Nursing in the Internet Age

One of the ways the Internet is being used by people is to find out about health information. A recent study (Fox and Jones 2009) found that 61% of Americans go online to look for health information. Research suggests that patients are finding the Internet to be a useful tool. A study of people using one health related website (Lemire, 2008) found that most users were trying to gain a better understanding of a health problem. Almost as many were seeking points of view that were not associated with mainstream medical thinking.

This is contributing to a new dynamic between patients and their healthcare professionals. Traditionally doctors and nurses have been intermediaries in this patient – information relationship. With the development of a more interactive Internet however patients are now not only able to find information themselves, they can discuss it with other patients, and direct each other to new information sources, a role that Eysenbach (2007) has called apomediation.

In 2009 Sir Muir Gray, the UK National Health Service (NHS) Chief Knowledge Officer, put patients firmly in the driving seat saying “In the past we’ve given knowledge to clinicians who’ve then passed it on to patients, now our principles are that we give knowledge to patients and give them the opportunity to discuss it with clinicians.”  (CfH, 2009) Health information on the Internet comes from a wide variety of sources, some is filtered and quality checked by government agencies such as the NHS. Some is managed by commercial organisations who have strict quality checking mechanisms in place. Some however is generated by patients themselves, and as Lemire et al (2008) found this is sought by patients almost as much as ‘official’ sources. Participating in online support groups has been found to make patients feel more empowered (van Uden-Kraan, 2009) and confident with an increase in knowledge, and improved health status (Åkesson, 2007). They conclude that an improvement in the nurse–patient can be gained from patients’ use of online support, and recommend that nurses have the ability to point their patients towards suitable resources.

There undeniably is a shift happening, one that requires nurses and other healthcare professionals to develop a new skill set and knowledge base to enable them to work within this new paradigm. Gilmour (2007) considers that in order to adequately support patients and their families nurses need to be experts in using online health information. Åkesson (2007) agree, identifying that an improvement in the nurse–patient can be gained from patients’ use of online support, and recommending that nurses have the ability to point their patients towards suitable resources. A Delphi study of the nursing informatics skills needed by nurses  (Staggers et al, 2002) identified that experienced nurses should have the skills to evaluated web based information, and be able to assist patients in its use.

This is often not happening however. Scott et al (2008), in a study of New Zealand undergraduate student nurses, found that few explored patients’ use of the internet, and even fewer helped patients to evaluate information they had accessed from the Internet. A study of qualified nurses attending courses at a UK university (Bond 2008) found that only 18% would usually recommend a website to patients, 33% would never do so. Even less, 8% would usually recommend an online support group, over half (57%) would never do so. They were not using it to locate patient information either, only 16% said they usually used websites that allowed them to create tailored information leaflets for their patients, 32% never using these sites. Nurses need Internet skills to support their own information needs as well as helping their patients to meet their information needs. Care is becoming more evidence based, and nurses are expected to be aware of best practice. A wealth of information is available through the Internet, this includes the research based information available from ejournals, policy documents from Government sites, professionally focused sites such as this one, and patient experience information from the types of site previously discussed. They also need to be able to work effectively with the various computerised systems in use in their health care systems, especially the ones intended to help them plan and record patient care.

In line with the general population, people choosing careers in nursing are also increasing their use of the Internet. I’ve undertaken regular surveys of new pre-registration nursing students, which has shown a steady increase in use. In 2000 34% of students were using the Internet weekly prior to starting the course, while 35% had not used the Internet in the previous 3 months (Bond, 2003). By 2004 69% of students were using the internet weekly (Bond, 2006) and by 2007 this had increased to 92% (Bond, unpublished).

Whilst use is increasing the skills and knowledge necessary to work safely with Information Technology, and to support patients in their use of Internet based resources isn’t being naturally acquired alongside. In 2002 the NHS Information Authority (NHSIA, 2002) published a survey of the health informatics competencies of staff groups. Although the response rate from nurses was acknowledged to be low it found that although use of the Internet was quite widespread 80% did not consider themselves to be competent users. This is supported by the findings of study into the use of the Internet by nurses undertaken by Morris-Docker et al (2004) who described nurses’ search strategies as being unsophisticated, with basic searches in ‘Ask Jeeves’ and Google being the most common strategies. Searches were seldom refined, if they were it was usually by repeating the same search in a different search engine. A study in Sweden (Ragneskog, 2006) found that nurse educators thought that 29% of their students had sufficient IT skills to work as a registered nurse. Less than half (48%) thought that they themselves had sufficient skills for their role as nurse educators. They recommend that IT is integrated into the nursing curriculum, a conclusion that I have also drawn from my research (e.g. Bond 2007,  Bond and Procter 2009). Earlier this year the NHS published ‘Learning to Manage Health Information: a theme for clinical education, (CfH 2009), setting out what should be included in the education of all healthcare professionals, including nurses. This includes recognition that the Internet is now a major communication channel, and that it should be included in both pre-registration and post qualification education.

I should be optimistic that the importance is recognised. I am also aware however that the first version of  ‘Learning to Manage’ was published in 1999. A review of progress three years later (Murphy at al 2002) found that understanding of health informatics was poor, and the recommendations had not been used at all in developing curricula in 38% of pre-registration programmes. Two years later the NHS (NHSIA 2004) concluded that health informatics standards needed to be more fully integrated into both pre-and post qualifying education.

The Nursing Informatics Group of the British Computer Society Health Informatics Forum organised a session at the 2009 Healthcare Computing Conference (HC2009), looking at what needs to be done to move the health informatics agenda forward. The people attending the session came from a range of backgrounds, but there was agreement that education was the top priority.

As the Chief Clinical Officer for Connecting for Health (CfH 2009) says, healthcare is undergoing a paradigm shift, moving from ‘Industrial Age Medicine to Information Age Healthcare’.  If we’re going to keep up with this shift, and indeed with our patients, we need to move quickly to make sure that all newly qualified nurses have the skills and knowledge that they need to work in this new and developing culture.

references

• Bond, C. S., 2003. Nursing informatics for all. In: NI 2003: 8th Nursing Informatics,  Rio de Janeiro.
  
• Bond, C. S., 2006, 2006. Nurses on the net. Paper presented at the 9th International Congress on Nursing Informatics, Seoul, SOUTH KOREA.
  
• Bond, C. S., 2007. Nurses' requirements for information technology: A challenge for educators. International Journal of Nursing Studies, 44 (7), 1075-1078.
  
• Bond, C. S., 2008. Stop the world wide web, i want to get off. In: Medicine 2.0 Congress, Toronto.
  
• Bond, C. S., and Procter, P. M., 2009. Prescription for nursing informatics in pre-registration nurse education. Health Informatics Journal, 15 (1), 55-64.
  
• CFH 2009. Learning to Manage Health Information: a theme for clinical education. NHS Connecting for Health.
  
• Eysenbach, G., 2007. From intermediation to disintermediation and apomediation: New models for consumers to access and assess the credibility of health information in the age of web2.0. Stud Health Technol Inform, 129 (Pt 1), 162-166.
  
• Fox, S., and Jones, S., 2009. Pew internet: The social life of health information. Washington: Pew Internet and American Life project.
  
• Gilmour, J. A., 2007. Reducing disparities in the access and use of internet health information. A discussion paper. International Journal of Nursing Studies, 44 (7), 1270-1278.
  
• Lemire, M., Pare, G., Sicotte, C., and Harvey, C., 2008. Determinants of internet use as a preferred source of information on personal health. International Journal of Medical Informatics, 77 (11), 723-734.
  
• Morris-Docker, S., Tod, A., Harrison, J., Wolstenholme, D., and Black, R., 2004. Issues and innovations in nursing practice nurses use of the internet in clinical ward settings. Journal of Advanced Nursing, 48 (2), 157-166.
  
• Murphy, J. Stramer, K. Clamp, S. Grubb, P. Gosland, J. & Davis, S. (2004) Health informatics education for clinicians and managers — What’s holding up progress? International Journal of Medical Informatics. 73, 205-213.
  
• NHSIA. 2002. National health informatics competency 2002 annual survey - developing nhs im&t capability & capacity. Birmingham: NHS Information Authority.
  
• ONS. 2007. First Release: Internet Access, Households and Individuals 2007. National Statistics. London.
  
• Ragneskog, H., and Gerdner, L., 2006. . Health Information and Libraries Journal, 23 (2), 126-132.
  
• Scott, S. D.; Gilmur, J.; Fielden, Competence in nursing informatics among nursing students and staff at a nursing institute in sSwedenJ. 2008. Nursing students and internet health information. Nurse Education Today 28 (8) 993-1001
  
• Staggers, N., Gassert, C., and Curran, C., 2002. A delphi study to determine informatics competencies for nurses at four levels of practice. Nursing Research, 51 (6), 383 - 390.
  
• Van Uden-Kraan, C. F., Drossaert, C. H. C., Taal, E., Seydel, E. R., and Van De Laar, M. A. F. J., 2009. Participation in online patient support groups endorses patients' empowerment. Patient Education and Counseling, 74 (1), 61-69.
  
• Åkesson, K. M., Saveman, B.-I., and Nilsson, G., 2007. Health care consumers' experiences of information communication technology--a summary of literature. International Journal of Medical Informatics, 76 (9), 633-645.