2003 report

Ruth M Sladek, January 2005

As the recipient of the 8th Biennial Anne Harrison Award, I used the allocated funds towards a small study tour in England. As per my original proposal, I undertook to visit at least three clinical librarianship (CL) positions/programmes, present the findings of the National Institute of Clinical Studies (NICS) clinical evidence researcher study at the 2nd International Conference on Clinical Librarianship, 4-5 November (London), and to report finding back to HLA, ALIA. This report therefore concludes my responsibilities in regard to this award.

My plan was to include visits/meetings with the following:

Jo Hunter, research and effectiveness librarian, Cairns Library, John Radcliffe Hospital, Oxford
Laura Tucker, knowledge resources librarian, Royal Free Infirmary, London
Marina Waddington, clinical effectiveness librarian, Great Ormond Street Hospital for Children, London
Mary Publicover, clinical librarian, Birmingham Women's Hospital, Birmingham
Linda Ward, clinical librarian, Leicester General Hospital (LGH), Leicester

Unfortunately the last two visits were cancelled due to a bus accident in London which required surgery, however I still met with both colleagues from these organisations (Mary Publicover and Linda Ward) whilst at the conference and I still presented my paper. However, as the LGH programme is the most well known and active CL programme with librarians responsible for different clinical areas, the inability to shadow a CL or observe aspects of their programmes was a loss to the overall visit.

In this report I will summarise my meetings with relevant individuals, and will also provide my perceptions of the CL developments overseas in relation to Australian practice. I will conclude with some suggested strategic areas for HLA to consider further.

Jo Hunter research and effectiveness librarian, Cairns Library, John Radcliffe Hospital, Oxford

This position is relatively new, and evolved from a vacated CL position originally filled by Helen Carter, which they had difficulty in filling. It is still in its evolutionary stages, with staff exploring future directions. The revised position aims to provide a single point of contact for specialist information support for research and clinical effectiveness, information consultancy services, particularly mediated literature searches and training in information searching and handling.

The position is evolving, but essentially the focus is on developing strategies to forge closer links with clinical staff. This does not involve attending ward rounds at present, but such a service would not be precluded. It could include, for example, support for hospital staff who are developing guidelines, working on integrated care pathways, auditing a service, researching a project or looking for information. At present the service is integrated primarily with the emergency department, where doctors are expected to develop a local guideline as part of their training programme, and the librarian is involved in this process. The CL, along with other librarians, is rostered to attend a weekly meeting to 'search for evidence' during case reports.

Laura Tucker currently knowledge resources librarian, Royal Free Infirmary, previously clinical effectiveness librarian (vacant position, appointment pending)

This 1000 bed hospital has approximately 4500 trust employees, and this permanent one FTE position was created in April 2002 as a strategy to support the clinical and research agendas of the hospital. The position recently became formally vacant, but appointment is in progress. The position works as part of a four person team within the library, along with other general library staff. There is an equivalent position solely for psychiatry and psychology, a trainer position, and an administrative position. There are no reference librarians per se - enquiries are handled by circulation staff and passed onto the most relevant available person.

In support of clinical governance, Laura developed the Clinical Effectiveness Enquiry Service (CEES). This was in initial preference to a ward rounds service because it was thought it could be offered to more people. A marketing approach was used (logo, printed materials etc), and the service started in April 2002 and peaked at 52 enquiries a month in January 2003. Most users were from nursing and allied health groups. When questions were raised, 80 per cent of the time they sat with Laura whilst she searched for answers. She also offered subsidised interlibrary loans for service users, ie, access to both University of Library e-collections regardless of employment status. Laura completed a comprehensive report on the CEES, and has provided me with a copy.

In support of research governance, she undertook two key tasks. Firstly, as the new component of practice, she assisted in literature searching for all trust research proposals before they were submitted for funding. Secondly, because funding for the hospital trust from the NHS used an equation including statistics on publications (similar to how universities receive funding), she undertook an annual 'publication stock' of all trust related publications, and including conference proceedings.

Laura also explained that in terms of the NHS, the NeLH was being relaunched as the NLH (National Library of Health), and was moving away from the information authority to the NPfIT (National Programme for Information technology).

Marina Waddington clinical information support librarian, Great Ormond Street Hospital for Children

This was a new temporary position (two years), that started one and a half years ago and apparently will not be renewed due to financial reasons. The remit is essentially to support the clinical staff in their need for evidence. The focus is on training, but with an evidence based focus. Whilst Marina originally envisaged going on ward rounds, she tried this over a ten month (once a week) and whilst the clinical team was welcoming, no questions were asked.

Mostly the position provides training in databases and resources, which are taught in the library and ward areas. She also undertakes Critical Appraisal Skills Programme (CASP) workshops, one of which she kindly allowed me to attend. This workshop is marketed as a basic introduction to critical appraisal skills, and is similar to the ones I have provided in my previous role at the Repatriation General Hospital. She advertises them on set dates (one to three per month) and anywhere from two to seven multi-disciplinary staff attend.

She has also be involved as a searching tutor at the Centre for Evidence Based Child Health Interim and Advanced Courses. Marina's colleague Angela provides training on 'finding the evidence'.

Linda Ward deputy manager, library, Leicester General Hospital (LGH)

LGH is a focal point for CL activities, with the most structured and widely known CL programme which has undergone extensive external evaluation. They employ four CLs (two are part time) totalling three FTEs. The service is run across two sites, and not all specialty areas are covered, which reflects capacity not requirements. The amount of clinical contact varies according to the clinical team. For example, the CL responsible for women's health covers perinatal, sexual health, and neonates. She attends one consultant's ward round per fortnight, which is enough to 'maintain contact'. She attends an audit meeting (O and G) weekly, and a clinical governance meeting in gynaecology, as well as a weekly multi-disciplinary team meeting in gynaecology , where case histories etc are reviewed. The CL also attends mortality and morbidity meetings.

Generally questions are responded to using a proforma, and are e-mailed using an e-mail signature. They do not include critical appraisal, but it depends on the question. They use a hierarchy of evidence, and highlight, for example, if they use narrative reviews. A disclaimer is included in responses. Questions come from both consultants and junior doctors. This would appear to be similar to the approach used in the NICS clinical evidence researcher study.

Clinical librarians are also involved in policy meetings, journal clubs and teach critical appraisal skills.

Further information is available from the publicly available report on the evaluation of the LGH clinical librarian service.

Mary Publicover clinical librarian, Birmingham Women's Hospital

This position is .6 FTE permanent in a small specialised hospital of 120 beds. There are two full time assistants (one professional, one administrative). It has joint roles as manager and clinical librarian. The position started in 2000 when the education department was created, with a director passionate about evidence based practice. The position appears to be very well integrated with the educational and procedural (eg clinical care pathway development) functions of the hospital. The remit includes one ward round in the delivery suite (once a month), which is effectively a teaching ward round. Mary is actively involved in three different journal clubs, and attends integrated care pathways meetings.

The journal clubs are each different, but somewhat experimental. The aims of all are to be relevant to clinical practice, and to teach and reinforce an evidence based approach, explore implementation issues, and record any appraisals.

The Obstetrics & Gynaecology Journal Club includes a compulsory presentation by a junior doctor, and the challenge appears to be getting them to use a 'real' question and not just one that matches the papers they have. The group uses CATmaker to summarise their topic.
The Neonatal Unit Journal Club starts with a current case and with the guidance of a tutor questions are identified. They then search together and look at abstracts together. Sometimes that is as far as it goes. Mostly they seem to look at case series. This group is looking at using the Bestbets (Archimedes) style of writing up the topic/appraisal.
The Nursing, Midwives and Therapists Journal Club draws questions from quality meetings. There is a very deliberate link between these two groups, ensuring there is continued conversation between the quality meeting and the journal club to follow up issues of relevance.

Mary undertakes a lot of enquiry work, with responses following a CAT format, although it depends on the question and context: a response would be anything from an annotated abstract from a literature search through to a response such as you would find on Bestbets.

CL conference

This conference was excellent. It was well organised, with a good balance of speakers and small group activities. A copy of the programme is attached. It seemed to meet three needs: the need to update on current CL developments, the need to update on related areas such as technology and government developments, and the need to update skills and knowledge. I presented the NICS clinical evidence researcher service paper and it appeared to be well received.

Whilst every paper was noteworthy, I specifically note the following:

Dr Muir Gray summarised: the NHS needs more librarians, more money to pay librarians, with more skills, and increasingly out of the library.
Dr Khalid Khan discussed the two different approaches for teaching evidence based practice, standalone (eg, separately teaching knowledge and skills) or integrated into clinical practice (comprehension and adaptation of evidence, and changes in attitude and behaviour). He authored a systematic review (recent BMJ) which supports an integrative approach.
The project which received the NeHL Evidence in Practice Award was presented by Jean Walker (clinician) and Linda Ward (clinical librarian). NICS might similarly consider presenting the NICS Cochrane Users Award at a CL related conference.
Dr Paul Glasziou explicitly isolated three roles for librarians within a 'pipeline of practice' (one) organising (two) answering services (three) teaching/coaching. Such a pipeline starts with the Haynes four s hierarchy of evidence (systems, synopses, syntheses and studies) but in order for improved patient care, certain things must happen. There needs to be awareness of evidence, it needs to be accepted, and applicable, it needs to be able to be applied, acted on, and agreed to and adhered to by patient. Problems that pollute such a pipeline include myth, opinion, and poor research.
J Vershuere (clinical librarian) and Dr Makhzoum (ophthalmologist) presented their experience in the development of an expanded clinical librarian role in ophthalmology - where she attends the outpatient clinic and is integrated in the clinical team consisting of one specialist, five registrars, one nurse and one librarian. Dr Makhzoum presented two case studies which highlighted the impact the involvement of the CL had on a (one) rare case which influenced patient management and (two) a new treatment which changed policy and knowledge of what can happen.
In a small workshop led by Linda Ward, a group focused on ongoing issues for CL. These were: developing communities of practice (ie a common purpose and task), holding specific training days (such as are used at Vanderbilt University), developing opportunities for secondments and work-shadowing, the needs of new CLs, and the need for quality standards and transparency.

Other observations/perceptions

Verbal estimates from attendees at the conferences suggested there are perhaps 20-30 librarians who would define themselves as clinical librarians in England. This term embraces previous roles of 'clinical effectiveness librarians'. In addition, there are 'outreach' librarians (numbers unknown) who are employed by primary care trusts who might be seen as working in similar roles.

Linda Ward of LGH recently completed a 'survey of UK clinical librarianship', the results of which are currently in press (Health Information Libraries Journal). Whilst not all results could be reported on at the conference, she concluded from 26 responses that there is a mixed picture of CL activity. She offered the following conclusions about CLs in her abstract (paraphrased):

Likely working in any geographical UK areas
Support multidisciplinary clinical team
Combine CL duties with other responsibilities
May spend up to 30 per cent of time in clinical setting
Up to 60 per cent times spent searching etc to answer clinical questions
Up to 45 per cent time teaching
Up to 28 per cent time on related information services
Might summarise responses but uncertainty exists re role of CL in constructing critical appraisal

Whilst my prior perception was that attending inpatient ward rounds was a somewhat commonplace CL activity in the UK, I identified very few clinical librarians who attended inpatient ward rounds. This appears to be an atypical activity at present.

Most clinical librarians are definable by an explicit role to support clinical effectiveness, and to creatively explore strategies to do this outside of the library. The range of activities differs librarian to librarian, organisation to organisation. In summary, the range of activities I identified that clinical librarians undertake which are different to traditional roles, include:

Facilitating evidence based journal clubs, using questions that have emerged in clinical practice in certain specialty areas, or focusing on topics for guideline development/clinical pathway developments within organisations
Integrating with clinical training programmes and supporting educational requirements which doctors must achieve as part of their programme, eg teaching how to search for evidence and critical appraisal skills so that doctors can develop a local guideline
Attending inpatient ward rounds.
Attending outpatient clinics and supporting health professionals in training and researching unit based clinical issues.
Attending a range of clinical and policy meetings, eg case review meetings, audit meetings, mortality and morbidity meetings, quality meetings, clinical pathway meetings etc.
Facilitating critical appraisal skills training workshops.
Offering specific 'finding the evidence' training.

Recruitment to clinical librarian positions has been difficult, with apparently few applicants for advertised jobs. This is apparently slowly changing as some expertise is being built up. Most positions appear to be contracts only, which is probably an influential factor in recruitment difficulties.

There is a group (about 24 members) called CLIST (clinical librarian and information skills trainers) that meets bi-monthly in London. Many come from one-person libraries so this group provides some support. Membership is growing so they now find it difficult to find a place to meet. They typically spend a day together and in the morning they discuss issues and in the afternoon have a plenary/workshop. Recently for example, they all undertook a critical appraisal skills training programme workshop as a professional development activity, to support emerging roles as trainers in critical appraisal. The extent to which they are actually leading such groups is unknown.

The goal of this report is not a summary of the state of health librarianship in the UK, however it does appear that the higher level of organisation and priority given to information in the NHS means there is access to funds for professional development in CL related areas activities through centralised government funding.

There are plans for several projects in the NHS relating to answering clinical questions. These include: establishing a board, developing standards for answering services, developing a national repository for questions and answers, developing a strategy for supporting training for service providers, promoting question answering skills, and developing an NeLH portal for questions. Jon Brassey, developer of TRIP and provider of the ATTRACT question and answering service, has the service contract for an NHS trial question and answering service which was subsequently launched in the UK.

Issues for consideration by HLA/Australian context

Clinical librarianship is an emerging area which is developing in the UK. There is a critical mass of professional interest, a developing body of expertise and experience, and an environment which is conducive to the goals of clinical librarianship, namely, finding ways to contribute directly and indirectly to clinical effectiveness. This is an important goal, which has perhaps been crystallised by the broader developments over the last 10-15 years within the healthcare environment.

Whilst some Australian librarians may feel uncomfortable with the prevailing image of a 'clinical medical librarian' as mostly attending ward rounds, the reality is that CL at present is more defined by its goals rather than any one specific 'duty'. That is, CL embraces a range of strategies (as may be appropriate) to contribute to clinical effectiveness in different organisations, and attending inpatient ward rounds is only one such strategy. The range is reflected in the duties listed earlier, which in my own experience, are rare in Australian practice. Whilst there are some examples of moves in this direction (eg, clinical librarian position at Royal North Shore Hospital), and I am aware that submissions for funding such positions have been made in several organisations, the UK is more progressed in this direction.

I would suggest HLA consider exploring and supporting ways for health librarians to explicitly contribute more directly to improving clinical outcomes. This support could be provided in different ways, however there are three strategic domains which I would suggest receive focus:

Support for ongoing professional development activities, but in particular, an HLA Workshop on clinical librarianship. This could be timed to precede the Evidenced Based Librarianship Conference in Queensland in 2005, when overseas colleagues with some knowledge of this area will already be in Australia. Colleagues whom I think would be worth considering for targeted involvement would be Linda Ward and Andrew Booth. Jon Brassey would also have significant expertise and knowledge to share.
Ensuring undergraduate and postgraduate formal librarian educational curricula include opportunities to develop the knowledge and skills necessary for working in a clinical/healthcare environment (research methodology, biostatistics, clinical contexts etc).
Collaboration with other organisations which are committed to improving clinical effectiveness: National Institute of Clinical Studies; Monash Centre for Clinical Effectiveness; Quality & Safety Council etc. Such collaboration might include collaborative research opportunities and joint meetings/workshops.

I am also enclosing a CD distributed at the conference which contains research reports sponsored by the NHS Information Authority into the implementation of 'Learning to manage health information: a theme for clinical education', as some of the papers contained therein are relevant for consideration by health librarians.

I am grateful for the opportunity to explore CL in the UK, which the Anne Harrison Award afforded me. I would be pleased to speak with HLA further about this report or any aspect of CL in Australia.

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