Preparing for practice: a higher education perspective. Commentary on . . . A clinical librarian pilot project in psychiatry {

clinical questions and think about how they might respond using the best available evidence to improve patient care. The extension of the project attempts to address the Summary Research suggests that contact time between clinical team and clinical librarian can have a direct and positive impact on patient care through encouraging a more rigorous approach to information retrieval and appraisal of the evidence base. This commentary focuses on the ﬁndings of a speciﬁc clinical librarian pilot project in a mental health trust. It discusses how clinicians could be better supported to develop improved information literacy skills through initiatives in higher education and what impact this might have on the model of clinical librarianship proposed by the project. Declaration of interest None.


Clinical librarians in England
The concept of the clinical librarian working closely with clinical teams to support evidence-based practice has been around for about 30 years. Currently, there are around 50 clinical librarians in England, 1 mainly based in the acute sector. 2 Although it is difficult to quantify, and most of the evaluations of the model undertaken are based on studies that are not methodologically robust, there is some evidence of the positive effect of clinical librarianship on patient care. [3][4][5] Numbers of clinical librarians are growing, but scalability is an issue. The Hill review 1 states that 'it is unrealistic to expect the widespread implementation of such a policy', recommending instead that resources be focused on key areas within acute hospitals where the impact on patient care might be maximised.
In contrast to Hill's view, such characteristics of mental health services as geographical dispersion of services, problems with staff access to IT, and a paucity of highquality evidence, make experimenting with the clinical librarian model in this setting worthwhile, and there is some indication that these very factors mean outreach library services can make a positive contribution to clinical practice. 6 The Birmingham pilot service sustainability issue by diluting the input required from the clinical librarian, while maintaining the momentum the pilot generated and spreading this more widely throughout the trust.

Students lacking in information skills
Clinicians' 'lack of time and limited skills in literature searching' are cited as common reasons why input from a clinical librarian can be so valuable. 2 The pilot stimulated an interest among some clinicians for further information skills training, and while continuing professional development might go some way to addressing both these issues and make the proposal to reduce clinical librarian input feasible, the model would stand a better chance of success if clinicians acquired a higher level of information skills during their undergraduate education.
One of the major objectives of academic health librarians is to equip students with the necessary information skills, not only for their academic work, but also for their future careers as evidence-based health practitioners. The extent to which we are successful is often hard to ascertain, 7 but the evidence from Gorring et al's study suggests we still have a way to go. 2 Whereas 'the ability to search, appraise and apply research evidence' may well, as Gorring claims, have become 'a standard part of medical training' -and indeed of the education of nurses, dentists and other health professionals -our own experiences of students' skills indicate there is substantial room for improvement. However, a number of ongoing developments could help to counteract the limited contact time clinicians are likely to have with a clinical librarian.
Teaching information literacy at universitycan it be done?
Universities have recognised for some time that the idea of evidence-based healthcare will only become a reality if graduates enter the workplace with the skills to access and interpret the knowledge base. Nonetheless, acknowledging that these skills need to be taught and finding time in the curriculum to do so has been difficult in many institutions. 8,9 In some, the approach to information literacy is still bottom-up and piecemeal, but a number of universities have taken a more strategic approach. 10 For example, in 2003 Leeds University adopted an institution-wide 'information literacy strategy', 11 which has made it easier for librarians to work with academic colleagues to embed information literacy more systematically within the curriculum. In the Faculty of Medicine and Health, the existence of a university-wide information literacy strategy has facilitated a number of initiatives. One such initiative was an information literacy audit, conducted in the Leeds University School of Healthcare in 2005, 12 which identified the information skills academics expect students to have at various stages in their course and highlighted where there were gaps in this knowledge. As a result, explicit information literacy learning objectives were built into modules in each year of the advanced diploma and undergraduate nursing curricula, delivered by academic staff and librarians.

Information literacy training at Leeds University
Although information literacy training has been delivered to medical students at Leeds for many years, it has had to compete for space in what was already a very busy timetable, and as a result its inclusion has relied to some extent on the support and interest of individual academics. Here, curriculum review has provided the main driver for changes in information literacy training. A new medical curriculum, to be launched in 2010 and developed very closely in line with Tomorrow's Doctors, 13 has provided the opportunity to embed a progressive programme of information literacy throughout the undergraduate medical curriculum. A working group, of which one of the authors (L.N.) is a member, is currently working on a research and evaluation skills thread to span the entire 5 years of the Bachelor of Medicine and Surgery course. Students will be expected to undertake a series of information retrieval and appraisal tasks as a key element of assessed research projects throughout years 1-5. Teaching will cover framing the clinical question, source selection and accessing the available evidence -including responding to scenarios where high-quality synthesised evidence may not exist or be most appropriate. Skills in searching sources to identify studies and critical appraisal of the literature will also be core.

Graduates' 'exit training'
If the clinical librarian model envisaged by Gorring et al is to succeed, close collaboration between librarians in higher education and the National Health Service (NHS) is essential. When graduates enter the workforce they are often confronted with a different range of information resources to those they have become used to using as students. Unless cross-sector purchasing of resources is introduced at national level, these differences will persist, but measures can be implemented to minimise the problem. Some university librarians already work with NHS colleagues to provide 'exit training' for students in the final year of their studies to smooth the transition from higher education to NHS, but there is scope for further initiatives in this area.

Working with the NHS
In Leeds, librarians from both of the city's universities are members of the city-wide Leeds Library and Information Services Programme Board, a cross-sector body whose remit is to provide strategic direction and decision-making in the development of library and information services for the Leeds health economy, which includes overseeing the development of information literacy curricula for NHS staff. Peer observation of training has been undertaken by local primary care trust librarians and University of Leeds health librarians. Working closely with NHS colleagues improves awareness of the information needs of students and clinicians, and facilitates, where possible, an integrated approach to information literacy training.

Clinical librarians of the future
Lack of time will continue to be a factor for clinicians, but if their information skills are more firmly embedded while they are students, the process of searching for evidence in the work setting should become less onerous. Furthermore, improving their information skills would equip them to get the most out of their interaction with a clinical librarian whose role as a catalyst will continue to be essential.
The pilot revealed the critical role of a team leader at consultant or specialist registrar level as a 'champion' of evidence-based practice and in some ways this is a hopeful sign. As increasing numbers of graduates steeped in the methods and values of evidence-based practice reach senior positions, the number of potential champions with an understanding of and commitment to the role of the clinical librarian should increase -with a direct and positive impact on patient care.