1. A prespecified question 
2. Defined inclusion and exclusion criteria
3. An extensive literature search that includes international research
4. Selection of studies based on the inclusion criteria
5. Assessment of the quality of the included studies
6. Extraction of the data
7. Analysis of the data
8. Presentation of the results
9. Interpretation of the results

The debate over standardization of nursing uniforms is well-documented, however, the existence of rigorous, well-designed studies is lacking. In the latest issue of JONA, Journal of Nursing Administration, an integrative review examining the professional appearance of RNs examines the evidence. While the strength of the evidence is low, it is essential for us to recognize the importance of patients being able to identify us as nurses and to understand how our attire impacts the public’s perception of our knowledge and skills.

Seven studies were included in this review and a nice table comparing each of the studies can be found in this supplemental digital content. One study found that among nurses, students, and patients, solid color scrubs reflect more skills and knowledge than print scrubs or T-shirt tops. Another study, which looked at uniform color preference among patients, found blue or white to be most preferred, while red was least preferred. Take a close look at this table to learn more about how both patients and nurses feel that uniform and general appearance impact perception. It’s pretty interesting.

Is there a standard uniform for nursing staff where you work?

Reference:
Cassidy, C., Del Guidice, M., Hatfield, L., Pearce, M., Polomano, R., Samoyan, J. (2013). The Professional Appearance of Registered Nurses: An Integrative Review of Peer-Refereed Studies. JONA, Journal of Nursing Administration, 42(2).

We know that evidence-based practice (EBP) leads to improved patient outcomes. Yet it is also known that nurses identify barriers to implementing evidence-based practice, such as lack of knowledge, support, time, and authority to change practice (O'Nan, 2011). Change can be difficult, but as nurses it is our responsibility to our patients and our profession to develop and implement activities that promote evidence-based practice. One such activity that can help us overcome barriers and incorporate research findings into practice is a journal club. A journal club can be described as “the sharing of contemporary knowledge and appraising the value of that knowledge for applications in clinical practice” (Duffy, Elpers, Hobbs, Niemeyer-Hacket, & Thompson, 2011).

What are the benefits of a journal club?

• Sharing knowledge of current clinical research
• Facilitating the learning process
• Enhancing literature critique and appraisal skills
• Encouraging interaction and dialogue with other nurses
• Encouraging research utilization
• Promoting team building
• Promoting EBP in a cost-effective manner

What are the steps for starting a journal club?

• Decide if the journal club will be unit-based or hospital-wide.
• Gain the support of unit managers or senior nursing administration.  Be prepared to discuss the benefits, objectives, scope of work, timetable, and key stakeholders (Chabot, et al., 2011).
• Determine meeting schedule and length.
• Identify a leader/facilitator.
• Identify the topic of interest.
• Select and disseminate article(s).
• Hold meeting and discuss the topic/appraise the evidence.
• Determine if further research or action is needed.

You can learn more by reading the articles referenced below. There are great ideas to help you get started and also to determine the best schedule for your group, the roles and responsibilities of the facilitator and members, and how to evaluate your group’s success. Also, consider the use of an online journal club or use of the tools available from the Joanna Briggs Institute to help you appraise the evidence. Good luck!

References:

Chabot, J., Conners, S., DeNigris, J., Dunn, R., Panzera, A., & Patel, P. (2011). Evidence-Based Practice and a Nursing Journal Club: An Equation for Positive Patient Outcomes and Nursing Empowerment. Journal for Nurses in Staff Development, 227-230. 

Duffy, J., Elpers, S., Hobbs, T., Niemeyer-Hacket, N., & Thompson, D. (2011). Evidence-Based Nursing Leadership: Evaluation of a Joint Academic-Service Journal Club. JONA: Journal of Nursing Administration, 422-427.

O'Nan, C. (2011). The Effect of a Journal Club on Perceived Barriers to the Utilization of Nursing Research in a Practice Setting. Journal for Nurses in Staff Development, 160-164. 

Systematic reviews, especially with meta-analysis, are often considered scholarly works at the top of the pyramid (See the Oxford Centre for Evidence-Based Medicine for example.) This is because they typically combine randomized controlled trials (RCTs) that may be limited by small sample sizes, enabling stronger conclusions to be better derived.  Yet, this seemingly golden offering of scholarly literature may have its limitations. 

A systematic review by Boyd, Quigley, and Brocklehurst (2007) on donor breast milk for preterm infants compared to formula is a frequently quoted reference on the subject. The seven studies examined included five randomized controlled trials. The section of the review that receives the most ongoing attention in the literature is the combined effects of three of the studies by meta-analysis on the variable of confirmed necrotizing enterocolitis (NEC), a complication of high concern in premature infants. This analysis combined two RCTs and one observational study. Separately, the sample sizes for these studies ranged from 39 to 162; the combined sample size became 268.  Individual study results did not meet the minimal level of statistical significance of p=0.05. Combined evidence from these studies created a relative risk (RR) of 0.21, 95% CI of 0.06-0.76, p=0.017. The conclusion was that donor milk reduces NEC by about 79% compared to formula. At face value, this is an enticing result. Why the worry?

The concerns with this analysis are partially acknowledged by the authors. The articles used for this study are dated no later than the early 1980’s with data from the 1970’s and the beginning of the 1980’s. Babies included in the studies were 30-33 weeks of age and 1310-1954g, much larger than the premature infant surviving today in our neonatal intensive care units. These studies involved non-fortified milk and exclusive feeding of the control and treatment groups. This too is contrary to today’s practices as fortification is much more the standard practice now. 

One of the authors (Quigley) went on to perform an updated review. This review (Quigley, Henderson, Anthony, McGuire, 2007) is published in the Cochrane Database of Systematic Reviews, a much revered source of scholarly literature. Here five studies were combined in meta-analysis with the addition of a more recent study (Schanler, 2005) of sizeable impact. Unlike several of the other comparisons in this document, the heterogeneity is assessed to be low (I2 of 0.00%) and results favored donor breast milk, with a RR of 2.46, 95% CI 1.19-5.08, p=0.015. This confidence interval was much better than some of the singular studies that reported such wide variances as 0.11 to 60.38. Yet, more limitations exist in this review. Growth restricted preterm infants that are already at high risk for NEC were noted here as excluded.  Again, many of the studies came from the pool described in the article by Boyd and colleagues and infant size and age along with the fortification issue remain. Preparation of the donor milk may also have differed in the early studies compared to today. In summary, the golden scholarly product is tarnished. 

A final note is that evidence reviews cannot end with the statistical analysis. Donor milk costs $3.50 per ounce or more via standard milk banks.  Cost effectiveness needs to be evaluated in order to make this costly recommendation. Given the limitations of the literature and the cost involved, a local team of experts decided against widespread adoption of donor breast milk for premature infants. 

References:

Boyd, C. A., Quigley, M. A., & Brocklehurst, P. (2007).  Donor breast milk versus infant formula for preterm infants:  Systematic review and meta-analysis.  Archives of Diseases in Childhood, Fetal and Neonatal Edition, 92, F169-F175.  doi:  10.1136/adc.2005.089490

Quigley, M., Henerson, G., Anthony, M. Y., McGuire, W.  (2008).  Formula milk versus donor breast milk for feeding preterm or low birth weight infants.  Cochrane Database of Systematic Review 2007, Issue 4.  Art. No.:  CD002971.  doi:  10.1002/14651858.CD002971, pub2

Submitted by: 
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System
www.meridianiebc.com