Nursing the evidence

Elspeth Hyams explores how the Royal College of Nursing's information strategy has set a shining example of best practice.

Nurses are hungry for information. That's official. At the AGM in October 2000, members of the Royal College of Nursing voted for a 10 per cent increase in subscriptions to cover a wish list of extra services. The first item on the list was employment-related, but the second was improvements to information services, including access to e-journals for all members. The extra funding, from a membership of 330,000, was ring-fenced for the purposes in question.

So far - and we are still at an early stage - this has been used to fund online access to British Nursing Index Plus (the UK abstract and index database of articles on nursing and health practice, now with newly negotiated live links to core nursing e-journals). There are also resources for e-learning (distance learning is growing); and access to e-communities of practice. This links in with the emphasis in all areas of healthcare on continuing professional development, and on evidence-based practice. Access to electronic and information services is through the RCN's website.

The concepts behind the service are simple, but implementing universal access for such a large, dispersed community has been a huge undertaking. There are, moreover, some 90 subject specialisms in fields of nursing practice, such as mental health, child health, sexual health, primary care, leadership, and gerontology. Implementing 'virtual branch libraries' (or virtual learning resource centres) for all of these specialist fields will take up significant resources and time during the next phase of development.

Physical modernisation
How did such an ambitious enterprise come about? And why is 'information' such an important priority? The RCN, like the profession it represents, is in the middle of an ambitious programme of modernisation. In keeping with this process, its London HQ in Cavendish Square has just been refurbished, in consultation with English Heritage. Behind the elegant facade the library, which houses the largest collection of specialist nursing literature in the UK, has been given 50 per cent extra space. It is now a state-of-the-art, light, airy, hi-tech study and browsing space. It epitomises the transformation of nursing through continuing professional development, with expertise underpinned by the evidence of best working practice.

The physical library used to be shabby and run-down. 'It demonstrated graphically the gap in status between nursing and the medical professions in the past,' says Jackie Lord, Head of the Library and Information Services at the London HQ. 'But now, the new library, opened officially in October, is a symbol of the value of nursing. But it is much more than that. The higher profile for information services has been achieved, not because of the highly seductive new library facilities, but because the library staff collaborated with colleagues from other departments in a bid to put information at the heart of the RCN itself.

Trade union/professional body
The RCN is in any case an extraordinary organisation. Its London HQ buzzes with purposeful activity from the moment it opens at 8 am. Over the last 20 years or so, trade union membership in Britain in general has fallen by approximately two thirds. But membership of the RCN has increased by 150,000 - a rise of more than 80 per cent. The RCN started life as a professional body but in the 1970s it was forced to became a union as well (to comply with certain compulsory legal criteria at the time). Since then it has never looked back. It is now a role model, not only for the more old-fashioned unions, which are struggling to retain members, but for the other Royal Colleges. In addition to fulfilling the functions of trade union and professional body (with a particular emphasis, these days, on lifelong learning), it conducts research and issues clinical guidelines. The National Institute for Clinical Excellence, for example, comes to the RCN for support in delivering clinical audit guidelines on behalf of the Department of Health.

It is against this background that the perceived value of library and information services has also been transformed. Four years ago, the library embarked on a consultation process intended to produce not a library strategy, but an information strategy. Senior personnel from outside the library service were included from the beginning. Focus groups with RCN members and students representing a wide variety of specialist and regional groups took place, and the advice of Jisc, UK universities' influential Joint Information Systems Committee, and the Office for Public Management was sought on developing an effective strategy.

Information is the key building block
The RCN had earlier conducted a strategic review that recognised information as 'one of the key building blocks of the new RCN Institute (its education, research and practice wing, led by its Director, Alison Kitson). But information was a building block of the RCN itself too, and the consultation process set out to identify and anticipate users' information needs so that information would underpin and support 'all aspects of the work of the RCN' in both the internal and external environments.

The vision of the information strategy was that it should 'reduce gaps and duplication within the RCN', and provide universal and equal access to core services, including 3,000 overseas members. (Even in the UK, lack of access to library facilities was an issue for many working nurses, particularly in the independent sector.) Information technology would provide the means. The highly ambitious strategy to meet users' information needs set out to be 'seamless, integrated and transparent' to staff, members and students. It was conceived as 'over-arching and cross-departmental'. It aimed to become one of the lynchpins of all RCN strategies, and a driving force. Indeed, it appears to be achieving this. In other words, by looking outwards and not inwards, collaborating with senior staff from marketing and communications, as well as staff involved in distance learning, training and lifelong learning, the library and information service has moved from a peripheral support role to centre stage. (Anyone thinking of adopting a similar approach for their information service should listen again to Jackie Lord, who advises: 'Don't try to badge any such enterprise as a library initiative - just persuade senior personnel before you start about what it is you are trying to achieve. You will raise the library and information service's profile anyway, even if you seem to surrender ownership.')

So, what were the needs that would be served by an effective information strategy? The RCN is a charitable body. On the one hand, it is the largest UK trade union for nurses and represents more than 70 per cent of all nurses, whether in the public or independent sector. It has recently extended its remit to cover healthcare assistants as well. It negotiates, collectively on behalf of the profession, and individually on behalf of members, with government, the NHS and employers' groups, and aims to improve welfare and working conditions for all its members. (Unlike librarians, who may be employers as well as employees of librarians, nurses are almost always employed by organisations which do not represent the nursing profession.)

On the other hand, the RCN is a professional body. It looks after nurses' continuing professional development. It develops nursing practice and standards of patient care. Its education, research and practice wing, the RCN Institute, commissions research and develops policy, as well as being a provider of higher education. The RCN publicises the expertise of the profession and promotes the 'science and art of nursing'. Thanks to high-flying General Secretaries like Christine Hancock and, more recently, the current incumbent, American Beverly Malone, it has become a powerful advocate and lobbying body. It is a formidable maker of headline news, with a published and publicised position, in Britain and abroad, on all issues to do with patient welfare and nursing.

Information strategy
All this needed to be fitted into a structure which would allow the RCN to streamline the way that information was 'created, communicated, maintained, accessed and managed'. This would enable the RCN to deliver what the members needed in order to do their job - the delivery of patient care - more effectively. The intention was to cut through the rhetoric, so that it would be possible to deliver nine key objectives, identified in the RCN's strategic review. They range from managing knowledge internally, to providing access and ensuring delivery to members of high-quality information services, to communicating effectively and working in collaborative ventures such as the NeLH (National Electronic Library for Health) and learning resource centres. (A diagram of objectives can be seen on p. 22 of the information strategy published on the RCN website: www.rcn.org.uk).

The consultation process took two years, and resulted in an impressive document (Royal College of Nursing Information Strategy, November 1999) with a list of ambitious action points. These included:

• creating effective knowledge management in the RCN;
• providing access to services when and wherever members needed it ('answers to any questions, at any time, from any place' - the 4 'a's slogan);
• promoting information literacy;
• facilitating the use of information for clinical effectiveness; and
• engineering access to quality information on the web.

Accomplishing any one of these presented a formidable challenge. Moreover, four years ago, nurses were still decidedly diffident about the use of IT-enabled information services.

In demand as a partner
From the strategy document it is easy to see why the RCN has become involved in all sorts of collaborative partnerships and initiatives. It demonstrated quite clearly that the RCN was a suitable partner in the development of portals to high-quality online learning materials. For this reason, the RCN was invited to become a partner in the development of the NMAP portal, which provides access to evaluated resources in nursing, midwifery and allied health. It is one of five gateways making up Biome, the biomedical 'hub' of Jisc's grand Distributed National Electronic Resource. NMAP was successfully launched in April. It is the younger sister to the Omni gateway (Organising Medical Networked Information), also hosted by the University of Nottingham. The NMAP project is a partnership between the RCN and the Universities of Nottingham and Sheffield, led by Rod Ward, a nursing lecturer from the University of Sheffield. The National Electronic Library for Health has picked up NMAP as a key part of the portals dedicated to nursing, midwifery and allied health professions. The RCN is working closely with Nick Rosen, a physiotherapist on secondment to the NHS Information Authority, to develop these portals and close links with other 'virtual branch libraries' of the NeLH, each focusing on a specific medical condition, or area of practice.

Pioneering pilot with Blackwell's
But the RCN's latest coup is a pioneer in the history of collaborative ventures. Even Jisc has not been able to negotiate universal access for universities to full-text journals through a single site (it is negotiated at individual institutional level, or through consortia like Nesli). Now the RCN, in an initiative piloted in the summer and launched officially in September, has done a deal with Blackwell Publishing. During the process of developing its information strategy, the RCN polled its members to identify the core resources to which nurses wanted 'seamless' online access. The research identified one crucial resource for distance learners as the British Nursing Index (BNI), an indexing and abstracting database compiled by the Royal College of Nursing, Bournemouth University, and Salisbury and Poole NHS Trusts. Of critical importance, BNI Plus uses English not US terminology, and includes the nursing subset of Medline. Electronic linking to the full text of some core journals in nursing made up the rest.

It was specifically the need to provide access to this core material online that produced the historic vote last year, approving an increase in subscription fees. What RCN has done is enter into an experimental collaborative pilot with Health Communication Network (HCN) and Blackwell's, which publishes many of the core journals. Access is through the RCN website, which checks the validity and currency of members' passwords. In the words of Sarah Cull, Serials Librarian for the RCN: 'Issues like licensing, passwords and authentication have, of course, been massive. Publishers have not dealt with something on this kind of scale before.'

The pilot will run for a year in the first instance. The RCN wants to know that the resources it is paying for are the right ones to meet members' needs. Blackwell's needs to be sure that the arrangement does not undermine the economics of its journals publishing, still predicated on a subscriptions-based business model; it is monitoring user behaviour and any parallel impact on sales of its hard-copy journals. The technology partners in this venture are Silver Platter and the HCN network. The scheme has been running for only a short time, but initial results are promising. The RCN has data indicating that between 10,000 and 20,000 members are active library service users. So far 2,000 have signed up and, in early September, 250 had actively used the system - according to Blackwell's, this is much better than the usual levels of active take-up. User data will be monitored closely, and shared. The RCN is watching how nurses access the information through its website, and there are plans to set up an extranet later.

Training facilitators
There are still formidable issues around training nurses to use the facilities. In this area, too, the RCN has used existing resources creatively. It works closely with members and has tried to identify ways to train certain members and staff to act as training facilitators. Training initiatives are just getting under way. Interestingly, a key finding of recent consultation with members has been that they want access to physical libraries, as well as online resources, and the RCN's 25 regional branches have been identifying nursing-friendly local resource centres, some of them in FE institutions, which can provide this service. An excellent publicity video promotes all aspects of the information service (including access to regional learning centres), using case studies based on individuals' diverse circumstances and individual learning needs.

Online lifelong learning portal
To complement the enhanced web-based library and information services, the RCN is developing an online lifelong learning portal. The first phase will comprise a number of elements and resources designed to support members' professional development. Central to the portal will be an electronic portfolio where nurses can record both their formal and informal learning. It will also include an information literacy module, that will help nurses map out the landscape of information sources, develop their query skills, locate credible evidence and critically appraise, interpret and apply evidence to practice. This will enable members to become more effective information brokers for all clients in the health services. The portal will also offer implementation guidance so that nurses can use clinical guidelines to develop local protocols and deliver healthcare based on the best available evidence.

There are other projects in the pipeline. With City University and the Universities of Ulster and Leicester, a huge project for e-learning is planned - 'e-NEd', incorporating online learning support, but with provision for some face-to-face contact.

'Start with the vision'
None of this would be possible without very streamlined, joined-up thinking, and without working internally 'across the boundaries of professional responsibility'. It needs cultural change, and in many institutions this simply would not happen. According to Jackie Lord, the essential thing is to start with the vision, and win converts to the dream, even before the focus groups or developing the details of strategy. At the RCN everyone was involved, from RCN publishing to those responsible for information quality improvement, to corporate affairs.

The key ingredients were partnership and collaboration, and a willingness to be driven by real user needs, even if the professionals still needed to temper the ambition with advice on the practical constraints. Whatever those may be, the RCN's information strategy, only two years old, is already enabling it to deliver a truly stunning range of membership benefits. And the best is yet to come.

Elspeth Hyams is Editor of the Library Association Record.

© The Library Association
Last updated: 15 November 2001