Launching and Leading Journal Clubs
Marti Buffum, DNSc, RN, PMHCNS-BC
Associate Chief of Nursing Service for Research
Deborah Burgoon, MS, RN, AOCN
Clinical Nurse Specialist, Oncology
VA Medical Center, San Francisco
March 8, 2011
Kaiser 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
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 skills
To increase comfort with presenting to peers
To evaluate evidence suitable for practice application
To acquire an evidence base that empowers staff with knowledge for improving practice and for communicating with other disciplines
Incentives/Options: Continuing education credit
Refreshments: food /drink (delegate, potluck, rotate, etc.)
Proficiency booster
Mentoring opportunity
Can 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, nursing
issues, 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 club
Make copies for all staff, place extra copies on established bulletin board and/or break room; post in staff bathroom
Encourage staff members to read the article prior to session
Choose main points or concepts you think are most important
Think 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)
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/ Conclusions
A. 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 research
A. 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?
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, question
II. Evaluation of methodology
A. Design
B. Sample
C. Procedure
D. Instrument
III. Evaluation of data analysis: results
A. Selection of themes
B. 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 research
A. 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.
Types of Study Designs
(Melnyk and Fineout-Overholt, 2005)
Randomized Controlled Trial: RCT
A 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).
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.
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 Practice
Ratings (see Grading Evidence Table)
Rating for type of research:
Rating for strength of evidence:
1
Buffum, 2011
Grading the Evidence and Making Recommendations
The 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 EvidenceI / 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 time
B / 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/.
Another Rating System for the Hierarchy 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 RCT
III / Evidence from well-designed controlled trials without randomization
IV / Evidence from well-designed case control and cohort studies
V / Evidence from systematic reviews of descriptive and qualitative studies
VI / Evidence from a single descriptive or qualitative study
VII / 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.
Evidence Table
Row for each article
AuthorsDate / Type of Study/Design / Level of Evidence / # Subjects / Subjects’ Characteristics / Intervention / Comparison / Outcome
Tips for Journal Club Participation
Motivating for Success:
1. Word spreads: ensure fun
2. 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 stupid
4. Structure the format and monitor time so all aspects get reviewed and all
can participate
5. Provide CEUs
6. Select interesting articles. Distribute in advance.
7. Do not overwhelm with too many articles (guaranteed DOOM)
8. Food?
9. Enthusiastic, positive, inclusive teaching style
10. Role model application to practice; determine readiness for application; determine “take home” messages
11. Decrease intimidation, provide chances for all to participate
12. Discuss potential research questions emerging from articles
13. 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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Buffum, 2011
Bibliography
Asking a Question: PICO
http://www.cebm.utoronto.ca/practise/formulate/pg2.htm