Implementing a journal club in a palliative care setting: A link in the chain of evidence-based practice

Article Outline

• Summary
• Introduction
  • Developing a journal club at a palliative care service
  • Aim and objectives of the journal club
• Method
  • The sample
  • Planning and conduct of meetings
  • Evaluation
• Results
• Discussion
• Conclusion
• Acknowledgements
• References
• Copyright

Summary 

This paper describes the implementation and evaluation of a journal club in a privately funded palliative care unit. Journal club meetings were initiated as part of a quality improvement process to foster the uptake of evidence-based practice. Nurses were presented with research articles each month and discussions were conducted focussing on methodological considerations of the research and implications of the research for patient care. The maximum number of attendees at any one meeting was nine and the minimum number was four. Overall, evaluations were positive about all aspects of the meetings. Attendees found that the selected articles were relevant, providing new information, stimulated discussion and reflection on clinical practice and encouraged further reading. One of the positive aspects of the meetings identified by participants was the facilitation style that enabled discussion in a safe and supportive environment. An important outcome of the meetings is the potential to explore evidence-based practices relevant to palliative care and to implement new practices or revise existing ones. As part of this process practice changes and clinical guidelines have been implemented. A dedicated facilitator with university links and a supportive organisational culture promoted club meetings as a practical way to provide clinical nurses with the opportunity to explore evidence-based research in the area of palliative care.

Keywords: Evidence-based practice, Journal club, Palliative care

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Introduction 

To provide quality, accountable care to patients and their families nursing care must be delivered using the best available evidence. Ervin (2002) defines evidence-based practice as “practice in which nurses make clinical decisions using the best available research and other evidence that is reflected in approved policies, procedures, and clinical guidelines in a particular healthcare agency” (p. 11). Evidence-based practice can empower nurses to improve the quality of individual patient outcomes (Patel, Moch, & Diemert, 2001) and, when implemented in practice guidelines, can decrease variations in care (Rutledge & Kuebler, 2005).

While research in all areas of nursing has progressed markedly over the last few decades, there are challenges in achieving an uptake of evidence-based information into the clinical environment (Cleary, Freeman, Walker, & Hunt, 2005; Ervin, 2002). Several researchers have identified barriers, both individual and organisational, that may interfere with translating research into practice. Organisations may not provide the settings and infrastructure where new information and knowledge can be discussed (Fitzsimmons, Shively, & Verderber 1995; Peters, 2005, Roy, 1999), or nurses may not have positive perceptions of research utilisation (Rycroft-Malone et al., 2004; Luby, Riley, & Towne, 2006). Thompson et al. (2001) showed that nurses lack the skills and motivation to access and synthesise research findings, and preferred the findings to be passed on to them via a third party, such as a clinical nurse specialist.

Research must be seen as being clinically relevant and appropriate to nursing and be perceived by nurses as being able to make a positive difference to patient care outcomes. In order to be able to sift through the wealth of information available, nurses need to develop and hone their critical appraisal skills to evaluate the research process, determine if studies are well conducted, their conclusions justified and are clinically relevant and appropriate (Williams, 2002). Using critical appraisal skills provides the means to translate research into practice (Roy, 1999). These skills are becoming increasingly important with the growth of information available to most people on the World Wide Web.

Journal clubs, formal meetings of clinicians to discuss and explore research publications, have been identified as one way of making research findings available to clinical nurses and increasing nurses’ awareness of the evidence base for interventions (Patel et al., 2001; McQueen, Miller, Nivison, & Husband, 2006). If led by someone with research knowledge and skills, journal clubs have the potential to help clinical nurses improve their general research knowledge and appraisal skills, assisting nurses to critically appraise the results of research projects relevant to their area of expertise (Luby et al., 2006, Speers, 1999). Participation in journal clubs has been shown to positively facilitate research use by clinical nurses (Fink, Thompson, & Bonnes, 2005).

As with any initiative, organisational structures can help or hinder the implementation of new practices. Positive organisational attitudes, such as awarding continuing education points for attendance at journal club meetings, can foster positive perceptions of using research, and may provide support for integrating evidence-based practices (Bevan and Pelosi-Kelly, 2006, Fink et al., 2005).

Developing a journal club at a palliative care service 

The journal club discussed in this paper was undertaken in a palliative care service in metropolitan Australia. This facility is part of a privately funded multi-site organisation and comprises an acute, short-stay, 22-bed inpatient unit and a home care service providing 24-h cover. The majority of patients have a diagnosis of advanced cancer and inpatients are admitted for symptom management or end stage care. Division one (registered) and two (enrolled) nurses and a personal care attendant provide inpatient care at the service, while home care is provided solely by division one nurses. Pastoral care workers form an important component of the patient care team. There are a total of 59 full and part-time nurses employed by the service.

An education committee has been meeting since the facility opening. In 2005, the membership of this committee was expanded and new objectives and activities were developed. One of the Education Committee's objectives was to increase nurses’ knowledge of current palliative care research with the aim of informing and enhancing evidence-based practice. A journal club had been previously implemented, but was unsuccessful due to other staff commitments such as their clinical workload, and a lack of guidelines or objectives for the conduct of meetings. The appointment of a research fellow at the service provided the potential for a dedicated facilitator for meetings, and it was decided by the committee to resume monthly journal club meetings.

To fully explore the presented articles and allow for meaningful discussion, the duration of meetings was planned for one hour. In order to allow clinical staff from both shifts the possibility of attending, meeting times were scheduled for 1500h, the end of the morning shift. As the overlap between the morning and afternoon shifts is 1h, journal club could not be held within the working hours of both shifts, and the timing of sessions precluded the attendance by night duty nurses.

Aim and objectives of the journal club 

The journal club was instituted primarily as a quality improvement process to stimulate practice review and the uptake of evidence-based practice by all nurses at the service. These meetings provided a forum for discussing research methodology and current issues in cancer and palliative care.

Specifically, the objectives of the journal club were to:

The aim of the club was deliberately broad, providing nurses with the opportunity to discuss current patient issues of their choosing. This differs from the aims of other clubs formed to answer a specific clinical question (McQueen et al., 2006). With the aims of fostering enthusiasm and providing a focus on clinical issues, we agreed not to include initial sessions discussing the meaning, objectives and potential formats for meetings as had been done by other authors (Luby et al., 2006, Speers, 1999).

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Method 

The sample 

There were a total of 42 registered nurses (known as Division 1 RNs in Victoria) and 17 enrolled nurses (known as Division 2 RNs in Victoria) on the roster comprising both permanent and bank staff; full and part-time. Ten registered nurses held postgraduate qualifications in advanced nursing and palliative care. Those attending the journal club were primarily nurses but also included pastoral care workers, and a personal care attendant thus illustrating the multidisciplinary character of the team. There were a total of 48 attendances at meetings between November 2005 and July 2006, with a mean meeting attendance of seven staff (ranging from 4 to 9).

Planning and conduct of meetings 

At the initial meeting, the facilitator provided a general introduction and explained the focus of meetings. The informal nature of meetings was also emphasised so that participants did not feel overwhelmed.

Articles reporting a variety of research methods and clinical topics were chosen for discussion. Choice of article was influenced by clinical relevance to palliative care, Education Committee objectives and staff suggestions regarding topics of interest. A mix of quantitative and qualitative research was presented, with one review article included. Other articles related to the chosen topic and further information about research methods was also available at meetings. Table 1 provides a list of the articles discussed at meetings.

Table 1. Primary articles presented at meetings (in order of presentation).

Two of the articles chosen for discussion were 10 and 12 years old. This reflects the lack of current research, in some areas, in palliative care, and also highlights the need to find any research in areas suggested by clinical staff as a means of increasing their sense of ownership of the journal club and perceived usefulness of meetings. The range of articles also reflects that nurses in the unit did not just want to focus on nursing interventions to patient problems, but were interested in expanding their knowledge in broader areas of symptoms and disease management.

The particular article to be discussed at each journal club was circulated to all staff ten days prior to the meeting to ensure they had adequate reading time. Retrieval and circulation of papers was facilitated through the partnership between the health service and an Australian University. The distribution list included all staff on duty in these 10 days. While it was realised some staff would not receive the article, a timely response to suggested topics and a recency of reading were considered most important (Luby et al., 2006). Night duty nurses were included in the distribution even though they were unable to attend meetings. Flyers advertising the meeting date and time were placed around the inpatient unit and in the home care office.

The Research Fellow organised and facilitated meetings. The research fellow position was a part-time university appointment supported jointly by the university and the health care facility. In addition, the incumbent held a part-time clinical position in the inpatient palliative care unit. Access to the university's facilities, such as electronic databases and the library, allowed for easier retrieval of relevant material than would have been possible for clinical nurses.

Organisational support for the journal club was made evident in a variety of ways from all levels of nursing management. For example, the Centre Manager encouraged afternoon staff to attend meetings in work time, and provided the necessary funds to cover administrative costs associated with retrieval and distribution of the articles and for the refreshments provided at each meeting.

Evaluation 

To describe the outcomes of participating in meetings, a small-scale exploratory study using questionnaires for data collection was undertaken with all attendees of journal club.

At the conclusion of each meeting attendees were given an anonymous evaluation form, consisting of statements requiring 5-point Likert scale responses, yes/no answers, and short answer questions. Issues such as the applicability of the article to practice, whether new knowledge was gained and if the article stimulated thought about current practice or encouraged further reading were all evaluated. Open-ended questions were also asked regarding the best and worst aspects of meetings. Attendees were encouraged to complete the evaluation prior to leaving the meeting to allow for maximal returns.

Evaluation forms were purpose-designed for the study, and checked for clarity by two researchers not involved with the study. Returns were analysed using summative descriptive statistics with the Statistical Package for the Social Sciences (SPSS) Version 11.5.

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Results 

Results are recorded from the evaluations of seven meetings held between November 2005, and July 2006. Due to the small number of attendees at individual meetings (from four to nine) and the strong positive results for each session, the results presented are a summative evaluation of the meetings. Most people attended more than one meeting, so the results reflect a smaller number of attendees than evaluations. Due to the anonymous nature of the questionnaires we are unable to detect the multiple responders.

For the seven meetings a total of 294 copies of articles were distributed, with a mean of 42 articles distributed for each meeting. Evaluation forms were distributed to all participants at every meeting. Forty-two evaluation forms from 48 participants were returned, giving a response rate of 88%. Some participants did not respond to all questions therefore different sample sizes occurred for evaluation statements. The five categories from the Likert scales were collapsed into three due to the small number of responses in some categories.

Evaluations were generally extremely positive about all aspects of the meetings. Table 2 presents the results of session evaluations.

Table 2. Summary evaluation of sessions.

Statement	Yes	Neutral	No	Total
Article read prior to meeting (n=38)	28 (74%)	0	10 (26%)	38 (100%)
Article relevant to practice (n=41)	39 (95%)	2 (5%)	0	41 (100%)
New information gained (n=39)	29 (74%)	8 (21%)	2 (5%)	39 (100%)
Article stimulated thought about practice (n=37)	33 (90%)	2 (5%)	2 (5%)	37 (100%)
Article stimulated further reading (n=38)	30 (79%)	6 (16%)	2 (5%)	38 (100%)
Length of meeting appropriate (n=41)	34 (83%)	3 (7%)	4 (10%)	41 (100%)
Timing of meeting satisfactory (n=39)	34 (87%)	3 (8%)	2 (5%)	39 (100%)
Enjoyed discussing article with colleagues (n=41)	39 (95%)	2 (5%)	0	41 (100%)
Sessions should be repeated to allow for greater attendances (n=39)	27 (69%)	11 (28%)	1 (3%)	39 (100%)
Would like to come to further meetings (n=41)	40 (98%)	1 (2%)	0	41 (100%)
Would like to choose an article for discussion (n=36)	19 (53%)	0	17 (47%)	36 (100%)

The majority of participants said the articles were relevant to their practice, they learned something new, and were stimulated to think about their current practice. Almost all wanted to attend further meetings. Most were happy with the duration of the meetings. Of those who made comments about the time, one would have preferred a longer session and three would have preferred sessions of 45min. The time of day of the meeting suited most people, but one participant who had worked a morning shift preferred that the sessions be held during paid working hours.

Participants nominated the best aspects of the meetings as being able to discuss the articles in a safe and supportive environment, learning about research methods, and having the opportunity to discuss practice issues with colleagues. They commented that the sessions were professionally facilitated, with a total of 17 positive comments made regarding the Research Fellow as a facilitator. Some of the positive comments regarding the input of the facilitator included:

Some of the positive comments made about the meetings included:

Not having time to read the article prior to the meeting, low session attendances, feeling tired after working an early shift, and thinking of work to be done if on an afternoon shift were all highlighted as negative aspects of meetings.

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Discussion 

The journal club was very well received by the majority of participants. Initially, articles for discussion were chosen according to topics planned by the Education Committee, but it was encouraging to see that as meetings continued, staff requests for topics for discussion, based on current clinical situations, increased. These requests were followed up and led to the choice of specific articles for meetings, with the last four articles selected from staff suggestions. For example, delirium was discussed during the first meeting, but because this is a major symptom affecting palliative patients and a common topic for informal clinical discussions among staff it was later revisited. While it has been suggested that 6–10 articles should be reviewed in the subject area (Patel et al., 2001), this was not always possible due to time constraints or a lack of research in many areas of palliative care nursing practice (Holmes, 2007).

It is important to use a consultative approach and respond to staff suggestions for meeting topics, as this may enhance a sense of ownership and encourage attendance. This also highlights the need for flexibility in planning topics for discussion. There is great advantage in having a clinically based facilitator who can engage nurses in informal discussions regarding clinical issues, and has experience with the current areas of concern in nursing practice.

There is usually a total of 12 nurses working morning and afternoon shifts (and this often included at least two agency staff), so seven attendees (58% of total staff) equates to over half the staff. The number of nurses attending meetings was encouraging, given the well-recognised problems of getting clinical staff to attend sessions in working time, or at the end of a shift, which was in their own time. Only one nurse who had worked a morning shift suggested that meetings should be held during paid time. Session attendance did not diminish over time.

The process for running the journal club was similar to those described in the literature (Doust, Del Mar, Montgomery, & Heal, 2008; McQueen et al., 2006). Staff received articles prior to the meeting, and the meeting discussions focused on both the research methodology presented and the clinical implications of the research.

A large number of articles were distributed for all meetings (n=294, M=42) compared to the attendance (n=48, M=7). However, the large distribution was considered to be worthwhile as all staff had the opportunity to read the articles with consequent exposure to evidence-based practice. It also provided staff who did not attend meetings the opportunity to discuss the article with colleagues, including the Research Fellow. Nurses who worked night duty held their own informal discussions relating to the articles—an unexpected but encouraging outcome. However, conduct of the journal club was time-consuming for the Research Fellow, with all administrative tasks undertaken without secretarial support.

Within the journal club, staff became more confident to share their ideas and raise questions that related to increasing knowledge in areas where they felt they needed to learn. The qualitative responses recorded in the evaluations supported this increasing confidence, with nurses stating they thought the meetings provided a safe and supportive environment for collegial discussion.

One of the limitations of the feedback questionnaire is that of expectancy effect. This occurs when the participants are aware of the desired responses expected by the researcher and tend towards these rather than their own true responses (Bowling, 2002).

An exciting outcome from the meetings has been the potential for nurses in the unit to initiate positive practice change. During the journal club discussions a nurse commented on her observation that there had recently been a high number of urinary tract infections among those patients who had an indwelling urinary catheter (IDC) inserted. The nurse asked if that issue could be discussed at an upcoming meeting. The paper chosen for discussion looked at the use of IDCs and infective complications in patients diagnosed with terminal cancer (Fainsinger, MacEachern, Hanson, & Bruera, 1992). Following the discussion, a two-phase plan arose aimed at initiating and monitoring practice changes in relation to more prompt recognition of urinary infections in those patients with an IDC, and potentially incorporating these changes into standard care. Following a further review of the literature and an examination of current evidence-based catheter management guidelines, a guidelines document and an education sheet were developed that outline the practice changes and nurses’ responsibilities in regard to catheter care. These will be distributed to all registered nurses, an implementation date will be agreed upon, and from that time the guidelines will be placed in the charts of all patients who have an IDC inserted. Nursing practice will be monitored, and if an improvement in the accurate recognition of infections is demonstrated, the changes will become a standard part of the nursing management of all patients within the unit. This outcome has been useful in validating the aims and objectives of the journal club method.

This practical example shows how research findings can be incorporated into nursing practice and that clinical nurses can be the drivers of such practice changes. It also highlights the importance of a clinically grounded research fellow in the overall process as this person had the time and skills to undertake a further literature review and develop guidelines and teaching documents for education about the proposed practice changes. Clinical nurses would have struggled to find time and resources to undertake these tasks, and this may present a barrier to their completion (McQueen et al., 2006).

The journal club has encouraged changes in nurses’ professional practices in the clinical setting. The third meeting and its discussion around subcutaneous fluid administration prompted one of the coordinators to undertake a literature review exploring different methods of fluid administration and the use of absorption-enhancing agents. Ongoing discussions around this topic included the palliative physician, and led to worthwhile debate on the current practices within the unit.

Another pleasing outcome has been the initiation of a journal club in the acute oncology area. Discussion between service managers led to a request for similar meetings to be held in the acute day oncology area (on another of the hospital's campuses). This was also facilitated by the research fellow. Nurses there were also responsible for the choice of topics, and evaluations received were similarly positive.

While it has been recognised that the dissemination of research findings is unlikely on its own to lead to the uptake of evidence-based practices (Rycroft-Malone et al., 2004), these journal club discussions are an important first step in the process, and reflect a positive and supportive organisational attitude (Fink et al., 2005). Other researchers have found that if nurses are encouraged to read and learn about research in their clinical area this may enhance awareness of the evidence base for their practice and assist with the conceptual utilisation of research findings (Ervin, 2002, McQueen et al., 2006).

The positive influence that a facilitator who also works within the practice context has to promote learning and access to research articles has been described by Locock and colleagues (cited in Rycroft-Malone et al., 2004). The benefit of having a facilitator with research knowledge and links to a university and its services to coordinate meetings (Patel et al., 2001) and generate interest in the journal club was seen as pivotal to its success and is reflected in the results described above. The journal club also flourished due to the positive organisational culture of fostering education and research within the service.

To provide a long-term more sustainable future for meetings it is planned to transfer the facilitation to full-time clinical staff, using a shared model of coordination. Mentoring will be provided by the Research Fellow for nurses involved in the ongoing conduct of meetings, and administrative support will be sought to reduce the time burden of meetings preparation for clinical staff conducting meetings.

This was a local study involving a small sample, so it is unclear if the changes identified in the journal club evaluations will be long lasting or transferable to other settings. Further studies are recommended to demonstrate the ongoing impact of meetings in terms of nurses’ development and implementation of research projects (Luby et al., 2006, Patel et al., 2001) and ongoing dialogue regarding evidence-based practice.

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Conclusion 

Many factors have been responsible for the success of the journal club in the palliative care unit. Ownership by clinical nurses has been enhanced by giving them the opportunity to choose topics for discussion, and encouraging discussions out of meeting times about current practice issues and potential topics. A facilitator with university links, clinical credibility and expertise and the ability to be flexible in the choice of topics for meetings has been highlighted as important. A supportive and non-threatening environment for discussion and a supportive organisational management culture have also been integral in the favourable evaluation of this process.

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Acknowledgements 

We gratefully acknowledge that Ms. O’Connor's position as Research Fellow was supported by a donation from the Page family in memory of Mayer Page. We would also like to acknowledge helpful comments on the manuscript from anonymous reviewers. All authors were associated with the Cabrini-Deakin Centre for Nursing Research at the time the project was conducted and reported.

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