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JOURNAL CLUBS & THE CNS
Cheryl Westlake, PhD, RN, ACNS-BC, FHFSA, FAHA, FAANProfessor, Doctoral Programs
School of Nursing, Azusa Pacific [email protected]
Objectives
1. Describe clinical nurse specialist’s (CNSs) role in journal club development & implementation
2. Review tools for critiquing clinical & research articles
3. Address barriers to journal club implementation
4. Consider journal club evaluation
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 3
What is a journal club?(Steenbeek, et al., 2009; Westlake, et al., 2015; Winterbottom, 2011)
•Cost-effective strategy for enhancing practitioner capability & satisfaction
•Educational tool that • Bridges research & practice• Facilitates application of research to clinical setting & • Raises awareness of new solutions to promote
value-based nursing
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 4
Why conduct journal clubs?(Bazarian, et al., 1999; Gloeckner & Robinson, 2010; Linzer, Frazier, DeLong, Siegel, 1988; Ploeg, et al., 2007; Luby, Riley, & Towne,
2006; Sciarra, 2011; Steenbeek, et al., 2009; Zarghi, Mazlom, & Rahban, 2012)
Enhances• Nursing care skills essential to translating research
to practice • Interprofessional credibility
• Reading habits • > # of articles read/month)• > time in daily literature reading (930 min/day)
especially pat care articles in nurses’ specialty• Utilizing current research in practice better patient
outcomesCheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 5
• Clinical thinking • Critical-thinking skills
Journal club benefits(Burstein, Hollander, Barlas, 1996; Elnicki DM, Halperin, Shockcor,& Aronoff SC. 1999; Linzer et al., 1988; Macrae, Regehr, & McKenzie, 2004; Moharari et al., 2009; Spillane & Crowe, 1998; Steenbeek, et al., 2009 Zarghi, Mazlom, & Rahban, 2012)
• Fosters scientific literature review germane to clinical practice
• Through critical analysis, helps develop knowledge & assess state of science
• d understanding of (Rice, et al., 2011)
• Research methods • Critical appraisal knowledge & skills • Critical reading ability of original research articles
• Qualitative paper review among those w/ • least prior qualitative methods experience & • more developed learners
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 6
• Statistical analysis
Journal club benefits• If created in concert w/ academic partners, may
• help boundaries b/t researchers & clinicians • provide routine place & time for networking,
coaching, & academic-practice collaborations (Moharari et al., 2009)
• Only 1 study reviewed, researchers found no significant change following journal club implementation (Langkamp, Pascoe, & Nelson, 1992)
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Who benefits(Ploeg, et al., 2007; Luby, Riley, & Towne, 2006; Sciarra, 2011)
• Nursing staff
• Organization - Fosters nursing practice changes (Luby, Riley, & Towne, 2006; Ploeg J et al., 2007; Sciarra E. 2011)
• Student nurses - learning promoted (Thompson, 2006)
• Journal club members (Burstein, Hollander, Barlas, 1996; Letterie & Morgenstern, 2000; Mukherjee, Owen, Hollins. 2006; Spillane & Crowe, 1998)
• Patients? Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 8
• CE • Educator prof dev
• Found social gathering enjoyable• Overall satisfaction w/ program • d confidence• Interest to continue
http://www.nacns.org/wp-content/uploads/2017/01/CNSCoreCompetenciesBroch.pdf
CNS Preparation & leadership • Determine
• Member #s • Meeting times/places
• Have clear aims, objectives & short- & long-term goals• Provide invitations w/ journal article• Consider inclusion of article-related challenging clinical
situation & question• Need clearly stated focus, e.g. - critical appraisal skills &
enhance EBP; assist in adherence to & achievement of goals • Disseminate articles prior to meeting - allow time to
• Read articles in advance & • Prepare for discussion
• Facilitate discussion• Document• Evaluate
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 9
CNS Preparation & leadership • Ideal member #s unknown
• Smaller group will promote meaningful discussion among members in the time allotted (Billingsley, et al., 2013; Kean, 2013; Silvey, 2013);
•Frequency• Weekly (O’Nan, 2011; Sciarra, 2011)
• Monthly meeting (Burstein, Hollander, Barlas, 1996; Mukherjee, Owen, Hollins. 2006; Nesbitt & Barton, 2014 2014 Silvey, 2013)
• Couple times/year (Billingsley, et al., 2013; Lehna, et al., 2010; Sortedahl, 2012)
•50 minutes to 2 hours (Kean, 2013; Mukherjee, Owen, Hollins. 2006; Silvey, 2013)
•Attendance voluntary (Bazarian JJ, Davis CO, 1999; Burstein, Hollander, Barlas, 1996)
• Convenient meeting times per member schedules (Berger, Hardin K, Topp., 2011)
• W/in normal working hours (Silvey, 2013)
• Repeated meeting may be necessary to meet needs of alternate shift workers (Kean, 2013)
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 10
CNS Preparation & leadership Article selection• Nurses/students (O’Nan, 2011)
• Participants & researcher (Nesbitt, 2013)
• Researcher & or author of journal club article (Lehna, et al., 2010; Sciarra, 2011; Sortedahl, 2012)
Original research • Universal appeal • Relate to:
• Clinicians’ questions• Patient population of interest• Important or interesting diagnoses• Common clinical problems
• Meta-analyses, guideline recommendations, & cost-effectiveness analyses not recommended - more difficult to appraise critically
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CNS Preparation & leadership Approach
• 2 articles on same topic, but w/ contrasting conclusions -facilitate lively discussions
• Multiple articles on 1 topic w/ high & low strength & evidence quality
Journal club facilitator• Researcher (Lehna, et al., 2010)
• Researcher, CNS, or MSN-prepared clinical nurse or nurse (Billingsley, et al., 2013; Nesbitt, 2013 ; Sciarra, 2011; Sortedahl, 2012)
Meeting preparation• Articles distributed in advance (Lehna, et al., 2010; Nesbitt, 2013 ; O’Nan, 2011;
Sciarra, 2011; Sortedahl, 2012)
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Article Selection•Resources
•American College of Physicians (ACP) Journal Club
• http://annals.org/aim/journal-club• Summarizes best new evidence for internal medicine from
over 120 clinical journals. • Monthly feature of Annals of Internal Medicine• Research staff & clinical editors rigorously assess scientific
merit of medical lit as published • Worldwide panel of > 5,000 physicians assesses clinical
relevance & newsworthiness of rigorous studies•TRIP database
Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 13
Article Selection•Resources - TRIP database
https://www.tripdatabase.com/about#pico
• Clinical search database to support their practice &/or care• Research evidence• Images• Videos• Patient information leaflets• Educational courses • News
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Appraisal Tool• Use established tool or reading guide• Encourage systematic approach to appraising evidence• Assessing research methods & results for threats to
internal or external validity and other biases• Article review questions may differ for research versus
non-research (clinical review) articles• Grading of Recommendations, Assessment,
Development and Evaluation (GRADE) system • Taxonomy that creates evidence quality tiers based on
multiple criteria • Uses standardized definitions (http://www.gradeworking group.org)
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Evidence Quality
GRADE system High Further research very unlikely to change
confidence in estimate of effectModerate Further research likely to have important impact
on confidence in estimate of effect & may change estimate
Low Further research is very likely to have important impact on confidence in estimate of effect & is likely to change estimate
Very low Any estimate of effect is very uncertain
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Documentation & TOE•Assist clinicians to create TOE to organize & document• Article’s evidence before adjourning• Group’s summation & description of f/u action• Potential practice /practice change
recommendation
•TOE may be used to • Facilitate discussions about evidence synthesis• Promote conclusions based on strongest evidence
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Journal Club Implementation Barriers
•Relevance•Attendance•Participation•Confidence •Limited research & evidence searching expertise
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Relevance
• Journal article agreed on by membership• Nursing governance committees may be accountable
for content & updates• Meeting - question driven• Ideally, questions come from journal club members, • Non-nursing personnel may provide unique
perspectives & broaden participants’ perceived value of article
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Attendance/Participation –Consider/experiment w/ formats
• Face to face (Fowler, Gottschlich, Kagan, 2013)
• Virtual at single or multiple sites (Berger, Hardin, & Topp, 2011; Sortedahl, 2012)
• WordPress.com – blogging; discussion boards (Kean, 2013; Lehna, et al., 2010)
• Second Life - Multiuser virtual environment - social media (Billingsley, et al., 2013)
• Twitter - @twitjournalclub, bimonthly w/ 3400 followers (Silvey, 2013; Zoonotica, 2013)
• Web conferencing program - Elluminate Live!
•Hybrid - both face-to-face & virtual component• Travelling poster board (Campbell-Fleming, Catania,& Courtney, 2009)
• Author in the Room - author invited to participate in meeting & address questions and issues (Bradley, et al., 2004)Cheryl Westlake, PhD, RN, ACNS-BC, PN, FHFSA, FAHA 22
Bradley, Schlesinger, Webster, Baker, Inouye, 2004; Campbell-Fleming, Catania, 2009; Evans, 2003; Howic, Chalmers, Glasziou, et al., 2011; Radhakrishnan & Jacelon, 2012; Silvey, 2013
Attendance - Consider members • Consultants - promote multidisciplinary attendance
• Multidisciplinary teams/consultants - clinical librarians, statisticians, pharmacists, MSWs, RDs, PTs or OTs, online discussion monitor, library resource person, & technical support person• Conduct orientation sessions • Generate journal club leadership discussions questions• Create Web sites and posts for article storage and access• Address technical issues• Assist w/ methodological & statistical discussions • Have each member present portion of critique or statistical
analysis at each meeting
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Attendance • Planned marketing strategy?
• Collaborate w/ education, communication, & marketing to develop marketing plan
• Journal club re-named Smarticles (Krugman, 2009)
• Promotional campaign used Smarties participation & + feedback
• Incentive = core characteristic (Berger, Hardin K, Topp., 2011)
• Article-specific, pre-/post-test learning achievement assessment, CEUs, Career/clinical ladder points (Billingsley, et al., 2013; Kean, 2013)
• Door prizes (i.e., book, gift certificate, free lunch)• Food - availability may (Silvey, 2013)
• Improve attendance & • Create environment conducive to participation
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Participation • Original research of universal appeal • Approach - 2 articles on same topic, w/ contrasting
conclusions• Food - may create environment conducive to
participation• When confident that learning, participation (Silvey, 2013)
• End meeting by asking for clinical ‘‘bottom line’’• Document
• Learning logbook (online, if possible) (Dobrzanska & Cromack, 2005)
• Completed critical appraisals- tangible report & reference to reread, when appropriate
• Group decisions about needed follow-up• Implementation of evidence and outcome monitoring
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Confidence• Journal club membership d confidence• Articles selected - Multiple articles on 1 topic w/ high & low
strength & evidence quality• Use active learning principles (Barnes, 1989)
• Purposive: task relevant to learners' concerns• Reflective: learners reflection on meaning of what is learned• Negotiated: negotiation of goals & methods of learning b/t learners & CNS• Critical: students appreciate different ways & means of learning content• Complex: learners compare learning tasks w/real life complexities & reflect• Situation-driven: situation need considered to establish learning tasks• Engaged: learning activities reflect real life tasks
• Select right multidisciplinary members • Statistician or nurse w/ strong statistical background to answer method, analysis,
& results-related • Librarian for resources
• Answering individuals’ questions central to learning & motivation (Silvey, 2013)
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Limited research & evidence searching expertise?
• Virtual journal club may bridge limited CNS research expertise (Billingsley, et al., 2013)
• Mentored, virtual, journal club w/ 4-session plan: (Silvey, 2013)
• Orientation session• 2 sessions - critiquing research literature using structured tool kit• Debriefing & planning session w clinical experts w/ literature critique
competency• Specialty group journal club participants
• competencies in determining design• interpreting statistics
• Pilot, online, school-nurse journal club using Elluminate Live! d (Howick, et al., 2011)
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• competencies in determining design• interpreting statistics
• linking conclusions/findings • Identifying limitations
• knowledge of link b/t evidence & practice
• understanding of evidence in articles
• connectedness to nurse colleagues
• intent to use evidence in practice
Evaluation Use structure, process, outcome model (Phillips & Glasziou, 2004)
(Donabedian, 1988)
Meeting’s structure (Duffy, et al., 2011)
• Format• Scheduling• Meeting frequency and duration • Actual participant #s
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Process Evaluation • Participants’ perceptions re: ideal participant
#/session • CNS’s ability to promote participation & discussion• Participation satisfaction, comfort, & or confidence• Intent to attend future meetings (Garcia, Judkins-Cohn, &Samsundar, 2013)
• Participant #s over year • Articles reviewed/meeting & or /year • Individual #s posting online • Connectedness to nurse colleagues• Intent to use evidence in practice• Discussion & postings/article
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Outcome Evaluation • Learning goals and objectives achieved• Knowledge improvement
• Articles’ content• Research process
• Applicability of enhanced content knowledge to practice• Clinical, quality, & cost impact of practice changes • Evaluation tools
• Created from articles reviewed • Other available tools
• CNSs publications about journal club structure, process, & outcome evaluation - lack of evidence on journal clubs’ impact on evidence-based nursing implementation
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• Participants’ perception • Objective assessment