‘Find the evidence’—reflections on an information skills course for community‐based clinical health‐care staff at the Cairns Library, Oxford

Since Spring 2000, following discussions with the then Continuing Professional Development Manager for Oxfordshire Community Health NHS Trust staff, we have offered courses of three 3-hour ‘Find the Evidence’ workshops to community-based clinical staff in the Beeson Training Centre at the Cairns Library, John Radcliffe Hospital, in Oxford. It was strongly felt that community-based health professionals have special and complex information skills suppport needs, may have been out of education for some time, view their ‘computer’ skills as poor, and often feel isolated and lagging behind hospital-based colleagues. Opportunities to develop search skills are rare, as many primary care workplaces still have at best a single, and not always dedicated, search computer available. We wanted to find out whether some staff—perhaps the most eager to develop the skills, such as team leaders or those involved in research, who might lead initiatives or cascade down to colleagues—would be prepared to travel to a dedicated facility to work with others and to have individual hands-on practice, in a ‘safe’ environment, away from the clinical pressures of the workplace. Some one hundred have done so to date, with many attending in their own time! Each course, delivered over three consecutive weeks, covers a range of search skills to support evidence-based health-care (EBHC) and clinical effectiveness, including searching literature databases and the Web. A short course allows more time than a single workshop to develop the complex questions often found in primary care settings, to address a variety of sources, and to develop practical skills rather than simply to raise awareness or show ‘what is possible.’ Experimenting with these small groups over multiple sessions has enabled us to focus more clearly on issues discussed below, which are actually problematic in all current information skills support. A similar approach can be developed for hospital-based staff, whose information needs may be different to those in primary care, but whose information skills support needs may be more similar than often perceived. Learner evaluations from the first rounds of workshops were very positive about the opportunity to practice what were perceived as advanced skills with close support. They appear to confirm the value to the learner of: small-group sessions (of 4–8), interactive and informal; the opportunity to learn over a series of sessions, rather than a single session; setting practical evidence-finding skills in a conceptual context meaningful to each learner; applying knowledge and skills to practical concerns from the workplace; the opportunity to discuss and review experience with other learners from similar (and dissimilar) situations. The core concepts of ‘evidence-based health-care’ were new to many. They are also daunting, due to increasing emphasis on clinical governance and clinical effectiveness in the workplace, higher expectations from more informed health consumers, and increased pressure from professional accrediting bodies for practice to be explicitly informed by evidence. Almost all learners said that they would have liked even more time than that provided by three workshops. All realized that they would need to develop skills further over time. As a professionally qualified adult teacher, I could see the difficulties facing these learners in and beyond the learning situation. They were in danger of being overwhelmed by having to suddenly learn new skills (often perceived as difficult for those not ‘computer literate’) and to use radically new types of information resources, and by having to look at how ‘evidence’ might support their practice in completely new ways. There are major issues for many learners in ‘owning’ EBHC concepts and in applying the products of evidence searching skills to their own practice in health care, in different types of practice, and in workplace cultures which may accept or qualify EBHC to different degrees. Some workshops left me with a strong feeling of our having got bogged down! Problem areas included: ‘overload’ of learners trying to acquire and relate practical search skills and background EBHC concepts; some learners lagging behind if completely new to using computers; learners not having time to rehearse key skills in depth—e.g. using time for ‘trawling’ rather than moving on to develop skills for more complex searches; time insufficient for covering specialist sources needed by some learners; learner frustration at finding ‘poor’ evidence or none; learners unsure about ability to apply the skills in new contexts, without support; learners unsure about how to further develop skills and knowledge from the course. Major changes were made following detailed analysis of learner and trainer workshop evaluations, and discussions with the client, as follows: A 4-step EBHC-based process now provides a framework of broad learning aims: formulate a clear search question; recognize the ‘best’ evidence to answer the question; identify the most likely sources to search; search information sources effectively; Specific performance-based learning objectives to support the aims were rewritten in detail, especially in support of 4, for database search skills; Learning materials supporting each aim build into a colour-coded pack; The Learning Cycle (Kolb)1—experience— reflection—conceptualization—experimentation —is explicitly built into the course plan and its activities to counter the didactic approach; A detailed evaluation form canvassing learner views on problematic issues (clarity of route through the content, skills applicability, etc.) is used; Informal follow-up sessions are offered to those who complete courses; Those who attend the whole course receive a Certificate of Attendance. The four EBHC-related learning aims provide a conceptual grounding for key skills, flexible enough to adapt to specific situations. They are used as a ‘route map’ for session content and activities, allowing us to iterate or ‘spiral’ around in this complex area, rather than forcing everything into a linear sequence and getting bogged down. Instead of separate fixed session plans for the three workshops, we now have a ‘course outline’ listing the specific performance-based learning objectives that support each key aim, suggesting options for learner activities to support these objectives, better indicating links between sections, and more clearly identifying learning support and development materials at each stage. They are translated into learner-centred questions, used as a searcher’s checklist: What is my search Question in full? What is the best kind of evidence to address this type of Question? Where would I most likely find this evidence? How will I get the best out of the resources I will use? Learners are asked to see this as a provisional framework, to test and adapt for themselves, rather than an imposed set of steps to work through sequentially. In workshops, we cycle back and forth through them, as in many a search. In the first workshop, attendees are invited to summarize relevant experience, reasons for attending, and specific expectations: standard practice, grounding the session in learner experience, and revealing learner level, expectation and need. For future skills development, ‘safety nets’ of continuing support are identified. On skills generalisability we agree that the course cannot cover everything, but will focus on key transferable skills. Rather than describe each workshop sequentially, it might be clearer to give examples of the work which supports each broad learning aim in this new plan. The work begins with the learner’s own search question, taken from clinical experience: learners take time to discuss, write down and develop their questions, however provisionally. A return to question definition may be necessary later, perhaps after a first search. Many novice searchers find the process of clearly formulating and finely tuning the question to express what it is they really want to ask very difficult, and often extremely enlightening. A skill which may be obvious to librarians or searchers is not obvious to everyone! The best methods here seem to be highly interactive discussion, as a group or in small groups, with input from all learners: there is often a process of struggle to achieve the full question. We have a question formulation tips handout, and we model an example, but simply to be shown or told is not enough. The Question needs time—it forms the strongest foundation for search strategy skills, and may link us to specific search sources. This aim is most likely to cause knowledge-skills problems, and is all too easy to treat didactically, or as if there were a fixed picture for everyone: ‘here is what you need to know, etc.’ The problem —not theoretical, but experienced by every teacher—is that didactically presented material may just not be ‘owned’ enough to internalize for practice. In addition, there are different types of evidence, not only for different types of question across health care, but for different purposes, situations, contexts and levels—so we must enable learners to start to build their own picture. Activities using the Learning Cycle—reflecting on experience, using new concepts to explain or predict, and ‘experimenting’ with new resources or techniques—facilitates this process. We break this question into two sub-questions: What type of question is it? What type of research study would produce the best evidence to address it? Highly interactive discussion, in various forms, with brief didactic ‘bursts’ to answer issues raised, and handouts or slides with basic definitions of research study types or systematic reviews, support this. The aim is to help learners recognize the ‘best’ type of evidence to address their own questions, of the type they will need to address in clinical work, first of all. (It has been fascinating to see the subtle variations between different disciplines and questions: giving learners a standardized ‘evidence hierarchy’ is just not enough). We may also use brainstorming, buzz groups, etc. to answer the question ‘What would you use as evidence to inform, change or … your practice in health care?’. The suggestions, collected from many workshops, form an impressive learning aid which could not have been written at the outset! Novices cannot be turned into sources experts: giving an overview of resources for all question types is impossible, and probably useless. The core objectives are to identify some key resources types, and to begin to use examples—browsing a secondary journal, searching a database or using a Web gateway. Learners thus begin, and continue throughout the workshops—we can informally introduce new resource types between activities, at the start of a session, after coffee, etc.—the process of using new resources, but within a conceptual framework they have started building for themselves, and which they can ultimately relate to their practice. During the first workshop, learners examine non-computer-based resources, e.g. in pairs or groups, to discover how they work. Health professionals are well able to spot the key ideas behind secondary journals like Evidence-based Nursing, rather than be told by a trainer. Single-page handouts give details of major types of resources, using a simple conceptual framework, linked to the discussions: research—journals— secondary sources. Above all, this helps set the mysterious computer databases (and the Web) into a wider resources context. It also de-emphasizes the IT skills and anxieties focus: PCs are switched off when learners arrive! Some resources—evidence-based digests like Bandolier —are accessible in the workplace, and link us back naturally to issues around research methodology or reviews. Much of the workshop activity supports this key learning aim—but in the context of the whole set of aims. Learners devise provisional search strategies from their search questions—described in detail by Snowball,2—testing them out and refining them in stages on the standard databases, Cochrane Library, medline, cinahl, amed, etc. In the third workshop, we transfer skills to PubMed—the most immediately accessible for most learners to continue to practice on—and explore the Web with reliable resources such as biome or trip. A very detailed set of objectives has been drafted, based on a formal analysis of the practical skills needed for searching databases—and will be described in a future article—using the work of the educationalist Robert Gagné3 on learning prerequisites. As search trainers, I wonder if we ourselves always analyse in fine detail the skills required, so that we can support learners? Evaluation and development continues, but the main lesson has been that running short courses rather than single workshops has given us a valuable opportunity to experiment in developing more in-depth support for evidence-finding skills for community-based health professionals. It has given learners in primary care, more time—away from the pressures of the clinical workplace—to learn and to practice these new skills and to begin to integrate them with new concepts in support of their early practice of EBHC. Perhaps they will become leaders and motivators of clinical colleagues for whom we can now provide a wider range of support options—better informed by our experience with these courses?