A pathway for hospital librarians: why is it vital?

OBJECTIVES
By the mid 2000s, reports of hospital librarians losing jobs and hospital libraries closing were rife. In 2005, Vital Pathways: The Hospital Libraries Project was established by 2005/06 MLA President M.J. Tooey, AHIP, FMLA, to assess the truth of these reports and to study and develop strategies to support hospital librarians. Throughout this long-term project, opportunities were sought to understand the issues more clearly.


METHODS
A steering committee, along with three task forces, was established to carry out the work of the project. The steering committee provided oversight and had responsibility for promoting and marketing the project. The three task forces were responsible for conducting a survey on the status of hospital librarians, determining the involvement of librarians in medical education and accreditation, and researching and writing a document reviewing current and future roles for hospital librarians. Along the way, these responsibilities grew and evolved.


RESULTS
After a little more than three years, the Task Force on Vital Pathways for Hospital Librarians Steering Committee presented a final report regarding its accomplishments to the MLA Board of Directors. A sampling of these accomplishments includes the status of hospital librarians survey, a website, a position document with an accompanying executive summary, a short promotional brochure, and a final culminating activity, this symposium.


CONCLUSIONS
Although these are difficult times for all libraries, hospital librarians and libraries seem particularly affected. In a competitive health care environment that is driven by the bottom line, influenced by real estate hunger, and affected by the belief of hospital administrators that access to health information comes from the Internet and is free, the hospital librarian seems doomed. However, even in these difficult times, there are hospital librarians who are not only surviving, but thriving. Is it because they are entrepreneurial? Opportunistic? Innovative? Flexible? All of the above? None of the above? There are no clear predictors of success or of failure. However, the Vital Pathways Project has shed light on some of the issues and identified opportunities and strategies for the future.

Methods: A steering committee, along with three task forces, was established to carry out the work of the project. The steering committee provided oversight and had responsibility for promoting and marketing the project. The three task forces were responsible for conducting a survey on the status of hospital librarians, determining the involvement of librarians in medical education and accreditation, and researching and writing a document reviewing current and future roles for hospital librarians. Along the way, these responsibilities grew and evolved.
Results: After a little more than three years, the Task Force on Vital Pathways for Hospital Librarians Steering Committee presented a final report regarding its accomplishments to the MLA Board of Directors. A sampling of these accomplishments includes the status of hospital librarians survey, a website, a position document with an accompanying executive summary, a short promotional brochure, and a final culminating activity, this symposium.
Conclusions: Although these are difficult times for all libraries, hospital librarians and libraries seem particularly affected. In a competitive health care environment that is driven by the bottom line, influenced by real estate hunger, and affected by the belief of hospital administrators that access to health information comes from the Internet and is free, the hospital librarian seems doomed. However, even in these difficult times, there are hospital librarians who are not only surviving, but thriving. Is it because they are entrepreneurial? Opportunistic? Innovative? Flexible? All of the above? None of the above? There are no clear predictors of success or of failure. However, the Vital Pathways Project has shed light on some of the issues and identified opportunities and strategies for the future.

INTRODUCTION TO THE VITAL PATHWAYS PROJECT
As early as 2004, the Medical Library Association (MLA) Board of Directors heard frequent reports of hospital library closures and hospital librarians' job losses. Although some actual closures could be documented through the National Network of Libraries of Medicine regional offices and actual contact with the affected librarians, most of the conversation was anecdotal. The original impetus for what became Vital Pathways: The Hospital Libraries Project was the need to gather data on the status of hospital libraries. The project quickly grew beyond the need for a survey to a more philosophical one focused on the future of hospital librarians. It became clear MLA needed to know more.
The status of and present and future role of hospital librarians was selected as a presidential priority by M.J. Tooey, AHIP, FMLA, for 2005/06. The underlying purpose was not to focus on the negative aspects of closures, but to identify elements of success and determine directions for hospital librarian viability in the future. The project was charged as follows: The Medical Library Association (MLA) and the Hospital Libraries Section of MLA [HLS] will collaborate on a project to study and report on the current state and future roles of hospital libraries and librarians. The project will consist of three initiatives including: (1) a hospital library survey designed to gather data regarding the number of hospitals with professional librarians and the types of library services that are available to health care providers, patients, and consumers; (2) an advocacy initiative to review accreditation standards for residency and [continuing medical education] (CME) programs and promote hospital libraries and librarians' inclusion in these standards; and Implications N This symposium will lead to increased focus on hospital librarians' issues and future.
N Increased focus will result in conversations and actions regarding new and emerging roles for hospital librarians.
(3) a report on the current and future roles of and challenges of hospital librarians in light of the changing health care environment.
A steering committee was formed and met for the first time in September 2005. Representation at the first meeting came from the MLA Board, MLA headquarters, and the HLS. Participation of the HLS was crucial for the success of the project. During that initial meeting, three committees were formed around the three major elements of the charge: & the status of hospital libraries survey & the health sciences librarians role in education and accreditation, and advocacy supporting those roles & a major document defining current and future roles for hospital librarians, including challenges and opportunities Initially, the steering committee focused on monitoring the progress of the three subcommittees. One or two steering committee members were assigned to each subcommittee, and conversely, the chair of each subcommittee served on the steering committee ( Table 1). The steering committee assumed the additional responsibility of public relations aspects of the project. Some of the public relations projects included: & articles explaining and promoting the project written for the HLS National Network newsletter and the MLA News & the Vital Pathways website, which identified and linked to additional materials supporting hospital librarians and the project [1] & the development of a short brochure, The Hospital Librarian: Your Competitive Edge [2], focused on how hospital librarians enhance a hospital's competitive edge, which was distributed at MLA chapter meetings in the fall of 2008 and is located on the Vital Pathways website, so that it can be customized for individuals or academic libraries & a standing room only ''Vital Pathways Project Open Forum'' at MLA '08 in Chicago & presentations regarding project status throughout the entire lifespan of the project; in fall 2008, steering committee members made a concerted effort to blanket fall chapter meetings with information about the project; model abstracts, facts, poster and presentation content, and a promotional video were shared by the committee in presentations and/or poster sessions delivered at five chapter meetings & a ''summit'' meeting of interested and concerned sections at MLA'09 in Hawaii to discuss items of mutual interest and identify possible collaborations; HLS is MLA's largest section; in the final report of the Vital Pathways Project (VPP), several other MLA sections who could support and mutually benefit from closer partnerships with HLS were identified [3]; for example, the Research Section could partner with the HLS on programming and courses to support research in hospital librarianship & this symposium, which will not only report on the VPP activities and products, but will also focus attention on the issues and possibilities confronting hospital librarians The VPP, originally slated to be in existence for two years, was expanded to three years. By the time the work was finally completed, with the publication of this symposium, the VPP will have been in existence four years.

THREE TASK FORCES: THREE CHARGES
The charge of the Task Force on the Status of Hospital Librarians (Table 2) was: The Task Force on the Status of Hospital Librarians will identify existing data and trends on the status of hospital librarians, collect data on the links between libraries and quality and financial outcomes, and develop an action plan for MLA to use this information to influence hospital decision-makers and key leaders in the health care field, in terms of the perceptions and support of hospital libraries. The task force should develop short-term immediate actions that can begin addressing the issue, as well as long-term initiatives.
To accomplish this, the task force attempted to use, as much as possible, the methodology developed by Wakely and Foster from 1993 [4]. This survey proved challenging, primarily due to changes in the health care industry and the status of hospitals in general. The results of this survey are found later in this symposium in the paper by Thibodeau and Funk, ''Trends in Hospital Librarianship and Hospital Library Services: 1989 to 2006.'' The work of this task force was substantially completed in 2007.

Introduction
The Task Force on the Health Sciences Librarian in Medical Education (Table 3) was charged to: Review the current and future roles of health sciences librarians in medical education at the graduate and undergraduate levels and work with national organizations to integrate library services, education, and staff into the requirements for training medical students and residents.
This task force faced challenges. Although their charge did not specifically mention hospital librarians, much of the work they did required them to research accreditation standards for areas such as residency programs that primarily occur in hospitals. Beyond the accreditation standards, their work also involved identifying and aligning competencies between librarians and accreditation requirements, preparing a basic library requirement standard for use by accrediting bodies, crafting letters for accrediting bodies, and defining new educational roles and strategies for hospital librarians. The full report of their work by Schwartz et al. appears later in this symposium.
The charge of the Task Force on Vital Pathways for Hospital Librarians (Table 4) [5]. The AAHSL report identified four areas of knowledge management: clinical practice, education, research, and community service. The challenge for the VPP group was to find a taxonomy that worked in the hospital setting and was relevant to hospital librarians. An extensive review of the literature was undertaken, and the task force decided on the taxonomy developed by Abels et al. to underpin this document [6]. Resulting from a study commissioned and funded by MLA, this taxonomy identified five major areas: clinical care; efficient and effective hospital operations; continuing education for staff; research and innovation; and patient, family, and community health information needs.
Over the next two years, the task force members discussed and researched those areas to provide documentation and scenarios for the final paper. A subcommittee of the task force took on responsibility for crafting the final document, which is the keystone document of this symposium. An Executive Summary was created from this document and is available on the MLA Vital Pathways website [3,7]. This summary was distributed at MLA '09 in Honolulu. It was intended that the Executive Summary, with or without The Hospital Librarian: Your Competitive Edge brochure [2], could be shared with hospital or clinical administrators to stimulate conversation about current and emerging roles for hospital librarians. If there was enough interest, the longer document with its examples and further exposition could then be given to the administrators.

SYMPOSIUM INTRODUCTION
From the very beginning, the steering committee envisioned that the culmination of its work would be a symposium in the Journal of the Medical Library Association. A symposium would accomplish a number of things: & It would be an opportunity to publish the results of any work that was done as part of the VPP.  The MLA Health Information Literacy Research Project was funded by the National Library of Medicine and queried hospital administrators regarding the perceived value of consumer and health literacy information. From that starting point, a health information literacy curriculum was developed, and a cohort of hospital librarians delivered this curriculum in their hospitals, resulting in an affirmation that this type of role was valuable to the hospital. Shipman et al.'s study validated this emerging role.
About the time the VPP was beginning, there were presentations and papers regarding Magnet status for hospitals and potential roles for hospital librarians in the process. Based on quality indicators and standards of nursing practice, the Magnet Recognition Program was developed by the American Nurses Credentialing Center (ANCC), the world's largest nurse credentialing organization. Much of the process of Magnet Recognition involves access to and application of best and evidence-based nursing practices in addition to professional growth and development. The Nursing and Allied Health Resources Section of MLA and the HLS invited speakers and engaged the ANCC in conversations about roles for librarians. The Allen paper in this symposium delineates these roles as a potential opportunity for hospital librarians.
The final paper in this symposium looks to the future as it reports on the planning underway for repeating the landmark study, ''The Impact of the Hospital Library on Clinical Decision Making: The Rochester Study'' [8]

THE FUTURE PATHWAY: COMMENTARY AND LESSONS LEARNED
In the fall of 2005, none of the members of the VPP Steering Committee suspected the project would take four years to complete. Initially, the project just encompassed the work of the three task forces, but the issues were much more complex and far-reaching than imagined. It was not enough for the project to address the stories of hospital library closings. The project grew to an examination of the very survival of hospital librarians and their libraries.
Along the way, the project expanded to discussions not only of survival, but of advocacy and innovation. Additional questions were raised. Unfortunately, no pat answers or easy solutions were discovered. Throughout the project, conversations were held, presentations were given, emails exchanged, and some insights gained. Over the four-year lifespan of the project, a number of anecdotal truths emerged.
First and foremost, it is not enough for our own community of medical librarians to know hospital librarians are vital. We cannot continue to just preach to the choir and then expect outsiders, including administrators, to know how valuable we are. Administrators and staff need to be aware of how vital we are. Hospital librarians become vital by: & Aligning themselves with the missions, goals, and priorities of their institutions, administrators, and key stakeholders and then suggesting programs that support those missions and goals: Understand the corporate culture and nonclinical information needs. Provide information and competitive intelligence supporting administrative goals and concerns. Know the business of the hospital or health system and know the competition & Doing relevant research and sharing the results: Research does not always need to be ''big'' research. It can be done within the confines of an institution or in partnership with colleagues at other institutions. If a hospital librarian introduces a new program, it should be assessed. Assessment of outcomes should be a component of any project or service that the library offers. Excellent resources explaining and supporting research and supportive colleagues can be found on the website of the Research Section of MLA [9]. Several MLA chapters and sections offer research awards. Research results should be shared. Publications and presentations locally, regionally, and nationally are imperative for information dissemination.
Colleagues benefit from learning about each others' experiences. & Promoting themselves, their expertise, and their services: There is nothing wrong with self-promotion. If administrators believe all information is on the Internet and is free and if they identify their hospital librarian with a room and resources, what is the value of the hospital librarian? Hospital administrators, clinical administrators, health care professionals, and staff need to be told often of the positive impact, particular expertise, and innovative services of the hospital librarian. Raise visibility by getting out of the library and embracing potential new roles such as clinical rounding, patient safety, health literacy, consumer information outreach, and support of accreditation activities such as the Magnet recognition program. Serve on committees. Write articles for house and community publications promoting services or interesting websites or health information. Share publications such as The Hospital Librarians: Your Competitive Edge brochure, the Executive Summary of the ''Vital Pathways for Hospital Librarians: Present and Future Roles,'' or even any of the articles in this symposium [3,7]. & Divesting themselves of old services that are no longer meaningful or take up too much time for very little return. & Networking with colleagues and extending beyond a comfort zone to become a lifelong learner: Colleagues locally, regionally, and nationally provide hospital librarians with a like-minded support base and a way to share ideas, concerns, and successes. Consider affiliating with groups other than hospital librarians. For example, joining the Leadership and Management or Corporate Information Services Sec-tions of MLA might provide a fresh perspective on issues and solutions.
None of these will guarantee success or survival. Unfortunately, one of the lessons learned in the Vital Pathways Project is there is no recipe for success, no one-size-fits-all solution ensuring the viability of the hospital librarian. No magic accreditation standard exists mandating the inclusion of hospital librarians and hospital libraries, nor is one likely to be developed and adopted. Sometimes libraries close and librarians are let go for nothing more than financial reasons.
Hospital librarians who survive and thrive will be defined by their value and indispensability to their individual organizations. All hospital librarians are not likely to be the same, and their value to their institutions is not likely to be defined the same way. For a librarian to succeed requires not only knowledge of their institution, but self-knowledge as well. Success will be marked by discipline, adaptability, agility, and vision. Change is inevitable and ongoing.
Through the VPP, hundreds of hospital librarians shared disappointments and setbacks, successes and triumphs. The work of the project led to a realization that hospital librarianship is at a critical juncture, where things are not as they were and the future is yet to be defined. Those definitions will most likely come from outside influences and challenges not within a hospital librarian's control. The response to these influences and challenges is within their control. The most successful hospital librarians will be closely informed about and aligned with institutional priorities. They will possess creativity and passion for their work, coupled with a willingness to explore new directions and pathways.