What Rural Nurses Hope to Find on the Internet

OJNI      © 2002    

Volume 6, Number 1 2002

 ISSN # 1089-9758              Indexed in CINAHL

What Rural Nurses Hope to Find on the Internet



Robert M Pringle, Jr. MLS



Theanecdotal report presented here describes a funded project which resulted in thedevelopment of a series of instructional sessions on Internet use. It reviewscurrent practice and barriers to nurses' Internet use while exploring how theinstructional sessions impacted the participants.

    Making the assumption that nurses want to usethe Internet for professional purposes and that useful sites could beidentified, provoked the asking of these two questions: 1)What do rural nurses, in smaller towns, search for on the Internet? and 2) Can a class on “useful web sites for nurses” be helpful to them in their searches? Discussions and reference work with students, faculty, and nurses, as well as discussions with librarian colleagues, confirmed that nurses could benefit from a class about searching the Internet for sites useful to their practice. In preparing for such a class, to enhance their searching ability, it was determined that they should begin from sites known to be useful rather than relying on general search engines. The success of this method of beginning to use the Internet for useful information  was confirmed by the California HealthCare Foundation’s recently published study (California HealthCare Foundation, 2001), which has also been reported in the May 23, 2001, issue of the Journal of the American Medical Association (Berland et al., 2001).

Development of Internet Instructional Sessions

The rapid spread of Internet use to find health care information, and the proliferation of articles on why nurses should use the Internet, were part of the impetus for developing these instructional sessions. Nurses themselves acknowledge that there is a need to be able to access information on the Internet to help their patients:

Nurses have an obligation to adapt to this new influence on health by helping their patients obtain sound advice from the Internet. Sharing legitimate sites and guidelines for assessing the quality of information are ways to help patients become better consumers of online health data. This means that nurses themselves must be knowledgeable and stay up-to-date on both helpful and unhelpful web sites. (Chitty, 2001, p. 239)

Many articles tout the professional benefits and uses of the Internet for nurses (Baxter, 1997; Blackburn, 2000; Haines, 2000; Richards, 2001). Nurse leaders promote the Internet as a potent resource for nurses. At the National Institutes of Health, the Internet "...allows [a staff nurse]… to find all this information in the middle of a night shift, without the limitations of an unavailable consult or a locked library door" (Burtt, 1999, p.58). Nursing administrators are recognizing the need for Internet access in order to enhance the rapid retrieval of relevant information. This new generation of “net nurses…will demand a fully networked computing environment" (Richards, 2001, p.10).

In response to the emphasis of the National Library of Medicine (NLM) on reaching out to underserved groups, the Regional Medical Library (RML) in the Pacific Northwest offered grants to librarians (Pacific Northwest Regional Medical Library, 2000). The RML expected the recipients to work with people they did not usually serve, or who fit the NLM’s definition of underserved (Pacific Northwest Regional Medical Library, 2001), to promote the usefulness of the Internet (or offer other outreach services), and highlight the value of NLM products and services. The goal of this funded project was to disseminate useful web sites, identified by our library staff, to nurses in rural communities. Using a laptop, digital projector, and a collection of useful web sites (see Appendix), a presentation was developed and delivered to nurses in three rural towns in the Inland Northwest. Before we could begin implementation, we had to examine the barriers to access.

Barriers to Access

Health care agency administrators in rural towns struggle to meet the technological needs of their personnel. The technology-dependent environment necessary to provide Internet access is not yet in place in many health care agencies, including the ones in the class sites. Even though the literature supports Internet access on-the-job (Baxter, 1997; Chitty, 2001; Richards, 2001), agencies have not yet granted full access to nurses or to librarians, another group which cannot work without the net (Carnall, 1999). Clearly, before we began teaching, we would have to address the barriers related to access, reliability, personal ability issues, whether or not the Internet was available in the workplace, if information on the Internet was reliable, if the provider had the skills to use it, and if they had the time to retrieve necessary information. In the United States, the National Library of Medicine (NLM) has been encouraging Internet connectivity in hospitals since 1992 (Rauch, Holt, & Horner, 1994). The NLM’s initial focus was on giving librarians full access. Many in the health science community, as exemplified in the nursing literature, expected that Internet access would spread to nursing as well as other personnel. In the only published surveys found, neither Britain’s National Health Service (Alderman, 2000) nor U.S. health care facilities in general offer full Internet access (Dumas, Dietz, & Connolly, 2001; Huber & Huggins, 2000).

According to the Texas survey conducted by Huber and Higgins (2000), 60% of long-term care facilities offered staff computer workstations. Of those, 73% had Internet access, but only 41% of the staff had the skills necessary to retrieve health information. Staff at 70% of the institutions responding did not use the Internet to gather health information (Huber & Huggins, 2000). Nurse practitioners in the San Francisco area reported somewhat better support with more than 70% of their institutions offering full access at work (Dumas et al., 2001).

   During the Inland Northwest Internet instructional sessions, a number of the nurses commented on how difficult it was to find time and Internet access to search effectively for clinically useful information at work. Participants in the last session were explicitly asked: “Do you have Internet access at work?” All four (employed at or associated with a 35-bed community hospital) answered “Yes”, but half of them indicated it was not convenient. The discussions held at the earlier sessions indicated similar circumstances. Participants often had Internet access, in some cases limited to electronic mail, at work. Neither the work area layout and equipment nor their workload facilitated searching for care information during the work day.

The impact of workload on computer use for decision support for nurses is confirmed in publications addressing the current nursing shortage (Leigh & Krier, 2001; Northwest Health Foundation, 2001). Nurses surveyed and participating in focus groups in Oregon and southwestern Washington, face demanding schedules, overtime, and heavy patient loads (Northwest Health Foundation, 2001). Specifically, nurses report three major sources of their increased workload: 1. Patients...are sicker than they used to be and discharged from care more quickly. Nurses talk about the rapid turnover of patients, the time it takes to admit and discharge patients from care, and the inability to really get to know their patients' health care needs in order to adequately respond to them. 2. While the nurse-patient ratios may have improved slightly over the last five years, there are significant reductions in nursing support staff...and in services available to some patient populations (e.g., the chronically mentally ill). 3. State and federal regulatory requirements are greatly increasing the volume of work for nurses (p. 17). A home health nurse commented "A typical home visit? Ten minutes with the patient, 30 with the paperwork" (Northwest Health Foundation, 2001, p. 13).

Both inconvenient access and non-availability have been reported in England as well as in the U.S. (Alderman, 2000; Dumas et al., 2001). Three-quarters of nurses responding to a Nursing Standard survey in Great Britain did not have Internet access at work (Parish, 2000). While a greater proportion of San Francisco Bay area nurse practitioners had access to computers at work, “applications were not used more frequently because they were often not available” (Dumas et al., 2001, p. 37).

In the San Francisco survey, the nurse practitioners rated Internet searching the second most useful computer application, after obtaining client medical records from other agencies (Dumas et al., 2001). Anthony (2000) advised British nurses that they need Internet search  capability in order to provide evidence-based care, and the respondents to the Nursing Standard survey agreed (Alderman, 2000). This confirmation that nurses want to know about useful Internet sites and services was welcome, and matched what nurses said in the Inland Northwest. Session participants in all three towns gave “finding journal articles”, or information to improve care, as major reasons for wanting to use the Internet.

Reliability of the information retrieved was another barrier identified. Reliability of the web sites was a problem. Some of the participants expressed concern that web pages did not always offer credentials of the creator, or listing of a reliable source for the information offered. Participants were happy to know about the Health On the Net criteria (found at www.hon.ch/HONcode/Conduct.html), or sites like the University of Albany, which outline evaluation criteria for web sites (library.albany.edu/Internet/evaluate.html). In the interval between sessions, but in time for the last two offered, the RML in Seattle released a draft of criteria for consumers to use in evaluating health sites (nnlm.gov/pnr/hip/criteria.html). The nurses at the later sessions were instructed on evaluation so they would be able to offer this guidance to clients doing their own Internet searches for health information.

Setting for Classes

Table 1 shows the population of each town, the number of nurses, and number of attendees at the sessions.

Yakima and Walla Walla each have two hospitals, several nursing homes, and community college nursing education programs. Yakima also has degree completion and graduate programs available via a satellite university campus. Moscow has one hospital, one university in town and another within eight miles, but it does not have a nearby nursing program. There are libraries in both Yakima hospitals, and library service at the Veteran’s Administration hospital in Walla Walla. Library support for nurses is not comprehensive and can be difficult to access for any of the nurses.  

Session Planning

Much guidance for planning and assessing the Internet sessions came from a workbook developed at the RML in Seattle (Burroughs, 2000). The plan included distributing the presenter’s email address as part of each session’s advertising flyer, along with a request to identify areas of interest before the session took place. At the beginning of each session, participants were given time to list their current uses of the Internet on one side of the evaluation form. At the end of the session, they were asked to list changes or improvements they expected to see after completing the session. Finally, those who were willing were asked to respond to an email request a few months after the session, to confirm if the session (and any NLM services) had in fact been helpful. Two prospective attendees did send notes before the sessions; both their areas had been planned for in the presentation.  


Table 2 outlines the participants’ current use of the Internet and their post-session expectations for use. They made it clear that their major reason for searching was a desire to improve the quality of the care they provide. Table 2 lists participants’ responses, only slightly edited and with most repetition removed.

  While not always using the language of evidence-based care, the nurses clearly want to be sure they have information that is timely and accurate as they care for clients. They were disturbed that the information was not always easy to find, that they had little time at work to find it, and that what they did find was not always considered reliable.

The nurses almost all noted that they could find something on the Internet on their topics, but what they needed was the kind of authoritative, results-based information they were used to finding in journal articles. They also needed to be able to find it reliably, without spending a great deal of time on the search. For many of them, searching from home over a dial-up connection, speed of searching and loading was also an issue.

           In summary, the nurses attending the presentations had some experience using the Internet.  They used it from home, and sometimes at work, for many things, but their professional focus was on reliable patient care information on a wide variety of topics.  They hoped to learn ways of quickly finding reliable, clinically useful information.

While the post-session responses echoed the content listed by their colleagues before the sessions, the nurses were generally confident they would be able to find reliable material more quickly, assess it, and know how to apply it in their practice.  Follow-up with each group included e-mailing them two months after the session to ask if they did, in fact, find it useful.  The small number who replied were positive about the benefit of having spent an evening with examples of high-quality sites.  The instruction did make a difference for them.



In conclusion, barriers to nurses’ effective use of the Internet for clinical information remain. Not all agencies have been convinced of the desirability of providing equipment and good access. Nurses’ workloads remain so heavy that adding even an effective new method of gathering clinical support information is difficult. The rural or small-community nurses who attended these sessions came because they wanted to do better by their clients. Their agencies have not yet offered all of them easy, convenient access to the Internet or to the techniques needed to use it effectively. Even though the promises of the Internet have not yet reached them all, or are not readily apparent, they are persevering in their desire to improve their own practice.

What Rural Nurses Hope to Find on the Internet



Robert M Pringle, Jr. MLS




Internet Sources for Nurses

Supported by
National Network of Libraries of Medicine
Pacific Northwest Region Local Outreach Grant

What Might You Find on the Web?

University publications and experiments
Non-profit organizations' information
Government information
Commercial information & ads
"Labors of Love" 

NOT all journal articles

How can I tell if it's any good?
Style and Functionality

Is this health information good for me?

In the field of health, we consider:
Health info criteria 

Health info criteria - 1
Health news or information is best for you if you are just like the people being talked about in reports of research studies. 

The news or information should say who was involved in the study--what gender, age, disease... 

News or information about a good therapy should compare the new therapy and other therapies. 

There is usually new research to help you and your health provider make better decisions. If you have information older than about 3 years, try to find some more recent information to go along with it. 

Health info criteria - 2
A good health study should have involved lots of patients, especially for a common disease. 

Read the whole thing. 

Any article which shows 100% success or 100% failure is not honest! 

Health info criteria - 3
An article about one person and his or her health problem, success, or failure can't be used as good evidence for anyone else's situation. 

Read opinions on different sides before making a decision. 

Health info criteria - 4
Look not only for information on effectiveness of treatments, but also for information on side effects. The medical literature shows that sometimes no treatment (or a placebo) is better in the long run than treatment. 

It's good to look for agreement or consensus. There are many different opinions on any health topic, so we try to find a report that brings lots of knowledge together. These reports might be called review articles, practice guidelines, consensus conference reports, or meta-analyses. 

Health info criteria - 5
Another kind of agreement is simply an historic continuity, especially in the area of complementary and alternative medicine (CAM). If a therapy has been successfully used for hundreds of years, it's reasonable to put some credence in it. 

Health info criteria - 6
It's difficult to design a study using academic scientific method in many traditional medical fields. For example, how does one have a control group in the study of acupuncture? The mind-body methods, prayer, and distance healing all depend on the orientation and opinion of the patient toward the treatment. Look for continuity in practice and cumulated evidence. 

Health info criteria - 7
The perfect article for you and your situation might not exist. We often have to work with the best evidence available. 

Strategy for the Busy Nurse
Is the Internet likely to have your answer?
Can you find it from your starting page or your bookmarks?
Search the web 
Ask on a discussion list

Audience: Who's it intended for
What does it try to accomplish
Page content, tone and style
Does it mesh with your needs? 

Author/producer is identifiable 
Expertise on the subject as indicated by credentials page
Sponsor/location of the site is appropriate to the material as shown in the URL

Source (continued)
.edu for educational/research material 
.gov for government resources 
.com for commercially-sponsored sites 
~NAME in URL may mean a personal home page with no official sanction 
Mail-to link is offered for submission of questions or comments 


Style and Functionality
Clearly laid out, well-organized sections
Writing appropriate for audience
Easy to navigate: Back, Home, Go to, internal indexing on long pages
Links to remote sites work
Search capability if site is extensive

Trusted Sites - by source
Education - universities, etc.
Commercial sites 
Others you've verified

Trusted Sites - by purpose
Patient Education
You tell me...



Education, Universities, etc.
Official sites
Faculty and department efforts


Professional associations
Interest groups


Commercial Sites
News sites


Search Engines
General: Google, Alta Vista
Subject: Phones, e-mail addresses
Pick the ones you like to use!

Google search results

Professional Organizations
Nurse Practitioners
Sigma Theta Tau


Patient Education
American Academy of Child & Adolescent Psychiatry
Mayo Clinic

NOAH's link to Lice in Spanish



Internet Sources for Nurses Supported by National Network of Libraries of Medicine Pacific Northwest Region Local Outreach Grant, Rural nurses' internet use 3

What Rural Nurses Hope to Find on the Internet

Robert M Pringle, Jr. MLS


Table 1 Population, Nurses, and Attendees


Population a

No. of nurses b


Yakima, WA




Walla Walla, WA




Moscow, ID


239 c


a (U.S. Census Bureau, 2001)

b [U.S. Census Bureau , 1990 #36] There is no recent count of nurses for Washington; there’s been no funding since 1997 for Washington’s Nursing Care Quality Assurance Commission to analyze licensing data by town (Tan-Piazza, 2001).

c December 2000 (Coley, 2001).

 What Rural Nurses Hope to Find on the Internet

Robert M Pringle, Jr. MLS



Table 2 Information Desired from the Internet

Current Use of Internet  



Patient Care

Information on care techniques and research  

Current disease and physiology descriptions

Latest procedures for various medical diagnoses

Trends in OB, labor, and delivery  

Psychiatric diagnoses and issues

Drug information, including side effects

Info from nursing point of view on patient care and treatment  

Exercise, diet, wound care  

Case studies  

Journal articles

The same and more

Medications not available in my drug books

Descriptions of diseases unable to find in texts

Journal articles  

More complete information on drugs

Health topics

General Reference

Consumer health info

PubMed, Medline, Docline


Info for short articles on health issues  

Info for writing research papers  

Classes for Certification, CE  

Grants for foreign students  

Physician license info  

Information on nursing issues, education issues  

Current research on alternative medicine  

Patient sites, e.g., cancer support group  

Respiratory providers in the US

Asthma info for families  

Vendor/product information  

Journal articles

Nursing law  

Nursing employment,

Continuing education  

Better access to health statistics  

Up to date consumer health info  

Children’s info, such as Bright Futures  


Drug information  

Nursing articles  

Disease physiology  

Patient education information  

Professional organizations  

PubMed Central, on complementary medicine



Career opportunities

Daily news, including financial


Looking up addresses

New sites

Library services

Best search engines to use  


Universities and professional organizations  

On-line education