brief communication : the patient library service in england

Brief Communication

The patient library service inEngland

PAULA MCGEE, Health and Social Care

Research Centre, University of Central

England, Ravensbury House, Westbourne Road,

Edgbaston, Birmingham B15 3TN, UK

Introduction

St John Ambulance has an established role

in First Aid but is perhaps less well known

for its work in caring and supporting

vulnerable members of the community.

The introduction of the NHS and

Community Care Act provided oppor-

tunities for St John Ambulance to review

this aspect of its work and develop services

that meet the needs of individuals in a

wide variety of settings. As a result, a

number of diverse schemes have been

developed. These include day centres for

people with physical disability and the

provision of first-contact health services

for homeless people. In addition to these

new initiatives St John Ambulance has also

been able to examine long-standing

commitments with a view to developing

strategies for change. Amongst these

commitments was the hospital library

service in England. St John Ambulance

had been involved in the delivery of this

service since the First World War and is

still one of the main providers of books

for patients in hospital.1

It was argued that a review of the

service was required for a number of

reasons. First the services had not been

reviewed for a long time and many of the

personnel involved were well advanced in

years. Second, the length of inpatient stay

was declining and this, coupled with an

increase in outpatient services and day

surgery, meant that individuals were often

not in hospital long enough to read a

book. Third, changes in the organization

of the NHS meant that the new Trusts

had no understanding of the hospital

library service. Local service organisers

reported that Trust managers seemed to

know little about it and did not appear to

value it. This paper presents some key

aspects of the review undertaken by St

John Ambulance in conjunction with the

Health and Social Care Research Centre at

the University of Central England.

Conduct of the review

The aims of the review were to determine

the current nature of the service provided

by St John Ambulance to hospital patients

and identify factors that required change.

In addressing these aims a number of

questions arose. For example, `How is the

service organized?' `How do people

involved in the service feel about it?' From

the multiplicity of questions it was evident

that no single investigative approach was

likely to provide the comprehensive

picture of the service that was required.2

Consequently, a multi-method approach

was used and this included:

. A telephone survey of the 22 personnelwho organized the library serviceprovided by St John Ambulance.

. Telephone interviews with servicemanagers and, where appropriate, staff inthe county library services.

All interviews were conducted using a

prepared question grid that provided space

204 # 1999 Blackwell Science Ltd

Brief Communication

in which the interviewer could record

answers. These were then analysed to

identify themes and key issues.

Findings

The books

The most popular books were said by all

organisers to be large-print fiction and

holiday-type reading. Some non-fiction

such as biographies, travel and hobbies was

also popular. Organisers thought it

unnecessary to provide health-related

books because the hospital staff gave such

good patient education. Only one

organiser reported supplying foreign

language books.

The weight of the books was

important, because some patients were

unable to lift heavy texts. This meant that

paperback editions were usually more

appropriate even if these did not last as

long as hardbacks. Several organisers

supplied talking books that were of

particular benefit to those with visual

impairment and people who could not

read. However, talking books were not

always a success in hospital wards because

a member of staff had to be responsible

for the equipment and know how to

operate it. Staff were not always willing to

take on this responsibility and

consequently cassette players were lost or

damaged. In addition there were

difficulties in ensuring that tapes were

returned. This was partly due to the

absence of secure collection points but it

was also not unusual for books to be

returned with the last cassette missing

because the patient had not finished the

book before discharge.

The county organisers

The organization and administration of the

patient library service was the responsibility

of unpaid county organisers. The service

depended very heavily on these individuals

and the commitment they brought to their

work. A lot was expected of them and they

invested a great deal of time and effort in

the service. Service reductions due to

hospital closure, failure to renew contracts

and the difficulties of trying to provide a

library caused despondency and dis-

illusionment for some individuals. Those

linked to the county library service did not

have to undertake book buying or

cataloguing. Both area organisers and

county staff praised these links as

advantageous because they provided

patients with access to catalogued, public

library stock. Books on loan to the

hospitals were changed regularly and the

library could afford to supply both tapes

and large print editions.

In contrast, organisers working alone had

to undertake all the work with the result that

some did not have a proper catalogue. Losses

generally were difficult to monitor because

no record was kept of patient details. Two

county organisers had set up deals with

publishing houses to obtain imperfect copies

of books; others relied on cut-price

bookshops, sales and donations. Main-

tenance of the stock was problematic in that

some patients, by nature of their illness or

disability, soiled books. In addition, every

library received donations that had to be

carefully vetted, because many were

unsuitable for patients; there were also

books in stock that were very old and

unread. Unwanted gifts of books and old

stock were sometimes sold to raise money.

Brief Communication

# 1999 Blackwell Science Ltd, Health Libraries Review 16, 204±212 205

The volunteers

The presence of volunteers was welcomed

because employing paid staff would have

made the service too expensive. The

number of volunteers varied greatly

between counties, from single figures in

some places to almost a hundred in others.

County organisers used a variety of

strategies to attract people, including the

volunteer bureau, advertising in

newspapers and in churches, speaking on

local radio and word of mouth. This last

strategy was very effective because people

found it difficult to refuse a personal

invitation.3, 4 Overall the results of these

strategies were variable, with some

counties recruiting more than others.

The majority of volunteers were older,

white women who been part of the service

for quite some time. Very few men or

young people joined the service. A

number of reasons were given for this.

Younger people were more likely to find

paid employment and were therefore not

available during the day when the service

operated. Women were thought to be

more generous with their spare time than

men and volunteering was associated with

a particular age group, level of education

and social class.4 It was generally agreed

that volunteers required certain qualities.

Social skills were the most important;

volunteers had to be able to approach

patients in a well-mannered fashion, strike

up conversations with strangers and not

mind being in contact with the sick. There

was recognition that patients needed more

than just a book handed to them. Older

adults in particular might have very few

visitors, or none at all, and the hospital

librarians therefore provided much

welcomed social contact. It was inevitable

that some patients would talk about their

problems. Consequently, the librarian

needed the maturity to maintain

confidentiality and the ability to show

concern without getting involved or taking

on work that was normally the province of

paid, professional staff. Volunteers had to

be reliable because the service depended

on their contribution and physically strong

to cope with moving the trolley and lifting

books. An interest in books and love of

reading was desirable but not as essential

as the other attributes. These qualities

echoed the recommendations of Going5

and Willis6 who argued that volunteers in

the hospital library service should be

discreet, friendly and able to work with

sick people. They should be able to co-

operate with others, respond to requests

from patients, and have a familiarity with

books and reading. The ability to maintain

records was also important to prevent

books being lost, as well as the strength to

do the work.

Discussion

These findings indicated that the patient

library service was in need of a new look.

Revitalizing the service should include

providing purchasers with specific

information regarding its value and what it

can offer to patients rather than rely on

the vague idea that it is in some way a

good thing. Service planning should take

account of the nature of the locality and

client groups to be served. In areas where

the number of inpatients has declined it

might be appropriate to target specific

groups of patients and develop the service

Brief Communication

206 # 1999 Blackwell Science Ltd, Health Libraries Review 16, 204±212

in a way that is suited to their needs.7 This

could provide opportunities for some

creativity. For example, volunteers could

be recruited to read to patients, form

special interest groups or facilitate activities

such as singing.8, 9 It is possible that

patient libraries could be joined with other

activities such as patient education to

provide a wider range of books and

information.

In all of this, attention must be paid to

the demands made on area organisers.

Providing the service required

considerable commitment on their part.

They were responsible for recruiting,

training and organizing volunteers, buying

books, maintaining the stock and handling

administration. The pressures on them

were immense and it was clear that they

required not only support but also

practical assistance. A final issue concerns

the nature of the volunteers who were

mostly older women. Contact with the

sick and dealing tactfully with people

requires a certain level of maturity and it is

therefore possible to argue that older

adults are better placed to undertake

patient library work. However there is a

need to consider both the demands

currently placed on existing volunteers,

especially county organisers, and the

future of the service, by recruiting and

retaining new people to meet the needs of

patients in a changing health service.

Acknowledgement

The author would like to thank Margaret

Forrest and the Archives of the British

Red Cross, London, for help in preparing

the report on which this paper is based.

References

1 Sturt, R. Hospital libraries in the United

Kingdom, an historical survey. Hospital libraries

in England and Wales to 1960. In: Going, M. ed.

Hospital Libraries and Work with the Disabled in the

Community, 3rd edn. London: The Library

Association, 1982.

2 Denzin, N. The Research Act. A Theoretical

Introduction to Sociological Methods. Englewood

Cliffs, New Jersey: Prentice Hall, 1989.

3 Davidhizar, R. & Bowen, M. Recruitment and

retention of older volunteers in extended care.

Nursing Management 1995, 26(12): 42, 44.

4 Wasserbauer, L., Arrington, D. & Abraham, L.

Using elderly volunteers to care for the elderly:

opportunities for nursing. Nursing Economics 1996,

14(4), 232±8.

5 Going, M. The hospital library. In: Going, M. ed.

Hospital Libraries and Work with the Disabled in the

Community, 3rd edn. London: The Library

Association, 1982.

6 Willis, A. The use of volunteers. In: Clarke, J. &

Going, M. eds. Hospital Libraries and Community

Care, 4th edn. London: The Library Association,

1990.

7 Bond, C. & Miller, M. Reading: The ageless

activity. Geriatric Nursing American Journal of Care

for the Ageing 1987, 8(4), 192±3.

8 Forrest, M. Reminiscence therapy in a Scottish

hospital. Health Libraries Review 1990, 7(2), 69±72.

9 Wenzel, E. `It sure beats looking out of the

window': literature for the elderly. Activities,

Adaption and Ageing 1993, 17(4), 232±8.

Meeting Report

Report on the 6th Congress of theAssociation for HealthInformation and Libraries inAfrica (AHILA 6), Lusaka, Zambia,14±18 September 1998

STEVE MCDONALD* and JEAN G. SHAWy,*UK Cochrane Centre, Oxford and yPartnershipsin Health Information, Bath, UK

Meeting Report


In his keynote speech Dr Phiri from Zambiaemphasized that librarians have a professionalresponsibility not only to library users butalso to the population in general. He stressedthe role of information in the quality ofhealth care and its capacity to effect changesin the health of the community. Delegatesheard a number of cases where librarianshave shown great determination andinitiative in endeavouring to makeinformation more available despite financialdifficulties and other problems.

At the University of Zambia, libraryautomation has begun, initially for thecataloguing system. Also, because theuniversity is a major stakeholder in theInternet provider Zamnet, the use of e-mailand the Internet is enjoyed by students andstaff alike.

The availability of computer equipmentmeant that three very popular full-dayworkshops on the Internet and HTML couldbe run. In partnership, the FloridaUniversity Health Science Center Libraryand the University of Zambia MedicalLibrary have produced a `Guide to MedicalResources'Ða click-on guide to Internetresources. The guide has links to searchengines, full-text electronic journals, full-textWHO documents and MEDLINE, makingrelevant information more easily accessible.

The HTML sessions were equallyexciting, with librarians from all over Africacreating their own Web pages using a fewbasic instructions from hand-outs and freesoftware. Given the barriers tocommunication between the countries ofAfrica, electronic communication is probablythe best way to disseminate healthinformation.

A workshop on evidence-based health careand the Cochrane Collaboration waspresented by Steve McDonald (UKCochrane Centre, Oxford) and EdwardMujera (University Medical Library,Zimbabwe). It was noticeable that manyparticipants were largely unaware of the termor its implications, but from this presentationthey learned how the concept of evidence-

based healthcare and the Cochrane Libraryhad been successfully introduced within anAfrican library.

The lack of awareness of current issues inhealth information is widespread andpresents a very real barrier to continuingprofessional development. However, withlittle LIS professional literature flowing fromnorth to south this is hardly surprising. Aproject `Articles for Africa' co-ordinated byPartnerships in Health Information (PHI)and funded by the Health Libraries Group inthe UK, was introduced to delegates by JeanShaw. This project aims to improve thissituation by printing specially selectedabstracts and providing the full-text of thearticles on request.

With resource-starved libraries a realityacross many parts of Africa, the Congressorganisers arranged several sessions andworkshops that emphasized the importanceof acquiring broader professional skills toenable librarians to be more effectiveadvocates. A workshop on proposal writingled by Margaret Mathai was followed by ahighly practical session on how to present apaper.

One day of the Congress was devoted todiscussing the African Index Medicus (AIM)project. The idea is to create nationalbibliographies of health, with the aim ofgiving greater visibility to health andbiomedical research carried out in Africa. Itis hoped that the north±south informationflow that currently dominates will begin tobe reversed.

So far, the records in AIM are good, buttoo small a proportion of the health literatureis being captured. In break-out groupdiscussions, several barriers to increasing thenumber of records were identified: technicaland training difficulties, absence ofinstitutional support, lack of recognition ofindividuals' efforts, and inadequatedissemination of the database amongcontributing countries. Although varioussuggestions were made to help overcome orameliorate these barriers, the need for greaterpersonal commitment among AHILA

Meeting Report


members was seen as crucial to thecontinued viability and success of the wholeenterprise. The project received animmediate boost when it was announced thatWHO AFRO would provide each centrecontributing records to AIM with a free CD-

ROM containing the database.Access to up-to-date and relevant health

information in practically all Africancountries is unacceptably poor and this is notthe fault of our hard-working AHILAcolleagues. It seems that at least onegeneration of health professionals will betrained with inferior information resources.

Donations will be required for some timeto come, but these cannot and do not bringthe range of educational material anywherenear the minimum standard we wouldexpect in the UK. Specific efforts toimprove the long-term outlook are needed,because donations tend to be irregular andcan come to an end at any time. AHILAmembers and Partnerships in HealthInformation are very grateful for the supportreceived from the Health Libraries Group toenable African librarians to advocate theirown cause.

Acknowledgements

The authors would like to thank the LibraryAssociation Health Libraries Group for theirtravel grants that defrayed some of theexpenses of attending the conference.

Research

Rural information deprivation?

JANE FARMER* and DOROTHY WILLIAMSy,*Department of General Practice and PrimaryCare, Aberdeen University, Foresterhill Healthcentre, Aberdeen and ySchool of Information andMedia, Robert Gordon University, Aberdeen

Tackling health inequalities is a statedpriority of the Government. Crisis in therural economy and growing difficultiesrecruiting and retaining health professionalsin rural areas has stimulated an interest indesigning rural-sensitive indicators of socio-economic inequality and examining theirrelationship with health status. A number ofauthoritative sources have researched orsuggested what these indicators might be.One organization, Rural Voice, suggested`information deprivation' as an indicator andit was this finding that inspired our interestin writing this column.

An initial trawl for recent research studiesfound little about the health information-related behaviour of rural patients/the public.A number of interesting responses wereobtained from information professionalsworking in UK, Australia, Canada anddeveloping countries who were providingservices to remotely located healthprofessionals. These indicated that healthprofessionals at a distance from resourcesexperience real problems in accessinginformation and there is no reason tosuppose that patients would find it anyeasier.

We could assume consumers will needand use health information in the same wayin rural as in urban areas, but because littleresearch has been done, can we be sure ofthis?

A growing body of evidence about thecircumstances of rural life would seem toindicate that this is an important issue toconsider.

Giarchi1 says health in the countryside isaffected by poor housing, insufficient healthand medical resources, poor access to welfareand social services, poor information aboutservice provision, reluctance and sometimesresistance to utilise resources provided by`outsiders'. For rural dwellers, the effort andthe cost of accessing services is greater. Forthose without a car, public transport could betoo expensive or non-existent. Research hasshown that the closer people are located toservices, the more often they will use them.

Research


It is not only more difficult for rural peopleto get to services, it is difficult for services toget to them.

McLaughlin2 reports that 20% of the ruralpopulation live on or below the poverty line.He says rural deprivation is the outcome ofongoing processes of decline in the availabilityand quality of service provision that haveoccurred in rural areas in the last 40 years. Hereports that young adults are at a particulardisadvantage in terms of lack of opportunitiesto access higher education, choice of jobs,levels of income and work conditions, qualityof social life and limited opportunities tomove out of the family home.

Cox3 emphasizes the rising problem ofrural homelessness. He also discusses theproblem of relative disadvantage wherevillages may have a number of richinhabitants and very poor people living sideby side. The richer will tend to spend theirmoney outwith the local community, thusputting local services at risk. Wheredeprivation is measured over spatial areassuch as postcode sectors, the income ofricher people will cancel the effect of lowincomes, thus making it appear that the areadoes not contain deprivation.

While these facts tell us that a proportionof rural people may be suffering fromdisadvantage, they do not give us anyconcrete evidence about what informationprovision, specifically health information,could do to help.

Some projects have examined theprovision of information in rural areas. Acase study of the rural area of Wexfordwas conducted as part of MacDougall's4

study looking at the provision ofconsumer health information for the IrishLibrary Association. The problem ofhealth information accessibility washighlighted by health professionalsinterviewed who said:

`This was especially the case in the ruralareas where dissemination and communi-cation of health information was felt to be areal difficulty'.

In Wexford, public library users andthose attending outpatients clinics wereasked about current sources of healthinformation and where people would liketo get health information. From a given listof options, most people (67%) said they goto their GP first for information on health;19% to friends and/or family; 6% to alibrary; 5% to the local pharmacy; 4% to acommunity care clinic. The types ofinformation service they said would be ofmost use to them were as follows: free andconfidential telephone service (25%);hospital/clinic information centre (19%);drop-in information shop in town centre(18%); GP waiting room (13%); publiclibrary (11%). MacDougall concluded thatthat there was probably a greater potentialrole for the public library in providinghealth information.

Yates-Mercer & Wotherspoon5 conducteda study of the information needs of ruralusers, which was funded by the BritishLibrary. Although this study did notspecifically look at health information needs,it does provide an excellent and thoroughreview of the literature of rural informationprovision. In reviewing the numerous,usually small-scale, initiatives to provideinformation services to rural areas, theauthors paint a picture of:

`a number of people wading into the seato try out different life saving techniqueswhilst the ship is sinking. Although a greatnumber of people will be saved by theseefforts, many will nevertheless drown,most of whom will consist of the secondclass passengers'.

While different approaches in differentareas are not necessarily a bad thing, theauthors think that the low expectations ofrural dwellers about accessing servicesmeans there is not as great a forcelobbying for improvement as might beexpected.

A questionnaire survey of UK libraryauthorities and organizations having aninterest in rural issues was also conducted

Research


to find out whether provision for ruralusers had been evaluated or projectsestablished to provide specific services torural areas.5 In addition, questionnaireswere distributed to residents in four villagesin England, Wales, Scotland and NorthernIreland asking about information needs andaccess to libraries.

Some library authorities had supportedhealth/community care information projects.Few had looked specifically at the needs ofrural users. The researchers suggest that co-operative ventures between libraries andother interested agencies seem to provide thebest way forward, but it is difficult to knowwhat to provide.

The highest profile initiative, from theperspective of the interest groups, was accessto Ruralnet6 which was launched on 1 April1998 and is designed to facilitatecommunication between those working withvoluntary, statutory and interest groups inrural areas.

The researchers perceived a generalemphasis on information technology toprovide for rural areas, but say this requirescareful consideration. Will all have access tothis resource?

Of the 117 villagers who replied, 85%thought it would be useful to have access toa computer located within the village andInternet facilities. Ninety-six per cent hadaccess to a telephone in their own home sotelephone help/advice lines could be useful.A substantial number said they read localnewsletters.

This study concluded that the mostimportant question to be asked in futureresearch is: What is the most cost effectiveand efficient method of assessing needs?

Savill et al.7 conducted an audit of publicinformation concerning health as part of theLLWYBPR (Welsh for Pathway) Initiative.They conducted a survey of public,voluntary and private sector agencies thatmight provide health information.

Public agencies indicated that the mostlikely development in their provision wouldbe Internet/intranet sites. Most frequently

mentioned difficulties with informationprovision were:

. lots of information, but no co-ordination,

. need for Welsh language/bilingualinformation,

. poor transport/access,

. poor accessibility of information foryoung people.

Voluntary sector agencies were mostconcerned about information on mentalillness/mental health and access for carers.

The general conclusions of the study werethat there was a lack of information needsassessment in rural areasÐboth with regardto the topics rural people might needinformation on and their preferred media fordissemination. They thought there was aneed for improved services, specifically foryoung people, carers and in relation tomental health.

From the foregoing discussion, it can beseen that there is a dearth of research that haslooked at the health information needs ofrural users. The research that has been doneseems to raise the following questions.

. Is there a difference between rural andurban dwellers in relation to the healthinformation they use, want to use and themeans to access it?

. Does the above vary according to distancefrom centres of population?

. Are there groups who are particularlydisadvantaged by a lack of access to certainhealth information in rural areas?

. What methods can we use to answer thesequestions?

References

1 Giarchi, G. Distance decay and information

deprivation: health implications for rural isolation.

In: Abbott, P. & Payne, G. eds. New Directions in

the Sociology of Health. Explorations in Sociology

no. 36. Basingstoke: Falmer Press, 1990: 57±69.

2 McLaughlin, B. P. The rhetoric and the reality of

rural deprivation. Journal of Rural Studies 1986,

2(4), 291±307.

Research


3 Cox, J. Poverty in rural areas is more hidden but

no less real than in urban areas. BMJ 1998, 316,

722.

4 MacDougall, J. Well Read: Developing Consumer

Health Information in Ireland. Wexford: The Library

Association of Ireland, 1998.

5 Yates-Mercer, P. & Wotherspoon, G. Information

Needs of Rural Users: an Update. British Library

Research and Innovation Centre Report no. 116.

London: British Library, 1998.

6 http://www.ruralnet.org.uk/

7 Savill, A., Gittoes, C., Bird, S. & Davies, R.

LLWYBPR Audit of public information

concerning health. Available on the LLWYBR

Website <http:www.llwybr.org.uk>.

We asked Steve Pritchard, DeputyDirector of Information Services at theUniversity of Wales College of Medicine(E-mail: [email protected]) to com-ment on our column. His contributionfollows:

Rural information deprivation?

Libraries have been unsuccessful indelivering adequate healthcare informationto rural communities. Some differencesbetween rural and urban needs areeloquently indicated in the researchreported above and reflect the crisis in thecountryside exacerbated by agriculturaldecline and a belief that rural life ismisunderstood and undervalued by apredominately metropolitan society. This isone UK minority that is disadvantaged.Even the Government's Health ActionZones appear to be targeted principally aturban areas.

UK programmes using the Internetand telemedicine to identify and alleviaterural health inequalities in Scotland1 and

Wales2 can be mirrored world-wide. The RoyalSociety of Medicine has cosponsored a recentreview of telemedicine's decentra-lizingpromise.3 The European Rural and IsolatedPractitioners Association (EURIPA) hasidentified common needs, priorities andexamples of good practice across Europe. Thevision of the proposed National ElectronicLibrary for Health of delivering relevant,useable knowledge to practitioners and thepublic at their point of need could, arguably,make an even greater difference in thecountryside than in the town. Flying doctorsand circuit riding librarians have been joined byWebsites4 and electronic libraries5 in bringinghealthcare information to rural communities.

Academic library experience in supportingdistance learning students may be atransferable model that could help toimprove information delivery and uptake invillages and farms as well as rural surgeries.

Urban based LIS professionals seeking tohelp should proceed with delicacy, alert tolocal sensitivities.

References

1 Farmer, J., Richardson, A., Lawton, S., Morrison,

P. & Higgins, R. Improving access to information

for nursing staff in remote areas: the potential of

the Internet and other networked resources.

Aberdeen: Robert Gordon University, 1997.

2 Research strategy 1998±2003: overview. Gregynog:

Institute of Rural Health, 1998 <http://

home.red.net/homepages/irh/>.

3 Wootton, R. (ed.) European telemedicine 1998/99.

London: Kensington Publications, 1999.

4 RuralNet <http://ruralnet.marshall.edu/>.

5 Guard, R., Haag, D., Kaya, B., Marine, S., Morris,

T., Shick, L. & Shoemaker, S. An electronic

consumer health library: NetWellness. Bulletin of

the Medical Library Association 1996, 84, 468±77.

Research


brief communication : the patient library service in england

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