launching and leading journal clubs -...
TRANSCRIPT
Launching and Leading Journal Clubs
Marti Buffum, DNSc, RN, PMHCNS-BCAssociate Chief of Nursing Service for Research
Deborah Burgoon, MS, RN, AOCNClinical Nurse Specialist, Oncology
VA Medical Center, San Francisco
March 8, 2011Kaiser Permanente Nursing Research Council
Objectives of this workshop:
1. Describe steps for creating a journal club 2. Define methods for motivating staff to participate
3. Identify best practice application to own setting
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Guidelines for Unit-Based Journal Clubs
Purpose: The purpose of conducting unit-based journal clubs is to engage staff in clinical questioning and active discussion about practice issues.
Objectives: To obtain skill in searching for literature that addresses clinical questions
To improve critical reviewing skillsTo increase comfort with presenting to peersTo evaluate evidence suitable for practice applicationTo acquire an evidence base that empowers staff with knowledge
for improving practice and for communicating with other disciplines
Incentives/Options: Continuing education creditRefreshments: food /drink (delegate, potluck, rotate, etc.) Proficiency boosterMentoring opportunityCan share the presentation with a colleague
Articles: May include but are not limited to: original research, reviews, expert opinion, guidelines
May include research and non-research: methods of doing research, theory, ideas for practice, populations, diseases,
nursingissues, nursing education, nursing management, patient
perspectives, ethical issues, etc.Topics that relate to identified patient care issue or clinical
question
Preparation: Find article at least 2 weeks prior to journal clubMake copies for all staff, place extra copies on established bulletin
board and/or break room; post in staff bathroomEncourage staff members to read the article prior to session
Choose main points or concepts you think are most importantThink of questions for discussion related to the article
Presentation: Plan to present about 10 minutes Remember: discussion is the goal!Use general outline for review (see attachment)
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Journal Club Research Critique Checklist (A guide)
Create EDUCATIONAL OBJECTIVES:By the end of this class, the participants should be able to:1. Identify the problem under investigation.2. Identify research methods used in this study 3. Describe the clinical significance of the conclusions.One hour of CE credit will be granted for this class
Suggested questions to answer in the OUTLINE:
I. Title: Does it represent the research report?II. Introduction: Does it state the problem and address its significance to nursing?III. Literature Review: Is it thorough? Quality of studies reviewed? Reflect critical
thinking? Address gaps in knowledge? Provide a rationale for the research?IV. Statement of problem, significance, research question/hypotheses
A. Clearly stated?B. Is problem compelling? Is the problem clinically significant?
V. Methodology. Appropriate for the question(s)? (address who, what, when, where, how?)
A. Design (type identified?)B. Sample (inclusion, exclusion criteria?)C. Procedure D. Instruments: valid and reliable (citations provided; instruments changed?)
VI. Data analysis: results A. Statistics (Are they appropriate? Are they clearly stated?)B. Presentation (Look for clarity)C. Charts and tables (Should stand alone and be very clear)D. MOST IMPORTANT: Do results match research questions?
VII. Discussion/ ConclusionsA. Limitations (stated clearly?)B. Discussion (match results? Are questions answered?)C. Is conclusion substantiated by results?D. Clarity?E. Extraneous information discussed?F. Is past research literature cited?
VIII. Implications for practice and researchA. Do implications go beyond findings?B. Based on the study, what is the next research step?C. Based on the study, what would you do to change practice? Is there enough evidence
to apply to practice? Will you change practice based on this study?IX. Personal opinions and need for further validation
A. Do you have questions that the study does not answer?B. What is your overall opinion about the findings? What is your opinion about the
methods used to determine the findings? What is your general opinion about the study? What more would you want to know about the study question before accepting the findings?
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Journal Club Research Critique (General Outline for offering educational credit)
“Title of Study”*Date
Presenter Name
One hour of CE credit will be granted for this class (BRN Provider #00583). (Be sure CV is with nursing office to provide CE)
EDUCATIONAL OBJECTIVES:By the end of this class, the participants should be able to:1. Identify the research problem under investigation.4. Identify research methods used to conduct the study.5. Discuss the most important concerns about how this topic applies to practice.OUTLINE:I. Evaluation of problem, literature review, questionII. Evaluation of methodology
A. DesignB. SampleC. ProcedureD. Instrument
III. Evaluation of data analysis: results A. Selection of themesB. Presentation of results; clarity, logic
IV. What are the conclusions? A. Is conclusion substantiated by results?B. Clarity?C. Extraneous information discussed?D. Is past research literature cited?
V. Implications for practice and researchA. Do implications go beyond findings?B. Based on the study, what is the next research step?D. Based on the study, what would you do to change practice?E. Are the study findings ready for practice? Do themes relate to you in your
practice?VI. Personal opinions and need for further validation
A. Do you have questions that the study does not answer?B. What is your overall opinion about ………… (topic related)?
*Author, Initials. (date). Title. Journal, Vol(No.), pages.
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Types of Study Designs(Melnyk and Fineout-Overholt, 2005)
Randomized Controlled Trial: RCTA true experiment, (i.e., one that delivers an intervention or treatment), the strongest design to support cause and effect relationships, in which subjects are randomly assigned to control and experimental groups.
Systematic Review: A summary of evidence, typically conducted by an expert or expert panel on a particular topic, that uses a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific clinical question and draw conclusions about the data gathered.
Meta-analysis: A process of using quantitative methods to summarize the results from the multiple studies, obtained and critically reviewed using a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific question and draw conclusions about the data gathered. The purpose of this process is to gain a summary studies (i.e., a measure of a single effect) that represents the effect of the intervention across multiple studies.
Case Reports: Reports that describe the history of a single patient, or a small group of patients, usually in the form of a story.
Case Study: An intensive investigation of a case involving a person or small group of persons, an issue, or an event.
Cohort Study: Longitudinal study that begins with the gathering of two groups of patients (the cohort), one that received the exposure (e.g., to a disease) and one that does not, and then following these groups over time (prospective) to measure the development of different outcomes (diseases).
Case-Control Study: A type of research that retrospectively compares characteristics of an individual who has a certain condition (e.g., hypertension) with one who does not (i.e., a matched control or similar person without hypertension); often conducted for the purpose of identifying variables that might predict the condition (e.g., stressful lifestyle, sodium intake).
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Cross-Sectional Study: A study designed to observe an outcome or variable at a single point in time, usually for the purpose of inferring trends over time.
Correlational Descriptive Study: A study that is conducted for the purpose of describing the relationship between two or more variables.
Correlational Predictive Study: A study that is conducted for the purpose of describing what variables predict a certain outcome.
Descriptive Studies: Studies that are conducted for the purpose of describing the characteristics of certain phenomena or selected variables.
Qualitative Studies: Research that involves the collection of data in nonnumeric form, such as personal interviews, usually with the intention of describing a phenomenon.
Quantitative Studies: Research that collects data in numeric form and emphasizes precise measurement of variables; often conducted in the form of rigorously controlled studies.
Quasi-experiments: Design that tests the effects of an intervention or treatment but lacks one or more characteristics of a true experiment (e.g., random assignment; a control or comparison group)
Melnyk.B & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare; a guide to best practice. Philadelphia: Lippincott Williams and Wilkins.
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Critiquing Articles and Rating Evidence
The following table outlines a critique format for research articles, adapted from the Tampa VA Nursing Research Committee. This format is designed for quantitative study designs but can be modified for qualitative studies.
Article Information Title:
Author(s):
Journal, date, volume, pages
Research Questions/Hypotheses
Methods Design:
Setting:
Sample:
Human Subjects Protections:
Procedures:
Study Variables Independent:
Dependent:
Measures/Reliability/Validity Instruments:
Results
Limitations
Summary:Decision/Reservations/Application to PracticeRatings (see Grading Evidence Table)
Rating for type of research:
Rating for strength of evidence:
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Grading the Evidence and Making RecommendationsThe proposed schematic can be used for judging quality ratings and recommendations, derived from American Geriatrics society (AGS),i previously used by the Registered Nurses Association of Ontario (RNAO)ii, and from the Scottish Intercollegiate Guidelines Network iii.
Level of Evidence
Type of Evidence
I Evidence from at least one properly randomized controlled trial. Includes systematic reviews, meta-analyses of RCT’s
II Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies or from dramatic results in uncontrolled experiments
III Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Includes qualitative studies, case reports, consensus statements, and panel guidelines i
IV Expert opinion
Recommendations schema based on strength of evidence
Rating StrengthA Good evidence to support the use of a recommendation: clinicians “should do this
all of the timeB Moderate evidence to support the use of a recommendation: clinicians “should do
this most of the time.”C Poor evidence either to support or to reject the use of a recommendation: clinicians
“may or may not follow the recommendation.”D Moderate evidence against the use of recommendation: clinicians “should not do
this.”E Good evidence against the use of a recommendation, which is therefore
contraindicated i.
i AGS Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics society, 50(6 suppl), S205-224).
ii Registered Nurses Association of Ontario (RNAO). (2002). Assessment and management of pain. Toronto (ON): Registered Nurses Association of Ontario.
iii SIGN (Scottish Intercollegiate Guidelines Network) 2001. A guideline developers’ handbook. SIGN Publication No. 50 http://www.sign.ac.uk/guidelines/fulltext/50/.
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Another Rating System for the Hierarchy of Evidence
Level of Evidence
Type of Evidence
I Evidence from a systematic review or meta-analyses of all relevant randomized controlled trials (RCT’s), or evidence-based clinical guidelines based on RCT’s
II Evidence from at least one well designed RCTIII Evidence from well-designed controlled trials without randomizationIV Evidence from well-designed case control and cohort studiesV Evidence from systematic reviews of descriptive and qualitative studiesVI Evidence from a single descriptive or qualitative studyVII Evidence from opinion of authorities and/or reports of expert committees
Melnyk.B. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare; a guide to best practice. Philadelphia: Lippincott Williams and Wilkins.
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Evidence Table
Row for each articleAuthorsDate
Type of Study/Design
Level of Evidence
# Subjects
Subjects’ Characteristics
Intervention Comparison Outcome
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Tips for Journal Club Participation
Motivating for Success:1. Word spreads: ensure fun2. Discuss options for enrichment (authors in the facility come to meeting)3. Professional nourishment: encourage discussion but keep a structure
All questions are valid; no question is stupid4. Structure the format and monitor time so all aspects get reviewed and all
can participate5. Provide CEUs6. Select interesting articles. Distribute in advance.7. Do not overwhelm with too many articles (guaranteed DOOM)8. Food?9. Enthusiastic, positive, inclusive teaching style10. Role model application to practice; determine readiness for application; determine
“take home” messages11. Decrease intimidation, provide chances for all to participate12. Discuss potential research questions emerging from articles13. Post schedule. Consistent time and place. Convenience. Enough time for discussion.
Administrative support for attendance! 14. Encourage evaluation of a series (semester or year) and suggestions for improvement 15. Encourage evaluation of application to practice
Questions to ponder: What outcomes would you use to measure success of journal club? What are some practical methods for maximizing participation in a journal club? How much time can be devoted to the journal club critique? How much preparation time can be given to staff? What elements should be part of a critique? How can you best match staff interest to articles? Are resources needed for finding articles? For evaluating articles? For determining
importance of the article and the level of evidence? What is the best way to guide staff in rating evidence? What aspects do staff apply to practice? Is this appropriate? Do staff ask more questions after the discussion of the article? Steps to resolve? Are staff asking more questions of their practice? Are staff feeling empowered to relate to other disciplines with more knowledge and
confidence? With physicians? With patients? With families? With peers? What is the role of guest consultants in doing article reviews? What are advantages/disadvantages of including entire teams in the journal club?
RNs/LVNs/NAs/techs/clerks/students other disciplines? What is the capacity for inviting staff from other units?
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Bibliography
Asking a Question: PICOhttp://www.cebm.utoronto.ca/practise/formulate/pg2.htmhttp://nursing.asu.edu/caep/pico.htmhttp://nursingandhealth.asu.edu/evidence-based-practice/pico.htm, retrieved 8/2/2010
Evidence Based Practice Tutorial and Library Literacyhttp://library.wcsu.edu/web/assistance/research/nursing/tutorial/ accessed July 22, 2010
Evidence-Based Practice: An Interprofessional Tutorial, University of Minnesota Libraries: http://www.biomed.lib.umn.edu/learn/ebp/ accessed July 22, 2010
Evidence Based Practice ReferencesBrown, S. (2009). Evidence-based nursing. The research-practice connection. Sudbury, MA: Jones and Barlett.
Fineout-Overholt, E. (2005). Teaching EBP: Asking Searchable, Answerable Clinical Questions. Worldviews on Evidence-Based Nursing 2(3), 157-160.
Johnston I., & Fineout-Overholt E. (2005). Teaching EBP: "Getting from zero to one." Moving from recognising and admitting uncertainties to asking searchable, answerable questions. Worldviews on Evidence-Based Nursing 2(2), 98-102.
Malloch, K., Porter-O'Grady, T. (Eds.). (2006). Introduction to evidence-based practice in nursing and health care. Sudbury, MA: Jones and Bartlett.
Melnyk B. M., Fineout-Overholt E. (Eds.). (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
Newhouse, R., Dearholt, S., Poe, S., Pugh, L., White, K. (2005). Evidence-based practice: A practical approach to implementation. Journal of Nursing Administration 35(1), 35-40.
Newhouse, R., Dearholt, S., Poe, S., Pugh, L., White, K. (2007). Johns Hopkins Nursing. Evidence-based practice model and guidelines. Indianapolis: Sigma Theta Tau International.
Rempher, K., Urquico, K. (2007). The p value: What it really means. American Nurse Today 2(5), 13-15.
Rutledge & Grant (2002). Introduction. Seminars in Oncology Nursing, 18, 1-2.
Sackett D. L. Richardson W., Rosenberg W., Haynes R. (2000). Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone.
Journal Clubs
Atzema C. Presenting at journal club: A guide. Ann Emerg Med. 2004 Aug;44(2):169-174.
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Campbell-Fleming J, Catania K, Courtney L. Promoting evidence-based practice through a traveling journal club. Clin Nurse Spec. 2009 Jan-Feb:23(1):16-20.
Denehy J. Starting a journal club. J Sch Nurs. 2004 Aug;20(4):187-8.
Dyckoff D, Manela J, Valente S. Improving practice with a journal club. Nursing. 2004 Jul;34(7):29.
Goodfellow LM. Can a journal club bridge the gap between research and practice? Nurse Educ. 2004 May-Jun;29(3):107-10.
McKibbon KA, Wilczynski NL, Haynes RB. What do evidence-based secondary journals tell us about the publication of clinically important articles in primary healthcare journals? BMC Med. 2004 Sep 6;2(1):33.
Rich K. The journal club: A means to promote nursing research. J Vasc Nurs 2006;24(1):27-28.
St. Pierre, J. (2005). Changing nursing practice through a nursing journal club. Medsurg Nurs, 2005 Dec 14(6), 390-2.
Stoner M., Rutledge DN. 10 statistical terms you should know. Home Healthcare Nurse 2005;23(3):183-187.
The Evidence-Based Medicine Working Group. Users’ guides to the medical literature. Essentials of evidence-based clinical practice. JAMA and Archives Journals. (Guyatt G. and Rennie D., eds) Chicago: AMA; 2002.
Valente SM. Creative way to improve practice: the research journal club. Home Healthc Nurse. 2003 Apr;21(4):271-4.
Journal Club Offerings within Oncology Nursing ForumFerrell BR. Understanding the Moral Distress of Nurses Witnessing Medically Futile Care. Oncology Nursing Forum. 2006 Sept;33(5):922-931.
Schaler-Royak R., Gadalla SM, Lemkau JP, Ross DD, Alexander C, Scott D. Family Perspectives on Communication With Healthcare Providers During End-of-Life Cancer Care. Oncology Nursing Forum 2006 Jul;33(4):753-761.
Useful Websites Adapted from: 1) Bedecarré and Ludvik, NurseWeek, 6/14/2008: http://include.nurse.com/apps/pbcs.dll/article?AID=2008106160014, accessed 7/15/2010 2) WCSU Libraries: http://library.wcsu.edu/web/assistance/research/nursing/tutorial/j_resources/ accessed 7/22/2010
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Agency for Healthcare Research and Quality: http://www.ahrq.gov/
American Nurses Association National Center for Nursing Quality: http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/NDNQI.aspx
Collaborative Alliance for Nursing Outcomes (CALNOC): https://www.calnoc.org/
Canadian Task Force on Preventive Health Care offers succinct evidence-based reviews that directly impact practice. Topics are relevant to nursing practice. Information is free and the website is easy to navigate: http://www.ctfphc.org/
Centre for Evidence Based Nursing- The University of York:http://www.york.ac.uk/healthsciences/centres/evidence/cebn.htm
CINAHL Database: http://www.cinahl.com/prodsvcs/cinahldb.htm
Clinical Queries- Search for Evidence Based Articles:http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Cochrane Review Home Page: http://www.cochrane.org/reviews/index.htm
Emory University, Atlanta: MedWeb: Biomedical Internet Resources
Example of a Cochrane Review: http://www.cochrane.org/reviews/exreview.htm
Evidence Based Nursing Online: http://ebn.bmjjournals.com/misc/links.shtml
Health on the Net (HON) http://www.hon.ch
Institute for Safe Medication Practices: http://www.ismp.org/
Joanna Briggs Institute: http://www.joannabriggs.edu.au/about/home.phphttp://www.joannabriggs.edu.au/pubs/best_practice.php
McGill Unversity Research & Clinical Resources for Evidence Based Nursing (EBN). http://www.muhc-ebn.mcgill.ca/
National Guidelines Clearinghouse: http://www.guideline.gov/index.aspx
National Institute of Health – Health Information – Consumer Healthhttp://health.nih.gov/
National Health Service in the United Kingdom: National Library for Health
National Library of Medicine: for health information in different languages:
http://www.nlm.nih.gov/medlineplus/languages/languages.htm l consumer health: http://www.nlm.nih.gov/medlineplus/portal for health professionals: http://www.nlm.nih.gov/portals/healthcare.html
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National Library of Medicine Databases http://www.nlm.nih.gov/databases/index.html
National Quality Forum: http://www.qualityforum.org/
Nesbit Guide to Evidence-Based Resources (Univ. of Rochester). http://www.urmc.rochester.edu/hslt/miner/digital_library/evidence_based_resources.cfm
Netting the Evidence: A ScHARR Introduction to Evidence Based Practice on the Internet. http://www.shef.ac.uk/scharr/ir/netting/
PubMed- Medline Database for literature searches: http://www.ncbi.nlm.nih.gov/sites/entrez
PubMed Tutorial – How to use PubMed: http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/
How to Order Articles found in Medline-fee based service- Loansome Doc Fact Sheet (useful for health professionals without access to medical libraries):http://www.nlm.nih.gov/pubs/factsheets/loansome_doc.html
Loansome Doc – Find a library: http://www.nlm.nih.gov/services/ldfind.html
Sigma Theta Tau International: http://www.nursingsociety.org/research/main.html
Study looking at which journals publish high quality clinically relevant studies: http://www.biomedcentral.com/1741-7015/2/33/abstract
The Iowa Model of Evidence-Based Nursing Practice. http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/iowamodel.html
User’s Guides to the Medical Literature XXI. Using electronic health information resources in evidence-based medical practice: http://www.cche.net/usersguides/main.asp
VA APN Website: http://vaww.collage.research.va.gov/collage/N_EBP/ retrieved 8/2/2010.
VA Health Services Research &Development- Evidence-based Synthesis Program: http://www.hsrd.research.va.gov/publications/esp/
VA Health Services Research &Development Quality Enhancement Research Initiative (QUERI website): http://www.hsrd.research.va.gov/queri/
VA Information Resource Center (VIReC): http://www.virec.research.va.gov/
VA National Center for Patient Safety: http://www.patientsafety.gov/
VALNET – VA Library Network Consumer Health Information:http://www1.va.gov/VALNET/page.cfm?pg=19
Virginia Henderson International Nursing Library:http://www.nursinglibrary.org/portal/main.aspx?PageID=4013
WORLDviews on Evidence Based Nursing http://www.nursingsociety.org/worldviews/index.html
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Locating BooksPublicly accessible site for locating books (in libraries) http://www.worldcat.org
Blogs & WikisEBM Librarian Blog: http://ebmlibrarian.wetpaint.com/Nurses blog: http://mediblogopathy.blogspot.com/Nurse.com: http://forums.nurse.com/
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Evaluation of Journal Clubs
Thank you for taking time to give feedback about your journal club. Your feedback is important to improve journal clubs at our VA Medical Center.
For Questions 1-11 please respond by circling your degree of agreement with the question.
How much do your journal club sessions:
1. Contribute to your goals for personal professional development?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
2. Enable you to discuss the articles with confidence? 1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
3. Create an atmosphere where you feel comfortable asking questions?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
4. Assist you with feeling confident to question practices you observe in your practice? (e.g., “is it really necessary to take vital signs every 4 hours?”)
1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
5. Assist you with feeling confident about your ability to make clinical practice changes based on “the evidence”?
1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
6. Provide a vehicle to adopt changes in your nursing practice?
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1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
7. Teach you about critiquing articles?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
8. Stimulate your ideas for topics for future sessions?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
9. Provide enjoyment for you?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
10. Create interest and enjoyment within your group or unit?1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
11. Do you feel the journal club has support from nursing leadership? (e.g., time to select an article, attend the session, etc)
1 2 3 4 5
Strongly Agree Agree Neither Agree
Nor Disagree Disagree Strongly Disagree
If not, what would help?
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