International Journal of Nursing Practice 2016; 22: 53– 60
RESEARCH PAPER
Primary health-care nurses and Internet health information-seeking: Access, barriers and quality checks Jean Gilmour RN PhD Senior Lecturer, School of Nursing, Massey University, Wellington, New Zealand
Alison Strong RN, MN (Hons) Clinical Nurse Specialist—Heart Failure, Hawke’s Bay District Health Board, Hastings, New Zealand
Helen Chan RN, BHSc (Nursing), MN (Hons) Melbourne, Victoria, Australia
Sue Hanna MA(App) Social Work PhD Senior Lecturer in Social Work, Department of Mental Health, Social Work & Interprofessional Learning, Middlesex University, London, UK
Annette Huntington RN PhD Associate Professor, School of Nursing, Massey University, Wellington, New Zealand
Accepted for publication June 2014 Gilmour J, Strong A, Chan H, Hanna S, Huntington A. International Journal of Nursing Practice 2016; 22: 53– 60 Primary health-care nurses and Internet health information-seeking: Access, barriers and quality checks Online information is a critical resource for evidence-based practice and patient education. This study aimed to establish New Zealand nurses’ access and evaluation of online health information in the primary care context using a postal questionnaire survey; there were 630 respondents from a random sample of 931 nurses. The majority of respondents were satisfied with work access to online information (84.5%, n = 501) and searched for online information at least several times a week (57.5%, n = 343). The major barrier to online information seeking was insufficient time, but 68 respondents had no work online information access. The level of nursing qualification was significantly correlated with computer confidence and information quality checking. A range of information evaluation approaches was used. Most nurses in study accessed and evaluated Internet information in contrast to the findings of earlier studies, but there were barriers preventing universal integration into practice. Key words: information literacy, Internet, nurses, primary health care, survey.
INTRODUCTION Correspondence: Jean Gilmour, School of Nursing, Massey University, Wellington 6021, Private Box 756, New Zealand. Email: [email protected] doi:10.1111/ijn.12361
Nurses are knowledge workers; their ability to select optimum nursing care options for each individual and family is predicated on reference to current evidence and © 2014 Wiley Publishing Asia Pty Ltd
J Gilmour et al.
54
guidelines, analysing individual relevance, and application in an effective and efficient manner.1 The medium of the Internet supports knowledge work activities with fast retrieval of health information to support evidence-based practice and patient education. The enablers of effective Internet use are access to requisite technology, such as computers and mobile platforms for Internet access coupled with information literacy skills. Information literacy requires: (i) judgement that information is needed; (ii) being able to locate information in an efficient and effective manner; (iii) assessment skills to ascertain the value of the information; and (iv) integration of that information as part of a personal knowledge base to achieve desired outcomes in an ethical and legal manner.2 The effective incorporation of online information sources into nursing practice is dependent on ready access to information in time-pressured workplaces, along with quick and accurate evaluation of information utility for care decisions and patient education. In New Zealand, Internet use is approaching a saturation point particularly for the under 40 year olds, and is valued by the public as a more important information resource than other media.3 Nurses have been slow to incorporate online information in their informationseeking activities, given public engagement with this medium. Research studies have pointed out gaps in nurses’ computer literacy skills,4–9 and noted a preferred mode of consulting with colleagues rather than individual searches for information.10–12 Primary health-care (PHC) research has similarly noted issues in computer literacy. In a New Zealand 2004 study, only 17 of 138 practice nurses working in PHC-listed websites they used frequently to access health information.6 A later survey in 2007 with 419 respondents found that one-third of the practice nurses did not access online evidence resources.13 Lack of Internet access can be a barrier with a finding that 20% of practice nurses and district nurses providing diabetes care did not have Internet access.14 These gaps in online information use contrast to the findings of New Zealand research in medical ward settings where almost all nurses replying to a survey had work online access and three-quarters were satisfied with that access.15 However, as with Hoare et al.’s13 earlier study on practice nurses use, 30% of the medical wards nurses infrequently searched for online information.15 The average age of the nursing workforce is presented as a possible explanation to computing skill gaps as many nurses would have been educated prior to computers © 2014 Wiley Publishing Asia Pty Ltd
being part of school education7 (the average age of New Zealand nurses is 45.616 and 44.3 years in Australia17). Nurses working in primary health settings have a major role in providing chronic illness education and support,18,19 along with health promotion activities. Nurses’ information-seeking activities are driven by factors such as the complexity of treatments and choices available, the need to ensure understanding in a context of quite varied health literacy levels,20 and the expanding role of PHC nurses in chronic illness education.21,22 Consequently, given the earlier findings of barriers to information access, we were interested in surveying PHC nurses to identify computer and information literacy issues that might impact on the access and use of online health information in practice.
METHODS Aim The research aim was to establish PHC nurses’ access to online health information, educational preparation for accessing online information, the type of information sought along with search strategies and information evaluation practices.
Design The research approach was a cross-sectional survey using a postal questionnaire. Massey University Human Ethics Committee (Application 09/68) approved the study. Information about the study was attached to the questionnaire and included the statement of respondent anonymity to the researchers. An administrator was responsible for the questionnaire mail out and two follow-up reminder mail outs.
Sample A questionnaire was mailed out to a random sample of 1000 PHC nurses. The sampling frame comprised of the Nursing Council of New Zealand practice categories Primary health care and Practice nursing: nurses select these work categories as part of the annual practising certificate renewal process. There were 4673 practising nurses in these categories at the time of data collection in 2010. We were informed by 39 nurses that they were no longer working in the PHC sector so the final sample was 961 nurses. The survey power was calculated as having an 83% probability of getting statistically significant result with 200 respondents and a 0.2 population correlation based on a 0.05 alpha level.
55
Primary care nurses and Internet information
Questionnaire The study questionnaire was developed from a questionnaire used in previous surveys of postgraduate students23 and medical ward nurses.15 The questionnaire was adapted for PHC use and piloted to check face validity and clarity. Specific questionnaire adaptations for this study included a category, during consultations, for the question on frequency of searching for online information at work and an open question on barriers to online use at work. This paper reports the findings from the first section of the questionnaire on Internet access and evaluation of information. Other sections were on Internet health information use in patient education and heart failure education activities as a specific example of patient education. There were 19 questions in Internet access and evaluation, along with questions collecting demographic data (see Table 1). The first group of questions focused on Table 1 Demographic characteristics Demographic variables
Gender Age
Ethnicity
Highest professional qualification
Work setting
Analysis
N = 630
Female Male Range-years Mean-years SD NZ European Ma¯ori Pacific Other Certificate Diploma Degree PG Certificate PG Diploma Masters General practice Ma¯ori health provider Pacific health provider NGO Plunket Corrections Other
n
%
620 6
99.0 1.0 23–70 49.45 9.274
501 57 11 52 162 94 112 150 65 38 385 54 7 33 18 8 111
access and barriers to Internet use. Questions collecting ordinal data were on frequency of use at home and work, along with confidence with computers. Categorical data were collected on satisfaction with work access, preparation for accessing information and barriers to use (multiple response question). There was also an open-ended question on barriers to use at work. The second group of questions for respondents who accessed online health information covers reasons for accessing the information using ranked order response categories and a multiple response question on search strategies. Questions collecting ordinal data focused on the frequency of finding relevant information, rating of believability of public access online health information, rating of the contribution online information made to patient care, and frequency of information checking by date and provider. The response categories are detailed in Table 2. An open-ended question was asked about ways of assessing the quality of online health information.
80.7 9.2 1.8 8.3 26.1 15.1 18.0 24.2 10.5 6.1 62.5 8.8 1.1 5.4 2.9 1.3 18
NGO, non-government organization; PG, postgraduate; SD, standard deviation; NZ, New Zealand.
The data were analysed using SPSS 20.0 (IBM SPSS Inc., Chicago, IL, USA) for Windows. Summary statistics are presented along with categorical data tests of relationships (Pearson chi-square) and non-parametric data variable correlations (Spearman’s rank correlation coefficient (rs)). The respondent total varies according to the question topic as respondents could choose not to complete questions, and the respondents who did not access online health information (n = 26) are not included in the analysis of questions relating to Internet use. The qualitative data provide illustrative comments to further expand on the quantitative data findings.
RESULTS The response rate was 65.5% with 630 valid responses. The demographic characteristics are detailed in Table 1. The most notable differences with overall nursing workforce are the mainly female group at 99% (92% in overall nursing workforce16); older mean age at 49.45 years (average age of the workforce is 45.616); and ethnic composition with 80.7% New Zealand European and 9.2% Ma¯ori (overall proportion of the New Zealand European total workforce is 68% and Ma¯ori 7%16). The sample matches more closely the overall primary health work force in gender and ethnicity (97% are female, 76% NZ European/Pakeha, 9.8% Ma¯ori16). The respondents had a mean of 25 years of experience working as a nurse and © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Primary Health Nurses and online health information Question
Categories
%
n
Median
Searching for online information at work
4 = During consultations 3 = Every day 2 = Several times a week 1 = Several times a month 0 = Every few months or never 4 = Always 3 = Mostly 2 = Sometimes 1 = Hardly ever 0 = Never 4 = Expert 3 = Confident 2 = Average 1 = Not confident 0 = Terrified 4 = All or almost all 3 = Most 2 = Some 1 = A small amount 0 = None 4 = Strongly agree 3 = Agree 2 = Neutral 1 = Disagree 0 = Strongly disagree 4 = always 3 = Most of the time 2 = Sometimes 1 = Hardly ever 0 = Never 4 = Always 3 = Most of the time 2 = Sometimes 1 = Hardly ever 0 = Never
5.4 16.4 35.7 26.0 16.4 16.5 69.5 12.8 1.2 0 2.6 40.0 51.5 5.3 0.6 2.5 31.6 60.5 5.2 0.2 9.9 47.5 38.6 3.5 0.5 37.5 37.1 14.2 8.2 3.0 24.5 38.2 19.4 12.7 5.2
32 98 213 155 98 99 417 77 7 0 16 251 323 33 4 15 189 362 31 1 59 283 230 21 3 224 222 85 49 18 146 228 116 76 31
2.00
Frequency of finding relevant information
Rating of relationship with computer
Believability of public access online health information
Using online health information improves the way patient care is provided Check who provides the information
Check the date
11.6 years working in the PHC sector. A sizable minority had a postgraduate qualification (40.8%, n = 253). Almost two-thirds of the group (62.5%, n = 385) worked in general practices. The findings showed that 95.9% (n = 604) of the respondents had home or work Internet access, 89.2% (n = 561) had work access and 84.5% (n = 501) were satisfied with that access. Over half the group who accessed Internet health information (57.5%, n = 343) © 2014 Wiley Publishing Asia Pty Ltd
3.00
2.00
2.00
3.00
3.00
3.00
searched for online information at work at least several times per week, with 5.4% using online information during patient consultations (Table 2). Half of the respondents perceived themselves as average in rating their relationship with computers (51.5%, n = 323). There were significant positive correlations between degree of confidence with computers and frequency of work access (rs = 0.298, n = 593, P ≤ 0.001) and level of nursing qualification (rs = 0.242, n = 618, P ≤ 0.001).
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Primary care nurses and Internet information
Figure 1. Barriers to accessing and using online information.
There was a negative correlation between increasing age and confidence (rs = −0.156, n = 622, P ≤ 0.001). There were barriers to online use, with 15.5% (n = 92) of the group using online information unsatisfied with work access and 68 respondents did not have work online access. Figure 1 illustrates the responses to barriers to use: lack of time was by far the most dominant issue. Other major response categories were inadequate computer resources, preferences for other information sources and distrusting the quality of information. Respondents’ comments included: ‘not everyone has passwords, only a few have access’, ‘no internet available for nurses’, ‘avoid perception that we are not busy/doing personal things’ and ‘time/cost/local setup, firewalls/ subscriptions’. A small number of respondents (4.1%, n = 26) did not access online health information at home or work. Educational preparation for accessing online information was predominantly through self-teaching (n = 479), colleagues teaching (n = 234) and as part of tertiary education (n = 206) (could have more than one answer). A minority had specific computer training (n = 74) or were taught by a librarian (n = 63). Only 13 respondents had been taught to access online health information at school. The most frequently listed highest ranked reasons for accessing online information were for information about specific conditions (n = 148) along with quick reference (n = 121). The choice of improving patient care was
ranked the lowest in terms of reasons (n = 19 ranked this choice highest). The most popular search strategies used by respondents were search engines such as Google or Yahoo (n = 553); specialist health professional sites, CINAHL and Pubmed for example (n = 316); and recommendations by others (n = 309). Wikipedia (n = 149) and general public sites (n = 129) were less frequently used (could have more than one answer). Relevant information was found by 86% (n = 516) of the respondents mostly to always. Just over half the respondents (57.4%, n = 342) agreed or strongly agreed that using online information improved patient care delivery, but there were concerns about the quality of online health information (Table 2) and only 34.1% (n = 204) of the respondents believed most or all of public access online health information. The majority (74.6%, n = 446) always or most of the time checked the information provider, and a smaller percentage (62.7%, n = 374) always or most of the time checked the date the information was provided on the site. There were significant negative correlations between higher ratings of the believability of access information and the frequency of date and provider checking (Table 3). Higher qualifications were positively correlated with provider and date checking. Age was not a significant factor in terms of associations with quality checking. The other main methods of checking the quality of online information were: (i) comparison with information from reputable peer-reviewed sources such as bpacnz (an organisation which provides primary health care evidence-based educational material) (129 comments); (ii) critically evaluating information in terms of the evidence and relevance to population group (69 comments); and (iii) discussion with colleagues and following up their recommendations (58 comments).
DISCUSSION Evaluating and using online health information are important elements in PHC nurses’ decision-making practices. Contemporary health care demands independent and responsive action1 requiring empowered and knowledgeable staff. In terms of the resources supporting information seeking, most nurses were satisfied with Internet work access in this study, but a lack of time is an enduring barrier to using online resources at work as has been found in other settings.15,24–26 One study noted that when patients and family were waiting for information, the time spent searching was prohibitive.25 Additionally, 68 © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Correlations (Spearman’s rho) between believability of public access health information, qualification level, age and quality checks Variable
Check provider
Check date
†
Correlation coefficient Sig. (2-tailed) N Correlation coefficient Sig. (2-tailed) N
Believability of public access information
Qualification level
Age
−0.102† 0.013 596 −0.142‡ 0.001 595
0.237‡ < 0.001 592 0.261‡ < 0.001 591
−0.055 0.183 592 −0.027 0.518 519
Correlation is significant at the 0.05 level (2-tailed). ‡ Correlation is significant at the 0.01 level (2-tailed).
respondents (10.8%) had limited or no work access to the Internet in this study which is a similar percentage to a UK study published in 2004.27 This is compared with an earlier New Zealand study, data collected in 2006–2008, which found that over 20% did not have Internet access.16 Insufficient workplace computers were mentioned as a barrier similar to UK findings, where 40% of respondents shared computers with atleast five other colleagues, with little improvement from a survey 3 years before.9 Lack of access is a concern, given the Internet is increasingly the conduit for obtaining the evidence supporting best practice and patient education. In theory, mobile platforms for Internet access with the advent of commonly available wireless technology and affordable tablet computers and smart phones should support Internet access for all healthcare professionals regardless of setting and role.28 Denying nurses the empowerment created through developing an expert knowledge of Internet resources to support patient education is a missed health promotion opportunity. The findings reported in this paper can be compared with a previous survey of medical nurses.15 Results are congruent in access to work computers, computer confidence, level of agreement that online health information improves patient care and frequency of quality checking of online health information. Proportionately, PHC nurses were more frequent users at work (57.5% searched at least several times a week for online health information compared with 39.2% of medical nurses15). A smaller number of PHC respondents (4.1%) did not access online information compared with medical ward respondents (9.6%).15 There were significant positive correlations between higher levels of qualification and computer confidence, along with negative correlations with confidence © 2014 Wiley Publishing Asia Pty Ltd
and increasing age in both studies which are similar findings to other research on correlations with computer literacy.7 Most of the respondents in this study reported checking the quality of online material by currency and author criteria, along with a range of strategies similar to those reported in a research study of how nurses judge the quality of nursing information on the web.29 Wikipedia was identified as a key source of online information for some respondents in this study and the associated medical ward study15 which has also been found in studies of physicians30 and pharmacists.31 This finding stresses the need to develop nurses’ information literacy and evaluation skills. Wikipedia has been a controversial medium for obtaining critical information as anyone can edit information with subsequent concerns about reliability. For example, studies evaluating Wikipedia sources of information on statins32 and dementia33 have found quality concerns with potentially harmful omissions in information. In this study, less than half the respondents had been formally taught computer skills in tertiary education or computer courses, over half rated their computer confidence rated as average or less, and there was an association with age and computer confidence as noted in another study.7 Bond states ‘the development of information literacy has been shown to need to be actively managed not left to chance or by osmosis’ (p. 488).8 Targeted professional development and investment in accessible technology for the sizable group that are not using online resources at work would support Nursing Council of New Zealand competency indicators, such as literacy and computer skills in retrieving data
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Primary care nurses and Internet information
underpinning care delivery, and ensuring consumers have up-to-date information to support informed choice.34 Limitations of this research include the potentially biased nature of the sample. Nurses who use online information are more likely to engage with this study than those who do not. Therefore, the findings could overrepresent nurses with well-developed information-searching skills and information literacy. Further in-depth qualitative research is necessary, focusing on the small but still sizable group (98 respondents in this study) who do not use online resources at work. The exploration of organizational and individual barriers to incorporating online information into nurses’ everyday knowledge work would be useful in informing effective information literacy education programmes in the workplace.
CONCLUSION Information literacy has become increasingly vital for every member of the community with the advent of the Internet and access to large amounts of complex information which must be processed and evaluated. The findings of this study of increasing engagement by nurses with this medium, along with much more readily available access to computer technology are not surprising. However, there are still a group of nurses who have barriers to access to online information at work, as well as a small group who do not use online information at all. The minority of nurses who have not engaged in the medium is concerning, given the ubiquitous nature of the Internet, the importance of being able to base care on the best evidence available, and the need to be cognizant of the education materials freely accessed and used by patients and their families. This study highlights the need for organizations to identify staff information literacy needs and invest in systematic and targeted education for the small group that have not engaged with online information resources.
ACKNOWLEDGEMENTS We thank Dr Steve Humphries for his statistical advice, Rachel Broadbent and Caroline McKinney for their contribution to the questionnaire design, and Helen Wilson, Bernie Leadbitter and Anthony Kippax for the survey administrative support and data entry. The study was funded through a Strategy to Advance Research Grant provided by the New Zealand Tertiary Education Commission. The goal of the grant is to enhance nursing and allied health disciplines research capability.
REFERENCES 1 Snyder-Halpern R, Corcoran-Perry S, Narayan S. Developing clinical practice environments supporting the knowledge work of nurses. Computers in Nursing 2001; 19: 17–26. 2 Association of College and Research Libraries. Information Literacy Competency Standards for Higher Education. 2000. Available from URL: http://www.ala.org/acrl/ standards/informationliteracycompetency. Accessed 21 November 2013. 3 Gibson A, Miller M, Smith P, Bell A, Crothers C. The Internet in New Zealand 2013. Auckland, New Zealand: Institute of Culture, Discourse & Communication, AUT University. 2013. 4 Estabrookes CA, O’Leary KA, Ricker KL, Humphrey CK. The Internet and access to evidence: How are nurses positioned? Journal of Advanced Nursing 2003; 42: 73–81. 5 Gosling AS, Westbrook JI, Spencer R. Nurses’ use of online clinical evidence. Journal of Advanced Nursing 2003; 47: 201– 211. 6 Janes R, Arroll B, Buetow S, Coster G, McCormick R, Hague I. Many North Island rural general practitioners appear not to use Internet websites as a frequent source of health information. New Zealand Family Physician 2004; 31: 239–244. 7 Campbell CJ, McDowell D. Computer literacy of nurses in a community hospital: Where are we today. The Journal of Continuing Education in Nursing 2011; 42: 365–370. 8 Bond C. Surfing or still drowning? Student nurses’ Internet skills. Nurse Education Today 2010; 30: 485–488. 9 Wallis A. Survey explores nurses’ use of e-health tools. Nursing Management 2012; 18: 14–19. 10 O’leary DF, Mhaolrúnaigh SN. Information-seeking behaviour of nurses: Where is information sought and what processes are followed? Journal of Advanced Nursing 2012; 68: 379–390. 11 Dee C, Stanley E. Information-seeking behavior of nursing students and clinical nurses: Implications for health sciences librarians. Journal of Medical Library Association 2005; 93: 213–222. 12 Clarke MA, Belden JL, Koopman RJ et al. Information needs and information-seeking behaviour analysis of primary care physicians and nurses: A literature review. Health Information and Libraries Journal 2013; 30: 178–190. 13 Hoare KJ, Steele J, Ram FS, Arroll B. Evidence-based resources use by practice nurses in the Greater Auckland region of New Zealand. The New Zealand Medical Journal 2008; 121: 51–58. 14 Daly B, Arroll B, Sheridan N, Kenealy T, Scragg R. Characteristics of nurses providing diabetes community and outpatient care in Auckland. Journal of Primary Health Care 2013; 5: 19–27. 15 Gilmour JA, Huntington A, Broadbent R, Strong A, Hawkins M. Nurses’ use of online health information in © 2014 Wiley Publishing Asia Pty Ltd
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medical wards. Journal of Advanced Nursing 2012; 68: 349– 358. Nursing Council of New Zealand. The New Zealand Nursing Workforce: A Profile of Nurse Practitioners, Registered Nurses, Nurse Assistants and Enrolled Nurses 2011. Wellington: Nursing Council of New Zealand, 2011. Australian Institute of Health and Welfare. Nursing and Midwifery Labour Force 2011. National Health Workforce Series Number.2. Cat. No. HWL 48. Canberra: Australian Institute of Health and Welfare, 2011. Heartfield M, Morello A, Harris M et al. e-Learning competency for practice nurses: An evaluation. Australian Journal of Primary Health 2013; 19: 287–291. Henty C, Dickinson A. Practice nurses’ experiences of the Care Plus programme: A qualitative descriptive study. New Zealand Family Physician 2007; 34: 335–338. Ministry of Health. Ko¯rero Ma¯rama: Health Literacy and Ma¯ori Results from the 2006 Adult Literacy and Life Skills Survey. Wellington, New Zealand: Ministry of Health, 2010. Caughey G, Vitry A, Gilbert A, Roughead E. Prevalence of comorbidity of chronic diseases in Australia. BMC Public Health 2008; 8: 221. Randell R, Mitchell N, Thompson C, McCaughan D, Dowding D. From pull to push: Understanding nurses’ information needs. Health Informatics Journal 2009; 15: 75–85. Gilmour JA, Scott SD, Huntington N. Nurses and Internet health information: A questionnaire survey. Journal of Advanced Nursing 2008; 61: 19–28. Gerrish K, Morgan L, Mabbott I et al. Factors influencing use of information technology by nurses and midwives. Practice Development in Health Care 2006; 5: 92–101.
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25 Jones J, Schilling K, Pesut D. Barriers and benefits associated with nurses information seeking related to patient education needs on clinical nursing units. Open Nursing Journal 2011; 5: 24–30. 26 Winters CA, Lee HJ, Besel J et al. Access to and use of research by rural nurses. Rural and Remote Health 2007; 7: 758. 27 Chan T, Brew S, de Lusignan S. Community nursing needs more silver surfers: A questionnaire survey of primary care nurses’ use of information technology. BMC Nursing 2004; 3: 3–4. 28 Duffy M. Tablet technology for nurses. The American Journal of Nursing 2012; 112: 59–64. 29 Cader R. Judging nursing information on the world wide web. Computers, Informatics, Nursing 2013; 31: 66–73. 30 Hughes B, Joshi I, Lemonde H, Wareham J. Junior physician’s use of Web 2.0 for information seeking and medical education: A qualitative study. International Journal of Medical Informatics 2009; 78: 645–655. 31 Brokowski L, Sheehan A. Evaluation of pharmacist use and perception of Wikipedia as a drug information resource. The Annals of Pharmacotherapy 2009; 43: 1912–1913. 32 Kupferberg N, Protus BM. Accuracy and completeness of drug information in Wikipedia: An assessment. Journal of the Medical Library Association 2011; 99: 310–313. 33 Anderson K, Nikzad-Terhune K, Gaugler J. A systematic evaluation of online resources for dementia caregivers. Journal of Consumer Health on the Internet 2009; 13: 1– 13. 34 Nursing Council of New Zealand. Competencies for registered nurses. Wellington: Nursing Council of New Zealand, 2007.
RESEARCH PAPER
Primary health-care nurses and Internet health information-seeking: Access, barriers and quality checks Jean Gilmour RN PhD Senior Lecturer, School of Nursing, Massey University, Wellington, New Zealand
Alison Strong RN, MN (Hons) Clinical Nurse Specialist—Heart Failure, Hawke’s Bay District Health Board, Hastings, New Zealand
Helen Chan RN, BHSc (Nursing), MN (Hons) Melbourne, Victoria, Australia
Sue Hanna MA(App) Social Work PhD Senior Lecturer in Social Work, Department of Mental Health, Social Work & Interprofessional Learning, Middlesex University, London, UK
Annette Huntington RN PhD Associate Professor, School of Nursing, Massey University, Wellington, New Zealand
Accepted for publication June 2014 Gilmour J, Strong A, Chan H, Hanna S, Huntington A. International Journal of Nursing Practice 2016; 22: 53– 60 Primary health-care nurses and Internet health information-seeking: Access, barriers and quality checks Online information is a critical resource for evidence-based practice and patient education. This study aimed to establish New Zealand nurses’ access and evaluation of online health information in the primary care context using a postal questionnaire survey; there were 630 respondents from a random sample of 931 nurses. The majority of respondents were satisfied with work access to online information (84.5%, n = 501) and searched for online information at least several times a week (57.5%, n = 343). The major barrier to online information seeking was insufficient time, but 68 respondents had no work online information access. The level of nursing qualification was significantly correlated with computer confidence and information quality checking. A range of information evaluation approaches was used. Most nurses in study accessed and evaluated Internet information in contrast to the findings of earlier studies, but there were barriers preventing universal integration into practice. Key words: information literacy, Internet, nurses, primary health care, survey.
INTRODUCTION Correspondence: Jean Gilmour, School of Nursing, Massey University, Wellington 6021, Private Box 756, New Zealand. Email: [email protected] doi:10.1111/ijn.12361
Nurses are knowledge workers; their ability to select optimum nursing care options for each individual and family is predicated on reference to current evidence and © 2014 Wiley Publishing Asia Pty Ltd
J Gilmour et al.
54
guidelines, analysing individual relevance, and application in an effective and efficient manner.1 The medium of the Internet supports knowledge work activities with fast retrieval of health information to support evidence-based practice and patient education. The enablers of effective Internet use are access to requisite technology, such as computers and mobile platforms for Internet access coupled with information literacy skills. Information literacy requires: (i) judgement that information is needed; (ii) being able to locate information in an efficient and effective manner; (iii) assessment skills to ascertain the value of the information; and (iv) integration of that information as part of a personal knowledge base to achieve desired outcomes in an ethical and legal manner.2 The effective incorporation of online information sources into nursing practice is dependent on ready access to information in time-pressured workplaces, along with quick and accurate evaluation of information utility for care decisions and patient education. In New Zealand, Internet use is approaching a saturation point particularly for the under 40 year olds, and is valued by the public as a more important information resource than other media.3 Nurses have been slow to incorporate online information in their informationseeking activities, given public engagement with this medium. Research studies have pointed out gaps in nurses’ computer literacy skills,4–9 and noted a preferred mode of consulting with colleagues rather than individual searches for information.10–12 Primary health-care (PHC) research has similarly noted issues in computer literacy. In a New Zealand 2004 study, only 17 of 138 practice nurses working in PHC-listed websites they used frequently to access health information.6 A later survey in 2007 with 419 respondents found that one-third of the practice nurses did not access online evidence resources.13 Lack of Internet access can be a barrier with a finding that 20% of practice nurses and district nurses providing diabetes care did not have Internet access.14 These gaps in online information use contrast to the findings of New Zealand research in medical ward settings where almost all nurses replying to a survey had work online access and three-quarters were satisfied with that access.15 However, as with Hoare et al.’s13 earlier study on practice nurses use, 30% of the medical wards nurses infrequently searched for online information.15 The average age of the nursing workforce is presented as a possible explanation to computing skill gaps as many nurses would have been educated prior to computers © 2014 Wiley Publishing Asia Pty Ltd
being part of school education7 (the average age of New Zealand nurses is 45.616 and 44.3 years in Australia17). Nurses working in primary health settings have a major role in providing chronic illness education and support,18,19 along with health promotion activities. Nurses’ information-seeking activities are driven by factors such as the complexity of treatments and choices available, the need to ensure understanding in a context of quite varied health literacy levels,20 and the expanding role of PHC nurses in chronic illness education.21,22 Consequently, given the earlier findings of barriers to information access, we were interested in surveying PHC nurses to identify computer and information literacy issues that might impact on the access and use of online health information in practice.
METHODS Aim The research aim was to establish PHC nurses’ access to online health information, educational preparation for accessing online information, the type of information sought along with search strategies and information evaluation practices.
Design The research approach was a cross-sectional survey using a postal questionnaire. Massey University Human Ethics Committee (Application 09/68) approved the study. Information about the study was attached to the questionnaire and included the statement of respondent anonymity to the researchers. An administrator was responsible for the questionnaire mail out and two follow-up reminder mail outs.
Sample A questionnaire was mailed out to a random sample of 1000 PHC nurses. The sampling frame comprised of the Nursing Council of New Zealand practice categories Primary health care and Practice nursing: nurses select these work categories as part of the annual practising certificate renewal process. There were 4673 practising nurses in these categories at the time of data collection in 2010. We were informed by 39 nurses that they were no longer working in the PHC sector so the final sample was 961 nurses. The survey power was calculated as having an 83% probability of getting statistically significant result with 200 respondents and a 0.2 population correlation based on a 0.05 alpha level.
55
Primary care nurses and Internet information
Questionnaire The study questionnaire was developed from a questionnaire used in previous surveys of postgraduate students23 and medical ward nurses.15 The questionnaire was adapted for PHC use and piloted to check face validity and clarity. Specific questionnaire adaptations for this study included a category, during consultations, for the question on frequency of searching for online information at work and an open question on barriers to online use at work. This paper reports the findings from the first section of the questionnaire on Internet access and evaluation of information. Other sections were on Internet health information use in patient education and heart failure education activities as a specific example of patient education. There were 19 questions in Internet access and evaluation, along with questions collecting demographic data (see Table 1). The first group of questions focused on Table 1 Demographic characteristics Demographic variables
Gender Age
Ethnicity
Highest professional qualification
Work setting
Analysis
N = 630
Female Male Range-years Mean-years SD NZ European Ma¯ori Pacific Other Certificate Diploma Degree PG Certificate PG Diploma Masters General practice Ma¯ori health provider Pacific health provider NGO Plunket Corrections Other
n
%
620 6
99.0 1.0 23–70 49.45 9.274
501 57 11 52 162 94 112 150 65 38 385 54 7 33 18 8 111
access and barriers to Internet use. Questions collecting ordinal data were on frequency of use at home and work, along with confidence with computers. Categorical data were collected on satisfaction with work access, preparation for accessing information and barriers to use (multiple response question). There was also an open-ended question on barriers to use at work. The second group of questions for respondents who accessed online health information covers reasons for accessing the information using ranked order response categories and a multiple response question on search strategies. Questions collecting ordinal data focused on the frequency of finding relevant information, rating of believability of public access online health information, rating of the contribution online information made to patient care, and frequency of information checking by date and provider. The response categories are detailed in Table 2. An open-ended question was asked about ways of assessing the quality of online health information.
80.7 9.2 1.8 8.3 26.1 15.1 18.0 24.2 10.5 6.1 62.5 8.8 1.1 5.4 2.9 1.3 18
NGO, non-government organization; PG, postgraduate; SD, standard deviation; NZ, New Zealand.
The data were analysed using SPSS 20.0 (IBM SPSS Inc., Chicago, IL, USA) for Windows. Summary statistics are presented along with categorical data tests of relationships (Pearson chi-square) and non-parametric data variable correlations (Spearman’s rank correlation coefficient (rs)). The respondent total varies according to the question topic as respondents could choose not to complete questions, and the respondents who did not access online health information (n = 26) are not included in the analysis of questions relating to Internet use. The qualitative data provide illustrative comments to further expand on the quantitative data findings.
RESULTS The response rate was 65.5% with 630 valid responses. The demographic characteristics are detailed in Table 1. The most notable differences with overall nursing workforce are the mainly female group at 99% (92% in overall nursing workforce16); older mean age at 49.45 years (average age of the workforce is 45.616); and ethnic composition with 80.7% New Zealand European and 9.2% Ma¯ori (overall proportion of the New Zealand European total workforce is 68% and Ma¯ori 7%16). The sample matches more closely the overall primary health work force in gender and ethnicity (97% are female, 76% NZ European/Pakeha, 9.8% Ma¯ori16). The respondents had a mean of 25 years of experience working as a nurse and © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Primary Health Nurses and online health information Question
Categories
%
n
Median
Searching for online information at work
4 = During consultations 3 = Every day 2 = Several times a week 1 = Several times a month 0 = Every few months or never 4 = Always 3 = Mostly 2 = Sometimes 1 = Hardly ever 0 = Never 4 = Expert 3 = Confident 2 = Average 1 = Not confident 0 = Terrified 4 = All or almost all 3 = Most 2 = Some 1 = A small amount 0 = None 4 = Strongly agree 3 = Agree 2 = Neutral 1 = Disagree 0 = Strongly disagree 4 = always 3 = Most of the time 2 = Sometimes 1 = Hardly ever 0 = Never 4 = Always 3 = Most of the time 2 = Sometimes 1 = Hardly ever 0 = Never
5.4 16.4 35.7 26.0 16.4 16.5 69.5 12.8 1.2 0 2.6 40.0 51.5 5.3 0.6 2.5 31.6 60.5 5.2 0.2 9.9 47.5 38.6 3.5 0.5 37.5 37.1 14.2 8.2 3.0 24.5 38.2 19.4 12.7 5.2
32 98 213 155 98 99 417 77 7 0 16 251 323 33 4 15 189 362 31 1 59 283 230 21 3 224 222 85 49 18 146 228 116 76 31
2.00
Frequency of finding relevant information
Rating of relationship with computer
Believability of public access online health information
Using online health information improves the way patient care is provided Check who provides the information
Check the date
11.6 years working in the PHC sector. A sizable minority had a postgraduate qualification (40.8%, n = 253). Almost two-thirds of the group (62.5%, n = 385) worked in general practices. The findings showed that 95.9% (n = 604) of the respondents had home or work Internet access, 89.2% (n = 561) had work access and 84.5% (n = 501) were satisfied with that access. Over half the group who accessed Internet health information (57.5%, n = 343) © 2014 Wiley Publishing Asia Pty Ltd
3.00
2.00
2.00
3.00
3.00
3.00
searched for online information at work at least several times per week, with 5.4% using online information during patient consultations (Table 2). Half of the respondents perceived themselves as average in rating their relationship with computers (51.5%, n = 323). There were significant positive correlations between degree of confidence with computers and frequency of work access (rs = 0.298, n = 593, P ≤ 0.001) and level of nursing qualification (rs = 0.242, n = 618, P ≤ 0.001).
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Figure 1. Barriers to accessing and using online information.
There was a negative correlation between increasing age and confidence (rs = −0.156, n = 622, P ≤ 0.001). There were barriers to online use, with 15.5% (n = 92) of the group using online information unsatisfied with work access and 68 respondents did not have work online access. Figure 1 illustrates the responses to barriers to use: lack of time was by far the most dominant issue. Other major response categories were inadequate computer resources, preferences for other information sources and distrusting the quality of information. Respondents’ comments included: ‘not everyone has passwords, only a few have access’, ‘no internet available for nurses’, ‘avoid perception that we are not busy/doing personal things’ and ‘time/cost/local setup, firewalls/ subscriptions’. A small number of respondents (4.1%, n = 26) did not access online health information at home or work. Educational preparation for accessing online information was predominantly through self-teaching (n = 479), colleagues teaching (n = 234) and as part of tertiary education (n = 206) (could have more than one answer). A minority had specific computer training (n = 74) or were taught by a librarian (n = 63). Only 13 respondents had been taught to access online health information at school. The most frequently listed highest ranked reasons for accessing online information were for information about specific conditions (n = 148) along with quick reference (n = 121). The choice of improving patient care was
ranked the lowest in terms of reasons (n = 19 ranked this choice highest). The most popular search strategies used by respondents were search engines such as Google or Yahoo (n = 553); specialist health professional sites, CINAHL and Pubmed for example (n = 316); and recommendations by others (n = 309). Wikipedia (n = 149) and general public sites (n = 129) were less frequently used (could have more than one answer). Relevant information was found by 86% (n = 516) of the respondents mostly to always. Just over half the respondents (57.4%, n = 342) agreed or strongly agreed that using online information improved patient care delivery, but there were concerns about the quality of online health information (Table 2) and only 34.1% (n = 204) of the respondents believed most or all of public access online health information. The majority (74.6%, n = 446) always or most of the time checked the information provider, and a smaller percentage (62.7%, n = 374) always or most of the time checked the date the information was provided on the site. There were significant negative correlations between higher ratings of the believability of access information and the frequency of date and provider checking (Table 3). Higher qualifications were positively correlated with provider and date checking. Age was not a significant factor in terms of associations with quality checking. The other main methods of checking the quality of online information were: (i) comparison with information from reputable peer-reviewed sources such as bpacnz (an organisation which provides primary health care evidence-based educational material) (129 comments); (ii) critically evaluating information in terms of the evidence and relevance to population group (69 comments); and (iii) discussion with colleagues and following up their recommendations (58 comments).
DISCUSSION Evaluating and using online health information are important elements in PHC nurses’ decision-making practices. Contemporary health care demands independent and responsive action1 requiring empowered and knowledgeable staff. In terms of the resources supporting information seeking, most nurses were satisfied with Internet work access in this study, but a lack of time is an enduring barrier to using online resources at work as has been found in other settings.15,24–26 One study noted that when patients and family were waiting for information, the time spent searching was prohibitive.25 Additionally, 68 © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Correlations (Spearman’s rho) between believability of public access health information, qualification level, age and quality checks Variable
Check provider
Check date
†
Correlation coefficient Sig. (2-tailed) N Correlation coefficient Sig. (2-tailed) N
Believability of public access information
Qualification level
Age
−0.102† 0.013 596 −0.142‡ 0.001 595
0.237‡ < 0.001 592 0.261‡ < 0.001 591
−0.055 0.183 592 −0.027 0.518 519
Correlation is significant at the 0.05 level (2-tailed). ‡ Correlation is significant at the 0.01 level (2-tailed).
respondents (10.8%) had limited or no work access to the Internet in this study which is a similar percentage to a UK study published in 2004.27 This is compared with an earlier New Zealand study, data collected in 2006–2008, which found that over 20% did not have Internet access.16 Insufficient workplace computers were mentioned as a barrier similar to UK findings, where 40% of respondents shared computers with atleast five other colleagues, with little improvement from a survey 3 years before.9 Lack of access is a concern, given the Internet is increasingly the conduit for obtaining the evidence supporting best practice and patient education. In theory, mobile platforms for Internet access with the advent of commonly available wireless technology and affordable tablet computers and smart phones should support Internet access for all healthcare professionals regardless of setting and role.28 Denying nurses the empowerment created through developing an expert knowledge of Internet resources to support patient education is a missed health promotion opportunity. The findings reported in this paper can be compared with a previous survey of medical nurses.15 Results are congruent in access to work computers, computer confidence, level of agreement that online health information improves patient care and frequency of quality checking of online health information. Proportionately, PHC nurses were more frequent users at work (57.5% searched at least several times a week for online health information compared with 39.2% of medical nurses15). A smaller number of PHC respondents (4.1%) did not access online information compared with medical ward respondents (9.6%).15 There were significant positive correlations between higher levels of qualification and computer confidence, along with negative correlations with confidence © 2014 Wiley Publishing Asia Pty Ltd
and increasing age in both studies which are similar findings to other research on correlations with computer literacy.7 Most of the respondents in this study reported checking the quality of online material by currency and author criteria, along with a range of strategies similar to those reported in a research study of how nurses judge the quality of nursing information on the web.29 Wikipedia was identified as a key source of online information for some respondents in this study and the associated medical ward study15 which has also been found in studies of physicians30 and pharmacists.31 This finding stresses the need to develop nurses’ information literacy and evaluation skills. Wikipedia has been a controversial medium for obtaining critical information as anyone can edit information with subsequent concerns about reliability. For example, studies evaluating Wikipedia sources of information on statins32 and dementia33 have found quality concerns with potentially harmful omissions in information. In this study, less than half the respondents had been formally taught computer skills in tertiary education or computer courses, over half rated their computer confidence rated as average or less, and there was an association with age and computer confidence as noted in another study.7 Bond states ‘the development of information literacy has been shown to need to be actively managed not left to chance or by osmosis’ (p. 488).8 Targeted professional development and investment in accessible technology for the sizable group that are not using online resources at work would support Nursing Council of New Zealand competency indicators, such as literacy and computer skills in retrieving data
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underpinning care delivery, and ensuring consumers have up-to-date information to support informed choice.34 Limitations of this research include the potentially biased nature of the sample. Nurses who use online information are more likely to engage with this study than those who do not. Therefore, the findings could overrepresent nurses with well-developed information-searching skills and information literacy. Further in-depth qualitative research is necessary, focusing on the small but still sizable group (98 respondents in this study) who do not use online resources at work. The exploration of organizational and individual barriers to incorporating online information into nurses’ everyday knowledge work would be useful in informing effective information literacy education programmes in the workplace.
CONCLUSION Information literacy has become increasingly vital for every member of the community with the advent of the Internet and access to large amounts of complex information which must be processed and evaluated. The findings of this study of increasing engagement by nurses with this medium, along with much more readily available access to computer technology are not surprising. However, there are still a group of nurses who have barriers to access to online information at work, as well as a small group who do not use online information at all. The minority of nurses who have not engaged in the medium is concerning, given the ubiquitous nature of the Internet, the importance of being able to base care on the best evidence available, and the need to be cognizant of the education materials freely accessed and used by patients and their families. This study highlights the need for organizations to identify staff information literacy needs and invest in systematic and targeted education for the small group that have not engaged with online information resources.
ACKNOWLEDGEMENTS We thank Dr Steve Humphries for his statistical advice, Rachel Broadbent and Caroline McKinney for their contribution to the questionnaire design, and Helen Wilson, Bernie Leadbitter and Anthony Kippax for the survey administrative support and data entry. The study was funded through a Strategy to Advance Research Grant provided by the New Zealand Tertiary Education Commission. The goal of the grant is to enhance nursing and allied health disciplines research capability.
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