Clinical librarians, a new tribe in the UK: roles and responsibilities

Authors


Janet Harrison, Department of Information Science, Loughborough University, Loughborough, Leicestershire LE113TU, UK. E-mail: j.harrison@lboro.ac.uk

Abstract

Aims:  The aims of this research were to determine the background, education, training experience, roles and responsibilities of practising Clinical Librarians (CL) in the UK. This paper reports the findings of a survey undertaken in 2007 at the third Clinical Librarian conference.

This research builds on research undertaken by Harrison and Sargeant in 2002 and Ward in 2004, and can be considered as part of a longitudinal study of the role of the CL in the UK.

Objectives:  The objectives of the research were to define and gain a broad understanding of the role of the CL in the UK highlighting similarities and differences amongst the professionals and provide evidence for a baseline of skills and activities for the CL role. The type of sampling used was Judgemental.

Results/analysis:  Results/analysis detail the skills and activities undertaken by CLs. Searching for information for Clinicians was the activity most frequently undertaken. Developing good relationships with other healthcare professionals was considered essential. Two-thirds of the respondents held a postgraduate library qualification.

Conclusions:  Crucially a new model for the UK CL role is derived drawing on the findings of this study and the existing literature.

Introduction

The Clinical Librarian (CL) has been around both nationally and internationally for many years. Its roots are firmly based in the early work by Goodall,1 who said that ‘every clinician and research worker should be at home in a library and should have sufficient knowledge to use the bibliographic aids with ease and confidence’. Acting as a guide in the guise of a librarian for the clinical team is the concept that Lamb,2 Chief Medical Librarian developed at the University of Missouri, City Medical Library in 1972. The CL role was developed in response to unmet need for clinical questions to be answered on ward rounds. Following this beginning funding was obtained from the National Library of Medicine to support several CL initiatives in the USA.3 The CL role was introduced in the UK in the 1970s by Jean Farmer following her visit to the USA in 1976.4 She pioneered the role at the Wills Library, Guys Hospital in 1977. Her objective was to establish the information needs of the clinical team, as ‘user-oriented rather than subject-oriented’. In 1985 Cimpl5 reviewed the literature and proposed that the common purpose for the CL was ‘to provide information quickly to physicians and other members of the healthcare team; to influence the information seeking behaviour of clinicians and to improve their library skills; and to establish the medical librarian’s role as a valid member of the healthcare team’.

In the 1980s widespread financial constraints particularly in the USA resulted in the demise of many CL intitiatives.6 It can be said that the CL role has waxed and waned over the years in the NHS. Resurgence of the role in 1999–2000 was initiated by the Leicester General Hospital Trust who funded a pilot scheme; this was one of the first in the country since the early work by Farmer. Evidence to support this funding was provided from research by the Department of Information Science, Loughborough University.7 At this time the CL role seemed to gain momentum and receive renewed interest from both the NHS and the profession. This prompted research to define and explain the role and educational background required for this job throughout the NHS in the UK.8,9

A systematic review of the literature in 20036 built on previous work by Cimpl5 in attempting to establish the evidence base for the CL, and concluded by asking for further high-quality research. Ward directly responds to this call with a survey of activities of all ‘known’ information specialists and librarians offering CL or similar services in the UK in the acute (secondary and tertiary) sector.10 The conclusion shows a very mixed picture of activity whilst a systematic review at the time concluded that good quality research was still needed to prove the effectiveness of the CL.11 Research in 2007 presents a ‘simple model’ for a CL, from a user perspective, within evidence-based nursing,12 whilst the Hill13 report provided further insight into the role of the CL in the UK.

Against this background fascination and interest for researchers in the unique role of the CL in the NHS remain. The research presented here contributes to the established literature and body of evidence surrounding the debate in trying to establish a ‘blue print’ for the role.

The research interest is translated into several key research questions:

  • • Is there a definite identifiable Clinical Librarian role emerging in the NHS in the UK?
  • • If so what and where is it being practiced?
  • • Is the role so clearly defined that it could provide a ‘blue print’ to enable the replication of the role in another country?

Aims and objectives

The aims of this research were to determine the background, education, training experience, roles and responsibilities of practising Clinical Librarians in the UK.

The objectives were to:

  •  identify educational qualifications of Clinical Librarians in the UK;
  •  quantify and define the role of the Clinical Librarians in the UK;
  •  gain a broad understanding of the duties of the Clinical Librarians highlighting similarities and differences between these responsibilities;
  •  provide evidence of a baseline of duties for a Clinical Librarian in the NHS.

Methodology

In the UK the target population of CLs and the literature is acknowledged, within the NHS, to be relatively small. Exact numbers and locations of CLs in the NHS are not easily obtained. The traditional route to obtain this information would have been to conduct a survey of all NHS Trusts Hospital Library staff, identifying CLs therein. However, this process was considered too costly, complicated and lengthy. Also with a third party involved in distribution and collection of data it is doubtful that the correct data would have been retrieved. It was therefore deemed to be outside the scope of this research project. Therefore, the decision was taken to conduct a survey of CLs attending the third UK Clinical Librarians Conference held in York in 2007. This was considered to be timely and gave an ideal opportunity to add to the literature and gain further insight into the role of the CL. The conference would attract many practising CLs who were highly focussed upon their professional needs, aspirations and goals. Therefore, responses to a questionnaire concerning their role would generate thoughtful and reflective comments. Cohen acknowledged this type of sampling to be judgemental, subjects being judged to be typical of a population as a whole.14 A questionnaire was chosen as the ideal data collection tool for this research.

Discussions with practising CLs informed the questionnaire design which was piloted prior to distribution. Following the pilot several changes were made to incorporate views of the professionals. The questionnaire contained both closed and open questions allowing respondents to express their opinions within the framework of the questionnaire. Whilst adopting a quantitative approach in the research, the inclusion of the free-text questions provided an opportunity for the researchers to adopt an interpretative perspective more usually associated with qualitative research methods. It was deemed vital to see things from the perspective of the CL using an interpretive/qualitative paradigm.

Questionnaires were distributed to delegates attending the Conference over a 2-day period. Completed questionnaires were returned to a central collection point or returned directly to the researchers. A total of 59 questionnaires were distributed. Fifty-three fully completed questionnaires were returned. Of the responses certain exclusions were subsequently made; 15 international delegates who completed questionnaires were deemed to be outside the scope of this study, as were another 12 respondents from the UK who did not identify themselves as CLs. Table 1 provides details of how respondents identified themselves.

Table 1.   Job title of respondents
UK Clinical Librarians26
NHS Librarians 7
UK University Medical Librarians 5
International Clinical Librarians10
International Medical Librarians 5
Total53

Analysis and discussion

Following exclusions the 26 completed questionnaires received from practising UK CLs constitute the focus of the analysis in this paper. This was an excellent result given the relatively small size of the CL population in the UK. Interestingly this is the same number of responses to a survey in 2004.10 It cannot be assumed from this that the size of the UK CL population has remained static since 2004 nor that the same 26 CLs responded to both surveys; however, it is likely that some of the respondents did complete both surveys.

What’s in a name?

Table 1 provides details of how respondents identified themselves. There is an overwhelming need for CLs to be called by their professional name and to have a definite role so that other professions can understand and interact with them fully and effectively. Disappointingly of the 26 respondents who identified themselves as CLs only 12/26 held the title of Clinical Librarian; the remaining 14 respondent were called various other types of librarian, e.g. ‘outreach’, ‘specialist’ and ‘clinical effectiveness’, with one respondent entitled ‘Learning Resources Services Manager’. It can be reasonably concluded, therefore, that in the eyes and minds of hospital management, these CLs do not exist as an individual service let alone belong to a wider UK group of professionals. The existence of different ‘tribes’ of professionals working within the NHS is an acknowledged fact. The largest and most notable ‘tribes’ are doctors and nurses; the other tribes know them as such and interact accordingly. It is surely a first step towards gaining recognition as a ‘tribe’ for all UK Librarians practising CL work to be given the title Clinical Librarian in order to begin to gain tribal status within the NHS and to move the profession forward.

Qualifications/background of the Clinical Librarians

One-third of the respondents in this survey had an Undergraduate degree in Library and Information Studies and two-thirds of the respondents had a Postgraduate degree in Library and Information studies; 50% of respondents rated their Postgraduate study as significantly contributing to their competence at work; 48% of all respondents had studied modules in healthcare and/or medical information whilst at University. The respondents were a well-educated group reflecting of the profile of other professionals working in the NHS. The growth in degree professions in the NHS has been advancing since the 1980s and 1990s, as exampled by Speech and Language, Physiotherapy and Occupational Therapy. Both of these professions are now degree entry level. Librarians should be no different. In practice CLs often work in multi-disciplinary groups in a competitive and complex environment of healthcare. It is important to hold a degree in the appropriate subject to be acknowledged as an equal and professionally qualified member of that group. Establishing the individual as a competent professional is necessary in order to be recognised as a member of that particular ‘tribe’ with the NHS.

Although 57% of the respondents reported that they had a Clinical background prior to becoming a CL, analysis revealed that only 19% had Medical Library experience and only one had a clinical background as an ex-Nurse, thus negating the 57% initial response rate. This result also seems to suggest that confusion abounds in what is and is not actual clinical experience. However, what cannot be ignored is that all of the respondents had the perception of working with health library services and information. It would seem that many roles in the health service provide this perception and this contributes to the make up of the CL role.

Who should provide education and training for Clinical Librarians? And Where?

Respondents to these questions were equally divided between the NHS and University Library and/or Information Science Departments as to who should provide bespoke training courses (Fig. 1).

Figure 1.

 Understanding healthcare professional’s information needs

However, in order to understand the information needs of healthcare professionals and for career development the majority of respondents agreed that it is essential to participate in clinical meetings and case conferences. In the words of one of the respondents:

‘A short course to understand the healthcare professionals and the healthcare environment and the likely /potential needs’.

The healthcare environment is complex and multi-layered and medical terms are difficult for the untrained to understand. The NHS also has a considerable amount of jargon known only to those who work within it. Without bespoke training courses, recruits to CL posts often lack the necessary skills to decipher the language and jargon. They train on the job and lack the requisite knowledge of the workings of the NHS and the personnel within it. Bespoke training is therefore essential to enable the CL to understand how their skills can benefit other healthcare professionals and become an established professional in providing a successful service. Reassuringly, 62% of all respondents stated that they had received induction or specific training in their role. However, there was no consistency in this provision, induction ranged from a 1-day programme for all members of the NHS Trust to a 1- or 2-month personalised orientation programme. One respondent’s employment had overlapped with the previous incumbent for 1 year, thus, providing an excellent opportunity for training and knowledge exchange.

‘You can’t really get a better understanding than that which you get from seeing how healthcare professionals work within their own environment, obviously there are scenarios where it may be inappropriate for a non clinical professional to be involved however you gain a far better understanding and constantly increase your knowledge and improve your skills by actually participating’.

This comment reflects the desire of the CLs to develop their skills and contribute in a multi-disciplinary team, showing openness, honesty and a willingness to build on their own knowledge. Requests from the CLs to be shown what others do in the healthcare setting were quite modest. This is summed up in a phrase from one of the respondents:

‘Even just one opportunity to observe goes a long way’.

The ‘showing and telling’ of what others do could easily be met by all NHS Trusts, as time spent and cost associated with this would be borne by the Library Service. In order to establish what scenarios potentially exist for the Clinical Library Service, it is important that CLs understand the processes of clinical work. This should also assist them in identifying and establishing their role with other professionals in the NHS. These findings support the conclusions in Ward’s survey.10

Where are Clinical Librarians working?

Given the spread of Hospital Libraries within the NHS in hospital-based Trusts the majority of respondents were based in secondary care, 16/26, with only two respondents working in primary care, the remainder were distributed between academic libraries and the undisclosed ‘other’ category.

Which clinical specialities are using Clinical Librarians?

From the results it has not been possible to categorically state in which clinical speciality CLs are most effective. The most frequently cited specialty served by the respondents was paediatrics with five of the 26 respondents working in this area. There may be many reasons for this speciality being the most popular. Three respondents gave Clinical Governance as their area of work. The remainder reported working in a range of specialities from anaesthetics to trauma and orthopaedics. As noted in previous studies and in other areas of healthcare provision, local circumstances and availability of local funding dictate which clinical specialties are served by CLs.

Essential subjects and skills in education and training for Clinical Librarians

From the responses to the questions ‘What essential skills and subjects should CLs study’ it should be no surprise to learn that the highest response was literature searching. However, this was qualified by one respondent commenting that ‘it was not just enough to be able to do a successful search, you need to be able to interpret what you have found and communicate it back to your service users’. This provides evidence that skills need to be acquired and honed to successfully search literature and disseminate the results.

Classification and indexing and medical database searching scored second and third in the group of essential skills and training, demonstrating that the traditional elements of library education are still regarded as essential. Perhaps information science/library departments should take note and retain and develop these topics in their curriculum. It is not a question of rejecting the new all encompassing virtual web world but retaining the subjects that enable students to make sense of the new world in a structured and orderly manner, which will ultimately equip them to become good librarians. This is also echoed by the respondents who indicated that another high-ranking essential skill for a CL is an effective use of technologies. It is a popular myth that anyone can search a database or ‘Google it’ and get the right result without training. The results from this research suggest that CLs think otherwise.

What key activities are Clinical Librarians performing?

The key activities undertaken by the respondents are shown in Table 2. The majority of respondents also stated in free-text responses the requirement to identify the information needs of the clinicians was of paramount importance in their information searching activity.

Table 2.   Activity of Clinical Librarians (n = 26)
ActivityNumber of hours dedicated per week
Rank1–45–89–1213–1617–2021–2425–28>28Total
Performing information searching13581501124
Promoting/marketing service215401000020
Attending case conferences, and clinical meetings311530000019
Providing search-skills training410620000018
Performing critical appraisal57400000011
Attending ward rounds6440000019
Developing clinical guideline7231000006

What makes a successful Clinical Librarian?

This is a difficult question to answer given that the sample was self-selecting and the CL role is at best described as complex. CLs were asked to rank the top five skills essential for their role (Table 3). The ability to develop good working relationships with other healthcare staff was ranked as number one.

Table 3.   Top five skills as rated by Clinical Librarians (n = 26)
SkillsRank 
Development of good rapport with colleagues113
Use of technologies211
Oral and written communication35
Computer and electronic literacy35
Development of retrieval strategies and techniques54

Without a doubt the most important element contributing to being a successful CL given by the respondents in the survey is the existence of trust and developing good working relationships between health professionals and CLs. Table 4 shows the top three elements CLs reported as important for the role.

Table 4.   Essential elements to develop Clinical Librarian services (n = 26)
ElementRank 
Trust/good working relationships between health professionals and librarians123
Good availability of data and information tools and resources212
Well educated information professionals38

Building trust and good working relationships is not easy. The fact that this is also identified as the most important element in the make up of the CL role by the respondents may highlight an aspect of Clinical Librarianship that was not determined by this study, that of personality. It requires a certain type of personality to be able to broker good working relationships and maintain them. It does beg the question, is there a typical personality for a CL to have, to be successful in the role?

Future development

In answer to the question ‘Have there been any real changes in the last five years affecting Clinical Librarians?’ 95% of the respondents in the survey reported ‘yes’. The resulting comments demonstrate a positive and gutsy approach which is refreshing and signifies that Clinical Librarianship should be encouraged further by managers and educationalists alike. The following comments from the respondents indicate their thoughts:

  •  ‘Rapid developments, including technology and the role’;
  •  ‘Improvements in access to full text articles improvements in search databases more training required’;
  • • ‘More resources available now, role of Clinical Librarian is a bit better known’;
  • • ‘More accepted both by Librarians and Clinicians’;
  • • ‘More emphasis on Evidence Based Practice’.

Increased use and development of Clinical Guidelines by CLs is testament to this last point; healthcare staff need to be encouraged to use the best evidence in decision making.

  •  ‘We are progressing in taking the service outside the library walls and adapt to the changing needs of users’;
  •  ‘Virtual library without walls is on its way moving services away from traditional library to more outreach services’.

These are clear signs of the profession moving forward, confident of their own ability to adapt their service as required.

  • • ‘Job losses, less time for clinicians to attend courses on training—more reliance on Clinical Librarians to provide information’;
  • • ‘Information explosion, technological changes and different e-resource make it difficult for Clinicians to keep up to date’.

Interestingly this precise point was made in the 1970s by Farmer.4 In the last 30 years the explosion in the provision of information available via the Web is the major change. The Web can and is regarded as uncharted waters with little in the way of regulation to assist the user of health information. Doctors today are frequently faced by patients saying ‘here is the information about my illness I got it off the internet’, by-passing in effect the role of the doctor and librarian. The skills of the CL in interpreting such information for doctors is a legitimate use of his/her time and can contribute towards effective patient care and assist in efficient use of medical staff time. The development of the use of first class evidence to treat patients is the ultimate goal of the CLs, yet as Winning and Beverley6 commented, this needs tangible evidence. This still appears to be the case.

The UK Clinical Librarian model

A new model identifying the key skills and activities for the UK CL has been derived by Harrison and Beraquet drawing together the findings from this research and the existing literature.

Key skills for the UK Clinical Librarian role

Using evidence from this survey the role of the UK CL has clearly been identified in terms of what key skills are required. In Table 5 these are shown against the findings from the work by Ward9 and create a strand of the new Harrison and Beraquet model for a generic and definitive UK CL.

Table 5.   Key skills for Clinical Librarians
SkillCL’s perspectiveNew Model Harrison/Beraquet 2009
Harrison/Beraquet 2007Ward 2005
  1. ✓ indicates strength of activity.

Ability to use all technologies✓✓✓✓✓✓✓✓✓
Ability to use all technologies. Ability to teach others to use all technologies
Develop good rapport with other healthcare professionals✓✓✓✓✓✓✓✓✓
Ability to develop and maintain good rapport with other healthcare professionals.
Highly developed sense of emotional intelligence.
Ability to search and critically appraise information✓✓✓✓✓✓✓✓✓
Ability to search and critically appraise information. To understand users requirements within the clinical setting

Key activities for the UK Clinical Librarian role

The findings from this study and the research by Ward are used to denote the key activities of the CL role. The work by Tod et al.12denoting a simple model for a CL to facilitate evidence-based nursing and the work by Brookman et al.23exploring the clinicians’ requirements of a CL are used to group the user perspective of the role. The conclusions offered create a new strand of the Harrison and Beraquet model for a generic and definitive UK CL, the key activities of which are presented in Table 6.

Table 6.   Key activities for Clinical Librarians
 CL’s perspectiveUser perspectiveNew Model Harrison and Beraquet 2009
Harrison and Beraquet 2007Ward 2005Tod et al. 2004Brookman et al. 2006
  1. ✓ indicates strength of activity.

CL Service Promotion✓✓✓✓✓
Essential for sustainability of the CL service
Literature Searching✓✓✓✓✓✓✓✓✓✓✓-✓✓✓
Essential core activity, one of the expected norms of the role
Critical Appraisal✓✓✓✓✓✓✓✓
Local circumstances dictate and other demands on the CL service
Attendance on Ward rounds✓✓✓✓✓✓-✓✓
Essential to gain initial entrée to Clinical world. Thereafter local requirements prevail
Attendance at other clinical meetings.✓✓✓✓✓✓✓✓✓✓
Essential for sustainability of the CL service

The Harrison and Beraquet UK Clinical Librarian model

At the core of skills and activities required for the UK CL role is literature searching. It is from this central function that all other activity radiates out. All of the key skills and activities are interwoven and interdependent (Fig. 2).

Figure 2.

 The Harrison and Beraquet UK Clinical Librarian model

Moving forward

The findings of this survey echo the conclusions of previous research9,16,17 suggesting that the time has come to shout loudly about the benefits of a Clinical Library Service and to demonstrate its worth or risk being replaced by knowledge management or health informatics roles performed by non-Librarians. The work by Marshall18 and the ‘Tool Kit’ for measuring impact developed by Urquhart et al.19 reinforces and illuminates the need and how to show value of the CL service. It is imperative that CLs record all success and satisfaction with their service and follow the ethos of Evidence-based Medicine to affect Evidence-based Management for themselves. Demonstrating effective service delivery in strategic and financial terms, i.e. ‘value and worth’ is what matters in the NHS. CLs have the evidence to prove that a good Clinical Library Service is a vital part of the healthcare strategy for professionals and patients. Now is the time to gain professional distinction and confirm the existence of the ‘CL tribe’.

Key Messages

Implications for Practice

  •  Clinical Librarians should use performance measures to evaluate their own service.
  •  Clinical Librarians should develop and maintain good working relationships with Clinicians.
  •  The clinical skills and knowledge of healthcare professionals can be complemented by Clinical Librarians’ information skills and knowledge.

Implications for Policy

  •  Clinical Librarians need to be valued by the NHS not merely liked.
  •  Effective performance measures are required for Clinical Library Services.
  •  Wider dissemination of the effective practice of Clinical Library Services is required.

Ancillary