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Nurses’ use of computer databases to identify evidence for practice—a cross-sectional questionnaire survey in a UK hospital Blackwell Science, Ltd

Peter Griffiths* & Lucy Riddington†, *Lecturer, Florence Nightingale School of Nursing & Midwifery, King’s College London, and †Staff Nurse, St George’s Health Care NHS Trust (formerly student nurse, Florence Nightingale School of Nursing & Midwifery)

Abstract The objectives of this study were to determine nurses’ use of electronic databases to inform practice. A questionnaire survey of 114 nurses working on five acute wards in a large inner city teaching hospital investigated their general use of computers and the three databases, ,  and the Cochrane Library. Eighty-two qualified nurses responded (response rate 72%). The results show limited confidence and low frequency in using the databases. Thirty-four per cent expressed low confidence using . Twentyseven per cent used  on a regular basis. Twenty-two per cent never used it. Eighteen per cent were unaware that it was available locally. Knowledge and use of  was even lower with only 18% using it regularly. Knowledge of the Cochrane Library was extremely limited, with 75% unaware of its existence. Use of a home computer and higher education were associated with higher frequency of use of  and . If nurses are to make use of electronic resources to contribute to evidencebased practice, effort needs to be put into ensuring that already qualified nurses have basic computer skills and specific knowledge of available resources. More emphasis should be placed on ‘evidence-based’ resources, such as the Cochrane library, as sources of information for practice.

Background One of the major planks of evidence-based practice is the use of electronic means to allow practitioners to access up-to-date clinical information.1 The use of information technology to deliver current, research-based and accurate clinical information has been a repeated theme in discussions of health service developments throughout the 1990s Correspondence: Peter Griffiths, Florence Nightingale School of Nursing & Midwifery, King’s College London, Waterloo Road, London SE19 2QU, UK. E-mail [email protected]

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and seems set to continue. A series of UK policy documents have highlighted the importance of developing information technology for the benefit of patients and clinicians alike.2,3 This study set out to explore nurses’ use of information technology to obtain information for practice. It focused on the use of two of the most widely available bibliographic databases ( and ) and the Cochrane Library, a source of critically appraised evidence of effectiveness, which contains a number of databases and full text of systematic reviews.

© Blackwell Science Ltd 2001 Health Information and Libraries Journal, 18, pp.2 – 9


Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington In the UK, the National Health Service’s research and development strategy places emphasis on a variety of electronic means for the dissemination of research findings2 and its information strategy clearly identifies electronic transmission of information to support clinical decisions as a goal.3 It is clear that in a ‘knowledge-based health service’ much information will be delivered electronically. Because the evidence-based health care movement has largely rejected the textbook as a source of upto-date clinical knowledge4 it becomes increasingly important that nurses are able to use electronic means to access up-to-date clinical information.5 While the personal library of research articles gleaned from journals is recognized as important4 such libraries can only ever provide answers to a small proportion of questions emerging in practice. At best they are likely to only answer questions the practitioner has asked already. Bibliographic databases that provide ready access to citations and abstracts of primary research and reviews are advocated as a prime resource to answer questions that come up in everyday clinical practice.6 Access to and skills in using electronic information resources are seen as key facilitators for researchbased practice.5  is the largest and most well-known bibliographic database of health care literature,1 while the largest and most well-known specialist international database of literature in nursing is . In addition to the traditional bibliographic database, a number of resources offer direct accesses to high quality critically appraised summaries of research evidence.7 Probably the most comprehensive of these is the Cochrane Library, which contains the full text of high quality systematic reviews (the Cochrane Database of Systematic Reviews) in addition to other databases of high quality research evidence on the effectiveness of health care.8 It is produced under the aegis of the UK Cochrane centre, a key part of the NHS research and development strategy2 and aims to provide access to the evidence ‘which is needed to make informed health care decisions’ (p. 34). In the UK an evaluation of the effects of the reforms of nursing education revealed that 92% of those trained to diploma (associate degree) level felt adequately prepared to utilize libraries to access research-based materials, although the means they

would use to access them were not specified.9 Nurses certainly can make use of such electronic resources for their practice. A Canadian study10 evaluated the use of electronic literature search and retrieval by nurses in the hospital work environment. A computerized literature search and retrieval system was installed on a selected hospital unit. Thirty-three nurses were taught how to use six CD-ROM bibliographic and full-text databases (including  and ), electronically request articles from the librarian and to critique the literature. After training, nurses successfully answered questions related to patient care, general health issues and education courses using the system. Over 6 months the nurses attempted 192 searches of which 160 were completed to the point of answering the question. The knowledge gained appeared to be of value in practice. Nurses spoke of being able to answer clients’ questions better. They also spoke of feeling more confident in their responses when patients developed symptoms and side-effects that they had read about. In the UK, the Front Line Evidence-based Medicine Project11 placed great emphasis on the provision of access to a range of databases. The two databases universally provided as part of the project were  and the Cochrane Library. For 11 participating medical firms and associated multidisciplinary teams at least one ward-based terminal was provided. The project identified some success in promoting evidence-based practice, but even with specific resources and training provided as part of the project, a lack of basic computer skills and training in literature searching proved major obstacles for ward-based staff. An additional obstacle for nurses was the project’s failure to provide a database directly identified with their own clinical speciality. As with many areas of health care it is less clear whether electronic resources are used in day to day practice. In the UK only 27% of midwives working in two labour wards made use of a computer installed with the Cochrane Pregnancy and Childbirth Database (the precursor to the Cochrane Database of Systematic Reviews) to inform practice.12 Overall, midwives claimed to have a positive attitude towards information technology, but said they did not have the requisite computer skills to use these tools.

© Blackwell Science Ltd 2001 Health Information and Libraries Journal, 18, pp.2 –9

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Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington All the studies of database utilization identified here have generally examined the use of wardbased computers, which are not the norm in the UK. In addition, the only study that specifically focused on nursing staff examined the effect of training and support. This study aims to examine the use of electronic databases in normal practice among general nursing staff in a UK hospital.

(39%, n = 32) and admitting and discharging patients (20%, n = 16). Nurses also use the computer for preparing the duty-roster (17%, n = 14), for e-mail (15%, n = 12) and accessing the Internet (12%, n = 10). Fifty-two per cent (n = 43) of the sample use a computer at home, mostly for word processing (50%, n = 41), the Internet (18%, n = 15) and e-mail (16%, n = 13). Only 15% (n = 12) reported using their computer at home for finding professional literature.

Methods A sample of registered nurses was selected from five wards at a large inner city teaching hospital in the UK. The five wards included care of the elderly, medical oncology, cardiac surgery, orthopaedic surgery and intensive therapy. The range of wards was chosen to give a broad spectrum of specialities. All staff were asked to participate, except on the ICU a sample representative of the grade mix was selected from the ward duty roster. Data were collected using a structured questionnaire containing 19 closed questions, which elicited information concerning the use of computers. The questionnaire included questions about knowledge, confidence and frequency of use for the databases ,  and the Cochrane Library. The selection of these three databases adds a specialized nursing database to the two core resources used in the Front Line Evidence-based Medicine Project. All are available at the on-site health care library but not on the wards.

Results Out of the 114 questionnaires distributed, there were 82 qualified nurse respondents, giving a response rate of 72%. Junior staff (D and E grades) made up 67% of the sample (n = 55). Senior staff (grades F, G, H and I ) made up 33% (n = 27) of the sample. Twenty per cent (n = 16) had completed a first degree and 35% (n = 31) were currently undertaking a post-registration course at a higher education institution. Of these, five were undertaking a first degree and one a Masters degree. Ninety-six per cent (n = 79) use a computer at work. The most frequent use is obtaining laboratory results (70%, n = 57), followed by word processing (49%, n = 40), finding professional literature

Use of the databases Sixty-six per cent said they were confident or very confident using  and 55% confident or very confident in using . However large numbers expressed a lack of confidence or had never heard of the databases. In the case of  a total of 45% of the nurses fell into one of these categories (Table 1). Six of the sample (7%) claimed not to have heard of  and 13 (16%) had not heard of .  was the most frequently used database, but only 27% of nurses reported its use on a regular (monthly or more frequent) basis. Twenty-two per cent reported never using it. Only 18% used  on a regular basis and 28% reported never using it (Table 1). Although most nurses (correctly) identified that the databases were available in the on-site library, a large number either did not know or thought they were not available. In the case of  18% were unaware of availability. For  26% were unaware. A very different picture emerges for the Cochrane library (Table 1). The majority of nurses (87%) were very unconfident using it or had not heard of it. Those who had not heard of the database were prevalent, making up 76% (n = 62) of the sample in total. Most (89%) never used it; none used it as often as monthly and only 9% were able to correctly identify that it was available locally (Table 1). Factors related to knowledge confidence and use For  and  junior staff were slightly more likely to use databases regularly but were also more likely to never use the databases. However, this apparent relationship was not statistically



Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington Table 1 Confidence, knowledge and frequency of use of databases.

Database

Confidence

Very Unconfident/have never heard of the database

Unconfident in using database

CINAHL

n % n % n %

18 22 22 27 71 87

10 12 15 18 6 7

Frequency of use

Never use the database

Use the database less than monthly

n % n % n %

18 22 23 28 73 89

42 51 44 54 9 11

Knowledge of local availability

Do not know the availability

Know the availability

All

n % n % n %

15 18 21 26 75 91

67 82 61 74 7 9

82 100 82 100 82 100

MEDLINE

Cochrane

CINAHL

Cochrane

CINAHL

MEDLINE

Cochrane

significant (Table 2). There is certainly no basis on which to conclude that senior staff are more likely to access databases regularly. Those with some past or current experience of higher education were more likely to use  regularly (P < 0.05). This relationship appears to be replicated in the use of  (although it is not statistically significant), but not in the use of the Cochrane Library where levels of use are universally low. Only 9% of those with higher educational experience (HE) and 10% of others ever use the Cochrane Library (Table 3). Use of a computer at home appeared to be strongly predictive of a higher frequency of use of databases (Table 4). Those who used a computer a home were three times more likely to use  regularly (40% vs. 13%, P < 0.05) and six times more likely to use  regularly (30% vs. 5%, P < 0.05). Although not significant, those who used

Very confident/confident in using the database 54 66 45 55 5 6 Use the database weekly/monthly 22 27 15 18 0 0

All 82 100 82 100 82 100

All 82 100 82 100 82 100

a computer at home also appear more likely to use the Cochrane library (16% vs. 5%, P > 0.05). A similar series of cross tabulations were constructed to explore factors related to confidence in the use of databases. The findings for confidence in the use of  (as the most widely used database) are presented in Table 5. A pattern of findings similar to those for the use of the databases emerged. There is no relationship between seniority and confidence. Those who had experience of higher education were more confident (although for  this relationship was not significant). The strongest relationship was between use of computer at home and confidence. Seventy-nine per cent of those who used a computer at home were confident or very confident in the use of  compared to 51% of those who did not (P < 0.05). Conversely, 33% of those who did not use a computer at home were very unconfident or had not heard of  compared to only 12% of those who did.


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Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington Table 2 Use of databases by grade. Never use the database


Use the database weekly/monthly

n % of group n % of group

13 24 5 19

25 45 17 63

17 31 5 19

55 100 27 100 χ2 2.34, d.f. 2, P = 0.311


17 31 6 22

27 49 17 63

11 20 4 15

55 100 27 100 χ2 1.40, d.f. 2, P = 0.496


48 87 25 93

7 13 2 7

0 0 0 0

55 100 27 100 Fisher’s exact test P = 0.377

Staff group

All

CINAHL

Junior Senior

MEDLINE

Junior Senior

Cochrane Library Junior Senior

As no-one used the Cochrane library monthly or more frequently all analyses for this database are based on a 2 × 2 contingency table.

Table 3 Use of databases by level of education. Never use the database




7 24 11 21

19 66 23 43

3 10 19 36

29 100 53 100 χ2 6.43, d.f. 2, P = 0.040*


10 34 13 25

15 52 29 55

4 14 11 21

29 100 53 100 χ2 1.19, d.f. 2, P = 0.522


26 90 47 89

3 10 6 11

0 0 0 0

Level of education

All

CINAHL

No HE

Done/doing HE

MEDLINE

No HE Done/doing HE

Cochrane Library No HE Done/doing HE


* Statistically significant.



Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington Table 4 Use of databases by home computer use. Never use the database




13 33 5 12

21 54 21 49

5 13 17 40

39 100 43 100 χ2 9.93, d.f. 2, P = 0.007**


17 44 6 14

20 51 24 56

2 5 13 30

39 100 43 100 χ2 13.52, d.f. 2, P = 0.001**


37 95 36 84

2 5 7 16

0 0 0 0


Home use

All

CINAHL

No home use Home user

MEDLINE


Cochrane Library No home use Home user

** Highly significant.

Table 5 Confidence in the use of CINAHL by seniority, education and home computer us. Very unconfident/ have never heard of the database

Unconfident in using database

Very confident / confident in using the database


12 22 6 22

7 13 3 11

36 65 18 67

55 100 27 100 χ2 0.04, d.f. 2, P = 0.98


8 28 10 19

5 17 5 9

16 55 38 72

29 100 53 100 χ2 2.36, d.f. 1, P = 0.31


13 33 5 12

6 15 4 9

20 51 34 79

39 100 43 100 χ2 7.40 d.f. 2, P = 0.025*

Group Junior Senior

No HE Done/doing HE


All

* Statistically significant.

Discussion This research has provided a clearer picture of nurse’s use of information technology. The nurses in this study are using computers at home and at

work for a variety of purposes. Some nurses are using computers to access professional literature, but the majority either do not do it or do so only rarely. Most nurses knew of the availability locally of two of the three databases, although a surprisingly


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Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington large number did not. However, regular use of databases is not the norm and a large number of nurses never use any of the databases studied, although a minority are very confident and use databases regularly. Nurses with experience of higher education and nurses who use a computer at home are more likely to use databases regularly. The low number actually using their home computers to access professional literature suggests that it is not access to databases per se that is the issue, although clearly this is pertinent in some settings13 and may be of more significance outside the relatively well resourced setting of a teaching hospital. Rather it would appear that the issue is one of familiarity and confidence in using computers in general. Increased exposure to computers in secondary and tertiary education will gradually reduce this problem but not necessarily solve it completely. There is no doubt that, at the moment, in this sample at least, regular use of electronic databases is not currently the norm. We would urge replication of this study in other settings in order to establish the typicality of these findings. However, there is no reason to suppose that the nurses in this sample are radically different from others in the UK. If this is the case the current nursing workforce demonstrates a significant deficit in knowledge and ability to access its own professional literature using electronic means. Certainly the findings here demonstrate that it is not sufficient to simply provide the resource. Previous research suggests that this will hold true even if ward-based access becomes the norm. A lack of general computer skills, confidence and knowledge of available resources will need to be addressed if the promise of electronic information resources is to be realized. Because senior staff use the databases no more than junior staff do, they are unlikely to provide role models. Higher education appears to provide a partial solution but not a complete one. In this study we have not considered the use that is made of the results of searches on databases. Many studies of research utilization demonstrate that knowledge of the evidence does not guarantee its use.9,14,15 Nor did we examine the sources of evidence that nurses currently choose to use. Nurses may make wide use of research journals

and guidelines issued by professional bodies. However, unless searched electronically the individual can only acquire answers to a limited number of clinical questions through ‘browsing’. It is possible that nurses are more likely to use databases than other sources of evidence, although evidence clearly suggests that many nurses choose to rely on potentially unreliable sources of information such as literature from sales people.16 One final limitation is the omission of the British Nursing Index from our survey. Internationally,  is the most comprehensive widely recognized and used nursing database1 and so this was the specialist database of choice here. We believe that this recognition extends to the UK, but it may be that the locally produced British Nursing Index is the source of choice for British nurses. Similarly we could have examined the use of  (the electronic version of Excerpta Medica). However again we believe that recognition of , despite its European origins, is far lower than that of . One of the prime obstacles to research utilization that has been identified is that nurses are simply daunted by the practicalities of accessing, appraising and summarizing large volumes of information.14 While skilled use of databases may help access, they do little to reduce the burden of appraising and summarizing the research. Indeed less than optimal searching can often lead to vast quantities of irrelevant information being accessed. There are a number of sources of critically appraised distillations and syntheses of high quality research evidence that aim to reduce this burden. However, the one resource that we examined that attempts to offer such syntheses (the Cochrane Library) was the least well known and used. This suggests that had we examined the use of electronic versions of evidence-based journals or publications such as the effective health care bulletins our conclusions would not differ significantly. Of course it may well be that nurses do not recognize the Cochrane library because its coverage of nursing research is highly limited. However, at the time of the study there was no electronic version of any specifically nursing evidence-based source available. It is notable that the association between higher education and use of databases that was observed



Nurses’ use of computer databases, Peter Griffiths and Lucy Riddington here did not appear to extend to the Cochrane library. The skills and knowledge that nurses are taught may therefore not relate to those resources that are identified as the most appropriate electronic sources of information for day to day practice.17 This may require that the range of electronic sources taught to nurses on both pre- and postregistration courses be expanded and the merits of ‘evidence-based’ resources emphasized.

References 1 McKibbon, A., Eady, A. & Marks, S. PDQ Evidence-Based Principles and Practice. Hamilton: BC Dekker, 1999. 2 Department of Health. Research and Development: Towards an Evidence-base for Health Services, Public Health and Social Care. Information pack. London: Department of Health, 1998. 3 Department of Health. Information for Health. An Information Strategy for the Modern NHS 1998–2005. London: Department of Health, 1998. 4 Sackett, D., Richardson, W., Rosenberg, W. & Haynes, R. Evidence Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone, 1997. 5 Royle, J. A., Blythe, J., DiCenso, A., Baumann, A. & Fitzgerald, D. Do nurses have the information resources and skills for research utilization? Canadian Journal of Nursing Administration 1997, 10(3), 9–30. 6 McKibbon, K. & Marks, S. Searching for the best evidence. Part 1: where to look. Evidence-Based Nursing 1998, 1(3), 68–70.

7 Weightman, A. & Mann, M. Evidence in seconds? Format and design considerations in the provision of reliable information to support evidence-based practice. Health Libraries Review 2000, 17, 63–70. 8 The Cochrane Collaboration. The Cochrane Library [database on CD-ROM]. Oxford: Update Software, 2000. 9 Parahoo, K. A comparison of pre-Project 2000 and Project 2000 nurses’ perceptions of their research training, research needs and their use of research in clinical areas. Journal of Advanced Nursing 1999, 29, 237–45. 10 Royle, J. A., Blythe, J., Potrin, C., Oolup, P. & Chan, I. M. Literature search and retrieval in the workplace. Computers in Nursing 1995, 13(1), 25–31. 11 Donald, A. The Front-line Evidence-based Medicine Project. London: NHS Executive, North Thames, 1998. 12 Hillan, E. M., McGuire, M. M. & Cooper, M. Computers in midwifery practice: a view from the labour ward. Journal of Advanced Nursing 1998, 27, 24–9. 13 Griffiths, P. The challenge of implementing evidence-based health care. British Journal of Community Nursing 1999, 4, 142–8. 14 Rodgers, S. An exploratory study of research utilization by nurses in general medical and surgical wards. Journal of Advanced Nursing 1994, 20, 904–11. 15 Hunt, J. M. Barriers to research utilization. Journal of Advanced Nursing 1996, 23, 423–5. 16 Luker, K. A. & Kenrick, M. An exploratory study of the sources of influence on the clinical decisions of community nurses. Journal of Advanced Nursing 1992, 17, 457– 66. 17 McColl, A., Smith, H., White, P. & Field, J. General practitioners’ perceptions of the route to evidence-based medicine: a questionnaire survey. British Medical Journal 1998, 316, 361–5.


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