an evidence‐based context. Fundamental issues of nursing care are raised, and feelings of essential pride in nursing are facilitated. Thus, evidence‐based nursing practice is embarked through a journal club based on the participant's narratives.


| INTRODUC TI ON
Despite the need and the desire among many practicing nurses to include evidence-based knowledge in clinical nursing practice, doing so is challenging. In-depth knowledge of methods to overcome this challenge is warranted. A structured journal club incorporating reflective practice was developed and implemented in a Danish university hospital setting. The concept is described, and findings from an interview study of the significance to staff nurses and nurse educators of participating in Reflexivity are described and discussed.

| BACKG ROU N D
Patients benefit from evidence-based nursing practice to experience meaningful health benefits and avoid suboptimal or even harmful interventions (Grol & Grimshaw, 2003). An evidence-based approach should permeate every aspect of nursing practice and is a high priority for healthcare institutions worldwide (ibid.). Globally, it is a challenge for health systems to optimally use evidence that can reduce inappropriate use of knowledge and improve the quality of life (Straus et al., 2011). Knowledge arising from rigorous research evidence should be incorporated into care to give more useful services and improve health care and patient satisfaction. Recognition of this challenge has created interest in implementation science, the integration of knowledge translation into clinical practice (Straus et al., 2011). Journal clubs for nurses are a key strategy to facilitate evidence-based practice (EBP) (Häggman-Laitila, Mattila, & Melender, 2016). However, it is not clear how nurses experience participating in journal clubs and further whether participating in journal clubs may facilitate concordance between fundamental clinical experiences and research-based evidence.
Nurses' perceptions, attitudes and beliefs about EBP are statistically significant predictors of research uptake (Lizarondo, Grimmer-Somers, & Kumar, 2011); it is relevant to investigate how to initiate a discussion between nurses and researchers. Although many nurses have positive attitudes and beliefs about EBP, many also find that the best research evidence is not readily available in a form that is immediately applicable in clinical practice and they lack confidence in their evidence-based practice skills (Saunders & Vehviläinen-Julkunen, 2016). Since journal clubs are a vital strategy to facilitate research among nurses (Fink, Thompson, & Bonnes, 2005), it is necessary to investigate how they can help ensure that the best research evidence will be easily available and applicable to clinical practice (Fink et al., 2005).

| Aim
To investigate what it means to staff nurses to participate in structured evidence-based reflections in a journal club setting that draws on their narratives from clinical practice.

| ME THODS
A qualitative study employing focus groups and a phenomenological hermeneutic approach was designed. Data analysis and interpretation were based on the philosophy of the French philosopher Paul Ricoeur (1976).

| The concept of Reflexivity
A combination of selected elements from narrative pedagogy (Brady & Asselin, 2016) and critical reflection through problem-based learning (Hmelo-Sivler 2004) may motivate staff nurses to apply relevant evidence-based knowledge to clinical practice and boost confidence in their skills. Furthermore, it is assumed that raising questions for reflection based on staff nurses' narratives has the potential to identify fundamental issues of nursing care relevant to the participating nurses. On these considerations, the concepts of Reflexivity were developed. Figure 1 illustrates the process when participating in Reflexivity. Table 1 illuminates the core elements in the concept of Reflexivity.
Reflexivity is a structured facilitation of evidence-based reflections, promoting active learning from nurses' narratives from clinical practice. The concept was named Reflexivity to indicate that a central structure throughout the journal clubs is a reflective inherent movement based on fundamental clinical experiences and that higher level of reflections may be accomplished (by participating in the course). Reflexivity is a method of establishing a relevant F I G U R E 1 Overview of workshops in the concept of reverberation discussion about core elements of nursing between facilitators and staff nurses; here, relevance is defined by nurse practitioners. The learning outcomes and curriculum were defined by nurses, and the researcher's role was to facilitate the process. To our knowledge, these pedagogical strategies have not previously been used concerning journal clubs.

| Focus group interviews
To study the nurses' perspectives on participating in the structured evidence-based reflections, we used a qualitative approach consisting of focus group interviews influenced by the methods described by Halkier (2009). The interviews allowed the nurses to disclose their clinical experiences on participating in dynamic discussions with the opportunity to elaborate on this by their own concepts and language (Halkier 2009). The interviews were analysed and interpreted using a phenomenological hermeneutic approach influenced by the French philosopher Paul Ricoeur's theory on narrative and interpretation (1979,2002). The nurses' narratives obtained in the focus group interviews were used to elucidate their experiences of engaging in evidence-based reflections during Reflexivity.

| Participants
Nineteen staff nurses participated in six different but similar courses of Reflexivity between June 2017-November 2018.
Participants were motivated and selected in cooperation with the departmental management team (Malterud, 2011). To obtain variation, the participant's selected differed in age, educational level, seniority and experience in nursing care (Halkier, 2009). Six focus group interviews were held after session 3 of the Reflexivity course. All participants consented to participate in the interviews.

| Data collection
The focus group interviews took place at two different hospitals in three different departments: a paediatric department (seven nurses), a neurological department (six nurses) and a medical and a surgical department (six nurses). The interviews occurred between December 2017-December 2018. A semi-structured interview guide influenced by Halkier (,2009Halkier (, , 2010, Morgan (1996) was used. CS and MB conducted the interviews. The interviewers strived to let the participants disclose their experiences with the concept of Reflexivity based on the course in open and dynamic discussions and acted as a moderator to encourage discussion and elaboration among participants about their experiences and perspectives in a dynamic and trusting setting (Halkier, 2009(Halkier, , 2010Morgan, 1996). The interviews were held in a quiet meeting room and lasted between 45-70 min. Initial impressions were immediately written down, and digitally recorded conversations were transcribed verbatim. Ricoeur (1976) describes the phenomenological-hermeneutic approach as a spiral following the text and its movements from "sense" to "reference" or from "what the text says to what the text talks about" (Ricoeur, 1976, p. 87-88). By continually moving between the whole text and parts of the text, the authors achieved what Ricoeur calls a "sophisticated understanding" (Ricoeur, 1976). This sophisticated understanding gave a new in-depth and nuanced understanding of what it meant to the nurses to participate in Reflexivity. The process of analysis and interpretation included a dialectical movement among a naïve reading, structural analysis, critical interpretation and discussion (Dreyer & Pedersen, 2009;Pedersen, 2005).

| Ethical considerations
In this study, the ethical guidelines of the Helsinki Declaration were followed, and the nurses participated voluntarily and were guaranteed that their statements were not recognizable. The participants were informed verbally and in writing about the purpose of the study and their anonymity and confidentiality throughout the study. The Danish Data Protection Agency approved of the study (REG-209-2017), and their guidelines on the storage of data were followed. The regional ethics committee in Region Zealand, Denmark, stated that approval was not needed because the study was not biomedical. Furthermore, it was stated before the interviews started that the confidentiality also applied to participants to establish a trustful situation where the respondent felt secure that their statements were not taken outside the room.

| Naïve reading
Based on the naïve reading, the concept of Reflexivity seems a stepping stone for working with evidence-based reflections on nursing based on staff nurses' narratives about their clinical practice. "Evidence-based reflections" are defined as reverbing self-addressed clinical questions in a research evidence-based context. Experiences with reflecting on self-addressed clinical issues deriving from clinical practice and based on their professional engagement facilitated professional pride and made it possible to ask critical questions to the nursing profession, as it was presented by the participants themselves. In the material, it was repeatedly implied that reflection on one's professionalism and working with evidence-based practice was not a part of staff nurses' job responsibilities. It was indicated that being critically reflective was not permeated into daily clinical nursing practice and that this practice was perceived as something reserved for a few employees. Reflexivity made the participants realize that reverbing a clinical question is a method of establishing learning close to clinical practice and that Reflexivity potentially facilitated an "educational journey" to reclaim time for nurses to reflect in clinical settings. It seems that participating in Reflexivity was a revelation to staff nurses. Throughout the course, the nurses experienced a growing sense of nursing professionalism that gave rise to a wish to include evidence-based knowledge to their care practices. TA B L E 1 Presentation of the rationale and content of the concept Purpose The idea behind Reflexivity was developed and adjusted based on collaborative research on pedagogical experiences and experiences with previous journal clubs. The purpose is to cultivate professional dedication, and the engagement of participants is crucial. A level of engagement that both reflects and demands sincere dedication from participating nurses is crucial to the significance of their professional work. This includes emotional engagement, which supports positive energy and motivation. To allow genuine engagement to be in the foreground, the overall approach claims high dignity. It is crucial to meet the nurses with respect and sincere interest into their preoccupations. Therefore, the providers of the concept must hold a high engagement in both clinical nursing and evidence-based knowledge. The concept draws upon the theory of Personalism that originates from of the French philosopher Emmanuel Mounier's philosophy of Personalism. Here, the method is used to support the professional to develop a critical consciousness that allows the individual's potential to unfold in practice (Mortensen, 2014). Dialogue is the main medium. A respectful dialogue where nurses and researchers meet and collaborate on their consciousness of nursing is necessary. Hence, the concept is both rewarding to the participating nurses and the researchers that provides the course.

Participants and providers
Participation is based on the desire to develop oneself as a nurse. The providers must have pedagogical reflections and a tentative plan that ensures participating nurses develop their critical professional consciousness. A core element of the pedagogical plan is that participants are responsible for chosen content. Reflection on one's experiences of nursing is a rewarding experience and is maintained as the foundation of the course. Participants are encouraged to write a narrative about a significant experience from their work life. This narrative is the basis of the work, and providers engage with the narrative, challenging aspects of the story and thus supporting participants in identifying one or more plots contained in the narrative. This process guides participants to reflect on the aspects of the narrative and the movement in their individual professional consciousness (Ricoeur, 1991). In this way, the curriculum of the course is a collaboration between participants and providers.

Structure
The course is held over 8 weeks. The curriculum derives from participants' narratives that explore demanding clinical cases that they have experienced and continue to reflect on. Nurses are invited to join groups of 3-5 participants. In the sessions, participants meet in a quiet room with two providers, who have both nursing backgrounds and research education and profiles.
Session 1-Introduction to the group: two-hour meeting Participants meet one another and the providers and asked to share their motivation for participating. Providers introduce the purpose of the course, which is to develop a critical professional consciousness through reflections on both clinical practice and evidence. After introducing key evidence-based practice concepts, participants are each asked to describe a demanding case from clinical practice. Providers ensure that a non-judgemental and trusting atmosphere is established and maintained in the group. Participants are encouraged to speak freely and openly about their work as nurses and their reflections on their work. They are invited to engage with curiosity, questions, creativity, honesty and patience. To ensure transparency, providers continuously identify and discuss key words and concepts. Crucial interpretations are presented and discussed.
Self-study-Identification of relevant issues: email correspondence within two weeks The participants send their cases to the mentor, who poses several clinical questions for each case. Each participant assesses whether or not the clinical questions are relevant to the case.
Session 2-Selection of focus for the sessions: two-hour meeting The group of participants decides the case and clinical question that forms the basis for an evidence search. A search question is collaboratively formulated using PICO or SPIDER tools (Cooke, Smith, & Booth2012)). The group chooses one research paper for self-study, supplemented by relevant guidelines for the study design provided by the mentor Self-study-Identification of relevant issues: email correspondence within two weeks As described above Session 3-Discussion of the nursing subject and the article: two-hour meeting The group appraises the quality of the evidence presented in the selected research article, discusses the selected clinical question in an evidence-based research context and discusses implementation approaches in clinical practice.

| Revealing nursing from the hidden
Reflexivity is perceived as a method for staff nurses to become attached to some of the clinical or organizational issues they experienced daily and serves as an opportunity to reflect on clinical practice based on their narratives: Reflexivity has been a break to me in some aspects. It has been helpful to talk about the problems we experience.
One thing is that the management is aware, but to unfold it here… during Reflexivity and also to do some literature search related to it has been excellent. You can empty your backpack, in a way.

(F1)
The staff nurses connected to professional thoughts and evi- The staff nurses considered the concept of Reflexivity as meaningful because it was a way to be present as a professional. The nurses described how the concept allowed them to address professional thoughts and ideas they had hidden away. Therefore, the nurses described Reflexivity as an appreciated activity that facilitated inspiration and gave life to professional actions for a brief moment. Words, such as "breathing" (F1), "creating" (F5), "boosting" (F2) or "dynamic" (F4), describe how the concept of Reflexivity was rewarding to staff nurses.

| Emerging consciousness in nursing
Focusing on nursing and the everyday life that staff nurses experience in the hospital was a positive driver for solving issues in clinical practice. Participating in Reflexivity meant that staff nurses presented a case that they often recalled, and one problem was formulated as a research question based on this experience. This process provided the staff nurses with a sense of trust in themselves about their professional skills and a feeling of ownership of a specific problem they could address: It has been nice that it was merely our reality or experi- The material covered that staff nurses' understanding related to evidence-based knowledge of nursing. Gaining evidence-based knowledge among novice nurses was a meaningful activity because they were familiar with this methodology from their education and they referred to their education not being "used" or "asked for" when working as a nurse in the hospital. Being able to address academic competencies in, for example, searching for literature is a method to address the emerging curiosity they had felt during their education. However, in many ways, this curiosity was oppressed by everyday clinical practice:

| Comprehensive understanding and discussion
Based on our findings, it can be argued that when staff nurses are Nurses in our study described a lack of interest in a working environment where they discuss care related to their actions and reflect on each other's thoughts and considerations. Therefore, the concept of Reflexivity is at risk of being perceived as something that must be directly transferable to and applied in clinical practice, in addition to its value for nurses' professionalism on a daily basis. However, participants perceived their personal reflections as having little or no value before they experienced the positive effect of reflection at a more abstract level on their nursing practice. Our study gives new knowledge by illustrating that the process of participating in Reflexivity gives a meaningful discussion in professional language between researchers and staff nurses that is centred on participants' narratives. A shared interest in core nursing subjects is clarified and identified. Accordingly, staff nurses, as well as their academic colleagues, gained a sense of professional pride and enhanced their commitments to professional reflection, which contrasted favourably with their descriptions of clinical settings.
A recent systematic review of journal clubs for nurses found that researchers often have a central role in selecting articles (Häggman-Laitila et al., 2016). This finding is in contrast to our study that, consistent with earlier research, emphasizes that other clinical activities will be prioritized unless personal motivation to reflect on professionalism during journal clubs is mobilized (Squires, Estabrooks, Gustavsson, & Wallin, 2011). Our study documents that it is possible to conduct a journal club where participants experience being a part of the process of investigating essential issues in nursing. A model where staff nurses are an integral part of the process of formulating nursing narratives, choosing topics and searching for literature compares favourably with a more traditional method of conducting journal clubs (Dall'Oglio et al., 2018;Häggman-Laitila et al., 2016;Patel et al., 2011). We also found that, in daily clinical practice, no tradition exists of reflecting on one's nursing practice by searching for and reading research articles. Academic reflection in Reflexivity exemplifies an innovative use of problem-based learning; the curriculum is not defined initially, and few requirements for participants' commitment other than motivation exist. The voluntary nature of participation is voluntary, and the deep involvement of participants in developing the course and process is essential to whether they find the reflections valuable and further integrate research-based knowledge into their practice (Fink et al., 2005).
Based on a comprehensive understanding of our findings, it can be argued that, although human learning is a lifelong journey, an innovative journal club is an excellent supplement to nursing practice.
Learning and reflection through reciprocal discussion and the acquisition of new knowledge enhance nurses' beliefs about the value of the evidence-based practice. Formulating one's professional identity happens through discussion with others about recognizable and essential narratives from clinical practice. This perspective is based on the philosophy of Martin Buber (1878Buber ( -1965. In his first work, I and Thou (1937), Buber focuses on the significance of the relationship between people. According to Buber, the relationship between people defines who man (one) is. The entirety of existence life consists of relationships because one is always in relationships. Even when alone, one's thoughts emerge in the context of relationships.
Buber emphasizes that humans are both relational and dialogic beings.
Dialogue is more than just a conversation. In Greek, dialogue means "through words" and connotes the intention of speaking through words.
In dialogue, one seeks and expresses intention through words and the intention in dialogue is most important in interaction with others.
Taking this philosophical framework into account, the concept Reflexivity is based on a pedagogical view where working with evidence-based practice can be viewed as a balance of giving and receiving and guiding a dialogue to achieve a common good for patients in clinical practice.
Giving refers here to the efforts of researchers to teach, guide and provide nurses with space and a framework, enabling the collec- allowing their stories to be actively incorporated into the process.
Our study also revealed that researchers could be very influenced by nurses' narratives when designing, developing and evaluating new research studies in clinical practice. Buber (1937) supports the perspective that dialogue provides nurses with acknowledgement of who they are as professionals. Thus, Reflexivity illuminates nascent aspects of nursing identity that were previously unformed.
Throughout the process, pride and feelings of safety concerning discussion with other professionals are nourished and flourished.

| Strengths and limitations
This study was conducted only in one setting. In terms of generalization, it would have been preferable to study nurse's perspectives in more contexts (to gain nuanced insight into how nurses articulated the opportunity to engage with evidence-based practice based on their own narratives). Furthermore, we collected data when Reflexivity was in progress and did not explore how participants actually applied the knowledge they obtained in the process, for example literature search in clinical practice. Nevertheless, our findings give new insight into the phenomena of learning and reflecting on clinical practice being a nurse practitioner. This study can be considered as pilot study of an innovative usage of problem-based learning in a journal club setting, to supplement nursing practice and improve patient satisfaction.
Study participants were selected based on interest in participating they expressed to departmental managers and they worked in different clinical areas. Nurses who were selected for participation by departmental management may have experienced the course differently. Also, this study included a relatively small number of participants. Selecting participants based on other factors, such as an application, interview or informal conversations with nursing staff, might add variation to the recruitment of participants and allow journal clubs to emerge in new ways (Malterud, 2011).

| CON CLUS ION
The concept of Reflexivity is an educational experience for nurses that fosters their reflection on their actions in a clinical context.
Supporting nurses in the professional development of evidencebased practice based on their narratives strengthens their engagement in meaningful reflection on daily nursing actions. Reflexivity renews professional concepts, theories and methods. Nursing is an individual and a collective form of professional activity with distinct theoretical concepts and methods that need to become activated daily to achieve practice excellence.
Reflexivity solicited participants' often very personal descriptions of demanding experiences that were sometimes written in emotional and informal terms and reframed them in professional language. Familiar theoretical concepts and methods became revitalized and could be applied in discussions, as personal descriptions nurtured the integration of meaningful, evidence-based knowledge into clinical practice.

| RELE VAN CE TO CLINI C AL PR AC TI CE
The findings of this study create awareness of how participating in a journal club based on personal narratives from clinical practice boosted participants' confidence and pride in nursing.
Reframing clinical questions in an evidence-based context is a way of creating a community of awareness in the nursing profession between staff nurses and nurse researchers. An inspiring dialogue is initiated between colleagues with different educational perspectives and skills at addressing challenges in daily nursing practice. Improvements in clinical nursing practice through future collaboration are likely to result. It is notable that the entire process was completed over eight weeks and involved a minimal time commitment from participants.

ACK N OWLED G EM ENTS
We would like to acknowledge the management of the clinical departments, as well as the nurses, who participated generously and positively to support this study. Furthermore, we would like to thank Jennifer Green for through language editing.

CO N FLI C T O F I NTE R E S T
None declared.

AUTH O R CO NTR I B UTI O N S
M.B, C.S, H.B and SHK: Study design, Data collection analysis and Manuscript preparation.

E TH I C S A PPROVA L
The study was approved by the Danish Data Supervisory Committee by Region Zeeland (REG-209-2017).