Vol.8, No.1 April 2002
Free-style PBL using a journal club
Allison Fiona Williams
Journal reading is considered to be an essential activity for nursing students as it enables their practice to be informed by current research while developing critical thinking and lifelong learning skills. Indeed, journal clubs exploring research publications are popular in the post-graduate domain, but have not been reported in undergraduate nurse education to date. This paper discusses the introduction, implementation and evaluation of a journal club into the second year of a three-year undergraduate nursing programme utilising problem-based learning in Semester 1, 1999. Overall, the journal club was a successful innovation, where the majority of students actively participated and enjoyed sharing differing perspectives of research in a positive learning environment. Recommendations for further utility and development of journal clubs in undergraduate nurse education conclude this paper.
Key words: Journal clubs, undergraduate nurse education, research, evidence-based practice, problem-based learning.
The health care system is the largest service industry in Australia, with nurses being its predominant employees. Nursing is essentially a practice discipline, with two-thirds of Australian registered nurses being employed in hospitals or day procedure centres (McLean, 1998). The explosion of new knowledge combined with increased technology and the increased complexity of the workplace in recent years has reinforced the necessity for new graduates to be clinically competent.
Undergraduate nursing education has been located in a system of tertiary education since 1993 and, unfortunately, has experienced reduced funding since that time over the past decade (Reid, 1996), creating an added challenge for nurse academics endeavouring to maintain educational standards (Worrall-Carter, 1998). This paper discusses the introduction of a journal club into an undergraduate nursing programme utilising problem-based learning (PBL) in Semester 1, 1999, explores the strengths and limitations of the club, and suggests future opportunities for using such clubs in the nursing education context.
Problem-based learning has been used as an educational strategy for a variety of health-related disciplines in contemporary times (Cheek, Gillham & Mills, 1997; Creedy, Horsfall & Hand, 1992; Kelly 2000; Pinto et al., 1993; Schmidt, 1998; Stockhausen 1998). Problem-based learning emphasises knowledge acquisition embedded within a contextual framework for professional preparation using the hypothetico-deductive technique (Barrows & Tamblyn 1980; Feletti & Boud 1997). Within an appropriate nursing curriculum, PBL is assumed to facilitate the development of clinical reasoning skills, and safe, holistic nursing practice. Indeed, a variety of creative educational opportunities have been implemented to support PBL in Australian nursing undergraduate programmes (Cheek et al. 1997; Creedy et al. 1992; Stockhausen 1998), reflecting its increasing popularity in nurse education.
Indeed, the undergraduate programme at this school of nursing uses PBL as a curricular design and as a teaching method, offering the nursing student the opportunity to apply knowledge attained at university into the practice setting, to hit the ground running upon graduation (Brans, 1997; Williams, 1999). Once in the practice setting, nurses have a responsibility to their profession to maintain and further develop life-long learning patterns to keep abreast of the changes within their workplace (Candy, Crebert & OLeary, 1994).
The problems that are used in PBL to stimulate active student centred learning can be presented in a variety of ways. They may be embedded in a reality-based scenario supplemented with actual nursing documentation, an actor session that involves role-playing significant practice situations, or a film clip that provokes conjecture. Nursing students gain skills in identifying and meeting their individual learning needs through a process of self-directed individual and collaborative group work.
Nursing remains a practice discipline and it is imperative that new graduate nurses are able to perform competently in acute care settings. With this nursing school currently having an enrolment of more than 1000 undergraduate nursing students across campuses, the need for students to be self-directed and have lifelong learning skills was seen by nurse academics concerned with educational outcomes to be paramount. The course at this school of nursing comprises 24 credit points, usually completed on-campus over a three-year time span. The schools educational framework enables students to develop competency in the five areas defined by the Australian Nursing Council, which are professional/ethical practice, enabling, problem framing/solving, reflective practice and team work.
Problem-based learning is reliant on the students ability to learn in a self-directed mode and is considered to bridge the theorypractice gap by being context-based and requiring knowledge integration and thinking skills. It has been argued that the thinking skills of problem-solving, analysis, decision-making and critical thinking are essential for the nurse graduate (Taylor, 1997), and the establishment of a journal club within PBL would facilitate the development of these generic skills.
Journal clubs in which research publications are explored have been reported in the post-graduate nursing domain (Kirchhoff & Beck, 1995; Koziol-McLain & Tanabe, 1996; Mackin & Sinclair, 1998; Morton, 1996; Sheehan, 1994) and in medical education (Burstein, Hollander & Barlas, 1996; Moberg-Wolff & Kosasih, 1995), but have received limited attention in undergraduate nurse education to date, particularly in relation to PBL. The aim of introducing and implementing a journal club in a unit at our school of nursing was an innovative stategy to increase students knowledge of current research that informed their individual and group work and ultimately, their nursing practice.
The journal club was established within a two-credit point core subject, Nursing people experiencing long term illnesses, that was part of the second level of the nursing programme. The journal club was considered an appropriate teaching strategy that fitted well within the parameters of PBL, with the added advantage of informing a research culture and evidence-based practice. Evidence-based practice is rapidly gaining momentum in nursing and it has been predicted that within 20 years it will be available at nurses fingertips in the form of an on-line electronic pocket pal' to inform care that is based on sound research (Ciliska, 2000). Evidence-based practice typically values the randomised, controlled trial in which the research question must include the patient, a nursing intervention, comparison and outcome. Part of the evidence-based practice process is the ability to conduct a literature review, critically appraise the evidence and apply the results to nursing work prior to evaluation skills that the club enables students to practice while concurrently informing their knowledge base.
Previous experience with encouraging students to locate and critically evaluate journal articles in PBL had been relatively unsuccessful in this school without the structure of a journal club. Additionally, passive dissemination of research literature has been found to be ineffective (Ciliska, 2000). Labelling this activity a club and giving it some structure helped to make it sound more attractive and user-friendly to students, while a sense of belonging and personal ownership was created through active learning.
The introduction of a journal club initially involved dividing each class of students into sub-groups of four or five to constitute their PBL group at the commencement of the semester. Each student was then given an identical problem concerning the care of a person and family experiencing a chronic illness. Students in their sub-groups then set out to identify what they needed to know to solve the problem. Once these learning needs were established, each student then went to the library after the facilitated session and sought out current articles relating to the learning needs of the problem under study. Each sub-group arranged to meet informally before the next facilitated session to debate, critique and discuss the merit of each article and decide which was the most worthy to present back to the group. For example, research literature relating to an adolescent with Type 1 diabetes that addressed compliance issues or insulin administration was evaluated. Students then took it in turns to present an overview of the chosen article back to the whole class in the next facilitated session, allowing time for questions and group discussion regarding the application of the findings to clinical practice. And so the cycle continued throughout the semester.
Evaluation of the journal club
Summary of student feedback reported that the journal club was well received by the majority of students. Academic evaluation noted that the journal club was an effective strategy to engage students in actively locating and reading literature concerning their area of study, although the ability of each PBL sub-group varied depending on the capabilities of the individuals constituting the group. As the semester progressed, so did the confidence of students and concomitant quality of student contributions. It was considered that the journal club activities of locating and critiquing research facilitated collegiality and the presentation, assessment and group work skills that are necessary for effective problem-based learning within nurse education.
The journal club not only facilitated the sharing of a deeper and more insightful exploration of the topic under discussion, but provoked further questioning that fed back into the PBL process. Additionally, students gained fundamental research skills earlier in the programme through searching electronically for relevant articles and developing preliminary research critiquing skills that informed the quality of their essay writing. For example, most students initially had difficulty differentiating between a research article and a discussion paper, and a qualitative or quantitative study. However, curricular changes within the school have seen an alteration in the sequencing of subjects, so that students are exposed to their core research unit earlier in the programme. While it was initially thought that this change in curricular scheduling would diminish the value of the club, it has only served to improve its effectiveness as students who join a journal club now are better prepared than previous students who participated in the clubs.
The journal club was evaluated by questionnaire to all students who participated in the piloting of the club in Semester One, 1999 by 81% (n = 62) of the total cohort of students. Examples of questions included How did you locate articles?, Has the journal club improved your ability to access journals?, and How did this activity facilitate your learning?. Evaluation of student responses revealed that the majority of students enjoyed actively participating in the club's activities and sharing differing perspectives of research in what they viewed as a positive learning environment, citing reasons such as being able to control their own learning needs and a sense of pride and ownership in their work. Students found the club motivated them to work, as supported by the following typical comment: It made us get to the library and do research. The students also considered the club to be a valuable exercise through which they discovered more current information than their texts could offer, and not to take everything they read in a journal or on the internet as gospel, a basic critique skill.
Students found the club improved their knowledge of the subject, the experience of chronic illnesses, supported by a students comment: We researched different areas, linked new concepts. The club was without doubt an interesting exercise. Within the club issues that had not previously been considered were raised by the students, which made for vibrant class discussions. Knowledge acquired through participating in the club improved the students ability to access electronic data bases as students learnt what journals the library held, the speed in which accessing journal articles was achieved, and generally discovered that accessing electronic data bases and on-line journal articles was far more effective and time-efficient than manually looking through journals. The club was also viewed by students as being collegial in that it encouraged individual and group work in a respectful yet casual environment, with some students even making new friends they may otherwise not have made.
What students did not like about the club was the time-consuming nature of locating articles. One student commented, I spent ridiculous amounts of time looking for useful articles. This may have been the comment of a student who did not use information technology to locate literature. Another complained that journals were not where they were supposed to be, while another said, Some people do nothing!. These comments reflect one of the down sides of group work, and the difficulties for the novice engaging in research work.
More conspicuous was the students inability to access electronic data bases and on-line journal articles. This was surprising given that the students had plenty of opportunity for this activity and support to learn these skills through free library and information technology orientation classes. Interestingly, research conducted by Telstra (Barker, 2000) found that 33% of Australians have access to the internet at home, and this figure is greater in the higher income bracket and the city. Given that this school serves predominantly middle class Victorians from a metropolitan pool, it was evident that there was still some hesitancy in using computers to access data bases and one can only speculate as to why this was so.
In the initial stages of implementing the journal club students wanted to participate, but some were unsure of how to access and critically appraise the worth of an article and its application to the scenario under study. Indeed, students initially had difficulty determining the difference between a research article and a discussion paper. As the semester progressed, so too did the effectiveness of the club and the confidence of students in learning this way. As a result, students were seen to be more motivated, and came to their facilitated class with quality resources to share with their group that improved the students' knowledge and clinical decision making skills through integrating theory and practice.
Budgetary constraints are still paramount in undergraduate nursing education, however, the journal club incurred no additional expenses for the school to implement (the students had to copy their own articles), popular with students, student-centred, easy to implement across groups and campuses, and did not require the educator to be undergo special training, thus reducing the risk of work-related stress common to contemporary nurse academics (Worrall-Carter, 1998). The journal club promoted active reading of relevant material and exposed students to evidence-based practice and lifelong learning patterns that are surely essential qualities for nurses practicing in health care that is characterised by rapid change.
The major untoward finding of this evaluation was that some students still did not access electronic data bases or on-line journals when they joined the club. However, changes to the sequencing of subjects within the curriculum in 2001 have resulted in the core research unit preceding this unit that utilises the journal club. This has enhanced the effectiveness of the club as students who join the journal club now are better prepared in generic research skills than previous students who participated in the clubs.
The introduction, implementation and evaluation of the journal club reported in this paper highlights the need for innovative and contemporary strategies to meet the needs of PBL in nurse education in an era marked by economic rationalisation. Recommendations for further utility and development of journal clubs in undergraduate nurse education include on-line development of the journal club. This subject exploring the experience of long term illnesses has been developed for on-line delivery in Semester 2, 2001, that includes the journal club process. The journal club within a PBL curriculum at this school has served to promote and reinforce an inquiring mind in the nursing student, which is imperative for confronting the unprecedented rate of change in nursing practice.
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