Meeting the information needs of clinicians for the practice of evidence-based healthcare

Authors


Abstract

This article reports on clinicians’ use of library resources and the competencies they require to access information necessary for the practice of evidence-based healthcare. It is based on the results of a study commissioned by North Thames Region to identify the training needs of clinicians for the adoption and practice of evidence-based healthcare. Participants in this qualitative research study included librarians, clinicians (doctors, nurses and PAMs) and managers from four Acute and Community Trusts in and around London.

The research indicates that the majority of clinicians recognize the need to keep up-to-date with changes in their specialty and many visit their libraries on a frequent basis, however, few appear to be searching for information with which to inform their immediate clinical decisions. Our sample acknowledged their low usage of journals such as Bandolier, the Health Effectiveness Bulletin and Journal of Evidence-Based Medicine. Similarly, low use of electronic databases, such as Cochrane and Cinahl, were reported. Examination of skill and self-efficacy levels in accessing and using information databases revealed wide variations across professions, specialities and Trusts. Qualitative research methods were employed to elicit the key competencies required to access clinically relevant research evidence, and a framework for integrating these competencies is presented.

Introduction

In recent years, the demand for proven, clinically effective treatments has increased as a result of the need to ensure the highest quality patient care whilst making the most effective use of limited resources.

Given the pace of rapid clinical advance, textbooks are inevitably out-of-date. To keep abreast of relevant developments and inform their practice with current research evidence, clinicians are estimated to need to read 19 articles per day, every day of the year, an impossible task for even the most dedicated and tireless clinician. 1 This information explosion is particularly apparent in areas such as general practice. A study looking at the bureaucracy in general practice reported that individual partners in a general practice receive up to 141 documents relating to patients each week, 18 documents related to practice management and up to 44 profession-related documents, such as journals and items from the Local Medical Committee. In addition, up to 2 kg of unsolicited junk mail arrives each week. 2 This trend is similar, although less developed, within the other clinical professions. The Government recently announced the creation of a Professor of Nursing post at the Department of Health to champion the development of nursing research, and the professions allied to medicine (PAMs) are increasingly working to develop their research bases to provide evidence-based guidelines and protocols for their professions.

In addition to paper-based information, and in order to store clinical research evidence in an accessible format, there is an increasing volume of data now available on electronic databases, such as Medline, the Cochrane database, Psychlit and Cinahl, as well as the resources of the Internet. The implication for all clinicians is that new skills are required in searching for, accessing and appraising such research findings.

Although the volume of clinical research evidence is accumulating rapidly, the degree to which these research findings have actually been incorporated into daily practice is by contrast considerably retarded. 3 There is concern about the length of time it takes doctors to implement research findings as well as the variance in treatments applied by clinicians. 4 The difficulties in changing clinical behaviour are recognized, 5 and although many initiatives, including guidelines, protocols and continuing education, have been introduced to address the issue of adoption and implementation of research evidence, no single strategy of change has been found to work effectively. 6 It is within this context that the NHS R&D Directorate commissioned research throughout the Regional Offices, and North Thames commissioned a number of studies to examine ways of advancing the promotion and practice of the principles of evidence-based healthcare.

This study, sponsored by North Thames R&D aimed to identify the individual and organizational obstacles to implementing evidence-based healthcare and to develop a competence-based framework that would support the development of training and education programmes 7. The four key stages of evidence-based practice as identified by Sackett et al. 8 were used as the basis for the development of this framework:1 The formulation of answerable questions2 The search for the best evidence3 Critical appraisal of the evidence4 The decision to apply conclusions to patient healthcare

While competencies in all four of these stages are clearly essential to the translation of research into practice, this article will focus on the second stage of the process and the identification of the skills, attitude and knowledge required for accessing research evidence relevant to clinicians’ practice. It will also consider the apparent obstacles to retrieving information and factors that facilitate clinicians in their search for information.

Method

A survey of the literature relevant to evidence-based practice and clinical effectiveness was conducted using a variety of well-established electronic databases, the Internet, specialist libraries and relevant clinical and managerial journals and research reports.

This primarily qualitative study focused on four NHS Trusts in the North Thames Region. The Trusts were selected to represent both the Acute and Community sectors of care, and were geographically located in both inner and outer London. In-depth interviews lasting approximately 1 hour were conducted with doctors, nurses, midwives, therapists and senior managers. A total of 84 interviews were carried between November 1996 and May 1997. The sample consisted of 18 doctors, 20 nurses and midwives, 12 therapists and 14 senior managers across the four participating Trusts. In addition, in-depth interviews were held with Chief Executives, Medical Directors, Nursing Directors and Senior Therapy Managers in order to understand the Trusts’ policies and plans for the support of evidence-based practice. A further 20 interviews were carried out with a range of relevant NHS personnel.

The primary research for this study began with a range of exploratory interviews with a cross-section of individuals who had participated in the design and delivery of training courses and workshops to promote evidence-based practice. These interviews were designed to explore their perceptions and experiences of these training courses and to identify the learning needs and obstacles for those acquiring the skills to practice evidence-based healthcare.

Preliminary interviews with librarians from participating Trusts as well as regional librarians from the British Postgraduate Medical Federation were undertaken to discuss their experience of advising, facilitating and training clinicians in searching and information retrieval skills and the range of difficulties experienced by library users.

Results

The findings of our research study will focus on two areas, namely (1) clinicians’ use of the library and information sources required to keep up-to-date with relevant research findings in their fields, and (2) the competencies that are required of clinicians to identify and access the information they require to practice evidence-based healthcare.

Utilization of library and information resources

The primary phase of this research aimed to gauge the level and extent to which clinicians in the participating Trusts utilized library and information resources to inform their practice with relevant research evidence. The degree of activity (frequency of library visits and number of literature searches), and the accessibility of the relevant resources was examined.

Activity There was almost unanimous recognition from doctors, nurses and PAMs of the need to keep up-to-date with any changes in their particular speciality and to consider the research evidence available in the relevant clinical fields.

The majority of our sample claimed to have visited a library within the past month, although circumstances and resources utilized varied somewhat between the professions.

Doctors Eighty per cent (15) of the doctors in the sample claimed to be keeping up-to-date with current relevant literature. Many had personal subscriptions to professional journals and journals specific to their speciality. Some claimed to read these journals thoroughly each month, however, most agreed that they just ‘skimmed’ the contents and read those articles directly relevant to their current practice. Further examination of doctors’ reading habits revealed that while they were likely to read the British Medical Journal on a regular basis, and those journals specific to their clinical field, few ever read sources such as Bandolier, The Health Effectiveness Bulletin or the Journal of Evidence-based

Medicine This pattern of activity reinforces estimates that ‘the average UK medical mortal spends about 30 min a week reading journals’, 9 and reinforces the results of various studies on the excessive amount of reading that would be required of doctors in order to keep fully up-to-date. 8

The majority of doctors interviewed were able to cite recent examples of their quest for clinical research evidence. This search for evidence appeared to vary both in method and in motivation. Some considered consulting a senior colleague or informed peer for their opinion as a search for evidence, whilst others engaged in systematic reviews of gold-standard research evidence.

A number of doctors in this sample were registrars whose activity in the library may have been motivated more by forthcoming professional examinations than by the desire to search for evidence to inform their immediate clinical practice.

Nurses and PAMs Almost all of the nurses we interviewed visited the library on a fairly frequent basis, many of them claimed to visit at least once per week. However, on further questioning, the motivation for these visits was usually connected to a course of academic study being undertaken. Most of the sample claimed that they would visit the library to inform their clinical practice, but admitted that it would be less frequently. The same comment can be made for the number of literature searches completed. Most of our sample had carried out several literature searches in the preceding 3 months, but many of these had been prompted by the need to inform dissertations or project work related to their further education rather than their clinical practice. A small number of nurses and midwives were searching frequently for research evidence to inform clinical decisions.

These findings reinforce the results of a survey into the usage of nursing libraries in the Northern Region, which found that the majority of nurses visiting the libraries were either student nurses or qualified nurses currently enrolled on a course of study. Library usage by qualified nurses who were not studying was comparatively small. 10 The impact of any such usage of library information is difficult to assess, however, the authors of the EVINCE project (Establishing the Value of Information to Nursing Continuing Education) reported that ‘96% of participants agreed that there was, or would be an effect on future practice through enhanced competence in one or more areas’. 11 Similar results were found for the PAMs, with library visits being fairly frequent activities for a number of the physiotherapists and occupational therapists. The individuals in our sample, however, are not necessarily representative of the actions of the rest of their profession, rather, several of these individuals were employed in special research-orientated posts with the aim of helping to build the research base of their profession.

Access In order to facilitate staff in their efforts to keep up-to-date and carry out literature searches as appropriate, it is important to consider a number of aspects of library and information accessibility. Location—proximity to the library is an issue of critical importance in determining whether or not the resources within it are likely to be utilized, as are the opening hours of such facilities. If clinical decisions are to be made on the best available research evidence, it is imperative that this is accessible 24 hours a day. A wide range of paper-based resources, including national and international journals and current texts catering for all professionals, is also required. Electronic resources including relevant CD-ROMs and the Internet need to be easily accessible without long waiting periods in order to encourage staff to access timely information. The hardware resources required by the library include fast PCs and good quality printing facilities. Clinicians also need access to IT facilities in their offices and on the wards if conducting reviews of evidence is to be incorporated into daily clinical practice. Finally, specially trained, experienced library staff who can carry out searches for clinicians when necessary and who can teach clinicians to conduct a thorough literature search and use relevant resources for themselves are essential.

Doctors All doctors in this sample reported that they had easy and convenient access to a library for their work. Distances from such resources varied from libraries located on the same corridor to those within a 15 minute drive. Most of the doctors were satisfied with their access to paper-based information. The combined resources of their own subscriptions and the journals and textbooks available in their postgraduate libraries gave most doctors access to the full range of paper-based resources they required. Access to electronic information was more problematic. None of the Trusts examined provided widespread access to the Internet with the result that only a third of our sample of doctors ever utilized these resources. Of this minority, most only had access from their libraries or from their homes. Access to relevant CD ROMs (Medline, Cochrane, Embase, etc.) was similarly restricted to the library. While a few isolated departments had their own IT facilities allowing access to all the relevant electronic resources, for the majority of clinicians, conducting a systematic review of research evidence necessitated organizing a visit to the library, which as one consultant explained can be a time consuming process:‘Time is a major limiting factor. An actual search takes about an hour. You often need to change terminals if you want to look at more than one database and the terminal you need is often not free. The whole process usually takes about 2 hours to complete. It is not easy to find 2 hours free from clinical duties’.

Access to IT facilities, such as appropriate databases, directly reflected the various Trust policies and their decisions on investment in IT for various departments. One of the Trusts was in the process of investing in appropriate hard and software for every directorate in the Trust, whilst another had no computers for a large part of its buildings and could not even provide access to word processing facilities for clinicians.

Nurses and PAMs All the nurses based on hospital premises in this study were reasonably happy with their access to library facilities, whilst predictably district nurses, health visitors and practice nurses had less convenient access, but all claimed to visit the library frequently despite this.

Access to appropriate paper-based information was generally regarded as satisfactory, with many individuals subscribing to those journals most relevant to their professional practice. Some difficulties in accessing useful journals from Australia and America were reported by those working in professions allied to medicine. The specialist nature of such journals and restricted budgets of some departments meant that the full range of research information was not necessarily available to all clinicians as they required it.

Although the majority of our sample were able to gain access to the information they required, other issues regarding the availability of resources arose. One of the Trusts in this North Thames sample employs a policy of charging nurses for photocopies at the on-site library, whilst doctors’ expenses are met by their postgraduate budget. Such a policy is perceived as inequitable in an environment that is professing to encourage evidence-based practice by all.

Nurses and PAMs experienced similar barriers to the doctors with regard to restricted access to electronic resources, with the exception of maternity facilities, which in general were the best equipped units in terms of ward access to relevant databases. One Director of Midwifery described the facilities in her directorate:‘We have a PC on the labour ward with the Cochrane Database … there is one on every floor. My PA will do searches for the midwives, she’s excellent’.

Interviewees expressed the opinion that clinical risk was a strong factor in the decision to purchase such resources for these areas.

Other studies have identified problems in information retrieval, which have resulted from the removal of nursing information resources from hospital sites to university libraries. 12 Wakeham reports on a survey that established that amongst those nurses carrying out research, the greatest obstacles to accessing information were: time to get to the library (67%), lack of information required (60%) and distance from the library (40%). 13

Comments regarding the services provided by the librarians and other information managers were on the whole extremely positive. A typical comment regarding library support was:‘They are very good, and very helpful and they will do the search for me. But they’re only open from 9 to 5’.

Convenience of the opening hours was the most likely obstruction to timely access to the required resources for all clinicians. Just one Trust facilitated 24-hour access to clinicians by lending keys to those likely to want information out of hours.

Other points regarding facilities that would be welcomed from the library included a faxing service. A consultant based at a Community Trust explained the problem of working in a Trust where staff are spread throughout numerous buildings:‘We have access to the Internet (in the office) and the library is a 10 min walk from here, but they won’t fax. us articles so people decode things from abstracts. Making decisions on the basis of abstracted information can be a dangerous practice’.

All of the staff in our research sample were based in and around London, and were unlikely to be further than a 15 min drive away from library information resources, however, it is arguable that even this obstacle to convenient and timely access to resources has a detrimental effect on the application of clinically-relevant research to clinical practice. Merry has suggested that any action that takes longer than 30 seconds is unlikely to be generally adopted in clinical practice, because the cumulative effect on the time of the professionals is too great. 14

Competencies required to search for relevant clinical research evidence

A well-stocked, accessible library is essential for ensuring convenient access to clinical research evidence, however, even the best equipped library is of limited use if staff do not have the knowledge and skills to find the information they need. The increasing availability of new research evidence on electronic databases has resulted in clinicians requiring new skills in IT and in developing appropriate search strategies to retrieve relevant information from electronic databases and the Internet, as well as from the growing range of paper-based resources such as the Journal of Evidence-based Medicine, Bandolier and the Clinical Effectiveness Bulletins.

Database skills All clinicians were asked to rate their abilities in using the various electronic databases.

Doctors The database most frequently used by doctors was Medline. Most considered their abilities adequate in its use, although several expressed a need for further training. Several individuals in the sample used the Cochrane database and just one consultant used Embase. None of the doctors used Cinahl and only one regarded himself as proficient in using the resources of the Internet. Few of the sample regarded themselves as more than adequate at carrying out an effective and efficient database search.

Nurses and PAMs Approximately half of the nurses, midwives and PAMs had used Medline and considered themselves competent in the use of it, less than half had used Cinahl, the database dedicated to collating information for nurses and PAMs, and just an isolated few had accessed other databases such as Cochrane or Psychlit or the resources of the Internet. Reasons for the low level of exploration of these resources were attributed to a combination of lack of awareness of the existence and the contents of certain databases and lack of skills in operating them.

One of the Trust librarians pointed out that it is not only the technical skills to manipulate databases that clinicians lack, but also an awareness of searching strategies and the nature and quality of research information they locate:‘if I had my way not only searching and keyboard skills but also database and information scepticism should be tackled during the course. I would also like to see much more preparation time before people jump in and start searching’.

Searching competencies Our sample were asked to rate their abilities in designing an effective and efficient search strategy and in using a range of electronic databases to conduct a literature review.

On the whole, our sample of doctors were reasonably confident about their ability to design and conduct a literature search, although many still thought that they were likely to need the assistance of the librarian to use electronic databases.

Nurses and PAMs were less confident about their abilities and many of them rated themselves as less than adequate in the skills required to formulate an effective search strategy. One of the Trust librarians put this difference down to the type of training the various professions have had—both in terms of the approach and the timing. She explained that the group who have the biggest difficulties coming to terms with searching skills and strategies are qualified nurses who have returned to education:‘Nurses are scared, they are not familiar with PCs and you have to build up their confidence. Project 2000 nurses are better, but there aren’t many of them. There are bulges of nurses preparing to re-register. Qualified nurses are forced back into education and ‘‘dumped’’. The nursing tutors assume they know how to search when in fact a returning nurse has a huge learning curve…tutors are not helpful, they have the wrong attitude ‘‘if they don’t know how to use a library it’s their problem’’’.‘Nurses lack keyboard skills, especially older nurses and community nurses. Doctors have greater searching techniques—a hangover from their student days. Doctors have different problems…they behave as if they’re self reliant and won’t ask for help. They’re not trained to ask for assistance’.

Some individuals had experienced a barrier to the effective retrieval of information at the very beginning of the process when trying to identify the focus of the clinical problem and the information they required. There was a considerable spread in the self-efficacy ratings regarding the degree of confidence with which they felt able to identify the ‘right question’ and their ability to design a search strategy that would elicit the information they required. A registrar in Care of the Elderly explained her difficulties in conducting a literature search for a clinical question:‘I don’t know how you’re supposed to carry out a search. I use Medline regularly, but recently I wanted evidence on the management of diabetes and stroke in the initial few days when people can’t drink, feed, etc. I put in diabetes, stroke and the two together and I didn’t get anything much except a small group of studies on diabetes and stroke, and they weren’t on what I was really looking for. I don’t know what I missed. I know I don’t formulate questions well enough. I have asked the librarian to get articles for me, I have never been trained and I don’t know what I don’t know. Medline came out since I trained.’

An experienced consultant known for her work in developing evidence-based guidelines made a similar point:‘I do know what I want to know, but I’m poor at defining it precisely, consequently my searches are not nearly as efficient as they should be. I’m sure I could save loads of time if I were better at this’.

The way in which individual doctors went about conducting their searches for research evidence and retrieving the information required varied considerably. Factors such as ease of access to information as well as the availability of librarians or other facilitators who would assist in conducting the actual literature searches clearly influenced the way in which they conducted their searches. The alternative to spending time in the library was to brief either a junior colleague or an information expert to conduct the search. One consultant had adopted a very satisfactory strategy of enlisting the help of a facilitator within the Trust who completes all literature searches for her:‘She (the facilitator) is my means to an end. I describe the problem to her and she carries out the entire search for me. This works very well’.

Issues such as the clarity of the clinical problem in question, the confidence placed in colleagues or junior staff and the time and resources available also affect decisions about the delegation of evidence-based searches:‘I’ve never asked someone else to do a search for me. I’m not geared up to ask someone else. I’m normally the one with the most time anyway, the registrars and SHOs don’t usually have time’.

On training junior staff to carry out a literature search, even the most competent of consultants rely heavily on librarians to cascade skills in information searches:‘I wouldn’t really try to brief someone else in how to carry out a search, we have an excellent librarian for that’.

Training requirements All interviewees were asked about the various elements of searching and collating research information, the following areas were identified as areas where problems exist and training would be welcome:

• computer skills,

• selection of appropriate databases,

• selecting relevant information,

• identifying salient facts,

• saving relevant information,

• building banks of information,

• bookmarking Websites, and

• a list of potential requirements for training.

On reviewing a number of searches carried out by clinicians in her library, Jane Stevens, librarian at one of our sites, reinforces these observations and notes the following spoken and unspoken questions which reveal the distance between the mechanistic and effective use of medical databases.

The top 10 questions librarians are most often asked by clinical searchers: 1 How can I print this search? 2 How can I get nursing research? (unclear about which databases to use) 3 What does this stand for? (looking at field labels) 4 How can I throw out some references I don’t want? 5 How do I know if you’ve got the information? 6 Where does it print out? 7 How can I see the rest of the articles? 8 Why haven’t you got these periodicals? (assumed all citations would be in stock) 9 Can’t I see the whole article? (assumed full text availability)10 How do I switch off?

Some questions that are never asked:11 Who publishes this database?12 Is there a hidden bias in the information supplied?13 What is the quality of the indexing?14 What periodicals are included and excluded?15 What is the currency of the information?16 Are there other better ways of searching than my method?

With regard to the training required by clinicians Jane Stevens commented:‘I would like to see a greater understanding of what is included and excluded in databases when literature searching and a more questioning attitude given to the results. I would like users to recognize their ignorance (which comes with better teaching)…. Although more people are now using evidence-based techniques, perhaps too few are aware of their searching limitations and some need more help than the library staff can offer during a normal working day’.

Competency framework. In order to facilitate the future acquisition of appropriate skills for clinicians practising evidence-based healthcare, the results of this research have been assembled to provide a skeleton-framework for assessing and developing appropriate competencies. The framework is derived from a combination of information sources including interview data from a cross-section of practising clinicians, opinions from librarians and information specialists in the Trusts and from North Thames Postgraduate Medical Federation, and other evidence-based practice experts together with the relevant literature.

The competency framework is two-dimensional and attempts to document the skills, knowledge and attitudes necessary for the effective practice of evidence-based healthcare according to Sackett’s 4-stage definition. The framework is both prescriptive and generic in approach. Attitudes, knowledge and skills have been grouped into five broad categories or clusters of competencies—personal attributes, interpersonal skills, self-management skills, information management skills and technical knowledge and skills (see Table 1).

Table 1.   Competence framework for searching skills
Personal attributesThe personal styles, attitudes and attributes necessary for effective practice of EBHC
Interpersonal skillsThe abilities necessary to communicate effectively with others
Self-management skillsThe ability to effectively organize and take responsibility for personal practice in the workplace
Information management skillsThe ability to manage and make effective use of information
Technical knowledge & skillsThe ability to execute the relevant skills and knowledge necessary to access, adopt and implement EBHC 1
InitiativeInitiative to translate the need for information into searching action
CommunicationCommunication with librarians and other key information sources to facilitate effective search for information
Time managementWilling and able to spend time conducting a search and retrieving results
Knowledge of appropriate resourcesFamiliarity with full range of information resources and useful channels of communication
Formulation of questionsFormulation of appropriate and focused questions
PersistencePersistence in the search for and retrieval of information
Self directed learningMotivation to explore new information sources and review research findings
Reading skillsAbility to read quickly and systematically
Strategic search skillsAbility to design and employ sound searching strategies
ConfidenceConfidence to complete a search
ResponsibilityResponsibility for ensuring a thorough search for research evidence is completed
Identifying relevant informationExtrapolation of important points of information
Library skillsFamiliarity with indexing and referencing systems
MemoryRemembering key findings and sources of information
IT skillsBasic computer skills and database familiarity

Our research suggests that the level to which any individual needs to be proficient in these competencies is dependent primarily on the level of responsibility and the degree of autonomy they hold. We suggest that three levels of competence could easily be identified and managed (basic, intermediate and advanced), however, because the degree to which clinicians practice evidence-based healthcare is dependent on multiple factors, including the resources available to them, the local Trust policy, individual skills, the profession and specialty to which they belong, location of work, etc., it is essential that such a framework be adapted to meet local needs as appropriate.

Conclusion

In conclusion, there are four main requirements necessary to facilitate the effective searching for information for the practice of evidence-based healthcare, these include: capital investment in resources such as libraries and appropriate computer hardware; information resources including a wide range of paper-based and electronic information; skilled librarians with the ability to conduct searches for evidence to assist in clinical decision-making and the time and ability to train clinicians in these skills; and a critical mass of clinicians who have the necessary competencies to design and conduct a systematic review of relevant clinical research evidence.

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