Assessment and impact of a new role as an embedded librarian in nursing online journal clubs

At the Christ Hospital—a 555-bed, not-for-profit, Magnet-designated, acute care facility in Cincinnati, Ohio—staff nurses are actively encouraged by the hospital's Research and Evidence-Based Practice Council to participate in a journal club. In addition to providing a discussion mechanism for improving patient outcomes and satisfaction through research and evidence, journal club participation may also contribute to the research component of the hospital's registered nurse (RN) professional advancement program. 
 
The electronic resources librarian was approached by the council's nurse educators to explore options for online journal clubs (OJCs), primarily as a means of including more staff nurses on various shifts than existing face-to-face clubs allowed. A rationale for selecting WordPress as a hosting mechanism for the OJC sites and a detailed description of the technical process in establishing the sites are discussed in detail elsewhere 1. Since October of 2011, the electronic resources librarian has been overseeing technical support for numerous nursing OJCs throughout the hospital. Technical support consists of creating sites using WordPress as a site administrator; electronically inviting new members selected by the club's nursing leadership; creating WordPress posts for articles and discussion questions that nurse leaders provided; conducting orientation sessions for new clubs as requested; and addressing ongoing technical issues, such as lost passwords or access issues. 
 
In addition to providing technical support, the librarian has received permission from nurse leaders to join each club as a member, monitor the clubs' discussions, and post library-relevant comments as opportunities arise. The Christ Hospital library staff has a long history of participating as members on various councils in the hospital's nursing shared governance structure, but the inclusion of the librarian in the OJCs was the first attempt at assuming a role of embedded librarianship at the nursing unit level. As a means of assessing this new role and determining the impact of librarian participation in OJCs throughout nursing units, the librarian conducted statistical data analysis and surveyed nurse participants.


INTRODUCTION
At the Christ Hospital-a 555-bed, not-for-profit, Magnet-designated, acute care facility in Cincinnati, Ohio-staff nurses are actively encouraged by the hospital's Research and Evidence-Based Practice Council to participate in a journal club. In addition to providing a discussion mechanism for improving patient outcomes and satisfaction through research and evidence, journal club participation may also contribute to the research component of the hospital's registered nurse (RN) professional advancement program.
The electronic resources librarian was approached by the council's nurse educators to explore options for online journal clubs (OJCs), primarily as a means of including more staff nurses on various shifts than existing face-to-face clubs allowed. A rationale for selecting WordPress as a hosting mechanism for the OJC sites and a detailed description of the technical process in establishing the sites are discussed in detail elsewhere [1]. Since October of 2011, the electronic resources librarian has been overseeing technical support for numerous nursing OJCs throughout the hospital. Technical support consists of creating sites using WordPress as a site administrator; electronically inviting new members selected by the club's nursing leadership; creating WordPress posts for articles and discussion questions that nurse leaders provided; conducting orientation sessions for new clubs as requested; and addressing ongoing technical issues, such as lost passwords or access issues.
In addition to providing technical support, the librarian has received permission from nurse leaders to join each club as a member, monitor the clubs' discussions, and post library-relevant comments as opportunities arise. The Christ Hospital library staff has a long history of participating as members on various councils in the hospital's nursing shared governance structure, but the inclusion of the librarian in the OJCs was the first attempt at assuming a role of embedded librarianship at the nursing unit level. As a means of assessing this new role and determining the impact of librarian participation in OJCs throughout nursing units, the librarian conducted statistical data analysis and surveyed nurse participants.

LITERATURE REVIEW
EBSCOhost's CINAHL Plus with Full Text and PubMed were searched for articles describing librarians' involvement as journal club participants alongside health care professionals. Several articles describe the benefits for clinicians in consulting librarians for traditional library support services, such as providing literature search assistance to journal club members, but do not discuss librarians actively participating in the clinicians' journal club discussion [2][3][4]. Anuradha et al. describe the librarians' role as a more active facilitator in establishing and providing guidance to clinicians in establishing journal clubs with the goal of putting evidence-based practice into action, although the librarians are again described only as support figures, not active journal club participants [5]. Ender describes a scenario of active librarian participation in the Rex Healthcare Nursing Research Council journal club, providing assistance with coordination as well as using the opportunity as a discussion participant to promote library resources to nurse participants [6]. Ender mentions plans to survey nurse participants in the article. Email correspondence with Ender reveals that survey results of nurse participants have not been published but that nurse participation in the journal club has grown over time [7].

BACKGROUND
Using a process similar to that described by Ender, the author was able to receive real-time email notifications for all OJCs containing each commenter's username, full comments, and the date and time the comment was made [6]. These comments were organized with Microsoft Outlook using club-specific folders and were monitored daily during designated times, so that OJC duties did not interfere with library duties. It is worth noting that the librarian only commented in response to nurses' comments on library-or research-orientated topics, in other words, questions on supplementary topics; requests for additional information; or opportunities to mention library resources, databases, or services that apply to nurses' needs.
As the sites gained popularity, there were initial time and staffing challenges for the library: 1.0 fulltime equivalent (FTE) of the 3.0 FTE library staff oversaw all aspects of the involvement in the OJCs, and difficulties were experienced, at times, in trying to meet the demand of new sites needing creation, while balancing reference desk coverage and maintaining library duties. The library began tracking reference statistics in June 2012, and early data showed that only 4% (n540) of all reference transactions (n51,036) over the course of 6 months (June 2012 through November 2012) were related to OJC support; however, due to the fact that this was the first attempt to involve the librarian in an embedded role, it was determined that further analysis was warranted to provide rationale for the librarian's participation as an OJC member.

METHODS
From January 2012 to December 2012, the number of OJCs increased from 11 to 18. During that time, 7 of Using WordPress's administrator dashboard, data were obtained that reflect the librarian's involvement in participating in and commenting on the OJCs over the course of one year (January 2012 to December 2012). These data were analyzed to answer the following questions: (1) Did the discussions of the nurse participants necessitate librarian involvement? (2) If additional literature searches were conducted by the librarian and shared with the nurse participants via commenting on the OJC posts, were the results viewed by nurse members?
An online survey was mounted using SurveyMonkey in October 2012 and remained available for 4 weeks. At the time of the survey launch, data obtained from the WordPress administrator dashboard reflected 183 registered OJC members, all of whom were emailed the survey link by the electronic resources librarian outside of regular OJC activity. The survey included a statement notifying recipients that they were receiving the survey because of their OJC membership and the data were being collected by the library staff to determine the impact of librarian involvement in their OJC. The survey consisted of the following questions: (1) Did the librarian's contributions to the online journal club discussion (for example, sharing additional literature search results or linking to library resources) add value to the nurses' journal club discussion? (2) Does the involvement of the librarian in the nurses' online journal clubs increase the individual's: (a) awareness of library resources, (b) actual use of library resources, or (c) likelihood of requesting assistance from the librarian?

RESULTS
Data analysis showed that 19.2% (n514) of the 73 OJC posts from January 2012 to December 2012 necessitated librarian involvement. The 14 nurse comments prompting librarian involvement were made by 9 different staff nurses from 5 different OJCs, 4 of which post articles monthly. Table 1 lists categories of librarian involvement with sample quotations of nurses' comments and the librarian's responses.
Nurses' comments are not posed directly to the librarian but made in response to the article being discussed. As the librarian monitors all comments and as opportunities for involvement arise, librarian responses are provided via commenting alongside the OJC's participants. Opportunities to provide additional literature search results (n56) were the most prevalent type of librarian involvement. Of these 6 comments sharing additional literature, 33.3% (n52) yielded comment responses from nurse participants discussing the content of the information that the librarian presented. Analysis of the OJC website statistics showed these 2 searches had 7 and 5 outward bound ''click stats,'' indicating the search results were accessed by nurse participants.
Of the 183 OJC members invited to participate in the online survey, 54 completed the survey yielding a response rate of 29.5%. Survey results indicated that 42.6% (n523) of OJC members strongly agreed that the librarian's contributions added value to the nurses' discussion and that 43.4% (n523) strongly agreed the librarian's participation raised their awareness of library resources. Moreover, 29.6% (n516) strongly agreed that their actual use of library resources had increased, and 42.6% (n523) strongly agreed that they were more likely to request assistance from the librarian due to librarian involvement in the OJC.
The 74.4% (40) of survey participants who strongly agreed (42.6%, n523) or agreed (31.5%, n517) that they were more likely to request assistance from the library staff due to the librarian's involvement in their OJC were asked a follow-up question, to which 67.5% (n527) responded. These respondents were asked to indicate all areas in which they had requested assistance from the library staff as a result of the librarian's OJC participation. This follow-up survey question allowed respondents to choose more than 1 response. Obtaining full-text journal articles and requesting additional literature searches were indicated by 77.8% (n521) of respondents. Instruction on subscription point-of-care tools, such as EBSCOhost's Nursing Reference Center, was indicated by 25.9% (n57) of respondents. Additional database instruction and library staff assistance for clinical questions were both indicated by 22.2% (n56). Requesting assistance from the library staff for patient education received 7.4% (n52) of responses.

DISCUSSION
While the data analysis reflects that the need for additional literature searches provided by the librarian in response to nurse participant comments has not been as significant as was initially expected, the overall data picture does reflect a somewhat substantial use of librarian involvement: fourteen comments on seventy-three posts over a twelve-month period and forty reference questions documenting technical support during an overlapping six-month period. Moreover, remarks from the survey of the nurse participants clearly demonstrate their appreciation of the resources that their library offered, as well as their recognition of librarians as valuable colleagues in their journal clubs and ongoing research endeavors. Comments from the survey of nurse participants describe the librarian as ''a wealth of knowledge,'' ''an amazing resource to our unit council,'' and ''very valuable to the initiation and success of our journal club.'' One nurse remarked: ''Thanks to our library. Your imput [sic] and effort have helped nurses at TCH with their research and professional development efforts.'' Additionally, due to undertaking a new role as OJC site administrator, the electronic resources librarian was one of two nonclinical personnel asked to assume a cochair role for nursing councils in the organization. The librarian's new role as the cochair of the Research and Evidence-Based Practice Council, as well as continual monitoring of the electronic comment sections for the nursing OJCs, lends itself to further potential collaboration in clinical areas throughout the organization. While the results of this particular study focus solely on assessing the librarian's OJC involvement, other potential implications of using centralized administration for monitoring journal club comments have not yet been fully explored. One of the early recurring themes from observing comments of numerous clubs is the potential to spot trends occurring over multiple units as they develop and are discussed in real time. Future goals include exploring ways that the librarian can facilitate multidisciplinary discussions regarding these trends observed in OJC discussions.

CONCLUSION
Even though the data analysis reflected that the majority of OJC discussions did not necessitate librarian involvement or additional literature searches, survey results of nurse participants indicated that the librarian's involvement has been successful in raising awareness of library services, growing library usage, and increasing the likelihood of requests for librarian assistance among nurse OJC members. These positive survey results demonstrate that the benefits to promoting and marketing library resources and services outweigh the added nontraditional responsibilities and demands on the librarian's time and support the decision that the librarian's participation in OJCs should continue.