Necessary prerequisites for evidence-based practice: results of investigating nurses’ informatics competency and information literacy skills
Article Category: Original article
Online veröffentlicht: 26. März 2024
Seitenbereich: 67 - 76
Eingereicht: 16. Feb. 2023
Akzeptiert: 31. Aug. 2023
DOI: https://doi.org/10.2478/fon-2024-0007
Schlüsselwörter
© 2024 Jamileh Farokhzadian et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Evidence-based practice (EBP) is a cornerstone of clinical practice in many healthcare disciplines1–3 and its goal is to integrate the best available research evidence, clinical expertise, and patient expectations and choices into nursing practice, so the nurses can make the best clinical decisions.4,5 EBP improves patient outcomes, quality of care, skills of care providers, and the cost-efficiency of care.6–8
Nursing informatics (NI) competency is a key component for nurses to implement EBP, which is defined as sufficient knowledge, skills, and abilities to perform specific informatics tasks9,10 and use computers and information technology in nursing practice.11 It can facilitate EBP delivery, manage resources, prevent errors, and support educational resources for nurses’ education by collecting, storing, processing, and modifying patient data in nursing care.11,12 Nurses with a high level of NI competency are more ready for EBP and can manage multifaceted medical data of patients, evaluate and follow up on their diseases and conditions, and finally enhance their care and safety.13 As the healthcare system includes many technological tools, nurses need to understand informatics competency and manage patient information in a complex environment.11,14
Information literacy is a set of skills needed to create appropriate research questions, seek and retrieve relevant literature, appraise search results critically, and evaluate the applicability of research evidence in clinical practice, and it is an important prerequisite for EBP.15,16 Intensive care unit (ICU) nurses need a high level of information literacy skills to make informed decisions and provide higher-quality services.17,18
According to various studies, some nurses are somewhat familiar with the EBP concept in the nursing curriculum, while most of them have not been involved in EBP.1,17 The informatics competency of most nurses varies from ineffective to expert levels13,19,20 and they still lack computer and internet search skills.17,21–23 Critical care nurses were unwilling to use the EBP due to their low levels of information literacy.17,24 Some studies reported that nurses had no or insufficient knowledge and skills in computer and search strategies in online scientific databases.13,16,25–29
To develop EBP in real conditions, we must implement and adapt the research findings in daily practices, identify potential barriers, and provide appropriate solutions for the protection of EBP in nursing practice. Despite the significance of the necessary prerequisites of the EBP, only a few studies investigated the NI competency and information literacy of ICUs’ nurses, so the present research aimed to investigate the intensive care nurses’ NI competency and information literacy skills in EBP, as well as the relationship between NI competency and information literacy to design future interventions and increase nurses’ readiness for EBP.
This cross-sectional study was conducted in 10 ICUs of 3 hospitals affiliated with Kerman University of Medical Sciences in southeastern Iran.
All nurses (N = 235) working in ICUs during the data collection were included in the study using the census method. The inclusion criteria were nurses with bachelor’s degrees and at least 6 months of work experience in ICUs; 184 nurses completed the survey.
Data collection was performed using 3 questionnaires; the demographic information questionnaire included the participants’ gender, age, work experience, organizational position, type of shift, level of education, marital status, history of attendance in research, EBP, and information literacy courses (Table 1).
Demographic information of the ICU nurses.
| Variables | n | % |
|---|---|---|
| Male | 32 | 17.4 |
| Female | 152 | 82.6 |
| 25 | 49 | 26.5 |
| 25–35 | 62 | 33.5 |
| 36–45 | 50 | 27.0 |
| >45 | 24 | 13.0 |
| Single | 63 | 34.3 |
| Married | 121 | 65.7 |
| <5 | 82 | 44.6 |
| 5–10 | 28 | 15.2 |
| 11–15 | 42 | 22.8 |
| 16–20 | 12 | 6.5 |
| >21 | 20 | 10.8 |
| <5 | 114 | 62.0 |
| 5–10 | 31 | 16.8 |
| 11–15 | 24 | 13.0 |
| 16–20 | 4 | 2.2 |
| >21 | 11 | 6.6 |
| Head nurse | 7 | 3.8 |
| Nurse | 177 | 96.2 |
| Fix | 11 | 6.0 |
| Rotation | 173 | 94.0 |
| Low | 27 | 14.7 |
| Moderate | 85 | 46.2 |
| High | 72 | 39.1 |
| Yes | 32 | 17.4 |
| No | 152 | 82.6 |
| Yes | 42 | 22.8 |
| No | 142 | 77.2 |
| Yes | 40 | 21.7 |
| No | 144 | 78.3 |
| Yes | 28 | 15.2 |
| No | 156 | 84.7 |
The Nursing Informatics Competency Assessment Tool (NICAT), designed by Rahman30 in the US (2015), investigates the respondents’ NI competency via 30 items under 3 dimensions of computer literacy (items 1–10), informatics literacy (items 11–23), and information management skills (items 24–30). This questionnaire is rated on a 5-point Likert scale: not competent (1 score), somewhat competent (2 scores), competent (3 scores), very competent (4 scores), and expert (5 scores). The total attainable scores range from 30 to 150, with 30, 31–59, 60–89, 90–119, and 120–150 scores indicating a novice, advanced beginner, competent, proficient, and expert respondents, respectively.
The validity and reliability (α = 0.846) of NICAT have been evaluated in the previous study.31 Iranian researchers conducted a study and used this instrument for the first time after cross-cultural adaptation and confirmed the validity and reliability (α = 0.95) of this instrument.20
The third questionnaire was about information literacy skills, which was developed by Mokhtar et al. in Singapore.32,33 This questionnaire includes 2 sections: the first is to use different information resources and collect information about patient care and clinical decision-making (19 items), which consists of electronic, print, and human information sources. The items are rated on a 5-point Likert scale ranging from “never = 1” to “always = 5”. The second section deals with information searching skills and the use of different search features of online databases and web search engines. The nurses were asked how frequently they used several search features, such as subject headings and search operators (10 items), and their responses were rated on a 5-point Likert scale from “never = 1” to “always = 5”. Nurses’ knowledge of Boolean/Connectors (“OR”, “AND”, “NOT”, or “AND NOT”) and Proximity (e.g., W/nn; PRE/nn) operators was measured via 4 items through the following options: yes (one score), no (zero scores), and not sure (zero scores). Nurses were given a hypothetical search topic (Effect of cigarettes on lung Cancer) with 5 possible search statements to select the most appropriate search statement by using Boolean operators for searching on MEDLINE. Item 4, which was about (Cigarettes OR Smoking OR Tobacco) AND (“Lung Cancer” OR “Lung Tumor” OR “Lung Neoplasm”) was a more appropriate search statement. The content validity and internal consistency of each subsection of the questionnaire were assessed using Cronbach alpha coefficients (α). The Cronbach alpha of different sections of the questionnaire was between 0.681 to 0.954, indicating that data collected through this questionnaire were reliable. Farokhzadian et al.17 conducted a study in Iran and assessed the validity and reliability (α = 0.87) of this questionnaire.
The anonymous, self-reported questionnaires were distributed among nurses to collect the study data. The first author visited the research settings during different shifts and asked the eligible participants to complete the questionnaires. She explained to the participants the study objectives, instructed them on how to fill in the questionnaires, and eliminated any ambiguity in terms of the questionnaire items. In addition, the nurses’ consents were obtained to participate in the study.
The data were analyzed in SPSS 21 (IBM Corporation, Armonk, New York, United States) followed by the application of descriptive (frequency, percentage, mean, and standard deviation [SD]) and inferential (independent samples
In this study, we obtained a 78.30% response rate (184 out of the 235 nurses completed the survey). The majority of the participants were female (82.6%), married (65.70%), aged between 25 years and 35 years, with work experience less than 5 years (44.6%) and work experience less than 5 years in ICUs (62.00%). Most of the respondents were regular nurses (96.20%), had shift rotation, (94.00%), and had a moderate tendency to use databases (46.2%). In addition, most of the nurses had not attended research and EBP courses (82.60%), information literacy courses (77.2%), and computer skills courses (84.7%) (Table 1).
Results showed that mean scores of the intensive care nurses’ NI competency were at the “competent” level (88.69 ± 22.76) (Table 2). The results revealed that 42.9% of the nurses were competent, 37.5% of them were proficient, 12% were expert, and 7.6% were beginers. We used the ANOVA and independent sample
Scores of the intensive care nurses’ NI competency and its dimensions.
| Variables | Minimum | Maximum | Mean ± SD | Mean ± SD per items |
|---|---|---|---|---|
| Computer literacy | 11 | 50 | 30.20 ± 8.95 | 3.13 ± 0.89 |
| Informatics literacy | 13 | 65 | 38.36 ± 10.17 | 3.03 ± 0.78 |
| Informatics management skills | 7 | 35 | 20.13 ± 5.87 | 3. 01 ± 0.84 |
| Total of NI competency | 35 | 150 | 88.69 ± 22.76 | 3.05 ± 0.83 |
The total score of use of different information resources was 3.05 ± 0.65 among the intensive care nurses and it was at a moderate level according to the median score of the subscale (score = 3). The results demonstrated that nurses used human resources (3.05 ± 0.65) followed by printed information resources (2.90 ± 0.74) and electronic resources (2.63 ± 0.84) more frequently (Table 3). We used ANOVA and independent sample
Scores of use of different information resources for patient care and clinical decision-making.
| Information resources | Categories | Mean | SD |
|---|---|---|---|
| Pamphlets/handouts (produced by healthcare companies, hospitals) | 3.08 | 0.90 | |
| Reference books (e.g., medical dictionaries, encyclopedias) | 2.67 | 1.07 | |
| Textbooks | 2.43 | 1.06 | |
| Newspapers | 3.35 | 0.99 | |
| Journal articles | 2.95 | 0.96 | |
| Total | 2.90 | 0.74 | |
| Electronic | Google (websites providing information about a specific medicine, treatment, or symptom) | 2.70 | 1.08 |
| Hospital resources:electronic SOP (i.e., work instructions, support documents) | 2.78 | 1.08 | |
| Nursing e-books | 2.31 | 1.08 | |
| Digital medical and nursing libraries | 2.54 | 0.99 | |
| Up to Date | 3.34 | 1.05 | |
| Online tutorials provided by professional associations, medical libraries, and overseas hospitals | 2.57 | 1.05 | |
| Medical databases (e.g., CINAHL) | 2.50 | 1.07 | |
| Blogs on EBP | 2.30 | 1.11 | |
| Total | 2.63 | 0.84 | |
| Human | Ward colleagues | 3.60 | 0.87 |
| Physicians | 3.03 | 0.90 | |
| Nurse supervisor | 2.89 | 0.99 | |
| Professional friends working in other hospitals and clinics | 2.69 | 0.99 | |
| Nursing management staff | 3.09 | 0.99 | |
| Nursing Research Committee/EBP Group | 2.98 | 0.97 | |
| Total | 3.05 | 0.65 |
The total score of skills of searching information and using different search features was 2.48 ± 1.15 among intensive care nurses, which was lower than the average based on the questionnaire’s median score (score = 3). Nurses used the “quick/basic” search option (3.17 ± 1.11) more and “Proximity operators” less frequently (1.95 ± 0.99) compared with other search features. “AND” (2.42 ± 1.24) and “NOT” (2.19 ± 1.17) were the most and the least frequently used Boolean operators, but the mean scores attributed to using all Boolean operators were quite low (Table 4).
Comparison of scores of information searching skills and use of different search features.
| Search features | Mean score | SD |
|---|---|---|
| 3.17 | 1.11 | |
| 2.97 | 1.11 | |
| 2.72 | 1.11 | |
| 2.50 | 1.05 | |
| 2.25 | 1.29 | |
| 2.30 | 1.27 | |
| 1.95 | 0.99 | |
| ‘AND’ | 2.42 | 1.24 |
| ‘OR’ | 2.37 | 1.21 |
| ‘NOT’ or ‘AND NOT’ | 2.19 | 1.17 |
| 2.48 | 1.15 | |
The ANOVA and independent sample
The total score of knowledge about search operators was 0.27 ± 0.04 among intensive care nurses, which was lower than the average according to the median score of this section (0.5). The majority of the nurses (72.8%) selected items no and not sure. These results showed that most of the nurses had no knowledge about the function of search operators and how Boolean and proximity operators would change their searches (Table 5).
Scores of knowledge about search operators.
| Operators and items | N | % | Mean | SD |
|---|---|---|---|---|
| Yes | 59 | 32.1 | 0.32 | 0.04 |
| No and not sure | 126 | 67.9 | ||
| Yes | 54 | 29.3 | 0.29 | 0.04 |
| No and not sure | 131 | 70.7 | ||
| Yes | 50 | 27.2 | 0.27 | 0.04 |
| No and not sure | 135 | 72.8 | ||
| Yes | 39 | 21.2 | 0.21 | 0.04 |
| No and not sure | 146 | 78.8 | ||
| Yes | 50 | 27.2 | 0.27 | 0.04 |
| No and not sure | 135 | 72.8 | ||
The ANOVA and independent sample
The intensive care nurses were asked to choose the most appropriate statement from a list of 5 possible search statements. Only 31.5% of the nurses selected the most appropriate statement using some synonyms of the concepts “cigarette” and “lung cancer” and putting them in parentheses.
According to the Pearson’s correlation coefficient test, NI competency and all its subscales had a significant direct bidirectional correlation with information literacy skills
Correlation between NI competency and information literacy skills in EBP.
| Variables | Computer literacy | Informatics literacy | Informatics management skills | Total of informatics competency |
|---|---|---|---|---|
| Electronic | ||||
| Human | ||||
| Total | ||||
The multivariate linear regression (Forward stepwise method) indicated that the use of different information resources, skills of information searching, and use of different search features, as well as the frequency of selection of search statements were the significant predictors for NI competency (Table 7).
Multivariate regression model for all variables and NI competency.
| Variables | Beta | ||
|---|---|---|---|
| Use of different information resources | 0.27 | 3.39 | 0.001 |
| Information searching skills and use of different search features | 0.51 | 5.89 | <0.001 |
| Knowledge about search operators | −0.10 | −1.63 | 0.104 |
| Frequency of selection of search statements | 0.51 | 5.89 | 0.001 |
| Gender | −0.089 | −1.60 | 0.11 |
| Age groups | 0.046 | 0.61 | 0.54 |
| Marital status | −0.300 | −0.48 | 0.62 |
| Work experience (year) | −0.033 | −0.35 | 0.72 |
| Work experience in ICU (year) | −0.135 | −1.75 | 0.08 |
| Work position | −0.090 | −1.42 | 0.15 |
| Shift work | 0.018 | 0.29 | 0.77 |
| The tendency to use databases | −0.069 | −1.01 | 0.31 |
| Attendance at research courses | 0.043 | 0.63 | 0.52 |
| Attendance at information literacy courses | −0.084 | −1.29 | 0.22 |
| Attendance at literature search and retrieval courses | −0.031 | −0.43 | 0.66 |
| Attendance at computer skills courses | 0.064 | 1.09 | 0.27 |
This study investigated NI competency and information literacy skills in EBP among ICUs nurses in southeastern Iran. Based on the findings, 42.9% of the nurses were competent in NI.
This finding agrees with Jouparinejad et al.,20 who investigated NI competency level and indicated that critical care nurses in the intervention and control groups were competent in the pretest stage. Some studies supported our findings and assessed NI competency among nurses; they reported nurses’ NI competency at a competent level.31,34 The reason for the same results can be the low percentage of participation in computer skill courses.
The present study finding disagrees with Hassona and Ali,19 who indicated that most of the nurses were expert in NI competency, as well as with Elsayed et al.,13 who demonstrated that 34% of the studied subjects were proficient and 32% were expert in NI competency. The reasons for disagreements with present study can be attributed to the participants. The above authors selected nurses from all wards of the hospital, who participated in computer training courses and had extensive experience in using computers. Jouparinejad et al.20 found that the intervention group became proficient in NI competency after using the training program in the post-test stage.20 The findings suggest integrating computer skills into the nursing curriculum and holding more practical workshops.
The total score of nurses’ use of different information resources was at an average level and nurses also tended to use human resources more than print and electronic resources. The result is similar to the findings of Agyei et al.35 and Farokhzadian et al.17 indicating that nurses used human and printed resources more frequently than electronic resources to seek information because human resources were easier, more accessible, and less time-consuming and they required no special skills to obtain information. However, Wahoush and Banfield16 reported that electronic sources of information were the most resource used by novice nurses. They concluded that newly graduated nurses were more inclined to use electronic resources than experienced nurses working in clinical practice.
The findings reported that nurses’ information searching skills and use of different search features were lower than the average; nurses usually used quick/basic search but rarely used Boolean operators. The results also revealed that most of the nurses had no knowledge about the function of search operators and how Boolean and proximity operators would change their searches, and most of them were unfamiliar with the search strategy and selection of search statements. Janavi et al.24 supported the results of the current study and showed that participants rarely used advanced search but usually used proximity operators. Agyei et al.35 indicated that the nurses were unaware of how to use online searching tools like the “advanced search options”; truncation/wild-cards (e.g., “*”, “?”); Boolean Operators (“OR”, “AND”, “NOT”). Farokhzadian et al.17 found that nurses had no information about the search operators’ purpose or function, such as Boolean and proximity operators and selection of search statements. According to Alving et al.,36 nurses were unable to use bibliographic databases due to a lack of skills in information searching. Unfamiliarity with search skills in the present study is because only 22% and 60% of the samples participated in information literacy, literature search and retrieval courses, respectively, and they had a low-moderate tendency to use medical databases; therefore, strategies should be designed to motivate more nurses.
The investigation of these subscales shows that the information literacy of the participants is between low and moderate which is a prerequisite for EBP.37 Janavi et al.24 agreed with the result of the current study and showed that the subjects’ levels of information literacy were not up to mark. Osman38 mentioned that nurses’ levels of information literacy skills were low and they needed these skills to use electronic databases and select high-quality clinical practice guidelines for decision-making. Janavi et al. study,24 our study, and Osman’s study on nurses working in clinical wards, and nursing, midwifery, and community health students reported similar results.38
The results of the current study disagree with Carter-Templeton,39 who reported that the vast majority of participants self-reported their information literacy skills as proficient to highly proficient. The reason for the discrepancy is that participants are nursing faculty members and nursing students involving information literacy in theoretical and clinical settings.
The findings of the current study showed a bidirectional correlation between the total NI competency and information literacy skills in EBP, meaning that the higher the information literacy skills, the higher the informatics competency and vice versa. The positive correlation between the use of different information resources and NI competency shows that the use of various information sources, especially electronics, requires a high level of NI competency. A significant correlation is available between the use of different search features and NI competency, so a high level of NI competency is necessary for the effective use of search features.
The results also showed that information literacy subscales, such as the use of different information resources, information searching skills, and use of different search features, as well as the frequency of selection of search statements were predictors of NI competency.
Al-Hawamdih and Ahmad40 explained that nurses competent in NI competency knew how to find, evaluate, and use information efficiently; therefore, competent nurses have a high level of information literacy. Özbıçakçı et al.41 mentioned that information literacy provided the baseline for informatics competencies and an information-literate nurse could weigh the quality and significance of evidence for patient care and decision-making. Therefore, NI competency and information literacy skills are essential components for applying EBP and hence they should be enhanced.
To enhance NI competency and information literacy among nurses, the following interventions are recommended: incorporating computer and information skills into the nursing curriculum as a core course for nurse students, planning and running continuous training and practical workshops on information literacy and computer skills for nurses of clinical wards, giving access to online resources in clinical wards and subscription of medical databases, as well as conducting programs to motivate and encourage nurses to use EBP. It is also suggested that researchers evaluate the effectiveness of these interventions through longitudinal or interventional studies.
Based on the findings, nurses were competent in informatics, but their information literacy level was between low and moderate. Nurses do not have the necessary skills to search for the information they need and are unfamiliar with many search principles. Nurses require a high level of NI competency and information literacy for EBP to acquire up-to-date information and provide better care and decision-making. The use of human and print resources is due to a weakness in information literacy skills. Our results support the need for an educational plan to train nurses in NI competency and information literacy. Therefore, health planners and policymakers should pay significant attention to NI competency and information literacy in the use of EBP to enhance clinical practice. This is the first study that examines the relationship between NI competency and information literacy. The findings facilitate employing EBP in the clinical setting to increase community health.
The current study used a questionnaire to determine the level of informatics competency and information literacy skills in EBP, so nurses might have perceived their skills more than the actual amount. Therefore, real skills can be measured by performing practical tests. This study was conducted among nurses working in the intensive care units; other researchers are recommended to investigate nurses in other wards for the generalizability of the findings.