Happy Open Access Day !

Today, October 14, is the first Open Access Day--a day devoted to broadening awareness and understanding of free and available information. Open Access Day is a joint venture of the Public Library of Science (PLoS), the Scholarly Publishing and Academic Resources Coalition and Students for Free Culture. In response to the call for synchroblogging, I've decided to direct some attention to the issue of open access in nursing.

Although nursing research is promoted in BSN programs and as an ingredient of professionalism, the relationship that research holds to nursing is not the same as the relationship that research holds to medicine or the biological sciences. I think the difference can be seen through the quintessential nursing research project--hand washing. Although much "sexier" and really more complex research has been done in nursing, hand washing is still taught as a model of what nursing research is--a test of and guide for best practice in the clinical setting. Although you might think that the same is true for medicine, it really isn't. A brief perusal of an (open access!) medical journal like PLoS Medicine will reveal that medical research is closely tied to biological research. (Hence, the sometimes-used moniker "biomedical" research.) At first blush, this might seem like a silly truism, but see what it means:

Medical vs. nusing research

Case-based: As we can learn from Foucault, the medical gaze can use the patient as opportunity to isolate pathogenesis. This approach to the patient is totally inimical to the perspective of nursing, and it is no accident that case-based literature is almost absent in nursing publications. In fact, when I asked a question about case-based literature in my Nur427 Nursing Research course, the instructor was momentarily flummoxed in trying to place it in the literature spectrum.

Inquisitive: Although you have your occasional Grey's Anatomy doctors, for the most part, students that go into medicine are the geeky kids who spend their time in the bio lab, while students who go into nursing are very average if hard-working. This is reflected in the professional literature by the ongoing interest of medical doctors in knowledge for its own sake.

Exploratory: Building on inquisitiveness, the core of biological and biomedical research is exploratory research. Although undergrad students are taught the hypothesis-confirmation method of research, the reality is different. As we discussed in Bio416 Virology, sometimes papers are constructed backwards--researchers perform some experiments out of curiosity and then try to make a paper out of them by tying them together with a plausible hypothesis. There really isn't exploratory research of this kind in nursing.

Systems-oriented: Science is constantly trying to make facts like symptoms fit into models. Nursing doesn't really care about models. This is the flip-side of case investigation avoidance. Cases and models both make patients into biological objects. Nursing research stays focused on improving the clinical milieu and nurses' posture. This comparison is a little over-generalized, but not completely.

These characteristics of biomedical research are ones that make open access sensible and important for it. Cases and exploratory research reveal occult characteristics that can lie dormant inside inaccessible journals. Free and disseminated information can provide just the right clues to help researchers put the final pieces in a puzzle.

Nursing research is also useless when not accessible, but timliness and particularity are less important. So, the researcher-to-researcher sharing that can come from open access and confer advantages in biomedicine is less relevant to nursing. Instead, open access relates to nursing mostly vis-a-vis three other avenues: (1) integrated self-care, (2) information access in the clinical milieu, and (3) education.

Integrated self-care

Although most synchrobloggers will probably be focusing on the access of synthesizers to research on Open Access Day, we should note that the access issue can be generalized to users and knowledge. The financial resistance to open access in the publishing world can also be generalized to financial resistance in the broader world. Knowledge is not only a commodity in its own right, it's also leverage for decision-making.

Electronic Medical Records (EMRs) are often addressed as a benefit to healthcare professionals, especially doctors, and as a benefit to patients secondary to the increases in efficiency and portability that will assist professionals. However, as Gladwin points out in the June 2007 Nursing Times, giving patients access to their own medical records can improve their care as well. An opinion piece in a 2007 Hospital Home Health titled "...continuation of care not just end of the road: open access could help patients avoid 'terrible choice'" suggests how: open access EMRs could act as loci for patients to re-visit and conceptualize their own care as a continuum across the life span.

Currently, hospitals and primary care offices act as gatekeepers for patients' medical information. In my local hospital, there's bureaucratic process, though no charge, for seeing one's own medical records, but there is a photocopy charge for taking one's own medical records out from the hospital. This combination of restricted access and copy charge models the access issues of the publishing world.

Can it be changed? This question is also asked by Detmer et al. in a paper awaiting publication this month in the open access journal BMC Medical Informatics and Decision Making. They describe several different models for Personal Health Records, but a common theme is the use of technologies. Just as technology has facilitated open access publishing, it can facilitate open access medical records as well. We have seen this already in Google's free Google Health app. But if we are to move toward RFID or other bio-integrated formats, the open source movement will become a necessary ingredient in open access. Proprietary storage and reading formats must not be allowed to predominate in the field of EMRs.

Access in the milieu

My hospital's made great strides in having the Internet available to all nurses through a proliferation of computers at nurses' stations and, now, in rooms and through Computers On Wheels (COWs). Nurses have "ready access" to some clinical information via the MDConsult database. However, this access is paid for by patients and taxpayers, and, in one instance, was disabled by a problem with the hospital's MDConsult account. It is not a true open access system. Moreover, MDConsult is what it says it is--a system geared toward doctors. Where is our RNConsult database to provide up-to-date clinical information specific to nursing or allied health?

My experience is echoed by the nurses in a qualitative study by Tod et al. (2003), who explored nurses' use of the Internet on a clinical ward. Here are some of the participant comments:

I use it more for non-work as I started getting disappointed with there not being much stuff around on practice...
Somehow I don't see how all these so-called models or theories of nursing are going to help... that's one thing I've learnt in this project, don't go to nursing databases, go to Medline or Google.

Morris-Docker et al. (2004) found that use of Internet-based resources was dependent on nurses' capabilities--on their inherent capacity with searches but also the access they were granted in the work place.

More recently, Estabrooks et al. (2008) looked at the organizational context for the clinical application of research at the level of the nursing unit. Besides the predilection of the unit nurses to use research, the next biggest factor was organizational support of research use, such as the authority to integrate findings into care.

These three studies point out issues of access in the use of research by nurses in the clinical milieu. Access is dependent on some factors that are inherent in users, and usability also interacts with access at the level of control. However, all use is fundamentally based on de facto and de jure access to information--availability and freedom, the core tenets of open access. Access in the clinical milieu must include the time and physical resources to use the Internet but also useful information must available to nurses when they go online. Clinical practice guidelines like the AACN's Procedure Manual for Critical Care should no longer reside behind walls of price and print.

Nursing education

Anyone in nursing school today or who has graduated recently will probably be familiar with the HESI preparatory exam and integrated textbook websites such as Elsevier's eVolve sites. Digital resources such as university extranets are spreading in popularity, but their use is limited by the imagination of nursing instructors. In my own school, nursing students are forced to communicate and download instructions and lecture notes through the college's ANGEL system, but access to resources inside the system is limited and access to resources outside the system is discouraged. Gibbon (2006) found similar disposition when reviewing literature for an article on the UK's open access SONIC system: "Reproducing lecturers' notes can be meaningless... Savin-Baden (2003) acknowledges that some resources that are used for web-based education do not enhance PBL, such as the provision of lecturer notes online."

Perhaps this failure on the part of instructors is a result of the generational gap. Floor nurses in my hospital resist every technological innovation for difficulty in adaptation, and Cole and Brunk (1999) identified unease with computer education as an impediment to obtaining advanced nursing degrees.

The under-usage of the Internet's ability to disseminate free information in nursing education is partly the fault of nursing faculty, but there is also a large component of publisher manipulation. The NIH already provides a large number of free medical texts online--but online nursing textbooks and educational resources remain behind pay walls. And, as I have noted previously on this blog, rather than moving toward open access models, textbook publishers are trying hard to create systems that lock students into continuing to make purchases (such as the bundling of books with online passwords) and that seduce faculty into using proprietary websites (such as providing online assessment services with protected educational material).

There is simply no excuse for nursing students to be spending hundreds of dollars on disposable nursing textbooks anymore. Textbooks are not pieces of literature that are enhanced by the ability to become physically connected with the printed material. Textbooks are only repositories and are subject to rapid change. The failure of the nursing educational system to move toward open access models of educational materials is wasteful and keeps students behind the information envelope unnecessarily.

Nursing culture

Nursing culture is a mixed bag. On the one hand, threatened, mean, controlling nurses and nursing instructors are common and characteristic enough that almost any nurse can recognize sayings like "the instructor is always right" and "nurses eat their young." On the other hand, nursing is also full of progressives and pseudo-hippies who will believe in the benefit of almost any intervention. In actuality, both these types are threats to improved patient care because both refuse to recognize the objective superiority of evidence-based care.

Of course, there are exceptions (Brennan, Ripich, and Moore (1991) were using a "free, public-access computer network" to develop their own computer-based home-care system back before "the Interwebs" became popular), but for the most part, nursing needs to be lead and is most comfortable when it has a institution impetous for change. The current model for this observation is Keeping Patients Safe. Rather than a grass-roots effort at improving conditions in individual hospitals, this is a top-down program from the Institute of Medicine (IOM).

So, what about open access? Open access publishing is currently flying under the radar in nursing. In a CINAHL database search, the most comprehensive treatment was an essentially informational article describing what open access is (Schloman, 2007). Position statements and comments from publishers were found in a few journals, but for the most part open access publishing has not been discussed within the literature.

Of current journals, one can count the number of serious attempts at open access publishing on the fingers of one hand:
The Directory of Open Access Journals lists 25 nursing journals, most of which are in Spanish and some of which do not contain the degree of publishing standards needed for them to be taken seriously.

Creating open access culture

Although BMC has a good service going, I generally regard PLoS as the flagship of open access academic and research publishing. (At one point a year or so ago, I even e-mailed PLoS to find out if they were going to expand into general health fields, but the editor who wrote back said they were planning to stick to biological sciences.) So, it seems appropriate that the Policy Forum column in PLoS Medicine should address the promotion of open access publishing in academia and health care.

Piwowar et al. (2008) recommend that Academic Health Centers take a lead role in promoting open access publishing. They recommend an institution-wide approach to help change the culture of AHCs to embrace open access. Recommendations include formally committing to opening access to data, funding the infrastructure and human resources needed, rallying AHC members through recognition and education, and developing the community by working on standards and social networking.

In nursing, Casida and Pinto-Zipp (2008) identified a strong correlation between organizational cultural change and transformational leadership behaviors by nurse managers. These behaviors are in many ways similar to the recommendations of Piwowar et al. for AHCs.

The time is right for nursing leaders to make a push to create a culture of open access for nursing as well. Just as the importance of open access to nursing is different from its importance to biomedicine, the open access culture needed in nursing is different from the open access culture needed in biomedical research. Nursing needs to shrug off some of its heavily authority-oriented cultural baggage.

Nurses need education in basic economics and principles of software development to understand how open access can impact patient consumption of health care.
The infrastructure and intellectual resources necessary to utilize research should be supported by health care institutions, including ongoing education.
Nursing educators should disentangle themselves from the large publishing houses and start teaching more from primary literature, review papers, and reliable online resources.
Most importantly, nursing leaders in practice and instruction at all levels of institutions should avoid squelching dissent and support independent initiatives to improve the dissemination and application of research. Inspiring and engaging leadership practices are proven to have an impact in changing the cultural in health care.

  1. Gladwin, J. (2007) Opinion: Giving patients open access to medical records would help nurses improve care. Nursing Times, 103(25), 14. Abstract retrieved from CINAHL database.

  2. n.a. (2007) Hospice as continuation of care not just end of the road: open access could help patients avoid 'terrible choice'. Hospital Home Health, 24(6), 66-68. Abstract retrieved from CINAHL database.

  3. Don E. Detmer, Meryl Bloomrosen, Brian Raymond, Paul Tang (2008). Integrated personal health records: Transformative tools for consumer-centric care BMC Medical Informatics and Decision Making, 8 (1) DOI: 10.1186/1472-6947-8-45

  4. Tod AM, Harrison J, Docker SM, Black R, & Wolstenholme D. (2003) Information technology. Access to the internet in an acute care area: experiences of nurses. British Journal of Nursing, 12(7), 425-434.

  5. Morris-Docker SB, Tod A, Harrison JM, Wolstenholme D, & Black R. (2004) Nurses' use of the Internet in clinical ward settings. Journal of Advanced Nursing, 48(2), 157-166.

  6. Carole A Estabrooks, Shannon Scott, Janet E Squires, Bonnie Stevens, Linda O'Brien-Pallas, Judy Watt-Watson, Joanne Profetto-McGrath, Kathy McGilton, Karen Golden-Biddle, Janice Lander, Gail Donner, Geertje Boschma, Charles K Humphrey, Jack Williams (2008). Patterns of research utilization on patient care units Implementation Science, 3 (1) DOI: 10.1186/1748-5908-3-31

  7. Gibbon C. (2006) Enhancing clinical practice through the use of electronic resources. Nursing Standard, 20(22):, 41-46.

  8. Cole BH & Brunk Q. (1999) Six rules for computers and other stumbling blocks to obtaining an advanced degree. Journal of Continuing Education in Nursing, 30(2), 66-70.

  9. Brennan PF, Ripich S, & Moore SM. (1991) The use of home-based computers to support persons living with AIDS/ARC. Journal of Community Health Nursing, 8(1), 3-14.

  10. n.a. (2004) American Nurses Association commends House Patient Safety Bill aimed at open access to information on nurse staffing practices. Nevada RNformation, 13(4), 11.

  11. Schloman, B. (2007). Open access: The dust hasn’t settled yet. Online Journal of Issues in Nursing, 12 (1)

  12. Baggs JG. (2006) Open access. Research in Nursing & Health, 29(1), 1-2.

  13. Paquette M. (2005) The public-access movement. Perspectives in Psychiatric Care, 41(2), 49-50.

  14. Harington R. (2005) Commentary on the public-access movement. Perspectives in Psychiatric Care, 41(3), 97-98.

  15. Lawson L. (2006) Research dissemination, open access, and the cost of doing business. Journal of Forensic Nursing, 2(2), 57-58.

  16. Heather A. Piwowar, Michael J. Becich, Howard Bilofsky, Rebecca S. Crowley (2008). Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers PLoS Medicine, 5 (9) DOI: 10.1371/journal.pmed.0050183

  17. Casida, J, Pinto-Zipp, G (2008). Leadership-Organizational Culture relationship in nursing units of acute care hospitals Nursing Economic$, 26 (1), 7-13

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