Librarian office hours in a family practice unit

: Objective – To determine if the implementation of well-advertised “librarian office hours” in a busy clinical department of a teaching hospital would increase utilization of library services. Setting – The open-concept office of the Department of Family and Community Medicine at the Toronto Western Hospital site of the University Health Network. Program – As of June 2004, a librarian provided monthly office hours during the lunch hour in the Department of Family and Community Medicine. Staff were encouraged to e-mail any specific issues or questions to the librarian in advance of consultation, if possible, but all consultations were otherwise provided on a first-come, first-served basis. Results – In the 7-month period since the librarian office hours were initiated, 21 separate training sessions or consultations were provided to this department. This constitutes 15 sessions more than the number of sessions provided to this group in the same 7-month period in the previous year. Concurrently, the number of literature search requests made by this department has doubled compared with the same 7-month period in the previous year. Conclusion – User-centered information services for primary care professionals need to be mindful of clients’ information-seeking preferences and lack of time. While providing librarian visits to individual hospital departments may not be the best use of a librarian’s limited time and resources, in the drive to meet the unique needs of general practice, such an approach may be an ad-vantageous way of librarians meeting client needs in the context of their own environment. Further examination of the benefits of approaches similar to this concept, for both librarians and hospital staff, is warranted.


Introduction
"Office hours", a concept familiar to those associated with the hallowed halls of academe, is not a concept common to the literature of librarianship. It refers to the "time set aside for advisees and students who want to consult with the professor outside of the normal classroom hours" 1 and is associated with the professional habits of professors. The closest comparison is perhaps a scheduled reference interview. Yet, in a teaching hospital, where habits of lifelong learning are encouraged, such a concept is perhaps not too unusual even for a librarian. Similarly, the concept of a "walk-in clinic", where appointments are unnecessary and help is available on short notice, while arguably similar to the type of service provided by a library, is not a term associated with the provision of its services. Both these concepts, familiar to primary care, were, however, used to market library services tailored to meet the needs of this specific client group.

Background
At the Health Sciences Libraries of the University Health Network (UHN) -a three-site library system servicing the Toronto General Hospital, Toronto Western Hospital, and Princess Margaret Hospital -information specialists are assigned the task of providing librarian services to specific client groups. These services include librarian-mediated literature searches and training in the use of bibliographic databases and evidence-based search techniques. The information specialist's role is to market these free services and tailor them to meet the individual needs of their clients. Thus, training can be provided to an individual or group and take place either in the library or in the client's office, depending on the client's preference and learning style. In addition to having the assistance of a designated librarian, staff at the UHN also have a virtual library that provides 24-7 access to bibliographic databases, online journals, and e-books, and is available both onsite and remotely via the hospital's intranet.
The information specialist responsible for the UHN's Department of Family and Community Medicine felt that this client group was underutilizing the library's services. When discussing training opportunities and preferences with department staff, it was suggested to the information specialist that monthly literature search office hours would be preferable to scheduled training opportunities.

Information needs and preferences of primary care
Literature on the information needs and organizational culture of primary care professionals, notably from the UK, identifies unique challenges in delivering information services to this population. The Primary Care Sharing the Evidence (PRISE) project, for example, identified the need for tailored information services with flexible working patterns on the part of health care librarians responsible for providing service to primary care staff. Because of their busy schedules, it was discovered that primary care staff were most likely to access electronic resources at key times of the day ("pressure points") -before work, during lunch, or in the evening. It was thought that "practice-based training" would allow "busy health care staff to make the most of limited time available for training" [1]. Other studies also identified workload problems and lack of time as key factors influencing information-seeking behaviour in primary care [2][3][4]. Rose states that "it has been shown that GPs [general practitioners] are likely to be too busy to express information needs or to try to get them answered" [2]. Interestingly enough, "an increase in the promotion of sources of evidence may raise awareness, although primary care professionals may still perceive that they have little time to utilize them effectively" [2].
Rose outlines various primary care initiatives in the UK to demonstrate the "importance of taking information services out to the communities they serve, rather than expecting end users to visit a central source, for example, a multidisciplinary hospital-based library" [2]. An outreach approach is generally suggested for meeting the needs of practices in the community because they are physically remote from an institutional library, but in a multisite hospital setting, the size and culture of the institution may also result in a sense of isolation. Some departments will invariably be more physically remote from the library than others, and services designed to meet the needs of multiple disciplines may be perceived as impersonal or generic. Two of the roles for information professionals that Rose identifies are "outreach worker" and "educator and trainer" [2]. Both roles can reap the benefits of providing services within the practice environment of primary healthcare workers.
The role of the clinical librarian, as another example, requires the librarian to meet clinician needs by going out of the library and into the busy clinician's environment. This too is an answer to time constraints and limitations in search skills on the part of the clinician [5]. However, while the clinical librarian responds to information requests directly related to patient care, what about questions related to teaching, research, residents' projects, program development, or evaluation? All of these, ideally, do not require immediate responses.
Pearson and Rossall [6] point out that those general practitioners "involved with teaching, training, and research have additional information needs and often need clinical and nonclinical material from original sources". Pearson and Rossall are specifically referring to the value of librarians linked to individual practices or practice libraries. However, it may not be possible to have a dedicated librarian for each clinic's dedicated use. Primary care professionals have varied information needs, not just patient-related, and if the professionals do not come to the library to make these requests, the drive to provide library services outside library walls must include services that are not limited to ward rounds, clinics, or practice libraries. When marketing library services, it is just not only about the actual service, but about "engaging people in a relationship", "knowing or anticipating what users want, communicating to them what is available, and being able to provide it to a level that is satisfactory to them" [7]. Each segment of the library's client group may require a different style of services: "it is the role of the librarian to customize and package the service for the groups that use the library" [7]. Regarding the future of hospital libraries, Brice and Gray [8] refer to a "workplace library model", where the library would "operate much more fully outside the boundaries of their physical structures and would only be truly effective if fully tied into the business needs and working patterns of their organizations". They argue that "knowledge has to reach the point where it is needed and be available when it is needed" [8]. This is not a new idea. Similar to this model is the idea of a "librarian in context", where the information specialist, being fully integrated into the practice setting, works as a peer with those they serve [9].

Program description
As of June 2004, a librarian provided monthly office hours during the lunch hour every second Wednesday of the month in the UHN's Department of Family and Community Medicine. The objective was to provide a face-to-face librarian presence within the Family Practice office at a time convenient to department staff to provide training and assistance in conducting literature searches. Office hours were advertised to a group of 75 department staff, residents, and students via monthly e-mail (Fig. 1) as a walk-in "literature search clinic" during the lunch hour. This service was open to all those involved in the UHN's Family and Community Health Program, a multidisciplinary program consisting of pharmacists, social workers, physicians, primary care nurse practitioners, staff nurses, and other health care providers. It was felt that despite departmental underutilization of free literature search and training services already provided by the librarian, department staff might be more inclined to seek out these services if the librarian were available within the department rather than in the library or even remotely via email or telephone. The e-mail reminder of this service was sent out the week before and the morning of the actual office hour. Staff were encouraged to e-mail any specific issues or questions to the librarian in advance of consultation, if possible, but all consultations were otherwise provided on a first-come, first-served basis.

Outcomes
During the first 7 months of this program, office hours were well attended. Most months, the librarian met with several staff back to back, sometimes even working past the designated hour until all staff waiting had a consultation. Each consultation consisted of an informal reference interview where the client and librarian would discuss the particular training or information need, followed by either training in the particular skill or database, troubleshooting a search previously attempted by the client, or a hybrid form of training where the librarian would conduct the literature search while at the same time explaining the process to the client.
Depending upon the specific need, a consultation could range from 10 to 40 min in length. The average encounter with physicians was 10-15 min, while the average encounter with allied professionals was 30-40 min.
The nature of the inquiries tended towards information needs related to teaching or research rather than clinical queries. For example, physicians were often preparing to present at rounds or planning to submit a paper for publication. In both cases, the types of search conducted were very different from those that would have been conducted for a treatmentoriented patient issue. On most occasions, searches previously conducted by the client were not successful because the searches were not conducted in the most suitable database. Most clients were familiar with basic searching in MEDLINE but had not been exposed to other useful databases such as CINAHL, PsycINFO, or Health and Psychosocial Instruments. Research needs often related to qualitative research methods such as conducting surveys, developing or validating research instruments, program evaluation, and measuring patient satisfaction or quality of life. If the queries were clinical, the issues were related to the comprehensiveness of a search. This provided the librarian with the opportunity to introduce clients to resources other than MEDLINE that they may not have considered, such as EMBASE or the Cochrane Collaboration. The nature of the query also determined if there were also opportunities to demonstrate the value of secondary Evidence Based Resources such as BMJ's Clinical Evidence and to discuss the pros and cons of Google versus MEDLINE or MEDLINE versus one of the other available biomedical databases.
In the 7-month period since the librarian office hours were initiated, 21 separate training sessions or consultations were provided to this department. This constitutes 15 sessions more than those provided to this group in the same 7-month period in the previous year. Concurrently, there was a 104% increase in literature search requests made by this department compared with the same 7-month period in the previous year (Fig. 2). This constitutes more than double the amount of work generated by this client group. For the purposes of librarian statistics, a query was considered a "literature search request" when it was made outside of office hours and required the independent work of the librarian, whereas "training" included one-on-one work with a client during office hours or troubleshooting a literature search.

Discussion
The librarian found the encounters during office hours to be extremely rewarding. It afforded the opportunity to meet with clients regularly, as well as the opportunity to receive updates on their work. In addition, it was rewarding to see a dramatic increase in client usage of librarian services. The librarian noticed a level of satisfaction from face-to-face encounters that was not akin to that derived through mere virtual interaction. Moreover, it was felt that face-to-face contact was more conducive to building relationships and trust with clients.
A number of clients had attempted a search on their own and were requesting help because they either were not satisfied with their results or were curious if their results would match those retrieved by a professional librarian. Other clients returned to more than one office hour to discuss their searches, thereby continuing to improve their search skills. Both these observations were consistent with those reported from the Front-Line Evidence-Based Medicine project [4]. An official survey to verify anecdotal observations by the librarian would be needed to evaluate the results of this intervention.
It was interesting to note that clients preferred to consult informally with a librarian during a designated time, even waiting their turn, rather than make appointments. It is possible that this provides a level of flexibility that is more suitable to work in primary care.
One of the challenges in providing training and services to general practice is the tension between providing individual attention and making the most of the librarian's limited time and resources. A single group training session, for example, could have addressed all members of the family practice staff at once, allowing the librarian to attend to other services and departments after the initial session. Single group sessions were provided in the past and were regularly suggested; yet they did not result in greater utilization of services, nor did they necessarily result in self-sufficiency on the part of staff in successfully conducting their own literature searches.
In reference to family doctors in the town of Aylesbury, UK, Bryant states that "group sessions are bound to disappoint most GPs to some degree … family doctors favour one-to-one sessions of an hour or more. This preference may reflect an unconscious reluctance to demonstrate hesitation in front of colleagues as well as the undeniable difficulties of arranging training sessions around a demanding clinical and management schedule" [10]. Such an observation could be generalized to refer to staff in the UHN's Department of Family and Community Medicine as well. Bryant goes on to identify practical guidelines that would be useful for a librarian in approaching general practice with information services: liaise, build alliances, and offer choice. Bryant describes general practitioners as "individualistic" [10], which may explain why office hours provided on the clients' terms and at a time chosen by the clients was more successful than the use of virtual resources on the library's terms. Bryant points out that "it is understandable that busy professionals are reluctant to commit the time needed to conduct literature searches, let alone to read and reflect upon the findings of previous studies" [11]. In addition, the literature reflects a low use of medical libraries by GPs and emphasizes the importance of convenience, accessibility, and availability in choosing information sources [3,6,10]. By sitting at a computer in the actual department, the librarian was providing a convenient and available information source. Specific factors would need to be identified in trying to explain previously low library usage by this client group within the UHN, because the librarian believes the relative proximity of the site library and the 24-7 accessibility of electronic resources via the virtual library on their desktop were equally convenient and accessible. It is possible that this specific client group is not yet comfortable or confident in the use of electronic resources. More likely, the issue may be that what a librarian considers accessible and convenient is not necessarily accessible and convenient from the perspective of a client. Ultimately, the librarian may need to step outside her comfort zone to provide services in a manner most suitable for the clients she serves.
The nature of the actual inquiries was consistent with research on the educational needs of GPs in a teaching practice [6,12]. Further research would need to be done to determine whether the provision of office hours was directly related to the increase in literature search requests by this department. Once office hours have been in place for a full 12-month period, the librarian intends to conduct a survey of staff to elicit feedback on the service. It would be useful to determine why clinicians were more likely to discuss a need with the librarian in person rather than make a request via e-mail or submit electronic search request forms. It is possible that in this particular departmental culture, speaking face-toface is considered faster and more convenient than composing an e-mail message or keying into an online form. Alternately, it may be the development of a personal relationship with the librarian that is the more important factor. It would be interesting to note whether this client group is more willing to embrace virtual services after the establishment of a relationship with their specific librarian.
Though personal contact with the client group has been rewarding, providing office hours is also time-intensive for the librarian. It has yet to be determined if the current successes in increasing service utilization by this department will continue and whether they are a sufficient return on investment. How much effort is needed? How consistent does that effort need to be? Can it be maintained? For how long? Further evaluation will be conducted after the first full year of implementation of this program.