Personal reflections on the role of librarians in the teaching of evidence‐based healthcare

Practising Evidence-Based Medicine (EBM) involves the fundamental skills of finding evidence, critically appraising the evidence and acting on the results.1 While it is accepted that clinicians need to obtain these skills, it is also necessary for them to learn how to teach these skills to others. In order to help clinicians with this role, the workshop How to Teach Evidence-Based Clinical Practice (EBCP) at McMaster University in Hamilton, Ontario, Canada was established.2 This workshop has been running for 9 years, with clinicians from around the world attending. However, it is only recently that librarians have managed to infiltrate such EBM workshops to share and teach their knowledge of searching and accessing evidence-based information resources. The EBCP workshop week held at McMaster University relies on small group sessions, each group having two experienced tutors, a tutor trainee and between 8 and 10 participants (usually clinicians or nurses). The groups were divided into specialities, e.g. internal medicine, family practice, nursing. Participants self-select to beginner, intermediate or advanced level. In 2001, as a pilot scheme initiated by Canadian health care librarians, a librarian tutor was also assigned to each small group. Librarians were chosen for their knowledge of EBM and critical appraisal, and their searching and teaching skills. The librarian tutors originated from the USA, Canada and the UK. All librarians participated fully in the critical appraisal group sessions, but our particular role was to teach searching skills to participants using evidenced-based electronic resources, both in group sessions and on a one-to-one basis. Due to the success of librarian involvement in 2001, the workshop organisers invited librarians to participate again in 2002. The EBCP workshop runs from Sunday evening until Friday afternoon. Each day included several group teaching sessions, where participants would prepare and teach the appraisal of a research paper. Didactic sessions were also delivered throughout the week by workshop tutors and invitation speakers. The librarian's role in the group sessions varied, depending on group dynamics, the appraisal experience of participants or the objectives for the week as agreed by the tutors. Between the 2001 and 2002 workshops, the role of the librarian tutors was clarified further.3 In our experience, roles included: assisting the participant to find relevant articles before or during their teaching session; enabling participants to recognize the role and importance of question formulation and searching, to the process of evidence-based practice; prompting the participants to formulate a clinical question from their scenario and devise an appropriate search strategy; introducing the group to a range of information resources before, during and after teaching sessions. Some participants asked their librarian to join in the appraisal session, perhaps role-playing as a medical student, in order to ask questions that would force the leader of the session to explain concepts in different ways. In some instances, the librarian might be invited to lead a discussion on how the article under investigation might have been located, and which sources would be relevant for the topic under discussion. During the week, each librarian also taught a 2-hour searching skills session in the computer lab—these sessions often involved collaboration with participants or tutors. The sessions usually contained: question formulation using the Patient/Intervention/Comparison/Outcome (PICO) methodology;4,5 devising a search strategy; using Medical Subject headings (MeSH); demonstrations of a variety of evidence-based electronic resources, with emphasis on secondary sources such as the Cochrane Library, Clinical Evidence and TRIP; time for hands-on searching of ‘real’ clinical scenarios; raising awareness of the range of tools available to support evidence-based practice, such as sources of search filters, collections of critically appraised topics (CATs);6,7 and online statistical calculators. The librarian tutors also worked individually with participants from their group. These sessions would typically be arranged in the ‘free-study time’ slots, and could either take place in the computer lab or the Health Sciences Library. Individual sessions could include discussing the topic of the teaching session, tracking down a suitable article and raising awareness of appropriate resources. By concentrating on the participant's particular information and learning needs in a non-threatening, informal situation, it was possible to increase the effectiveness of their searching skills. This one-to-one tuition was especially useful to those participants who did not speak English as a first language, or who had little or no experience of searching. As an additional resource, a computer lab was available during study times. Participants using this facility could receive teaching support from librarians from the Health Sciences Library, who were not attached to specific groups. A specially created web page devised during the 2001 workshop, acted as a gateway to resources used during the week.8 Librarians and participants made suggestions for inclusion on this website, throughout both the 2001 and 2002 workshops. Participants were encouraged to use this website to access resources during the workshop, and later from their home countries. Feedback from the small groups about librarian involvement was positive.3 Most participants learned the importance of formulating a focused clinical question, and gained an understanding of how to search more effectively using appropriate sources. The librarians also benefited from this workshop. Participating in the appraisal sessions allowed the librarians to improve their critical appraisal skills and understanding of statistical concepts. Teaching the searching sessions and working individually with participants allowed the librarians to discover how clinicians search for information and what the barriers to finding good evidence might be. It also gave the librarians a chance to experiment with their own teaching skills. For example, as librarians we often teach skills at a certain level, to familiar audiences, in our own environment and with plenty of opportunity to plan ahead; we will usually use tried and tested examples that we know will work. In the workshop environment, the group may be more advanced than we are used to, they may come from a new speciality and might ask for specific resources to be demonstrated, or for particular topics to be searched. For us as UK librarians, we had to quickly familiarize ourselves with resources such as Up-To-Date and Stat-Ref which we do not ordinarily have access to. Networking with other librarian tutors was helpful for gaining additional knowledge on available resources and searching techniques, especially due to the mix of Canadians, Americans and Brits! For us, it was a unique opportunity to use some non-UK databases and be exposed to the similarities and differences in information seeking required by various healthcare systems around the world. It was also a fantastic opportunity to network with other like-minded individuals and have some fun! One of the constraints of the workshop was the lack of network access from the hospital in which the vast majority of small group work takes place. It was felt by librarians and participants alike, that ideally all rooms should have a networked PC or a laptop with access to a port. This would enable sessions in which the elements of question formulation, searching and appraisal could be followed through from start to finish. It would provide greater freedom for those participants who wish to concentrate upon their own skills in teaching information retrieval. There are also comparable EBM workshops run in the UK. In Oxford there are annual workshops run by the Centre for Evidence-based Medicine9 in Teaching Evidence-Based Medicine and Teaching Evidence-Based Mental Health. Similar workshops in Durham10 and in London11 are also available. We have been involved with teaching the searching sessions for some of these other workshops. Currently most of these workshops utilize librarians in different ways. The different types of librarian involvement that we have experienced include: the dedicated librarian tutor such as the McMaster experience; the 1-day intensive searching model at Durham and Oxford, where librarians teach a single searching session to participants; the librarian as a workshop participant with no distinct role as tutor. From our own experiences, dedicated librarian integration into the McMaster workshop has advantages that appear to be manifold. The librarian spends all week with their small group, getting to know the participants’ previous searching experience, preferred learning methods and personality, and generally feels an integrated part of the group. Participants benefit from receiving one-to-one tuition from their librarian. Allowing librarian tutors to participate in the critical appraisal sessions raises the profile of librarianship, as clinicians become more aware of the additional skills an information professional can bring. One possible disadvantage for the librarian is that this was a very labour-intensive model. Participants had a 2-hour session of free-study time each day, but this was valuable time for them to make appointments with their librarian to receive extra searching tuition. However, this one-to-one tuition was an aspect of the model that participants seemed very grateful to receive. During our regular librarian tutor meetings, it did become apparent that a few librarians had problems with the group tutors being hostile or not allowing them sufficient time to teach. At the Durham workshop, the groups do not have dedicated librarian tutors throughout the week. The participants at this workshop are given a lecture on searching for evidence plus a 2-hour practical session. This is a valuable opportunity to concentrate on searching skills and exploring evidence-based resources. The disadvantage is that participants have to cover many skills and resources during the searching session, and do not have access to librarians during the rest of the workshop. Falzon also attended the Durham workshop as a participant, and found that her expertise as an information specialist was highly valued by her fellow participants during the group sessions. They felt that having a librarian ‘on tap’ had been a distinct advantage, as searching issues could be discussed for each specific article. They could also utilize the skills and knowledge of the librarian when needed, and not just during a one-off session. It proved an opportunity to remind health professionals of the specialist help we can give to support the critical appraisal process, and not just for the evidence-locating function. We also continue to expand the breadth of our skills by learning more about evidence-based practice and how to teach it. Workshops where librarians attend full-time, in whatever role, are good value for the participants, as it ensures that they are given unlimited access to our expertise. The financial costs for integrating librarians into these workshops may be high, however, as it involves the participation of many librarians for a whole week. The one-off searching model used at Durham is more cost effective—having a dedicated librarian could be seen as a luxury. Perhaps a hybrid model of several ‘floating’ librarians for groups to share would be the most cost-effective model where resources are limited. However, we believe that this is not the best utilization of the librarian's skills. It is our perception that these workshops may be expensive in terms of both time and money, and health professionals who attend them feel that they need to make the most of the time and resources open to them during the week. It is important therefore that librarians give as much to the process as the tutors, who advise on the teaching approach and more technical elements of appraisal. We believe that more librarians should attend these courses, either as a participant to gain an understanding of evidence-based practice, or perhaps more usefully, as tutors providing information and teaching support to clinicians. This will provide an opportunity for the benefits and cost-effectiveness of the different models of librarian involvement to be evaluated.

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