living the hylife: addressing the information needs of physiotherapists

Physiotherapy May 2000/vol 86/no 5

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IntroductionThe key issues affecting the development ofthe physiotherapy profession, includingcontinuing professional development(CPD), evidence-based practice and clinicalgovernance, are dependent on access to,and assimilation of, a wide range of relevantliterature. The Chartered Society of Physio-therapy (CSP) is currently undertaking atwo-year project which seeks to establish anenabling framework to support members’needs for CPD (CSP, 1999a). The first phaseof this project has been completed andinvolved a survey of members’ current CPDactivities and barriers to learning. Resultsshow that reading literature relevant to theirrole was undertaken by 93% of respondents.

The literature base of physiotherapycontains both information (articlespublished in scientific journals) andknowledge (information which has beensynthesised for ease of use, for example insystematic reviews) (Gray, 1999). Physio-therapists will have differing needs forinformation or knowledge depending onwhich of their main roles – clinician,manager, educator or researcher – isparamount.

Knowledge and information are alsorequired over differing time scales (Gray,1999). For example, when clinicians arediscussing treatment with a patient theydraw on their immediate knowledge base.When they reflect on a particular patient’streatment or write to a colleague, time may be taken to refer to an appropriateguideline. However, when preparing apresentation for an in-service trainingsession or for a critical appraisal session of a journal club, more time and different skills are needed to review the full text ofarticles.

Living the HyLiFe Addressing the information needs ofphysiotherapists

Summary Physiotherapists need to access a wide range ofliterature in order to respond to such initiatives as continuingprofessional development, evidence-based practice and clinicalgovernance. The findings of the first stage consultation of theContinuing Professional Development/Lifelong Learning projectbeing undertaken by the Chartered Society of Physiotherapyconfirm the importance of libraries in supporting learning.

Library provision for physiotherapists has been and remainsproblematic. The requirement for NHS trusts to have a library andinformation strategy, together with the government’s commitmentto the National electronic Library for Health, and the drive towardsequipping clinicians with health informatics skills, have thepotential to affect clinicians’ access to information.

There has been a growth in electronic sources of information,ranging from databases to Internet health gateways, on-linejournals and electronic discussion lists.

The hybrid library concept seeks to draw together the wholerange of traditional print-based and electronic formats in whichinformation resources are currently delivered, and help library usersto find the most appropriate resources for clinical or studypurposes. Following the recognition that teaching and learning inthe higher education sector would become increasingly electronic,the electronic Libraries Programme (eLib) was founded under theauspices of the Higher Education Funding Councils.

Physiotherapists were one of the groups targeted under itsHyLiFe hybrid library project at the University of Northumbria atNewcastle. This aimed to harness computer technology to locateand provide library and information resources, print or electronic,customised to specific user groups. This paper explores the HyLiFecomputer interface in relation to its potential to address theconcerns expressed by practising physiotherapists about the use ofcomputer technology and accessing information.

Collaboration between a number of key players in education andhealth is required if the infrastructure to support evidence-basedpractice is to be put in place.

Key WordsPhysiotherapy, library andinformation services, accessing information,electronic information.

by Ieuan Ellis Graham WaltonCatherine EdwardsAngelina HuttonDiana Jones


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Healthcare professionals have largelylearnt information use and managementfrom role models in practice and from anisolated professional perspective (NHSE,1999a). As part of an attempt to change thisculture, a Health Service Guideline(HSG(97)47) was produced which requiredall health authorities and National HealthService trusts to have a library andinformation strategy. A review of libraryprovision for professions allied to medicine(Walton, 1995) identified this group’sdiversity of information needs, the variabilityof available services, difficulties in access,and the need to upgrade practitioners’information skills.

Accessing the InformationLibrary Provision for PhysiotherapistsThe difficulties identified by Walton (1995)have been exacerbated by the polarisation offunding. In 1994 nursing education wastransferred into higher education from theNHS. Physiotherapy has been based withinhigher education since the early 1990s in the UK.

In many NHS hospitals, libraries funded tosupport medical and nurse education werefreely accessible to physiotherapists and werewell used. Since 1994 problems of accesshave increased as universities haverationalised provision by closing NHSlibraries, or restricting access only to theirstaff and students. Physiotherapists havediscovered that the NHS libraries theypreviously used have either closed or elsethey are denied access (Capel et al, 1997).This trend has forced home the need for the NHS to take responsibility for thefunding of library services for its own staff,including qualified physiotherapists. Of all respondents to the CSP CPD/LifelongLearning survey (CSP, 1999a), 61% felt thatlearning should be supported throughimproved access to library facilities.

University libraries acknowledge that theyare charged with providing services to theirstaff and students. They are also clear thatthey do not service other groups unless on acontractual basis. Some trusts have taken onthe responsibility for funding while othershave not. Educational funding levies exist tosupport library provision in NHS trusts.Currently these do not provide equity ofaccess to all staff groups, with those workingin primary care being disadvantaged (NHSE,1999b). It is very rare that physiotherapistsin the private sector have access to anyservice. Libraries are recognised as one

of the basic building blocks of clinicaleffectiveness which underpins the conceptof clinical governance and the drive topromote quality in the NHS (Ayres et al,1998).

Electronic InformationThere have been substantial changes in theprofile and provision of electronicinformation. The NHS outlined itsinformation management and technologystrategy in the document ‘Information forHealth: An information strategy for the modernNHS, 1998-2005’ (NHSE, 1998). Thisstrategy explicitly states that it will deliver a‘National electronic Library for Health tokeep doctors and nurses, and otherprofessionals up to date with the latestclinical research and best practice at thetime they need it’.

Electronic bibliographic databases havebecome much easier to access. The AMED(Allied and Alternative Medicine) database,previously available on disk and monthlyhard copies, now provides an extensivecoverage of material relevant to physio-therapy in electronic format. Databases suchas those included in the Cochrane Library –Cochrane Database of Systematic Reviews,Database of Abstracts of Reviews ofEffectiveness, and the Cochrane ControlledTrials Register – offer clinicians access to theevidence base of practice (Anon, 2000a).

Electronic journals have become a reality.The British Journal of Therapy and Rehab-ilitation (Anon, 1999a), Physical Therapy, PTBulletin Online and PT - Magazine of PhysicalTherapy (Anon, 2000b) can all be found on-line. Various Internet gateways toappropriate websites, such as OrganisingMedical Networked Information (OMNI)(Anon, 2000c) have been produced. Upfieldand Salter (1998) describe the establishmentof the electronic discussion list PHYSIO(Anon, 1999b) and its hyperlinks to usefulInternet sites. The CSP website (Anon,1999c) has an expanding electronic library.

This fast growth of electronic informationhas heightened a need identified by Walton(1995): the importance of upgradingpractitioners’ information skills. There wasnotable support from workshops undertakenas part of the CPD/Lifelong Learningproject (CSP, 1999a) for the development oflearning opportunities that use informationtechnology, multi-media materials anddistance learning formats. Students weremore at ease than qualified physiotherapistswith these formats: 55% of students would

Ellis, I, Walton, G,Edwards, C, Hutton, Aand Jones, D (2000).‘Living the HyLiFe:Addressing theinformation needs ofphysiotherapists’,Physiotherapy, 86, 5, 249-256.


251Professional articles

welcome a searchable database provided bythe CSP, as opposed to 38% of qualifiedstaff. The CSP has contributed to thedevelopment of the document ‘Learning toManage Health Information. A theme for clinicaleducation’ (NHSE, 1999a). This presents acore framework for health informatics whichit is acknowledged will change in relation tonew technologies; research on the use ofinformation in the management of care; animproved NHS information environment;and changing health policies and practices.Hybrid libraries have the potential toimprove the healthcare informationenvironment.

Hybrid Library The recently coined term ‘hybrid library’, atits simplest, describes libraries as they arelikely to continue for some time, ie providersof information resources in both traditionalprint-based formats (eg books, journals,indexes) and also increasingly in electronicformats (eg on-line and CD-ROM databases,computer catalogues, Internet). The hybridlibrary concept seeks ways to draw the wholerange of media actively together in a moreintegrated way, thereby reducing thesomewhat daunting complexity of manylibraries. Fundamental to the concept arethe needs of library users in terms ofdiscovering and obtaining the mostappropriate information resources requiredfor work and study.

The Report of the Joint Funding Councils’Libraries Review Group (Follett Report,1993) brought into focus the current stateand future development of academiclibraries in the UK. There was a recognitionthat the development of new technologiesand new trends in teaching and learning in agreatly expanded higher education sector(Day et al, 1996) would mean that libraryand information services would becomeincreasingly electronically dependent. In thewake of Follett came the UK-wide ElectronicLibraries Programme (eLib) (Hunter, 2000)funded by the Joint Information SystemsCommittee of the Higher EducationFunding Councils (Anon, 2000d). The 60 orso projects under eLib phases 1 and 2 aimedto improve the delivery of informationthrough increased use of electronic libraryservices.

Now in its third phase, eLib has shifted itsfocus by supporting five hybrid libraryprojects (Pinfield et al, 1998) of whichHyLiFe is one.

The HyLiFe ProjectThe HyLiFe Project (Wynne, 1999) isfunded for three years from January 1998 to December 2000 and has six highereducation partners across the UK: theUniversity of Northumbria; the University ofNewcastle; the Centre for Urban andRegional Development Studies (CURDS) atNewcastle; the University of Plymouth; theUniversity of Central Lancashire; and theUniversity of the Highlands and IslandsProject.

Different groups of library users have beenidentified in the six sites and with theirparticular characteristics and requirementsin mind, work is under way to develop sixhybrid library computer interfaces.

Essentially, HyLiFe is harnessing computertechnology to locate and provide library andinformation resources, print or electronic,customised to suit a range of learners. Thetargeted groups at this stage include healthstudies students and practitioners, nurses,geography undergraduates, researchers andstudents working at home or in collegesaway from main campus libraries. Amongthese are many part-time and maturelearners.

As part of the HyLiFe project theUniversity of Northumbria (Wynne, 1999)has produced a web-based computerinterface and document delivery servicefocused primarily on the needs of physio-therapy students and practitioners. Potentialusers were consulted at every stage of theproject. This project, widened to serve theneeds of healthcare professionals generally,has now been adopted as a fully operationalinformation service within the University ofNorthumbria since Autumn 1999 (Hutton,2000).

Help in the WorkplaceThe problems of accessibility of journalswere highlighted during a pilot session for a national critical appraisal initiativemounted by the Association of CharteredPhysiotherapists in Neurology (ACPIN), aCSP Specific Interest Group. The session wasentitled ‘Taking the plunge in evaluatingresearch articles’ (Mawson, 1998). AnACPIN branch journal club, formed to takeadvantage of the initiative, agreed to theaudio-taping of one of their initial sessionsto allow analysis of issues in relation tomeeting information needs. Each of the sixmain themes to emerge could be addressedvia a HyLiFe-type interface.

Authors

Ieuan Ellis, GrahamWalton and Diana Joneswork in the Faculty ofHealth, Social Work andEducation and Catherine Edwards andAngelina Hutton work in the School ofInformation Studies, all at the University ofNorthumbria atNewcastle.

Ieuan Ellis MEdCertEd(FE) MCSP DipTPis head of the Division ofHealth, Disability andRehabilitation. He reviewed the contextof information needs for physiotherapists.

Graham Walton BSc MAMBA FETC ALA is facultylibrarian. He assessedlibrary provision forprofessions allied tomedicine.

Catherine Edwards BAMA is a research associateand assistant HyLiFeproject manager. She has been involved indeveloping the conceptof a hybrid library.

Angelina Hutton BA is aHyLiFe project officerwho worked on thedevelopment and use ofthe HyLiFe interface.

Diana Jones BA MCSP isa research Fellow whoassessed the potential useof a HyLiFe-type interfaceto address the perceivedbarriers to accessinginformation identified by physiotherapists.

This article was receivedon August 4, 1999, andaccepted on March 14,2000.


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1. ‘I don’t want the librarian to think I’mthick’HyLiFe has been designed to mimic a visit toa library where a helpful librarian promptsyou to look in particular sections or thinkabout accessing different forms ofinformation. The home page (fig 1)contains a Frequently Asked Questions‘FAQ’ button which opens a list of queries in alphabetical keyword order. This can be browsed, or particular questionsinvestigated, ranging from where to findbooks on specific subjects to how to cite

Internet resources. An electronic form isavailable for individuals to send an enquiryto library staff if their query is not alreadycovered.

2. ‘There’s so much information outthere’HyLiFe is a health interface designed toguide physiotherapists to informationsources that may be of use to them. Workingyour way systematically through the HyLiFeoptions can provide a structure to the searchfor information. Clicking on a buttonentitled Obtaining Library Books allows asearch of the home university catalogue, thecatalogues of other regional universities andnational catalogues such as the BritishLibrary.

Interviews with physiotherapy lecturers,students and practitioners undertakingresearch as part of the development ofHyLiFe revealed that journals and bookswere the most used information resources,with journals, both physiotherapy-specificand cross-discipline, being used more thanbooks. Obtain a Particular Journal Title orArticle (fig 2) is a gateway to searching forjournals by subject area, finding whereparticular journals can be accessed andobtaining information on electronicjournals. A description of the scope of arange of databases, such as the CumulativeIndex to Nursing and Allied Health(CINAHL) and Medline is provided, withadvice on how to access them via a passwordfrom HyLiFe.

Electronic systems such as CD-ROM andlibrary catalogues were well used byphysiotherapists interviewed by the HyLiFeteam, as were government publications. Arange of official publications of the UnitedKingdom and United States governmentsand the European Union can be accessed.Links are provided to full text UKgovernment publications such as Acts,Command Papers, Hansard and SelectCommittee reports.

Obtain Specific Information from theWorld Wide Web (fig 3) guides users to relevant health and professionalorganisations such as the CSP, health sitesand health news services including on-linenewspapers and the BBC health news. Linksare available via HyLiFe to subject gatewaysfor information on health such as OMNI; toservices for searching the Internet such asAlta Vista; and to mailbase discussion listssuch as Physio-Mailbase, a mailing list forgeneral information and discussion on all

Fig 1: HyLiFe home page

Fig 2: HyLiFe: Obtaining a particular journal title or article



matters of relevance to physiotherapists(Upfield and Salter, 1998). Most HyLiFeinterviewees described themselves ascompetent in using both printed andelectronic sources of information. However,they indicated that they encountered themost problems with electronic resources,especially when using CD-ROMs, theInternet and e-mail.

3. ‘It takes me such a long time toachieve so little’HyLiFe is designed to save time. The homepage provides a guide to all the informationsources available which can give a structureto a search. The short descriptions of many of the services available, such aselectronic databases, help users decidewhether they will be useful or not.Frequently Asked Questions can quicklyanswer many queries. A personal computerwith an Internet connection enables a userto check whether a book or journal isavailable or to access an electronic databasewithout going to a library. Time and energysaved by not travelling to a library can bespent developing skills in undertakingsearches and retrieving more focusedinformation. Reservations and renewals can be made.

4. ‘I don’t like computers’HyLiFe is designed to be user-friendly. Itshome page makes it clear what you will findin each area. Overall the look is clear andstraightforward, devoid of complicatedgraphics which can be time-consuming onless powerful computers. There are simpleinstructions to click on the information yourequire and guiding questions asking you tothink about what you want to do. The user isinvited to click on the relevant letter inalphabetical letter guides to access journaltitles or Frequently Asked Questions.

5. ‘I never seem to find what I want onMedline’There is a need for physiotherapists to accessthe full range of databases, available viaHyLiFe, and to understand the specific focusof each. In a study of core journals ofphysiotherapy (Bohannon, 1999), of thethree major bibliographic biomedicaldatabases Embase had the most com-prehensive coverage at 95.7%; Medline85.1%; CINAHL 72.3%; Medline andCINAHL 95.7%. To cover all 47 corejournals, all three databases had to beemployed.

6. ‘I do a search but can still only accessarticles in the local library’For anyone who needs to visit or contact a local library, Find Out about LibraryContacts and Facilities will provideinformation about it, but it will also giveinformation about other local and nationallibraries, and details of hospital libraries andtrusts locally. HyLiFe includes on-line formsto request a book to be sent or to obtain aninter-library loan of a book or journal article.

The HyLiFe inter face has broughttogether the full range of informationresources of relevance to physiotherapistsand enabled ease of access to them. Such an inter face has obvious benefits forphysiotherapists, especially if it is madeavailable to practising clinicians in theworkplace.

DiscussionThe current health service ethos, with itsfocus on each individual’s responsibility tocontribute to the delivery of quality patientcare, is forcing a change in the culture oflearning for healthcare professionals. Thereis a move towards independent problem-based learning, ideally supported bytechnology in the workplace, with the focuson ‘finding out’. This contrasts with thecontinuing culture within physiotherapy forcourse-based group learning outside theworkplace, with the focus on ‘being taught’,which was verified by the results of the CSPCPD/Lifelong Learning survey (CSP,1999a). A feeling of guilt was reported when

Fig 3: HyLiFe: Obtaining specific information from the World Wide Web


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taking time out for continuing professionaldevelopment activities, given work pressuresand staff shortages in the workplace.Respondents said that it was often easier togo on a course than develop workplacelearning because courses were generallyattended in their own time.

In a study of information accessingbehaviour by physiotherapists (Bohannon,1990), books and journals were the mostcommon reading materials, although fewclinically useful books and journals wereidentified. The study reported heavyreliance on other people for information,particularly other therapists in theworkplace, with seminars, workshops andlectures the main continuing educationactivities. In a study of journal readership by UK physiotherapy clinicians, Turner and Whitfield (1996) reported limitedreadership, with nearly one-third readingonly the CSP journal and newsletters.Readership figures were higher for degreerespondents. Of all student respondents tothe CSP CPD/Lifelong Learning survey(CSP, 1999a), 99% – all of whom would beundertaking degree courses – reported thatthey expected to read literature relevant to their role as part of their continuingprofessional development. Low journalreadership overall has implications for the uptake of research findings. In a later study Turner and Whitfield (1997) reportedthat research literature ranked least inimportance as a basis for choosing treatmenttechniques. Initial training, practiceexperience and courses were identified asprimary reasons for treatment choices.

This behaviour has implications forevidence-based practice in physiotherapy,which ‘is primarily about the interactionbetween a practitioner and an individual’(Bury, 1998). Evidence encompasses a broadrange of sources, which includes bothresearch and clinical expertise, leading tothe working definition of evidence-basedpractice (based on Sackett et al, 1996) as ‘theconscientious, explicit and judicious use ofcurrent best evidence in making decisionsabout the care of individual patients,integrating individual clinical expertise withthe best available external clinical evidencefrom systematic research’ (Bury, 1998). Theenhanced provision of information andknowledge provided by a system such asHyLiFe will not of itself ensure evidence-based decision making. Clinicians need tobe able to ask the right questions, find thebest knowledge, appraise the evidence

critically, implement useful findings andevaluate their impact in practice to ensureclinical effectiveness.

The development of HyLiFe for nursesand physiotherapists has highlighted theneed to unravel the inter face betweenhigher education and the NHS library andinformation services. One of the key issuesfor clinical governance is that ‘evidence-based practice is in day-to-day use, with theinfrastructure to support it’ (CSP, 1999b).There is a major need for the key playersinvolved in the creation of that infra-structure – NHSE, higher education, educ-ation and training consortia, individualtrusts, therapy managers, representatives ofthe independent sector – to ensure that thehealthcare professionals they represent arefacilitated to access and use the knowledgebase to the benefit of patient care.

Some Emerging Solutions In July 1999 the NHSE published itsdocument Continuing Professional Develo-pment: Quality in the New NHS setting out along-term vision for the local managementof CPD in health organisations as a crucialpart of delivery of high-quality care andclinical governance (NHSE, 1999b). In theforeword to this strategy document, theMinister of State for Health emphasised theimportance of partnerships betweenstakeholders in providing learningenvironments to promote lifelong learningand support excellence in clinical care. Thedocument highlights the need for locallibrary and information technologystrategies to provide a framework for equalaccess to library provision for all staffgroups, particularly those working inprimary care. It also identifies the need toprovide clinicians with opportunities todevelop their skills of informationtechnology to take advantage of newdevelopments in CPD, such as open anddistance learning accessible through anInternet-linked personal computer. Thisdocument provides strategic guidance whichshould lead to improved access to informat-ion for physiotherapists working in the NHS.

The mission statements and business plansof higher education providers are placingincreasing emphasis on widening access to learning, making information moreaccessible via flexible and distance learning,utilising developments in remote accessmedia (University of Northumbria, 1999).These modes of delivery appear particularlywell suited to meeting current and future



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Acknowledgements

Insights gained from thecontributors to theJournal Club of theNorthern Branch ofACPIN, and backgroundinformation supplied byCaroline Miller, CSPinformation officer, aregratefully acknowledged.

Address forCorrespondence

Ieuan Ellis, Head ofDivision of Health,Disability andRehabilitation, Faculty ofHealth, Social Work andEducation, University ofNorthumbria atNewcastle Coach LaneCampus, Newcastle uponTyne NE7 7XA.

information needs of qualified physio-therapists.

In November 1999 the CSP initiated aproject to review the role of its informationresource centre. This project recognises thegrowing importance of physiotherapistshaving access to information services andwill investigate the needs of different groupsof its members, including those working in

the private and independent sectors. Theproject will examine the extent to whichinformation needs are currently being met (and by whom) and its findings will inform future provision of informationservices by the CSP, including the scope for collaboration with, for example, the NHSand universities.


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Key Messages

� Physiotherapists need access to a rangeof information to evidence and developtheir practice, but currently access tolibrary services is problematic.

� Information technology has thepotential to widen information accessfor physiotherapists.

� It is important that key stakeholders –NHSE, CSP and higher education –collaborate to enable physiotherapists totake advantage of electronic informationsources.

living the hylife: addressing the information needs of physiotherapists

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