Community outreach library services in the UK - Wiley Online Library

Community outreach library services in the UK: a case study of Wirral Hospital NHS Trust (WHNT) Blackwell Publishing Ltd

Frances Maria Dowse* & Barbara Sen†‡, *Community Outreach Assistant, McArdle Library, Education Centre, Arrow Park Hospital, Wirral and †Lecturer, Department of Information Studies, University of Sheffield, Sheffield, UK

Abstract Aims and objectives: The study evaluates the Community Outreach Library Service at Wirral Hospital National Health Service Trust (WHNT). It considers the information seeking behaviour and information needs of primary care staff, and service effectiveness in meeting those needs. Methods: A literature review established the current context and areas of best practice. The investigative case study used postal questionnaires to 250 primary care staff and an interview with the Community Outreach Librarian. Findings: Themes emerged from the literature regarding information seeking behaviour, information needs, and meeting user needs through effective service delivery. Outreach services have value in terms of improving information skills and providing services at point of need. Time is a major constraint for both users and service providers. Conclusions: Investment is needed from appropriate funding sources to support the provision and marketing of outreach library services. Librarians benefit from sharing best practice. The continued evaluation of outreach library services is recommended.

Introduction Primary care is where 90% of patients receive their treatment,1 putting primary care staff in an ideal position to lead a health service designed around the patient. Staff need information to support patient care, clinical practice, research, and personal development. Primary care staff often lack easy access to libraries, the time, and sometimes the skills to search for the information needed. A good ‘imaginative’ outreach service offers library provision at the point of need within the community, supporting staff in practising evidence-based medicine (EBM) and providing first-class care.2

Correspondence: Frances Maria Dowse, Wirral Hospitals NHS Trust Library Services, McCardle Library, Education Centre, Arrow Park Hospital, Wirral, CH43 5PE, UK. E-mail: [email protected]

The Community Outreach Library Service at the Wirral Hospital National Health Service Trust (WHNT) in the UK established in 2002, provides library services for staff in the community. Services include interlibrary loans delivered to the workplace, enquiries, literature searches, and training in Dialog, Internet resources and Cochrane Library. Training is available at the library or workplace on a one-to-one basis or in larger groups.

Aims and objectives This study evaluates the Community Outreach Library Service at WHNT, through an analysis of the information needs and information seeking behaviour of primary care staff, and service effectiveness in meeting those needs.

© 2007 The authors Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.177–187

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Community outreach library services, Frances Maria Dowse & Barbara Sen

Method Literature review A literature review was carried out to establish the context of the study and areas of best practice. Searches were performed within medline, cinahl and lisa using both keywords and MeSH headings. Examples of keywords. Outreach, community outreach, primary care, community nurses, GPs, general practitioners, allied health professionals, librarians, library, information needs, informationseeking behaviour. Examples of MeSH. Primary Care Health, Community Health Nursing, Family Practice, PhysiciansFamily, Access to Information, Libraries-Medical, Library Services, Librarians, Needs-Assessment, Information Services, Health-Education. The term ‘outreach’ provided limited results outside the USA, indicating its development as a concept elsewhere. Most useful resources appeared in the literature from 1997 to date. However, there are classic texts on information behaviour from the 1980s.3,4 Themes from the literature informed the questionnaire design and interview schedule. Case study WHNT Community Outreach Library Service was chosen because the service is well established and has influenced the introduction of similar services regionally. The users. A postal questionnaire was distributed to 250 primary care staff to discover their thoughts on the service. The questionnaire was designed to look professional and appealing to encourage respondent participation. It comprised of two main sections with closed questions covering the library service (access, membership, resources), and training (attendance, satisfaction and impact). A final open-ended question allowed additional comments. An expert panel of appraisers suggested minor changes to wording. A random sample was compiled of 250 primary care staff including general practitioners (GPs),

managers, nurses and allied health professionals. The sampling frame was drawn from: • library management system; • interlibrary loan records; • training attendance records; • all Wirral GPs. A pilot questionnaire went to ten staff from the original sample. Feedback identified the clear structure and ease of use of the questionnaire. The final questionnaire was distributed through internal mail with a covering letter. Ninety-three useable questionnaires were returned (37% response rate). This response rate is acceptable.5 The librarian. A semi-structured interview with the Community Outreach Librarian provided background to the service and the Librarian’s perspective. This enabled a comparative analysis with issues raised by users, and from the literature. Questions focused on themes from the literature review; e.g. user needs and behaviour, training, and service delivery. The interview transcript and questionnaire are available electronically from the main author.

Literature review There is extensive research on the information behaviour of primary care staff. The term ‘outreach’ is more prevalent in the USA;6,7 only more recently adopted in the UK.8 Key themes emerged from the literature, information seeking behaviour and information needs,3,9,10 and the management of an effective service in meeting those needs.8,11,12. Information seeking behaviour and information needs Since the mid-1980s, availability of technology has increased, yet evidence shows that primary care staff still choose their colleagues and books as their preferred sources of information.3,9,13 Information seeking within primary care is principally for patient care.9,10 The pursuit of information specifically for a patient will be determined by the urgency of diagnosis or treatment, by the knowledge that a definitive answer exists, and the patient’s expectations.14 The current trend of



keeping patients well informed, while empowering patients, is time consuming for primary care staff and intensifies their information needs.9 Many things determine what resources primary care staff use; these ‘cost factors’ include time, energy, convenience and availability.3,14,15 Staff often choose colleagues as their primary information source; as colleagues meet these criteria and are respected for their expertise and knowledge.9 GPs need 40% of all their information needs while the patient is present, or within 15 min of seeing them.3,10 Primary care staff will consult a colleague or a textbook on their desk because it is quick and easy. Staff working on tight schedules must consider the time and effort needed to search a higher quality source against the possible extra benefit this would have for their patient.10 Information seeking behaviours can be confined by time constraints. There is an ‘enormous skills gap in primary care’, with many staff unable to use the resources provided.’16. Staff often have poor computer skills and lack confidence in their abilities.10 This can deter them from even beginning to search for information.17 Studies show that ‘few wish to develop the necessary skills’11 and ‘do not generally have the time or inclination to perform lengthy literature searches.’18 However, Doney et al. found that staff were willing to use electronic resources, but again did not feel they had sufficient skills.19 Doney et al. identify a lack of training as the key reason why electronic resources are not being fully utilized.19 Training If the lack of skills is a barrier, practitioners and researchers have offered solutions though the delivery of training. Robinson and Lawson12 believe that training on a one-to-one basis rather than in groups produces better results. Staff like familiarity, so learning on their own computers is an effective way of making them more comfortable, confident and likely to practise. Work-based learning is generally believed to produce more successful learning outcomes.20 Nevertheless, a report from a Derbyshire outreach library service, reported results in favour of classroom teaching. Staff attending library-based

sessions showed increased motivation to learn, practice and use their new skills in the workplace.8 Scherrer7 found that 70% of staff surveyed would prefer a one-to-one format for training as did Lacey-Bryant18 who believed GPs’ ‘preference may reflect a reluctance to demonstrate hesitation in front of colleagues and undeniable difficulties of arranging training sessions around a demanding clinical and management schedule.’ Robinson and Lawson found that staff in their study had little time to practise their new skills and 27% returned for refresher classes12 —follow-up sessions being essential ‘to improve the training component’6 and staff should ‘commit to a series of training sessions’6 which can be difficult when time constraints11,21 are already a major barrier. Outreach library services Libraries can be considered inaccessible, not just because of time factors, but for practical considerations; for example, travelling and poor carparking facilities.15 Many staff are not aware of what their libraries offer, a marketing problem that could be resolved.19,21 Librarians need to be seen positively as the key to successful information seeking and ‘improved information access.’6 The delivery of outreach training by librarians has been identified potentially as an effective way to introduce ‘both evidence-based medicine and computer usage to those who have strong negative perceptions about both of these.’17 Outreach library services deliver information at ‘point of need’.21 Services must be flexible, ‘imaginative’2 and tailored towards user needs. A successful outreach service needs a good librarian, adequate funding, resources and a network of informed supporters. This is currently not substantially on offer within the National Health Service (NHS).17

Findings—the case study Background ‘Information for Health’22 required that primary care staff have ‘easy access to local and national knowledge bases ... to support them in the evaluation of the care they give, underpinning clinical


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governance, planning and research, and helping with their continuing professional development’.22 To ensure WHNT met these requirements, the Community Outreach Library Service was created in 2002 funded by the established library service. In 2004, following its success, funding was secured for five further outreach librarians regionally and an assistant for the existing service. The Community Outreach Librarian runs a service across sites at Arrowe Park Hospital and Clatterbridge Hospital in Wirral. The library at Arrowe Park offers 24-h access via swipe card and has an IT suite and training room. The library at Clatterbridge houses the primary care book collection. The service also offers interlibrary loan (ILL) provision to the workplace and an enquiry and literature search service. Training sessions are run from Arrowe Park, with plans to extend to Clatterbridge. Training is offered in groups and on a one-to-one basis both at the library and within the workplace. Training is currently available in Internet Resources, Dialog and Cochrane Library.

Table 1 Level of computer skills

Findings from the questionnaires

Training. Sixty-six (71%) out of a total of 93 respondents had attended training delivered by the Community Outreach Librarian. Of respondents who had attended training, 41 (62%) recommended it to colleagues. Twenty-three (29%) of total respondents who did not attend training; 13 (56%) of these stated a lack of time, not lack of need as a reason.

Information seeking behaviour and information needs. Respondents from this study clearly preferred computer resources above printed sources, with 74 (80%) choosing computer resources as their initial source when searching for information (Fig. 1).

Respondents’ opinion of their computer skills level

Number

%

Excellent Good Average Basic Very basic No answer Total

2 30 37 19 4 1 93

2% 32% 41% 20% 4% 1% 100%

The majority of respondents (69; 75%) believed their computer skills to be average or above, with only (24) 25% considering their skills to be below average (Table 1). Respondents were asked to identify their reasons for searching for information, ticking one or more options: patient care 62 (67%), continuing professional development 69 (75%), research 33 (35%), academic qualification 37 (40%), other 0 (0%).

Training options (Fig. 2). When asked about their ideal training situation, staff preferences were split between one-to-one training and being trained with colleagues (Fig. 3).

Figure 1 Respondents’ preferred sources of information

Figure 2 Type of training sessions attended



Figure 3 Type of training sessions preferred

When asked to identify the impact of training on their work or studies, the most popular options were: ‘I now find the information I want more easily’; ‘I know where to look for the information I need’, with 35 (53%) selecting these options. Respondents could select any option applicable. There was limited negative impact reported (Table 2). The impact of training that staff received differed according to the type of sessions they attended. Staff attending training in groups with colleagues were less likely to use their new skills, while those attending anonymous groups or individual training were using their new skills more regularly (Fig. 4). Forty-two (63%) of those receiving training would attend refresher courses if available. Their reasons are given in Fig. 5. Outreach library services Of the total respondents: 58 (62%) were members of the WHNT library service;

Figure 4 Skills use after training

Figure 5 Reasons to attend a refresher session

29 (31%) were library members with a swipe card for 24-h access; 16 (17%) were library members with a swipe card, using it at least once to access the library; 13 (14%) were library members with a swipe card and had not used it for 24-h access;

Table 2 Impact of training Impact Positive I now find the information I want more easily I know where to look for the information I need I now find the information I want more quickly I use online resources more regularly now I save time because I am searching for information more efficiently I feel confident that I can find the information I need I am gaining confidence in my skills with practice I have helped others find the information they need Negative I am still unsure of where to look for information I still have little confidence in my abilities I have noticed no marked improvement in my searching skills

Staff who identified this as an impact

35 (53%) 35 (53%) 33 (50%) 33 (50%) 33 (50%) 23 (35%) 23 (35%) 23 (35%) 16 (24%) 7 (10%) 4 (6%)


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Community outreach library services, Frances Maria Dowse & Barbara Sen Table 3 Awareness of service How did respondents become aware of the Community Outreach Library Service? From colleague

Event in community

Visit to library

Advertising; e.g. poster

No reason given

Total

23 (35%)

18 (28%)

11 (17%)

11 (17%)

2 (3%)

65 (100%)

65 (70%) of respondents were aware of the Community Outreach Library Service (Table 3). Interview with the Community Outreach Librarian WHNT July 2006 See Table 4.

Discussion Information seeking behaviours and information needs Evidence from the literature recognizes books and colleagues as the first sources of information used by primary care staff.3,13,15 Results from this case study contradict this evidence showing a possible changing trend. Findings show that 80% of respondents were choosing computer resources as their first reference for information, with nearly one-third identifying online medical databases as their preferred source rather than the Internet. The Community Outreach Librarian had trained all but one respondent preferring online medical databases. These results indicate the improvements possible when information resource training is offered to staff. An initial needs analysis of primary care staff in Wirral identified their main need as being where and how to look for information. Signposting the appropriate information sources to best suit people’s needs became the principal aim of the service. This need has been met through the delivery of successful training, with 53% of respondents stating; ‘I know where to look for the information I need’ and ‘I now find the information I want more easily.’ Primary care staff choose resources by considering ‘cost factors,’3,14,16 Training has targeted the ‘cost factors’ identified in the literature;15,23 for example, time, convenience and availability of

resources. The flexibility of the training available at both the library and the workplace, on an individual and group basis, allows more staff to attend. The training encourages staff to use better sources of evidence, reducing the reliance on colleagues and books. The Community Outreach Librarian confirmed the need for ‘flexibility’. There is a narrowing of the information skills gap in primary care.16 The Community Outreach Librarian identified an improvement in the computer skills she encountered amongst staff from when the service was first established, there being ‘a definite improvement’ Most respondents in this study consider themselves to have average or above average computer skills, showing a growing confidence in their abilities. Thirty-five per cent of staff who had received training gained confidence in their abilities as a result. Other studies support the positive impact that training can produce.3,4 Training There is debate as to which type of training is most successful and most popular—one-to-one or groups.12,19 In this study, the majority of staff preferred not to train in anonymous groups (people they had not met before). Preferences were split evenly between groups of colleagues and on a one-to-one basis. The Community Outreach Librarian pointed out that, although training a group of colleagues is advantageous to her and staff because the session can be tailored, this type of training is difficult to organize as staff are rarely available at the same time. The librarian offers one-to-one training, but time constraints prevent all staff being trained in this way. Staff in this study did attend anonymous group training despite it not being their preferred choice (Figs 2 and 3). Evidence from the literature suggests that one-to-one tailored training is most effective.12 Research shows work-based learning has better


Community outreach library services, Frances Maria Dowse & Barbara Sen Table 4 Interview with the Community Outreach Librarian Theme: Informationseeking behaviour and information needs

Key finding There is a need to raise awareness of information sources, and improve users’ information skills

Supporting evidence ‘I designed the job around my strengths and the things I thought people needed. I wrote a questionnaire ... I got feedback saying ... people didn’t seem to know what was out there, and if they did ... they didn’t know how to use it, they’d never been given training.’ ‘I started slowly; enabling people to use what was there and telling them what was out there, supplying photocopies and books, answering enquiries, because I saw that as the main need.’ ‘They don’t know where to start looking. Often they haven’t a clue what they are looking for.’ ‘You get some GPs who are very computer literate ... and others who come and say “I haven’t a clue how to use the Internet”.’

The information skills gap is improving in primary care

‘Peoples’ computer skills—a lot better than they used to be ... a definite improvement over the last few years. They are getting better because they have access at work.’ ‘... they are not even confident using a mouse, but that’s getting less and less frequent now because everybody is forced really into using computers, so skills are getting better.’

Theme: Training

Key finding Flexible training required at point of need. A variety of training options required to meet different users needs

Supporting evidence When training a group of colleagues together the trainer ‘can tailor the session’. ‘... it’s useful to have them all together ... back in the office they can sit and jog each others memories...’ ‘If someone wants me to do a specific sort of training session at a specific practice, I’ll go out and do that.’ ‘... you need to be flexible.’

Training effectiveness

‘When it’s one-to-one, it’s harder to get them to sit and practice on their own.’ In groups people ... ‘remember because they’re doing it themselves.’ When asked which type of training was best, she remained undecided. ‘Depending on what kind of learner they are ... I couldn’t say which is best’. About nurses after training ...‘I saw them the following year, they were different women, the confidence in their own ability ... you could see the difference in them.’ ‘I ask people to fill in an evaluation ... I’ve not really had any negative feedback.’


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Community outreach library services, Frances Maria Dowse & Barbara Sen Table 4 Continued Theme: Outreach library services

Key finding The librarian needs confidence, subject knowledge, a range of information skills and flexibility to fulfil the role

Supporting evidence ‘I would rather enable people to do it (search) for themselves.’

‘You have to be a techie; you have to be able to solve problems.’ ‘... you need confidence, you need knowledge of your subject but you also need to be flexible, very flexible and friendly ...’ ‘I see myself as the gatekeeper to the resources ...’ ‘Some weeks I’ll be out (in the community) more, but my training room is here ... some weeks I won’t be out at all, it depends on the needs of the user.’ Quality services need planning, management and adequate resourcing

‘I try to do whatever I am supposed to do in the best and most effective way.’ ‘When I first started, there wasn’t really any examples (of best practice) to follow.’ ‘I wish when I had started off that someone had said this is a project. Project management would have been great for the service. I just did what I thought was best.’ ‘I now have (adequate funding, resources and support). I’ve got the training room, I’ve picked up resources along the way ... projector, laptop, phone extension, dial-in to the network.’ Service success—‘I’d like to think so.’ Limits of the service.—‘Time, time! There are too many things to do and I don’t have enough time.’ ‘I can only benchmark from talking to other librarians.’ ‘... health librarians do share ...’ (best practice and resources)

Marketing is essential

‘I started publicizing in a small way ... I started slowly ... word of mouth, getting into meetings, it sort of snowballed.’ ‘I used any champions I could.’ ‘I need more champions out there in the PCT.’ ‘Sometimes you can sow a seed and nothing happens and then suddenly a year later I’ll get an e-mail back.’ ‘... so many people have changed, the new people don’t know about me. it’s never-ending trying to get people to know.’ ‘I would like to make sure that every practice, every clinic, every service knows that this service exists.’



long-term results21 and is more popular with staff. Lacey-Bryant18 believes that GPs respond better when trained on a one-to-one basis. In group training there is a ‘reluctance to demonstrate hesitation in front of colleagues.’18 The Community Outreach Librarian (WHNT) was undecided about which training option was most effective, although the number of staff using their skills regularly was higher with those who had attended one-to-one sessions. Overall, the number using their skills, even to a limited extent, was similar in anonymous groups (75%) and one-to-ones (79%; Fig. 4). The success of anonymous group training, where staff come into the library, was paralleled by a recent Derbyshire study.8 Ayre8 considered the increased use of skills by staff after attending library training rather than work-based training could be a result of increased motivation. Staff attending training at the library have to make the effort to organize time in their schedules. This shows a real desire to learn, and they may be more likely to practise in the workplace. For staff trained with colleagues, the training may have been organized for them, attendance being mandatory. Overall, there is inconclusive evidence to support which training option is preferred, or most effective, this being dependent on individual needs and preferences. The studies of Banks et al.6 and Robinson and Lawson12 both found that staff need refresher training. Robinson and Lawson12 discovered that, with little time to practise, staff were returning for help. Sixty-three per cent of primary care staff in Wirral said that they would return if refresher sessions were available, and most because, as Robinson and Lawson12 found, they needed more practice (Fig. 5). The high percentage of staff wishing to return does not indicate unsatisfactory first sessions but, as Banks et al.6 reflected, one session is not enough and follow-up sessions are essential. However, primary care staff may not have time to attend numerous sessions. In this study, 56% of those who hadn’t attended training identified lack of time as the reason. The librarian also notes constraints on her time. This case study confirms evidence from the literature that time is a major constraint on information seeking behaviour and training.

The outreach library services The literature and the case study confirm the need for outreach librarians to have a range of skills.21 ‘Imaginative’ services2 rely on a broad skills base to meet the needs of primary care staff. Examples of good practice such as WHNT should be used to promote investment in outreach programmes, which are vital for practising EBM in the community, and supporting NHS demands. Adequate funding and support is not available universally across the NHS.17 The Community Outreach Librarian believes that the only thing that limits the service is time which prevents offering refresher sessions and additional services. Libraries can be inaccessible to primary care staff because of time, and practicalities such as poor parking.11 Twenty-four-hour access can ease the problem of parking during peak hours and can fit around busy schedules. However, staff in this study largely do not use the 24-h facility. Further investigation is needed as to why this might be. Staff have not responded to increased access to the physical space of the library. Their information needs are satisfied at ‘point of need’ by computer use or the support of the librarian.17 Marketing is essential in raising awareness of outreach services, a theme from the literature supported by this case study.19,21 Most staff in this study had heard about the service from a colleague. Word of mouth is important for raising awareness. The librarian uses ‘champions’ to promote the service. Internal marketing by ‘champions’ is essential to encourage investment and support. However, there is no structured marketing strategy. Without adequate marketing, outreach services are unlikely to be known by all primary care staff and stakeholders.

Conclusions • The information skills of primary care staff are improving, staff are gaining confidence in their abilities, and trained staff are choosing higher-quality evidence available via online databases. • Outreach library services can raise the awareness of quality information resources and improve search effectiveness.


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• Information provision is required at point of need in the community to meet individuals’ needs. • WHNT Community Outreach Service is a good example of delivering flexible training options. • A community outreach librarian needs confidence, subject knowledge, a range of information skills and flexibility to meet the information needs of primary care staff. • Time is a constraining factor for both the librarian and users. • The value of community outreach services needs to be recognized to ensure funding from appropriate sources. • Marketing is essential to raise the awareness of the services available to staff.

Limitations A single case study can give only indicative evidence. A national study of community outreach information services would provide a broader evidence base to inform service development. This study did not address differences between user groups, further research is needed.

Key Messages Implications for Policy • Outreach services should develop targeted marketing strategies and evaluate their effectiveness. • Further work is needed on measuring the impact of outreach services and the impact of training. The value of these services needs to be recognized nationally if outreach library services are to progress.

Implications for Practice • Training improves information-seeking skills and use of quality information resources, best delivered through a variety of flexible training alternatives tailored to user needs. • Continued creativity in service delivery and dissemination and sharing of best practice between practitioners is valuable for service development.

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Community outreach library services, Frances Maria Dowse & Barbara Sen education. Work-Based Learning in Primary Care 2005, 3, 202–7. 18 Lacey-Bryant, S. Information services for primary care: the organizational culture of general practice and the information needs of partnerships and primary care groups. Health Libraries Review 1999, 16, 157–65. 19 Doney, L., Barlow, H. & West, J. Use of libraries and electronic information resources by primary care staff: outcomes from a survey. Health Information and Libraries Journal 2005, 22, 182–8. 20 Coomarasamy, A. & Khan, S. What is the evidence that postgraduate teaching in evidence-based medicine changes

anything? A systematic review. British Medical Journal 2004, 329, 1017–9. 21 Monaghan, V. & Misso, K. Evidence into practice: an information service for primary care professionals. Health Libraries Review 1999, 16, 82–8. 22 NHS Executive. Information for Health: An Information Strategy for the Modern NHS 1998–2005. London: NHS Executive, 1998. 23 Verhoeven, A. A. Use of information sources by family physicians: a literature survey. Bulletin of the Medical Library Association 1995, 83, 85–90. Received 10 November 2006; Accepted 4 April 2007


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