JOG N N THOUGHTS & OPINIONS

Internet Technology: Resources for Perinatal Nurses Emily Drake, RNC, MSN

=The Internet and the World Wide Web (WWW) are being discussed in many forums. This huge body of information is becoming a widely used research tool. Within the last few years, the WWW has grown enormously. In 1993, there were approximately 130 WWW sites. By 1997, experts estimated there were over a million sites on the web, many of them useful for nurses and ac- cessible from the nearest computer. For perinatal nurses in practice, research, or education the need for information is great. Nurses need current data for clinical decision making, policy writing, patient education, continuing education, and research. Understanding how to use the Internet, being aware of its advantages and disadvantages, and knowing how to critically examine what is avail- able will assist perinatal nurses in making use of this newest form of information technology. JOGNN, 28, 15-2 1 ; 1999.

Accepted: July 1998

The Internet and the World Wide Web are not just for scientists, librarians, and computer nerds anymore. Everyone is talking about the In- ternet. You either use it or you don’t. I’ve heard many nurses say, “I don’t have time for that” or “I don’t like computers.” However, soon nurses will not be able to ignore the Internet and will have to incorporate this technology into their practice and research. Some experts predict that practicing health care without using the Internet will soon be considered malpractice. For nurse researchers, the Internet and the World Wide Web offer both access to information and a forum for disseminating find- ings.

The Internet The Internet offers e-mail and discussion lists

that can connect you with other clinicians and re- searchers throughout the world. It also offers ac- cess to a great collection of information known as the World Wide Web (WWW). The WWW is a giant computer library containing written material, pictures, and audio collections accessible to anyone with a computer, an Internet connection, and a software program for browsing. Millions of people are “surfing” the web right now from their own computer, and more are joining in each day. For a busy clinician, the WWW can be like having a library right at your fingertips. Thanks to large companies such as America Online (AOL) and Netscape, Internet access is now available from most offices, many hospitals, and homes.

K n o w i n g how to use the Internet is just the beginning. Evaluating and using

it effectively are the challenges.

The World Wide Web

The WWW was conceived in the early 1990s by a computer scientist in Switzerland as a way to share information with other researchers (Corco- ran, 1996). Text, graphics, sound, and video, he realized, could all be transmitted from computer to computer through the Internet. The Internet, which began as a 1969 U.S. Department of Defense project called Arpanet, had been used primarily to

January/February 1999 JOGNN 15

store and retrieve text documents and to send and receive e-mail between computers linked by a cable network. The Internet was used mainly by government and uni- versity researchers. The WWW format added a new di- mension to the Internet. With the help of commercial on-line services and service provider companies, the In- ternet and the WWW, with its attractive graphics and ease of use, have gained popularity. Within just a few years, the Internet has exploded with growth and be- come a sprawling web of wires, telephone lines, and modems that connect individual personal computers, businesses, and schools all over the world. People across the globe can now post or read information on the WWW. The web has become a potpourri of information, research, opinions, advertisements, games, art, radio, and even a lot of junk. Commercial companies were quick to get on the WWW-it was almost like free ad- vertising. Now pages are added to the web daily. This burgeoning new resource for instant communication and information is exciting and mysterious, sometimes intim- idating, and sometimes frustrating. Knowing how to use the Internet and the WWW is just the beginning; evalu- ating possible uses and using them effectively is another story.

Think of the web as a combination of newspaper, yellow pages, your favorite journal, the encyclopedia, and the postal service. Compress the largest library and the biggest shopping mall, a newsstand, talk radio, and cable TV onto the computer screen, and you’ve got the WWW. It has current news, advertisements, shopping, editorials, even entire textbooks, and research articles. Almost everyone has a home page these days: individu- als, businesses, governments, organizations, schools, and special interest groups from all over the world. The web is a giant global bulletin board, free and easy to use for browsing and posting information.

F o r nurses in rural areas, the Internet

provides access to information previously

easily accessible only in large

metropolitan settings.

All this is accessible from your home or office. Need a catalog from Childbirth Graphics? You can con- tact the company directly at its web site (http://www. childbirthgraphics.com). Interested in attending the next conference sponsored by the Association of Women’s Health, Obstetric and Neonatal Nurses

(AWHONN)? Check out the organization’s web site (http://www.awhonn.org). Need the latest research on Cytotec (Searle, Skokie, IL), fetal fibronectin, or the most recent recommended immunization schedule? Just point and click. Looking for a grant? Try connecting with the National Institutes of Health web site (http://www.nih. govlgrants). Interested in a midwifery program? Check out all the nursing schools on the web. Need some images for your next important presentation? There are beauti- ful graphics available on the WWW- from impressionist art to 3-D ultrasound images. All this information can be viewed, downloaded, or printed from your own com- puter.

Many of our patients are already using the WWW for information. On-line resources for new parents are growing. Examples are Stork Net, Moms Online, Whole Nine Months, and Parent Soup. Some sites provide ex- cellent information to parents, others are cleverly dis- guised sales pitches, and some contain inaccurate infor- mation. Therefore, the WWW must be viewed with a critical eye. Unfortunately, many people believe that any- thing coming across a computer screen is authoritative and accurate. However, taking health care advice from the WWW can be risky. Any health care information should be verified by a professional health care provider. As providers, we should be ready and willing to discuss this information with our patients.

What’s Out There Libraries

With its Virginia Henderson Library, Sigma Theta Tau International, the honor society of nursing, was one of the pioneers making information available to nurses elec- tronically (http://www.stti.iupui.edu/library). The Na- tional Library of Medicine at the National Institutes of Health provides free, on-line searching capabilities (http:// www.nlm.nih.gov/databases/freemedl.html). Even the Li- brary of Congress is accessible (http://www.loc.gov). Many university libraries have excellent connections to health- related information.

On-line Journals Several nursing journals publish their contents en-

tirely on-line as well as on paper. Many more journals post the table of contents and some complete articles as a sample. MedWeb is a site that contains a comprehensive list of on-line journals. Publishers Lippincott, Williams & Wilkins and Mosby each have informative sites (see Table 1).

Professional Organizations AWHONN recently made its debut on the WWW.

The American Academy of Pediatrics, the National As- sociation of Pediatric Nurse Associates and Practitioners

16 JOGNN Volume 28, Number 1

TABLE 1 Perinatal World Wide Web Sites:Journals and On-line Publications

Name o f S i t e World Wide Web Addrrs

Lippincott Williams & Wilkins http://www.ajn.org MedWeb Mosby SpringNet

http://www.gen.emory.edu/MEDWEBlkeywordlelectronic_pu blications. html http://www.Mosby.codmos by/nur.sing/ http://www.springnet.cod

(NAPNAP), the College of Nurse Midwives, the Ameri- can Association of Critical Care Nurses, and many other nursing organizations can be contacted through the WWW. These sites offer information on upcoming con- ferences, policy statements, and membership informn- tion. Professional organizations may take the lead in rcvicwing wcb sites for quality and providing links to them (see Table 2).

Educational lnstittitions Many colleges :itid universities offer information

on the WWW for prospective students. They also may post information about continuing education offerings, and A few cactiially offer on-line courses for credit. The field of distance education via the Internet is growing.

Government Agencies The National Institutes of Hcalth’s National I i

brary of Medicine site includes free access to Medline, I’ubMcd, and Grateful lMed for journal database searches. The Centers for Disease Control and Preven-

tion’s W e d l y Morbid i ty and Mortal i ty Report is a valu- able sitc on the WWW (http://www.cdc.gov).

Businesses Large and small companies alike are quick to take

advantagc of the free advertising space on the WWW. Companies offering everything from pregnancy support hose to fctal monitor parts are represented on the web. Even hospitals are getting involved; some post birth an- nouncements and newborn photos on the wcb.

Consumer Sites Patients who are web-savvy will find a boon of

pregnancy and parenting information (see ‘Table 3 ) . The hlarch of Dimes sponsors some excellent sites. hlany web sites also offer parenting “chat rooms” (on-line sup- port groups) and advice lines (“ask thc expert”). The Pregnancy Ring is a collection of consumer oriented WWW sites; they also have a companion collection called thc Pregnancy Services and Products Ring. Your patients can order hard-to-find items like nursing bras

TABLE 2 Perinatal World Wide Web Sites: Organizations

Name of Organkahn American Nurses Association (ANA) http://www.ana.org/ Association of Women’s Health, Obstetric and http://www.awhonn.org/ Neonatal Nurses (AWHONN) National Association of Neonatal Nurses (NANN) http://www.nann.org/ National Institutes of Health (NIH) http://www.nih.gov/ Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/ American Academy of Pediatrics (AAP) http://www.aap.org/ American Association of Critical-Care Nurses (AACN) http://www.aacn.org/ American College of Nurse-Midwives http:www.midwife.org/ Health on the Net Foundation http://www.hon.ch/ National Association of Pediatric Nurse Associates and http://www.napnap.org/ Practitioners (NAPNAP) March of Dimes http://www.modimes.org/ Sigma Theta Tau International ( S l T I ) http://www.stti.iupui.edu/

World Wide Web Addm

]anuury/February 1999 JOG” 17

TABLE 3 Pwinatal World Wide Web Sites for Families

Name of Site

Pregnancy Ring http://www.fensende.comNsers/swn ymph/Ring. html The Whole Nine Months http://homearts.com/depts/health/OOninec3.htm Moms Online http://www.momsonline.com/ Parent Soup httpy/www.parentsoup.com/ Olin Interactive Pregnancy Calendar httpd/www.olen.co&a by/ Stork Net httphww.storknet.org/ Web Babies (hospital birth announcements on-line) http://www .Columbia-utah.com/babiesjntro.htmI

World Wide We6 Address

and maternity pantyhose over the Internet. Patients using the WWW have become more informed consumers of health care. As providers, we should be ready and willing to discuss and critique information they have discovered.

Networking There is also a WWW site for the pcrinatal nursing

discussion list (PnatalRN) which contains information about how to join this excellent electronic mailing list. In addition, there are numerous other nursing discussion groups. You can find many of the nursing list-serves on the WWW (http://www.shef.ac.uk/-nhcon). There you will find connections for e-mail discussion groups for nurse educators, nurse researchers, midwives, lactation consultants, and others.

How To Access the World Wide Web Four things are necessary for WWW access: a com-

puter, a modem, Internet browsing software, and an Internet service provider. Most schools, libraries, many businesses, and some hospitals now have personal com- puter stations connected with the Internet. These are usually free for students, faculty, or employees. More and more home computers also are equipped for Internet access. Home Internet access has grown in popularity partly because of the success of large private companies such as Amcrica Online (AOL). Therc are now many other companies (ISPs or Internet service providers) that offer Internet access to home computer users. There may be n variety of local companies in your area offering Internet connection services. Check your local phone book for listings. These companies will provide the soft- ware and connections to the larger network for a monthly fee; you provide the computer and the modem. Just as when selecting a long distance phone company, when choosing an Internet service provider, consider their monthly charges, the speed of the connections, e-

mail and WWW options, and the availability of help (Erlanger, 1997). The best way to get started on the wcb is to find someone already using it and ask for help in locating some of the addresses in this article (see Ta- ble 4).

Searching for Information on the We0 Some people call it the information highway; oth-

ers call it the “information firehose” because it is so easy to become overloaded with information. Once y o u are on the Internet, the task of sorting through the billions of pages of information begins. Remember, the WWW is

m - 4 Suggesrions fwGettingStartedon tbe World Wide Web

Pair yourself with a friend or colleague who is

Try the computer a t your nearest library. Obtain help from medical librarians, who often

Ask for help locating one of the sites from this

Use the mouse to click on any highlighted words in

Let yourself explore, push the wrong buttons, and

already using the Internet.

provide excellent assistance.

article.

the web page text.

make mistakes. You can’t accidentally delete anything from the WWW.

any page.

technology.

community college.

0 Click on the ”back” key to find your way back from

Give yourself some time to learn this new

Consider taking a computer course at a local

0 Share what you find with your colleagues.

18 JOGNN Volume 28, Number 1

TABLE 5 Perinatal World Wide Web Sites: Search Engines

Name of Sitc

Mamma http://www.mamma.com/ Meta Crawler http://www.metacrawler.com/index. h tml TekCenter http:/NlrWW.tekcenter.com/searchlWWW/WWWserch.htm

World Wide Web Address

uncatalogued, unedited, and very cluttered. Fortunately, there are a variety of search engines on the Internet, whose sole purpose is to help you find what you arc looking for in this mountain of information. Unfortu- nately, these search engines are not very efficient or dis- criminatory. Click on the word “net search” and you will be offered a search tool with a fill-in area. Fhtering the word “breastfeeding” into some search engines will bring up a list of 100,000 sites-from Le Leche 1.eague to nursing bras, and even some pornographic sites. The search engine will bring up a list of the pages that in any way contain the word(s) you enter. The more specific you arc, the more focused the list of results. Some search engines will help you refine your search with the USE of operating words like “AND” or “NOT” and by using quotation marks around key words (this is called “Bool- ean logic”). Search engines have strange names like Ya- hoo, Alta Vista, Excite, Lycos, o r Galaxy. Each search engine has its own specialty. Some sites (e.g., TekCenter) are designed specifically to offer access to all the top search engines in one place, and they include descriptions of each. Other multi-search tools will search through several search engines a t one time (e.g., lMetacrawler o r Mamma) (see Table 5 ) .

Keep in mind that searching for specific informa-

tion on the web can be frustrating. The best WWW sites are found through word of mouth or through “links,” collections of related sites (see Table 6) . Link pa& ’c4 ’: con- tain references to other pages and function like directo- ries. “Internurse” is one such page, containing links to many other useful nursing sites. The University of New York a t Buffalo supports a web page, “Nursing Sites on the WWW,” which provides links to specialty nursing sites, grant information, and its own search engine. “Martindale’s Virtual Nursing Center” is an award win- ning nursing site. “Healthfinder” is a site produced by the U.S. Department of Health and Human Services and links to over 500 web sites and on-line documents, in- cluding a medical dictionary and glossary. “Hardin Meta Directory” is a large source of medical informa- tion. Another major health-related link is “Noah” (New York Online Access to Health), which provides health information for providers and consumers in Spanish and English. All these link o r directory sites contain lists of other sites; any words or titles that are underlined can be clicked on with a mouse and will automatically take you to a new site.

Favorite sites can be “bookmarked” (see Table 7). Some web sites have long and difficult addresses, and one small typographical error (e.g., misplacing one dot or

TABLE 6 Perinatal World Wide Web Sites: Links and Directory Sites

Name of Site

Nursing Sites on the World Wide Web nsgsites.htm1 Internurse http://www.internurse.com/ Martindale’s Virtual Nursing http://www-sci.lib.uci.edu/HSG/Nursing. html Center Health finder http://www.heaIthfinder.gov Hardin Meta Directory - http://www.lib.uiowa.edu/hardin/md/nurs.html Nursing Nursing & Health Care Resources on the Net Noah htt p://www.noah.cuny.edu/

World Wide Web Address http://u blib. buffalo.edu/li braries/units/hsl/internet/

http://www.shef.ac.uk-n hconl

I

]anuary/Fehruary 1999 JOG” 19

TABLE 7 Favorite Perinatal World Wide Web Sites

Site World Wide Web Address Diane Wink’s resources for nurses and families Perinatal nursing discussion list Joseph Woo’s obstetric ultrasound

Note. To locate sites for bookmarking, addresses must be entered exactly as written. Addresses can change frequently.

http:Npegasus.cc.ucf.edu/-wink/home.html#resources

http://wings. buffalo.edu/academic/department/nursin~mcca~ny/perintal. htm http:lhomc. hkstar.cod-joewoo/joewoo2.html

slash mark) will prevent you from connecting to the web site. Bookmarking allows you to save your spot on the WWW without having to remember the exact address. Once you have found a page that you want to go back to, use the mouse to click on the word “bookmark” or “favorites” or “hot lists” o n the cdgc of your computer screen and then click on the word “add.” This will make it easy t o return to this same spot on the WWW.

Important information can be downloaded to save o n your own computer or printed from your own printer. Be aware, however, that some web pages contain huge amounts o f information and graphics. They may be difficult to print or use a great deal of memory to save on the computer. Unlike program files, attachments, and computer disks, generally e-mail and web sites cannot infect y o u r computer with viruses.

F o r nurse researchers, the Internet and the

World Wide W e b offer access to information

and a new forum for the dissemination

of findings.

Evaluating Web Sites All information on the WWW must be evaluated

critically. Remember that no editor, n o peer review, and no references are needed to publish on the web. How- ever, there arc several ways you can judge the integrity of a web site. These include careful examination of the presentation of the web site, the material it contains, the sponsors, any user information (e.g., the number of vis- itors to that site), awards, and ratings.

Bridges and Thede (1996) recommend using six criteria for WWW site evaluation: believability, author- i ty , evidence, support, logic, and timeliness. Read all posted information with a critical eye. Check the bottom

of the web page for author credits or the name of the organization posting the information. Some web sites include a list of refercnccs o r a bibliography. Check for the institution that supports the page. A web site clearly supported by a university or a well-established organiza- tion probably will be a more objective source of infor- mation than those sponsored by a commercial entity. Also, check the date when the information was updated last. Some sites are posted and then left unattended, and their information can quickly become outdated.

Several groups provide KWW awards and ratings. Look for these awards on the page. However, the niajor- i ty of these awards are given by computer cxperts for glitzy graphics and design, and they do not indicate the accuracy of health-related content.

One organization that is beginning to advocate for quality of medical information posted o n the WWW is the Health on the S e t Foundation (HON) (1998), a nonprofit organization supported by medical profession- als and health care providers froni several countries. This organization provides guidelines for medical web sites and offers a code of conduct. To display the HON codc of conduct symbol, sites must adhere to eight principles, including respect for patient confidentiality, references to research sources, available contacts for further informa- tion (including the webmaster’s e-mail address), and a clear statement of sponsorship (whether commercial or noncommercial, trained profcssionals, o r advertisers). Full information about the H O N is available through their web site (see Table 2).

The WWW is the ultimate in free speech, and al- most anyone can place a page on it. Pages contain a variety o f information: individuals’ opinions, govern- ment publications, family photos, personal stories, and even credit card rip-offs. The WWW is a leveler and is free, bu t the buyer must beware. Safety features like encrypting and fire walls are increasing security but coin- puter hackers, Internet providers, or even your employer can track your activity on the WWW. Privacy and secu- rity issues on the Internet are still evolving. Because the Internet is not owned by anyone it can be a source of

20 JOG“ Volume 28, Number 1

information that otherwise might not be available. For example, grey material, such as early research findings or politically suppressed information, may be found on the Internet.

The web is merely one tool and should not be the only one used i n making treatment decisions or policy changes. All information on the WWW must be verified using established sources. The Internet provides a great amount o f freely accessible information, but it is not all-inclusive and should be used only as an adjunct to journals, textbooks, and documented research.

Other Perils and Pitfalls All of these facts at y o u r fingertips can be a great

time-saver or n great time waster. Traffic is n problem on the information superhighway. Depending o n the time o f day, the popularity of thc site you arc trying to reach, and the directness o f your Internet connection, computer link-ups may be amazingly fast one day and torturously slow the next. You can also get lost on this highway. As you are “surfing” (or perhaps floating ou t to sea), you may find yourself looking at a site in Australia one minute and then in America in tlic click o f a button. Internet addresses from other countries usually contain a n abbreviation indicating the country of origin (e.g., AU = Australia, UK = United Kingdom). It’s important to know that standards of care from many countries can be viewed on the WWW.

The WWW is constantly changing. Information posted there one day may be updated, moved, or deleted the next. T o use a WWW reference, it is best to print ou t a hard copy o f the page. There are guidelines for citing WWW pages as references that include listing the date the information was viewed. See this Wwrw address ( h t t p ://w w w . a pa. org/j o LI r n a ls/w cb r e f. h tin 1 ) for info rma -

tion on American Psychological Association (APA) for- mat for web references.

Conclusion The World Wide Web: It is huge, accessible 24

hours a day, and as convenient as the nearest computer screen. I t gives nurses in rural arcas access to information previously available only in large metropolitan settings. Despite its pitfalls, the web offers a wealth of informa- tion and can be a great resource for perinatal nurses, patients, and researchers.

REFERENCES

Bridges, A., K: Thedc, I.. (2. ( I 996). Electronic education: Nursing education resources on the World Wide Web. Nurse liducator, 21, 11-15.

Corcoran, E. (1996, J u n e 30). On the Internet, a worldwide information explosion beyond words. ’/’he Washington Post, pp. A l , A14, A1S.

F.rlanger, 1.. (1 997). Choosing your ISI’. IOnline] PC Magazine. Available: http://~vww.zdnct.com/pcnia~features/ispchoose/ -opcn.htm [1998,June 71.

Health on The Net I:owidation ( I 998). Code of conduct for medical and health we6 sites IOnlinel. Available: http:// www.hon.ch/I 10~code/Conduct.litinl [ 1998, March 231.

Emily Drake isan instructoratthe University ofVirginia School of Nursing in Charlottesville and co-teaches a course on evalu- ating and using information technology in health care. She is also a perinatal nurse at the University of Virginia Health Sci- ences Center in Charlottesville. Address for correspondence: Emily Drake, RNC, M S N , 202 15th Street, SW, McLeod Hall, University of Virginia, Char- lottesville, VA 2290.3-3395.

]anuarylFelmiary 1999 JOGNN 21