Spreadsheet and Relational Database Programs: Useful Tools for Perioperative Nurses
Patricia Newcomb, RN, PhD, CPNP
Information management has become a critical skill for all nurse professionals, including perioperative registered nurses (RNs). In perioperative nursing, combinations of high-touch and high-tech patient needs require staff to be acutely aware clinically. Staff members are focused on responsibilities for assessing, monitoring, and intervening in specific patient situations and may miss the importance of learning to successfully manage amounts of data greater than those generated by one patient at one particular time. When staff nurses and managers begin to think about collecting
evidence to demonstrate the quality of their performance or when they begin to express the wish to test their hunches about the factors that influence patient outcomes in their units the time to develop competencies in formal data management has arrived. Fortunately, the challenges of learning to organize and manipulate data do not approach the difficulty of the challenges faced by perioperative nurses in practice on a daily basis.
Most staff RNs are aware of spreadsheet and database programs loaded onto their workplace computers, but they may not take full advantage of them. These programs can be useful both as practice tools and as repositories of information that may be used in evidence-based projects or research. The current interest in evidence-based interventions to support patient safety and quality care, as well as the movement toward attainment of Magnet recognition in hospitals, mean that perioperative staff RNs serve actively on evidence-based practice and research councils and are
participating in clinical research themselves. These activities offer broad scope for common spreadsheet and database programs that are accessible to staff nurses. Staff nurses and managers increase their value to the organization when they learn to use these programs.
PROGRAMS
The term spreadsheet refers to lined “sheets,” or tables, of rows and columns that have been used in paper form by accountants or bookkeepers for hundreds of years.The columns and rows on a spreadsheet were a way of organizing data so that theuser could see how costs, income, taxes, and other items “spread.” Traditionally, figures were entered into the columns, and mathematical operations, such as addition and subtraction, were performed manually by the individual entering data into the tables. Row/column financial programs requiring large-scale computer capacity were
used in the 1960s, but the first electronic spreadsheet program designed to be used interactively on a personal computer was VisiCalc, developed by Dan Bricklin and Bob Frankston in 1979.1 Most electronic spreadsheets in use today are direct descendants of VisiCalc.
Currently most health systems use personal computers (PCs) with Windows-based operating systems in patient care units and across most of the system, with the exception of specialized departments such as marketing. Typically, workplace PCs are loaded with Microsoft Office products such as the spreadsheet program, Excel, which seems to be the market leader for electronic spreadsheets presently. In this article the Excel program is assumed to be the default spreadsheet program available
to staff nurses. At first glance, relational database programs look similar to spreadsheets, but they
have added sophistication. Commercial relational database programs designed for use on PCs include the Corel Paradox program that is part of the WordPerfect office suite and the Microsoft Access program that is part of Microsoft Office. Like Excel, Microsoft’s Access database came to dominate the market for PC-based relational databases. Because most health systems use Microsoft products on computers that are accessible to nurses, it is likely that Access will be available, and that is the
database program used as a model here.
A relational database is a system that stores data in tables, like spreadsheets, but a key difference between spreadsheets and relational databases is that the data stored in the relational database can be presented in many different ways, not just rows and columns. Another crucial difference is that, unlike spreadsheets, the data storage tables in a relational database can be linked (related) to each other in different ways. For instance, in a one-to-one relationship, a record in one table is linked to
another record in a different table. In a many-to-one relationship, one record in a table is related to many records in another table. Data stored in the tables are organized in a highly structured way that enables queries and the generation of reports. Relational database programs are typically more difficult for practicing.
SPREADSHEET PROGRAMS IN PRACTICE
Storing Information as Text
Data stored in tables are easily read, retrieved, and manipulated. Spreadsheets make tabulating both text and numerical data easy. As staff RNs become more engaged in evidence-based practice and conduct evidence-based projects supporting such practice, they are consuming greater volumes of research literature. Many staff RNs print out paper copies of articles and store them in file folders, accordion files, or other cardboard-type containers. Recall and retrieval of information from these containers is usually cumbersome.
Commercial reference management software such as RefWorks or EndNotes provides an excellent vehicle for storing citations, generating bibliographies, and preparing manuscripts, but such software may not be available for practicing nurses in the work environment. In the absence of commercial citation management software, spreadsheet programs can be used as “pinch charts” to store and organize critical information from references. A pinch chart is a table containing concise statements regarding critical components of scholarly articles. This type of chart is invaluable as a means of organizing and sharing information from the literature. In a pinch chart, each row in the spreadsheet is a reference such as a journal article, and columns contain the information the user wishes to find rapidly.
An advantage of a spreadsheet
pinch chart is that it can be easily customized to suit the nurse’s favored ways of tagging or locating information. For instance, information in columns can be sorted, and selected columns can be hidden by the reader when only one kind of information is sought. Columns, rows, and cells can be color-coded, and text can be highlighted.
RELATIONAL DATABASES IN PRACTICE
The Access database program available in the Microsoft Office suite of programs has been a workhorse for years but has been difficult for occasional users to master. The later versions (post-2007) have simplified the use of the tool, although it is still more challenging than Excel. Other important relational database management systems (RDMs) include Oracle, Apache Derby, CUBRID, Empress Embedded Database, Ingres, and others. Because Microsoft products are those most commonly available on PCs for staff nurses, the Access RDM will be the model in this article.
The first database management systems emerged in the 1970s after Edgar Codd2 published a report describing the application of elementary relation theory to systems that would provide shared access to large collections of formatted data. To appreciate the relational database, it is only necessary to look at an example of the flat database that preceded it . Flat databases were virtually impossible to search except for reading each data item from the beginning. Contemporary relational databases, which may contain thousands of linked tables of data, are easily searched using a special computer language called Structured Query Language (SQL). When using programs designed for PCs such as Access, the consumer need not understand SQL. The end user can perform complex tasks without specialized knowledge of computer languages because the sophisticated user interface is generally intuitive and reduces the work to mouse-clicks. The Help icon is also our friend! Data in an RDMS are stored in tables of columns and rows that look similar to a spreadsheet. The flat database (see Fig. 9) would be formatted as in Fig. 10, with each row representing a record and each column representing a field. The second table in Fig. 10 is related to the first table through the physician field. In this example (see Fig. 10), all physician information is kept in a table separate from the patient data but can be quickly and easily accessed through the physician number link. For those who are new to Microsoft Access, the newer versions feature “wizards” or introductory videos that walk the user through the creation of tables and the linking process. Relational databases are extremely useful in situations that require the quick generation of attractive reports. The information in a table (see Fig. 10) can be used in multiple different reports. After the tables are linked, reports can be generated in a matter of seconds simply by selecting the fields desired in the report (Fig. 11). For the beginner, using the report wizard in Access is easy and definitely the wiser course to avoid frustration. Among other advantages, keeping tables up to date in relational databases makes it possible to present well-organized information in an attractive format for last-minute meetings or impromptu briefings. More personal uses for desktop relational databases are common. For instance, a nurse manager who keeps information about staff such as T-shirt size, birthdays, hire dates, awards, and so forth in a table in a relational database can quickly generate special-occasion reports for staff celebrations. Because tables are linked, data updates are easy and organization of information is efficient. Information needs to be entered only once in a relevant table to be available for any data manipulation thereafter.
A benefit of relational databases that is not duplicated in spreadsheets is the ability to enforce integrity rules. The rules protect the validity of the data. For instance, if entity integrity is enforced, then every record will have its own specific identify and there will be no duplicated records. Referential integrity means that the user can define “primary” and “foreign” keys, which are fields in tables that act as links between tables. When properly defined, these keys prevent inconsistent deletions or updates. If a record is removed from one table, it will be removed from all tables, and if data are changed or added in one table, the change or addition will be reflected in all relevant tables or reports.
