Thoughts from the Tutorial presented at the American Medical Informatics Association

Annual Conference, Washington, DC

November 9, 2003



Since 1960 the number of nursing journals has grown from 5 to over 500! As the number of journals has increased, the number of subscriptions for each journal has decreased necessitating a price increase by the publishers because of fixed costs As the costs of all journals increase, libraries, whose budgets do not expand to keep pace with the increased costs of journals, are forced to decrease their subscriptions. This is turn fuels more price increases by publishers followed by libraries cutting subscriptions. This constant cycle has led academics and those concerned with the use of scholarly literature to look for alternatives.

Scholarly journals began in 1665 (Suber, P. (2003, preprint). and soon became the primary way of sharing new work with colleagues. Authors, who found rewards in intangible ways, accepted that the journals could not pay them. As the centuries have passed, although journal revenue has grown, authors have continued to create new knowledge without payment. Today, authors of works that are freely provided are beginning to question if their best interest is served when access to their work is limited to paying customers. In the print age, the economics left no alternative and until the 1970s the price barrier was relatively low. Since then journal costs have risen twice as fast as inflation. Profits of scholarly commercial publishers run as high as 40% (Scholars under siege, 2002) but authors are still unpaid. Further they are often restricted from using their own work by copyrights which are ceded to the journal.

Besides cost there are other limits to print journals. The length of articles is often set at an arbitrary 16 to 20 pages; too short for some topics, and too long for others. Additionally, the number of images such as tables, figures and graphs that can be printed with the article are limited. Each journal can only print so many articles with each issue, thus further limiting the dissemination of knowledge.

Dissemination of knowledge, although not the only goal of publication, is its primary purpose. Journal publication also serves three other goals: quality control, archiving of knowledge, and recognition for the author. Knowledge, however, has a limited use unless it is shared. In practice disciplines, knowledge needs to be shared beyond academia. Clinicians need this knowledge, and their knowledge needs to be shared. Neither of these happens to a great extent in the current print system. Unless a healthcare agency is large or connected to a university, often the nursing library, if it exists at all, has few resources, sometimes only what the staff donates.

Statements Supporting Open Access

In the past decade we have seen bibliographic indexes move from print to online. Additionally, in an effort to counter the serials pricing crisis, some academics have made their articles freely available online. The current move in freely given literature, that is, articles that are written and given for publication to a journal, is to have this information be freely available on line in what is termed “open access.” Note that freely given does not apply to books, or anything created when the creator has hopes of receiving payment.

Budapest Open Access Initiative (February 14, 2002)

Although the movement to open access started in the 1970s, the movement is gathering strength in the twenty-first century. In December of 2001, the Open Society Institute (, a grant making foundation that is part of the Soros Network, called a world wide meeting in Budapest of proponents of open access for scholarly literature. The outcome of this meeting was a proclamation known as the Budapest Open Access Initiative which was released on February 14, 2002. This group defined open access as:

By "open access" to this literature, we [BOAI] mean its free availability on the public Internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the Internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited. (Budapest Open Access Initiative, 2002).

Although the Budapest Proclamation was probably the first formal declaration of the intent of scholars to regain control of their freely given literature, since then there have been several more, some of which are described.

Bethesda Statement (June 20, 2003)

This group included representatives from medicine, prestige universities, other countries, the Public Library of Science, the Rockefeller Foundation and the National Library of Medicine. Their statement of support for open access included their intent to 1) encourage faculty/grant recipients to publish with open access to maximize access, 2) help defray costs of open access publishing, 3) Judge publications on intrinsic merit, not by the journal that published it, and 4) regard open access publishing as service to the community. (

The Berlin statement (October 22, 2003)

Representing scholarly agencies in Germany, this group recognized that the Internet has changed knowledge dissemination. They stated that dissemination is only 50% if knowledge is not readily available. They also affirmed that they will support the transition to open access by encouraging publication by open access, developing ways to judge publications on their intrinsic merit, and advocating that value be given to open access publications in promotion and tenure decisions. (

Wellcome Trust

The Wellcome Trust, a British independent research-funding charity, stated that for their grant recipients they will assure that the distribution of research knowledge from these grants is not adversely affected by publisher marketing policies. They further offered encouragement and support for the formation of open access journals. They will pay costs of open access publication for their grant recipients, and encourage researchers to use open access publications. (

Australian Infrastructure (October 22, 2003)

The government of Australia is putting up $12 million to build the necessary infrastructure for open access publishing for their citizens. The new information infrastructure will put Australian institutions in an even better position to take part in, and lead, national and international research projects ($12 Million for managing university information, 2003).

PubMed (October 2003)

Pub Med has announced that as of October 2003, in support of the Betheseda Statement they will accept open access articles from any journals that they index. The journal does not have to be a part of their PubMedCentral group.

Models of Online Publishing

The recognition by funding agencies of the need for a new publishing model is a recognition of a movement to online publishing that is slowly occurring. This movement has resulted in several different models of online publishing. Some achieve full open access, while others offer access only after an article has been in print mode for a period of time and some operate by subscription only just as in the print medium.

User Fees

Journals who employ this method generally are print journals who make articles available online for their subscribers. A variation of this is organizations who make articles available online to their members, often along with mailing them a print journal. Some journals have licenses with libraries to have their content available online to patrons of the library. This model is often seen in academic and other scholarly libraries. Additionally some journals and bibliographic indexes, such as PubMed, sell articles. Fees for these generally range from US $5 to $12.

Author Fee-Based

This model has been used in the print medium by some journals with fees generally being charged per page. Under this model the author pays to have their article peer reviewed, edited and posted on the publisher’s server, but access to the articles by readers is free. Two companies that employ this model are BioMed Central ( the Public Library of Science ( BioMed Central has started 60 journals, all in the field of healthcare. The nursing journal as of October 29, 2003 had three articles, two were research articles, and the third a case study. The United States Institutes of Health, the British National Health Service, and British Academic Society all are members of this organization. Associates of members do not have to pay the $500 publication fee BioMed charges. The Public Library of Science, which was started with a $9 million grant from the Gordon and Betty Moore Foundation, charges $1500 an article. They have just released the Public Library Biology Journal which will be followed in 2004 with the Public Library of Science Medical Journal.

Free to user and author

There are many different ways that online open access is achieved under this model.

Print journals with open access

Some journals, notably the British Medical Journal (, make all their articles freely available online at the time or publication. The U.S. PubMed has an agreement with some 60 journals to publish online all their research articles after a given time period. This period varies with the journal. Their search engine Entrez will search their entire collection, but they maintain a specialized search engine ( that searches only articles that are open access.

Online journals

For the most part, these journals are published only online. Nursing has several. A list of those available is maintained at These journals are generally a labor of love by those involved, and although started with a great deal of excitement, often fail to be kept up as their owners find that the amount of work involved is not compatible with their day jobs. Currently, although there are eight nursing open access jouranls, only four have articles from the year 2003: The Online Journal of Issues in Nursing, The Online Journal of Nursing Informatics, the Internet Journal of Advanced Practice Nursing, and the Online Brazilian Journal of Nursing (which is new this year).

Preprint model

A preprint is an article that has been written, but not peer reviewed, that is, a first draft released by the author. An example of the use of this model is ArXive (, which was started in 1991 by Paul Ginsparg for physics and related sciences. It is supported by the National Science Foundation and Cornell University. Currently it has 16,000 hits a day. Many of the preprints are eventually published in print journals. Under this model, peer review is done by the readers, who may send their comments directly to the author.

Self/institutional Archiving

Under this model, either an author or an agency with which the author is connected, post the article to an open access server. This model may use the preprint or finished product model depending on the policies of the party doing the publishing. There is a recognition by many institutions that the work of their faculty is a valuable resource and a concomitant move to archive (read publish) the work of their faculty on their own servers. This model is currently receiving a great deal of attention.

Combinations of self/institutional archiving and print

A growing number of scientific journals are allowing their authors to archive their papers online. Some (called green journals by those in the open access movement) allow an author to archive a paper online as well as publish in their journal. Blue journals (so termed by open access advocaed) permit the posting of a preprint, and the attachment of corrigenda after publication in their journal. "Gold" journals are fully online.

Issues in Online Publishing

A transition from one method of accomplishing a task, in this case, dissemination of knowledge, creates new situations that need attention. Some of the stumbling blocks are copyright, peer review, costs and finding the literature.


Copyright is a means of protection of published intellectual property, whether in print or digital format. Authors, whether writing a book with the hopes of gaining royalties, or freely providing scholarly work, need copyright protection. Open access does not mean that the article is in the public domain, but preserves copyright just as if the article were in a print journal. Under the terms of the Berne Convetion, to which the U.S. adhered in 1989, copyright is assumed from the moment information is in a fixed format, i.e. a paper, a CD, a Web page or even an email message. The only exception to this in the U.S. is work done by employees of the federal government as part of their job. These works are deemed to be in the public domain and available for free use by anyone (Bachrach, et al.1998).

A method for preserving authors’ rights to their own online work is the “Open Content” license. Under this model authors add a notice to their freely distributed work that specifies how it may be used. The model advocated by the Open Content organization ( relieves an author of any liability, and states the conditions under which others may use and or modify the work.(Open Content, n.d.)

Similar to the Open Content license is the Free Software Foundation's GNU Free Documentation License ( The purpose is to make documents"freely"available, but preserve for the authors a way to get credit for their work, while not being considered responsible for modifications made by others. This license has been described as 'copy left', and was originally designed for free software manuals, although it has also been applied to a number of books.

Peer Review

When open access publishing was first suggested many people thought that peer review could not be accomplished in this venue. The presence of many online journals that are peer reviewed, however, has laid to rest this fear. There may be differences, however, in how it is accomplished. In print, peer review is generally theoretically blind, that is, the author does not know the reviewers and the reviewer does not know who the author is. Although peer review for open access journals can take this format, with the preprint model generally the reviews are open, or transparent. That is, authors post their papers together with their name and usually their email address. Reviewers, instead of being assigned, generally are self selected. They may either post their review, or send it privately to the author depending on the policies of the publication venue. Some question the reliability of this method, wondering about the credentials of the reviewers. Reviewers for print journals are generally assumed to have a reputation and achievement in the content area when reviewing, yet editors know that this is not always the case (King, McGuire, Longman, Carroll-Johnson, 1997). Thus, having an open, or transparent review by self selected reviewers may be just as effective. The reliability of the reviewer can be further ascertained if reviewers are required to post their CV online so their credentials may be checked.


Online publishing, even if posting is free to the author and access is free to the user is not without costs. Even with preprints there must be a server with room for the work, and an administrator to keep the server operating, as well as the costs associated with being on the Internet which includes a domain name. Additionally, the documents must be posted in a Web readable format. If peer review is done, this is an additional cost. Estimates have been made that an online article incurs costs of about $400 -$500. (Given that BioMed Central is a for profit organization, this figure may be high.) Interestingly when the American Chemical Society (ACS) and the Royal Society of Chemistry put all their back journals online the cost was about $0.30 per page. For a 20 page article that would be $6.00. It is possible to cut peer review costs by using software that can automate most functions including tracking manuscripts through the peer review process, preparing and posting documents online and generating statistics (Suber, P. 2002).

Finding the documents

Searching the Web can be a fun experience, or a trial if you are trying to find scholarly documents. Unlike bibliographic databases in which all the information is located in one place and formatted by the database employees, open access documents, like Web resources, will be stored in many different locations and could possibly have different formats for their identifying information, i.e. title, author, date. The Open Access community has developed a method of standardizing this metadata for scholarly documents so that the documents on all servers that meet these standards are easily available. It grew out of the e-prints, or pre-print movement from the group. Information about the Open Accessibility Initiative (OAI) standards can be found at

Advantages of Open Access Publication

Publication in an open access venue assures allows for global dissemination of the document and provides ready acess to developing countries. This format also decreases the time from discovery of new knowledge to its being available for use. The flexibility and ease of change allows authors to update information and still preserve the original. Further, there is a greater probability that an open access article will be cited more frequently. Lawrence (2001) found that a freely available online article was cited 2.6 times more often than print articles.

Global Nursing Knowledge Network (GNKN)

With the exception of BioMed Central, a few online nursing journals, and those lucky enough to be employed where online access is available, accessing nursing literature requires a trip to the library. Further, with publishers demanding higher and higher subscription rates, what is available online today through large libraries may not be tomorrow. These practices disenfranchise most of our practicing nurses.

To meet this need a Global Nursing Knowledge Network (GNKN) is proposed. The GNKN would use the preprint model under which authors would post articles to a central server, known as the Global Nursing Knowledge Network (GNKN). Peer review would be done by readers and posted as comments along with the reviewer’s names and contact information, or the reviews could be sent privately to the author. Authors would self-index by selecting from two different types of categories for the article, one the type of article and two, the subject. Authors could request specific people to review their articles, but all readers would be eligible to review articles. Reviewers would be asked to provide information about their qualifications in a CV format.. An article that has no online reviews would be clearly labeled as a preprint. Authors would be able to revise their articles as needed, either by addenda from which the original would be linked, or by a complete revision in which case the original would still be available, but clearly labeled as an early draft. A metadata schema would be developed to meet the current and emerging standards for the Open Access Initiative ensuring that this literature is easily available by searches.

It is possible that many nurses would rather only see articles in a given topic that have been reviewed by a third party. Services could be started that would select and provide peer review for selected articles for specific topics. These services would provide subscribers links to articles they have selected and reviewed and charge a fee for this service. The articles would always remain on the GNKN server, and the list provided to subscribers would link directly to the article. Copyright for the articles would remain with the author.

Steps to achieving these aims include appointing a Board of Directors. The Board will include nurses and other interested parties from colleges, healthcare agencies, and professional organizations. Tasks for the Board will be to develop guidelines and write grants for initial funding. Long term plans for funding include fees from services that provide third party reviews and subsidies from library budgets that will eventually be lowered when they no longer must subscribe to many journals.

Benefits of the GNKN Model

New knowledge would be available much faster than from a print journal. Additionally, all articles would be available from any computer connected to the Internet. With immediate access to information from the entire globe, collaboration that would never have occurred due to lack of knowledge about the work of others, will be possible. When clinicians can easily access articles, their awareness of the body of nursing knowledge will increase. Easy access can also encourage clinicians to share their knowledge with those outside their institution by writing. With the literature easily available, healthcare institutions may realize the benefits of having their staff publish and provide incentives to do so.

The potential for education when educators both in academia and practice and their students have access to a large body of literature are now only dreams. With the GNKN model instructors can easily supplement their courses with articles presenting the latest knowledge without fear of violating copyright laws. This will enable classes to use the most up to date knowledge rather than rely on articles and texts that are several years or more old. Additionally, students can be taught searching techniques and experience positive results when the articles they locate are easily available. A laboratory for teaching evaluation will be readily available and can add to the critical thinking tools that nurses should possess.

Having the review process open to a broad base of readers will strengthen the review process because all those with knowledge of the topic can become involved. This can also promote scholarly discourse amongst nurses. A very important plus will be that information about current nursing research and issues will be available to those outside nursing. Journalists in the health field subscribe to medical journals, but not to nursing journals. When our literature is available online, those in the media will find it as easily as medical information, thus increasing the visibility of nursing.

Steps to Facilitate Nursing’s Progress Toward Open Access

Types of Papers

1. Research
2. Research with a new instrument
3. Research with provision of raw data
4. Meta analysis
5. Evidence-based guidelines
6. Opinion/Editorial
7. Report about a clinical practice
8. Case Reports
9. Report about an educational practice
10. Informational

(Back to GNKN)


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