Construction and application on the training course of information literacy for clinical nurses

Design A two-round Delphi survey was conducted to seek opinions from experts about the index system for the evaluation of training courses of clinical nursing staff’s information literacy. Besides, a non-randomized controlled experimental study was adopted to check the application effect of the training courses. Aims This study intended to construct a training course of information literacy for clinical nurses, train nurses in order to improve their information literacy level and provide theoretical reference for the training of information literacy courses for clinical nurses. Methods Two rounds of Delphi study were conducted for the study among 26 clinical medical and nursing experts as well as educational experts from 5 different provinces and cities in China. From July 2022 to October 2022, a total of 84 clinical nurses from two hospitals were selected by the convenience sampling method, of which the nurses in one hospital were the control group and the nurses in the other hospital were the observation group. 42 nurses in the observation group were trained by the constructed information literacy training course. Questionnaire evaluation was used to compare the differences in the level of information literacy of nurses and the training effect between the two groups. Results The results of the Delphi consultation showed that the expert’s judgment coefficient was 0.958, the expert’s familiarity was 0.946, and the expert’s authority coefficient was 0.952. Finally, a training course of information literacy for clinical nurses with 4 course categories and 45 specific course contents was formed. Among them, nursing information awareness included 7 courses, nursing information knowledge 15 courses, nursing information ability 19 courses, and nursing information ethics 4 courses. The results of the empirical study showed that the information literacy level of the nurses in the observation group after the training of the information literacy course was improved, and the scores in nursing information awareness, nursing information knowledge, nursing information ability, and information ethics were significantly higher than those in the control group after training (P < 0.05). Conclusions The constructed information literacy training courses for clinical nurses were clearly targeted and systematic. Empirical research showed that the course contents were scientific and reasonable, which could provide reference for the training of clinical nurses’ information literacy.


Introduction
With the rapid development of information technology, massive amounts of information are generated, circulated, exchanged, and exported at every moment [1,2].In clinical work, nurses have to face and deal with massive amounts of information every day [3].Evidence-based practice is a set of basic practical frameworks in which clinical nursing work practices are based on the outcomes of scientific research and best practices emerge from the available evidence, which is important in clinical work.Nurses are more likely to need information literacy in the context of Evidence-Based Practice which is changing the way of work and thinking patterns of nurses, and put forward new requirements for the ability of clinical nurses to collect, process and utilize information.
Information literacy, being a concept, was first posed in 1974 by Paul Zurkowski, Chairman of AIIC (American Information Industry Committee).The essence of information literacy is a basic ability required by people in the global information age which refers to the ability to perceive, obtain, evaluate, and use information creatively [4,5].Good information ability can help nurses improve the efficiency and quality of clinical nursing work.At the same time, it can help nurses better deal with problems in clinical nursing work [6].Nowadays, the use of information systems has become a central part of a nurse's work and research showed that nurses' high documentation and information competence were associated with fewer detected information-related errors [7].In order to meet the challenges in the era of big data, it is urgent to improve the information literacy of nursing staff [8].
Research showed that most Chinese nursing university students had a low level of information literacy, lacked keen information awareness, and were not good at using scientific and technological achievements, so they could not keep abreast of the latest research results in this professional field in time [9].Clinical nurses are not good at fully and correctly expressing their own information needs due to lack of information literacy.In clinical nursing work, the purpose of nurses to obtain information is not very clear, and most of them lack specific and indepth information needs [10].At the same time, most of them are not good at literature retrieval and lack of nursing research ability [11].In nursing research, they mainly focus on Chinese literatures, and are lack of the ability to retrieve foreign language literature information of nursing [12].Hence the information literacy of Chinese clinical nurses is not optimistic and need further training and improvement.It is urgent to developing nurse education in the field of information literacy.
However, the current textbooks in China focus on the cultivation of nurses' clinical nursing ability and the teaching of medical knowledge [13,14].In the education of nurses in China, there were relatively few specialized teaching materials on information education of nurses, focusing more on other aspects of nurse education [15].The information literacy education of nurses often relied on the textbooks of medical information education, which was lack of professionalism of nursing information education [16].Besides college education, further continuing education on nursing in hospitals normally did not include such information literacy courses systematically [17,18].Insufficient attention was paid to the skills training of nurses' information literacy, especially information awareness and application of information resources [19,20].To our knowledge there was no relevant research on specialized information literacy training courses for nursing staff, and there was no standardized training model for reference.
Therefore, the purpose of our study was to construct a training course and develop nurse education in the field of information literacy, and conduct empirical research to improve their information literacy level so as to provide theoretical reference for the training of information literacy courses for clinical nurses.

Setting up research group
The group was composed of 6 personnel, including 2 professors, 2 graduate students and 2 clinical head nurses.
Research group searched the literature on nurses' information literacy, and conducted qualitative interviews with nursing experts and education experts to clarify how many aspects of information literacy nurses should have, and held a group meeting to determine the first draft of the training course of information literacy for literacy level of the nurses in the observation group after the training of the information literacy course was improved, and the scores in nursing information awareness, nursing information knowledge, nursing information ability, and information ethics were significantly higher than those in the control group after training (P < 0.05).Conclusions The constructed information literacy training courses for clinical nurses were clearly targeted and systematic.Empirical research showed that the course contents were scientific and reasonable, which could provide reference for the training of clinical nurses' information literacy.
clinical nurses.This group also compiled the consultation questionnaire, selected experts, distributed and collected the questionnaire and analyzed the experts' opinions.

Constructing consultation questionnaire
Delphi expert consultation questionnaire consisted of 3 parts: (a) basic information of the experts, including age, work unit, year of working, educational background, titles and so on; (b) training courses of information literacy for clinical nurses.The first draft was formed on the basis of the search of information literacy related literature.Then we interviewed nursing and education experts, summarized the interview results, and finally formed the first draft through group discussion.The first draft constructed contained 4 courses categories and 33 courses contents.The importance of each level was assigned by the Likert 5-level scoring method, and "point 5 to 1" corresponded to "very important to very unimportant"; (c) expert familiarity with content of the survey and judgement.

Selection of the experts
The number of consultation experts was normally between 15 and 50 [21].And the more experts there was, the more reliable the result would be.The inclusion criterion of the experts in this study were: (a) specialists in clinical medicine and nursing: they should be engaged in clinical medicine or nursing for more than 15 years, obtain the intermedium or advanced level of certificate, acquire a bachelor degree or above, sign the informed consent form and voluntarily participate in this study; (b) specialists in nursing education: they should be engaged in nursing education for more than 15 years, obtain the intermedium or advanced level of certificate, acquire a bachelor degree or above, sign the informed consent form and voluntarily participate in this study.

Conducting expert consultation
On August 2020, the research group launched the first round of Delphi consultation to the selected experts.The consultation questionnaire was sent via E-mail to the experts.After the first round of questionnaires were collected, the index items were analyzed with reference to expert opinions.The index items were analyzed according to the criteria that the coefficient of variation should be less than 0.25 and the mean should be greater than 3.5 [22].If the coefficient of variation is large, it indicates that there is a disagreement among experts on the item.Based on the first round of consultation, items were deleted, modified and added to form the second round of consultation questionnaire.On September 2020, the second round of consultation questionnaire was carried out.The experts were also given two weeks to fill in the questionnaires.

Implementing the training courses of information literacy for clinical nursing staff Participants
In this research, a non-randomized controlled experimental study design was adopted and the required sample size was calculated by software G*Power 2.1.Repeated measures analysis of variance statistic method was chosen to estimate the sample size.According to the research purpose and design, the effect size was 0.8, α was 0.05, power was 0.95, allocation ration was 1 and the total sample size was 84.
From July 2022 to October 2022, a total of 84 clinical nurses from two hospitals were selected by convenience sampling method, the selected nurses in one hospital was the control group while the selected in the other hospital was the observation group, with 42 in each.The inclusion criteria for the clinical nurses were: having nursing qualifications, being engaged in clinical nursing work, signing informed consent form and voluntarily participating in the study.The exclusion criteria were: those who were nursing staff for internships, who were not on duty due to illness, personal affairs, maternity leave or business trips, and who may go out to study during the research period.

Research implementation
The two selected hospitals were two affiliated hospitals of the same university so the content of continuing education in both hospitals were similar.In the empirical study, the control group did not carry out systematic information literacy training, and they only participated in the relevant continuing education, while the observation group, apart from the regular continuing education and training, was trained as per the courses of information literacy for nursing staff constructed in the previous stage.Theoretical knowledge was mainly trained by classroom lectures and group discussions; information retrieval was trained by demonstration and computer operation; evidence-based nursing knowledge was trained by document retrieval and document quality evaluation.

Qualifications for lecturers
In order to ensure the quality of training, lecturers needed to have the following qualifications: obtaining a bachelor degree or above, having intermediate or above professional titles.When the course contents were settled, qualified lecturers were selected and provided with half a year to prepare for the lectures before they carried out the training.
Teaching methods At present, public gradually concern the effectiveness of classroom instruction.The more diversified and rationalization of the teaching models and teaching methods we adopt, the more positivity and creativity of nurses could be stimulated.So, the teaching of information literacy for nurses was not limited to the tra-ditional face-to-face teaching method.Diversified forms of teaching methods were adopted, such as group discussion and reports, lectures, flipped class and computerbased operations.
Evaluation methodology Nurses' information literacy is measured by self-report questionnaire measurement which is a questionnaire of confidence.The information literacy scale (Chinese version) was translated and adapted by researchers through expert meetings and discussions based on Wadson and Cantwell's researches [4,23].The scale has good reliability and validity among Chinese people [24,25], and has been validated in our previous study [26].The information literacy scale of nurses was used to investigate the two groups of nurses before and after the training.The scale contained 5 dimensions and 30 items: information awareness (8 items), information knowledge (6 items), information ability (4 items), information ethics (6 items) and information support (6 items).The 5-level scoring method which means a Likert scale set of questions was adopted.From "fully consistent with the item" to " completely disagree with the item ", the scale was scored from "5 point" to "1 points".The higher the score of the questionnaire, the higher the nurses' information literacy.
In July and October 2022, that is, before the start of the study and after the implementation of the training course, we distributed paper questionnaires to the two groups of nurses to investigate their information literacy.After the investigation, the questionnaires were checked one by one, and the invalid questionnaires, that is, the selected answers were identical or the answers were inconsistent, were excluded.The differences in the information literacy of the two groups of nurses before and after training were compared.

General information of the experts
26 specialists in clinical medicine and nursing, and nursing education from 5 provinces and cities including Shaanxi, Beijing, Shanghai, Chongqing and Zhejiang were selected.The age of the experts involved ranged from 36 to 57 years old, with an average of 45.92 (SD 4.98) years old.Their working years ranged from 15 to 33 years, with an average of 21.38 (SD 4.91) years.The details were shown in Table 1.

Experts' enthusiasm
The enthusiasm of the experts was assessed by way of the response rate of the questionnaires.In the first round of expert consultation, 28 questionnaires were distributed while 26 valid questionnaires were returned, with a response rate of 92.86%.In the second round, 26 questionnaires were distributed while 26 valid questionnaires were returned, with a response rate of 100%.In the two rounds of consultation, 16 and 3 experts respectively put forward their suggestions on the revision of the course items, indicating that the experts had a good enthusiasm in this study.The details were shown in Table 2.

Experts' authority and coordination
The expert authority coefficient (Cr) was the average value of expert familiarity with the indicators (Cs) and judgment criteria for the indicators.In this research,  the expert familiarity was 0.946, judgement coefficient was 0.958, and the authority coefficient of the expert was 0.952, indicating that experts' authority was relatively high and the result of the research was reliable and authoritative, as shown in Tables 3 and 4.
In the first round of consultation, the Kendall's W of course module and course contents were 0.291 and 0.321 respectively while in the second of consultation, they were 0.316 and 0.358 respectively.So the Kendall's W test had statistical significance (P<0.05),indicating that the experts' opinion coordination degree in the two rounds of consultation was preferable, as shown in Table 5.

Experts' opinions on the training course
If the average score of the importance of the item was lower than 3.5 and the coefficient of variation was higher than 0.25, it meant that the item should be deleted.In the two rounds of expert consultation, the average score of the importance of the item was higher than 3.5 and the coefficient of variation was lower than 0.25, it indicated that the experts' opinions were concentrated.
According to the opinions in the first round of the expert consultation, 1 course was deleted, 10 courses were added, 2 courses were advised and 1 course was split, while in the second round, only 2 courses were revised.Finally, a comprehensive description of the final content and methodology of the developed program was shown in Table 6, which was consist of 4 categories with 45 course contents and covered diverse teaching methods, such as face-to-face lectures, group discussion and reports, lectures, flipped class and computer-based operations.Among which the information awareness contained 7 courses, the information knowledge 15 courses, information ability 19 courses and information ethics 4 courses.

Application on the training course of information literacy for clinical nurses
Because hospitals in China have requirements for continuing education for clinical nurses, they organize nurses for continuing education every year, which can ensure that participants continuously participate in the research.Before the training course, we coordinate the time and location of the class with the hospital to ensure the implementation of the courses.The curriculum was implemented for the nurse from July to October 2022.
The general information of nurses in the two groups were shown in Table 7.The general demographic baseline data of the two groups were balance and comparable.Before the training, the difference in the information literacy of the nurses between the two groups was not statistically significant.After the training, the nurses in the observation group was significantly higher than that in the control group in terms of nursing information awareness, nursing information knowledge, nursing information ability and information ethics (P<0.05).Comparing the nurses in the same group before and after the training, the nurses in the observation group after the training was significantly higher than before the training in terms of nursing information awareness, nursing information knowledge, nursing information ability and information ethics (P<0.05), as shown in Table 8.This shows that the level of information literacy of nurses has been significantly improved after training especially in the aspect of information awareness, information knowledge, information ability and information ethics, and proves that information literacy training courses are scientific and effective.

Discussion
Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values.Evidence-based practice has been made possible by information technology.At present, with the rapid development of information technology and Evidence-Based Practice, nursing staff, as one of the largest groups in the medical and health field, must improve their information awareness and information ability [27,28].The level of information literacy of nursing staff was directly related to the quality of nursing services and directly linked to the quality of nursing service [29,30].Only by constantly mastering new knowledge and new technologies could nurses make full use of advanced information resources and meet the needs of the information-based medical society treatment [31].Therefore, it is imperative to improve nurses' information literacy in the background of the Evidence-based practice, and this is also the purpose and significance of our research.Nowadays, the information curriculum for nursing staff was not valued in China, and the medical information curriculum was insufficient [32][33][34].Based on this, our study constructed the training course of information literacy for nursing staff through a variety of methods such as literature review, group meetings, and Delphi expert consultation.Before the course contents were formulated, the research team held a group meeting to consult and listen to the opinions from clinical medical, nursing and education experts, and invited experts to make a feasibility assessment on the contents of the first draft of the course to ensure the practicability of the course contents.The finally information literacy training courses for clinical nurses constructed in our study included 4 course categories and 45 specific course contents.Among them, the nursing information awareness module contained 7 courses, the nursing information knowledge module 15 courses, the nursing information competence module 19 courses, and the nursing information ethics module 4 courses.The course contents were complete and comprehensive.
Among these course categories, Nursing information ability is given the largest proportion by experts, accounting for 0.255.When the nursing staff took their job in the hospital, in the case of many patients and few nursing staff in China, it was difficult for them to have time and energy to improve their professional quality through study [35,36].At the same time, they also face heavy work pressure [37,38].This shows that among nurses' information literacy, their information ability is the most important and it is the basis of clinical nursing and to meet that demand nurses use all the skills of evidence-based practice.Nursing information knowledge is the second important course category in nurse information literacy training courses, which accounts for   [39].Evidence-based nursing practice in computer is a good approach to achieve this goal.Therefore, it is particularly important to comprehensively improve nursing information knowledge.Nursing information ethics is also a course category that cannot be ignored, which accounts for 0.248.In Nursing information ethics, the most important courses are academic code of technologies and the right channels to obtain information resources.Nursing information ethics is important during the nurse work.However, research shows that despite the importance and acceptance of research ethics consultation as an entity in many medical research areas, little is known about its status in nursing research [40].Iran has taken nursing ethics, especially moral sensitivity, as an important part of nursing education, which provides a good reference for our nursing information ethics education [41].We should promote nurses' information ethics through the comprehensive improvement of nurses' information literacy.Nursing information awareness is another course category of nursing information literacy training courses.Nursing staff are lack of information awareness and think it is the task of doctors to collect information in clinical work, as a result, they do not know how to make use of the electronic resources [42].All these seriously hindered the progress and development of nursing staff.Nursing information awareness helps nurses to establish correct information awareness, which can be transformed into the search, acquisition and promotion of information knowledge [43].In the category of Nursing information awareness courses, application of information technology in nursing and introduction to the information literacy for nursing staff are the most important, which both account for 0.023.
After constructing a systematic and comprehensive information literacy training course for nursing staff through two rounds of Delphi expert correspondence, we conducted an empirical study.From July to October 2022, a total of 84 clinical nurses from two hospitals were selected by the convenience sampling method, of which the nurses in one hospital were the control group and the nurses in the other hospital were the observation group.The general demographic data of the two groups were balanced, and there was no statistically significant difference in their information literacy level between the two groups of nurses before the training.42 nurses in the observation group were trained by the constructed information literacy training course through face-to-face lectures, group discussion and reports, lectures, flipped class and computer-based operations.We compared the nursing staff 's information literacy level after training to verify the effectiveness of the training model.The results of the empirical study showed that the information literacy level of the nurses in the observation group after the training of the information literacy course was improved, and the scores in nursing information awareness, nursing information knowledge, nursing information ability, and information ethics were significantly higher than those in the control group after training (P < 0.05).There was no significant change in the scores of nursing staff in the two groups before and after the training in information support, which may be related to the fact that the hospital's information support did not change in a short time.It could be popularized and applied around China to comprehensively improve the information literacy of nursing staff, improve the quality of nursing, provide reference for information training of clinical nurses, and promote the development of nursing disciplines [44,45].

Conclusion
The training course system covers Nursing information awareness, Nursing information knowledge, Nursing information ability and Nursing information ethics 4 course categories and 45 specific course contents.Besides, the effectiveness of the training course was verified through empirical research.Empirical research showed that information literacy training courses for clinical nurses could effectively improve their information literacy levels and could be further promoted and used.

Limitations
Considering potential sources of bias or confounding factors, the extrapolation of the empirical study is limited, especially due to the use of convenience sampling method.Since the methods by which we evaluated nurses' information literacy are subjective, in the future research, we will adopt a more objective method to measure the information literacy of nursing staff.

Table 1
Demographic information of experts(N = 26)

Table 2
Response rate of the questionnaire

Table 3
Experts judgement

Table 6
Consultation result of training course of information literacy for clinical nurses (from the second round of the Delphi study)

Table 7
General information of clinical nurses in the two hospitals (n = 84)

Table 8
Comparison of information literacy differences between the observation group and the control groupNotes: * indicated the differences of the same group before and after the training (P<0.05)