Information-seeking strategies and data utilisation: theory and practice

Pergamon ini. J Nurs. Stud., Vol. 32, No. 6, pp. 601-61 I, 1995

Copyright tc) 1995 Elsevier Science Ltd Printed m Great Britain. All rights reserved

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Information-seeking strategies and data utilisation: theory andpractice

JULIA ROBERTS, B.A., M.A., R.G.N., R.C.N.T., R.N.T., Cert.Ed. ALISON WHILE, B.Sc., M.Sc., Ph.D., Cert.Ed., R.G.N., R.H.V.,

R.H.V.T. JOANNE FITZPATRICK, B.Sc., R.G.N. Department qf Nursing Studies, King’s College London, Uniuersitv qf London, Cornwall House Annex. Wuter.loo Road, London SE1 8TX. U.K.

Abstract-This paper explores the twin processes of information-seeking and data utilisation, two key components of the problem-solving process. The assessment and management of pain are examined as important exemplars of where varying degrees of skill and efficiency in these key processes emerge from the research conducted to date. It is suggested that if performance is to be enhanced, then a review of the current use of the nursing process, the main vehicle for the operationalisation of problem-solving in practice is required, coupled with further empirical study directed towards exploring how and when the development of advanced cognitive skills is best facilitated.

Introduction

The centrality of problem-solving in current nursing practice has been long acknowledged (McCarthy, 1981; Berger, 1984; Tanner et al., 1987; United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1987; Hurst et al., 1991), however, research in this area remains limited (Roberts et al., 1993). An integral part of the problem-solving process is information-seeking, indeed, it marks the first phase on the path to problem resolution. Errors at this early stage of the process will jeopardise optimal problem-solving performance. Equally, one of the most common difficulties in problem-solving is not the lack of information but a failure to utilise it (Rubenstein, 1975). In clinical practice, the issue of pain, its assessment and management is a clear illustration of the above phenomena.

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A consistent failure on the part of nurses to successfully assess and manage pain pervades the available literature (Baer et al., 1970; Oberst, 1978; Cohen, 1980; Seers, 1987; Puntillo, 1990; Park and Fulton, 1991; Scott, 1992). Inherent to the problem is poor information- seeking and data utilisation (Hammond et al., 1966; Donovan et al., 1987; Harrison, 1991). An exploration of novice and expert performance vis-d-vis information-seeking behaviours and data utilisation in clinical practice may however yield interesting insights into both the development and use of such skills.

The problem-solving process

Within the field of cognitive psychology, specific interest has focused upon the information-processing model of problem-solving (Newell and Simon, 1972) and variants of the stages model theory (Hill, 1979). The former, using the analogy of an engineering model of a simple processing system, depicts the problem-solving process in terms of a cognitive processing system, the crux of which, the central processor, sorts incoming information, sifting, imposing order, finally resulting in an output (Nisbett and Wilson, 1977). The stages model theory (Green, 1966; Hill, 1979) of which there are a number of variants, follows a linear format incorporating five main stages: problem identification, problem assessment, planning interventions, selection and implementation of chosen strategies and evaluation or verification of a solution (Hurst et al., 1991). Integral to both models is the process of seeking and utilising information.

Information-seeking strategies

Little research exists on information-seeking per se despite its significance in the problem- solving process. The early work of Pepper (1942) and Bruner et al. (1957) has proved influential in shaping subsequent knowledge regarding information-seeking behaviour. Pepper (1942) identified two principal strategies for seeking information: multiplicative corroboration and structural corroboration. The former involves establishing one fact before moving on to the next; once established, facts then lead on to hypotheses generation. In contrast, structural corroboration is concerned more with hypotheses generation than the accumulation of facts. Over a decade later Bruner et al. (1957) narrowed the process down to more specific skills: simultaneous scanning and successive scanning. Bruner et al. (1957) suggested that simultaneous scanning occurs when hypotheses are kept in mind until all facts are known, which is similar to the multiplicative corroboration of Pepper (1942). In contrast, successive scanning parallels Pepper’s structured corroboration and refers to limiting information-seeking to that which verifies or refutes hypotheses. Interestingly, both medical and nurse education emphasise a simultaneous scanning approach towards information-seeking (Marshall, 1977).

Medical education and practice

The problem of diagnostic reasoning in medicine has been studied extensively since the 1970s (Elstein et al., 1978; Gale and Marsden, 1982; Allen and Bordage, 1987). The traditional hypothetico-deductive model, exemplified by Elstein et al. (1978), has shaped medical education. Within this model, twin behaviours of data acquisition and hypothesis evaluation constitute key activities. An early study (Berner et al., 1977) of problem-solving

INFORMATION-SEEKING STRATEGIES AND DATA UTILISATION 603

skills amongst second year medical students (n= 190) examined the ability to identify pertinent data, select appropriate diagnostic tests and identify the most probable diagnosis. Results showed a moderate correlation between initial problem lists and final diagnosis (Y= 0.34) and between factors associated with choice of diagnostic procedures (r = 0.33).The authors conclude that problem-solving skills amongst medical students are indeed variable and that clinical problems differ in terms of the skills required for problem resolution coupled with the varied contextual constraints which may be encountered in practice.

It has been suggested that in practice diagnostic error is due less to faulty data acquisition than to a failure to manipulate large volumes of data successfully. Thus excessive data collection may impede the process of clinical inference by overloading the system’s capacity such that the sheer volume of facts impairs the clinician’s ability to sort out and focus upon relevant variables (Elstein and Bordage, 1988). It has been suggested however that data utilisation rather than data content may be the key variable (Sternberg, 1985).

Nurse education and practice

Nurse education emphasises the orderly collection and analysis of data pertaining to or about the health status of clients for the purpose of formulating a nursing diagnosis. The nursing process itself mirrors the stages model theory of problem-solving (Hill, 1979) and as such data acquisition forms the first phase in the assessment process (Kratz, 1979; La Monica, 1979; George, 1980; Hunt and Marks-Maran, 1981; Griffith and Christensen, 1982; Tanner et al., 1987). Such an approach predisposes towards a simultaneous scanning strategy (Bruner et al., 1957) as a method of information-seeking. This correlates with the vision of practitioners as mere ‘recorders’ of information (Hammond et al., 1966).

Research into the information-seeking strategies of nurses specifically is however limited. An early study by Hammond et al. (1966) investigated the manner in which nurses use various strategies for seeking information from patients. The study focused upon the information-seeking strategies employed coupled with how well they were utilised. The small sample of registered nurses (n = 5) were presented with 12 case scenarios and required to seek information to enable the rejection or acceptance of a hypothetical diagnosis regarding the state of the patient (SOP). Cues were selected from a board one at a time, simultaneously the participant made a probability estimate regarding the value of each cue selected. Findings were ranked in terms of: selection order, probability order, simultaneous scanning order and successive scanning order. The findings were inconclusive showing considerable variability of strategy components, utilisation coefficients and performance by each nurse across cases.

Jones (1989) in a pilot study, utilised the verbal protocol technique as a way of examining how nurses reach decisions about patient problems. A volunteer sample (n=6) of experienced registered and senior student nurses were provided with minimal information regarding a patient and by asking specific questions of the researcher obtained the information required to carry out the task of diagnosing patient problems. Each interview was then transcribed and segmented according to meaning, each segment representing a new knowledge state. The operator which brought the subject to each new state of knowledge was then identified. The subject’s progress during the problem solution phase could then be shown diagramatically on a Problem Behaviour Graph (PBG). Results showed a tendency for respondents to generate hypotheses and then select and integrate information immedi- ately rather than first collect data from which to build meaningful patterns. This preliminary


study highlighted the potential of the PBG as a means of identifying an individual’s problem-solving mechanisms.

An earlier study by Openhaw (1985) examined nurses’ initial information-seeking processes (n =48) and hypothesised that the adoption of an initial ‘successful scanning’ strategy would lead to a reduction in the number of possible hypotheses thereby resulting in increased efficiency in decision-making. However, this was not found to be valid which suggests that further empirical study is needed to identify when and how nurses use different information- seeking strategies.

A comparative study by Johnston (1982) examined the use of the nursing process by baccalaureate (n = 29), diploma (n = 5) and associate degree nurses (n = 8) in an attempt to identify qualitative differences in the use of the nursing process associated with educational level. The instrument used was a questionnaire based upon the nursing process strategies identified in the Rines (1977) model. The assessment strategy preferred by baccalaureate nurses within the sample was analytical questioning, whereas that preferred by diploma and degree nurses was measurement of body function. Both groups exhibited equal pref- erence for the strategies of identifying alternative sources of data and direct questioning. In view of the small sample size however, such findings have to be viewed with caution and the potential link between educational background and information-seeking strategies used requires further exploration.

Empirical evidence to date supports the cyclical nature of information-seeking, in that information is sought, inferences are made and further information sought to discount or support the hypotheses generated (Elstein et al., 1978; Jones, 1989). The emphasis placed upon the use of the nursing process in current nurse education curricula and practice, with its essentially linear format, therefore poses problems. In its current form it often fails to take into account the dynamic nature of the problem-solving process. Furthermore, it omits to acknowledge the immediate active interpretation of data made by clinical problem- solvers in response to clinical information once it is elicited (Benner and Wrubal, 1982). Equally significant is its goal-directed focus which limits its value as a heuristic when used in the classroom setting to develop problem-solving skills. The use of such conventional problem-solving activities as a means-end analysis while normally leading to problem- solution fails to develop schema acquisition, a salient feature of expertise in the cognitive domain (Broderick and Ammentorp, 1979; Sternberg, 1985; Sweller, 1988). Interestingly, research in other areas exploring the association between level of expertise and problem- solving strategies, has yielded illuminating results.

The role of expertise in practice

Early seminal work by De Groot (1966) comparing novice and master chess players showed major differences in performance. Further work in this area by Chase and Simons (1973) suggested that the difference between novice and expert lay in the size of the chess configurations or schema committed to memory. Such differences have been replicated subsequently in a number of other domains including electronics (Egan and Schwartz, 1979), computer programming (Jeffries et al., 1981) and mathematics (Sweller, 1988). Furthermore, research into the performance of expert and novice teachers shows differences in problem-solving skills (Shulman, 1987; Peterson and Commeaux, 1988; Gitlin and Smyth, 1989). Experts were again shown to possess more highly developed cognitive structures or schema which in turn supported sound reasoning and problem-solving. Expert-novice


research suggests domain-specific knowledge in the form of schema is of major importance in the problem-solving process.

Interest in experienced clinician’s problem-solving behaviour has attracted increased attention in the last decade (Benner and Wrubal, 1982; Benner, 1984; Caroll, 1987; Tanner et al., 1987; Holden and Klinger, 1988; Meerabeau, 1992; Orme and Maggs, 1993). This has followed, albeit slowly, a similar trend in medicine (Marshall, 1977; Gale and Marsden, 1982; Gale and Marsden, 1984; Berner et al., 1977; Berger, 1984; Bordage et al., 1990).

Focus on expertise in medicine

Research into qualitative differences in the areas of information-seeking skills and data utilisation in medicine has however proved inconclusive. The indoctrinated early belief that no history can be detailed enough and no physical examination complete without a thorough systematic approach, has been discounted in that few clinicians work in this fashion (Elstein et al., 1978). An early discussion paper by Marshall (1977) exploring the development of the Patient Management Problem (PMP) initially devised by McGuire and Babbott (1967), stressed the importance of efficiency when utilising information. The efficient and experienced problem-solver will, after considering relevant initial hypotheses, eventually solve the PMP with the minimum information necessary for that particular problem. This qualitative difference is in line with both a perceived improvement in focus which develops with experience (Kleinmuntz, 1966) coupled with a greater thoroughness in the collection of relevant information (Neufield et al., 1981). A study by Gale and Marsden (1982) looked at clinicians’ thinking prior to hypothesis generation and testing (n =66). The sample consisted of final year medical students (n = 22) pre-registration house officers (n = 22) and post MRCP Registrars (n=22). The tool used was a video-taped simulation of a doctor- patient interview after which subjects and researcher reviewed the subjects’ thoughts at the time of the interview.

Three types of response were identified: pre-diagnostic interpretation of clinical information, active diagnostic interpretation of clinical information and a decision regarding the need for further general or clarifying enquiry. Almost a third of respondents (n = 19) made two types of response and interestingly the relative distribution of types of response did not differ according to the status of the respondent. The study revealed that clinical problem-solvers do make active interpretative or evaluative responses to clinical information as soon as it is elicited and that cue acquisition and data collection are significant initial steps in problem-solving. Indeed, the clinical problem-solver in common with all individuals, is not a passive receiver of information but rather, actively structures the perceived world (Pomerantz, 1981).

Novice and expert nurse

Expert nurse performance relates in turn to the qualitative difference between knowing ‘that’ and knowing ‘how’ (Polyani, 1958). It is the ability to grasp a situation rapidly, to see the whole or ‘gestalt’ (Benner, 1984). The development of expertise means a movement away from the novice’s reliance on abstract principles and rules towards the use of concrete experience, thus creating a subtle change in the perception of any given situation in that all aspects will no longer be seen as equally relevant (Benner, 1984). However, empirical studies


exploring differences in information-seeking strategies, between novice and expert nurse, remain limited.

Tanner et ai. (1987) compared the cognitive strategies used by junior nursing students (n = 13), senior nursing students (n = 13) and practising nurses (n = 15). Verbal responses to three video-taped vignettes preceded by a verbal change-of-shift report provided the data. After listening to the report and viewing the video-tapes, subjects were asked to recount their thoughts. Participants were then asked to seek information from the researcher that would be obtained in actual practice and to continue to ask questions until they had obtained sufficient information to identify the major problem(s) and decide upon appropriate management. Data was subsequently scored. Hypothesis activation was scored in terms of the number of accurate and possible hypotheses generated and the earliness with which the diagnostic hypothesis was activated. Data acquisition was scored as the number of questions the subject asked coupled with a rating of the predominant strategy used. Results showed data acquisition strategies similar to those identified in the medical literature: hypothesis testing, symptom exploration and a review of systems approach (Barrows and Bennett, 1972; Elstein et al., 1978; Kassirer et al., 1982; Gale and Marsden, 1982).

Such findings are consistent with other studies that suggest experienced/knowledgeable subjects are more focused and systematic in data acquisition than less experienced/knowledgeable subjects due in part to their more extensive and complex cognitive schema (Kleinmuntz, 1966; Neufield et al., 1981). Subjects were consistent across cases in the number of questions asked and the relevance of the questions. The tendency to ask a large number of questions and/or direct these questions towards certain aspects of the situation may, the authors suggested, depend less upon the content of the task and more upon strategies that the subject characteristically employs. The small sample size however precludes generalisation of these tentative findings.

A study by Holden and Klinger (1988) investigated the effects of nurse education and experience upon the problem-solving process. The sample consisted of nursing students (n=26) in their first term, final year students (n =29), a group of students who were also parents (n= 15) and a sample of paediatric nurses (n= 30). The research involved the acquisition of information in order to evaluate competing causal hypotheses. Two computer-presented situations were used as the focus for data collection: the Cry Problem and the Insomnia Problem. The Cry Problem involved diagnosing the cause of crying in an infant. Two subtasks were required to solve the problem: searching for relevant facts from 25 information units available and determining the single correct hypothesis from among the njne possible hypotheses. The second computer-presentation acted as a control and was structured identically to the Cry Problem and was chosen specifically because it involved a situation independent of child-rearing experience. Data related to previous experience with crying in infants and insomnia in adults, coupled with demographic data, was obtained by the integration of a series of short ancillary questions into the exercise.

The findings revealed the number of information units used by different groups prior to solving the problem. All four groups found the Cry Problem easier to solve as reflected in the number of information units sought with 33% of the parent group acquiring only five or fewer units of information. A wide range of information was acquired in the process of determining the correct cause of the problem. Acquisition of the information unit contain- ing the infants’ age was found to discriminate between levels of experience. Parents and paediatric nurses were more likely to select that information unit on their first choice (PC 0.01) or at least by their fifth choice (P < 0.05).

INFORMATION-SEEKING STRATEGlES AND DATA UTILISATION 607

The study identified differences in the types of strategies utilised when information- seeking. Nurses with more experience were likely to employ a simultaneous information acquisition strategy (Hammond et al., 1966) and use a state of the patient/attribute approach (Gordon, 1980) than student nurses who tended to use a successive information acquisition approach and focus more upon contextual attributes than the state of the patient.

Simultaneous scanning is a difficult strategy to use for a complex task but experience may facilitate its use (Marshall, 1977). Selection of information about the infant’s age was symptomatic of a state attribute approach. Both parents and paediatric nurses realised from experience the significance of that information for understanding and organising subsequent information and therefore acquired that data early in their search. The authors acknowledged a number of limitations associated with the study: problems inherent within the software package, limitations of the Insomnia Problem as a control and a multiplicity of background variables. Nevertheless, the study generates some interesting questions related to the role of experience/expertise in both information-seeking and data utilisation. The latter plays a significant role in many key areas of clinical practice, not least in the assessment and management of pain.

Case study-acute pain assessment and management

The assessment of pain and its management remains one of the most significant cognitive tasks confronting the nurse practitioner (Hammond et al., 1966; Benner, 1984). The available literature suggests however a failure on the part of nurses to both accurately assess patient’s pain and provide appropriate relief (Hammond et al., 1966; Cohen, 1980; Taylor, 1987; Seers, 1987; Graffam, 1990; Puntillo, 1990; Harrison, 1991; Scott, 1992).

An early study by Hammond et al. (1966) explored nurses’ responses to complaints of abdominal pain following abdominal surgery (n=212). Report forms were devised to acquire information regarding decisions made. Responses were coded and 17 possible actions identified from the data, the most frequent being the administration of narcotics. A large number of cues were reported as available when evaluating a patient’s complaints of pain (n = 166). The data showed, however, that no single cue in itself provided the basis for action. The problem facing the nurse as highlighted in this study was to infer correctly the state of the patient from the available data (Hammond et al., 1966). Indeed, Benner (1984) has emphasised the highly complex nature of such a task.

Puntillo (1990) reviewed reported episodes of pain in an intensive care unit. A group of patients (n = 24) were interviewed after transfer from an intensive care unit (ICU). Of the sample, 7 1% reported pain in the ICU, with 63% of the sample rating their pain on being moderate to severe in intensity. The principal method of treating pain experienced by this sample was with analgesic drugs. All but two of the patients for whom data were complete (n = 16) received morphine for pain. The amount of morphine administered to a sub group of cardiac surgical patients was analysed. No correlation was found between the amount of pain recalled by a particular subject and the amount of medication administered. However, the significance of the study’s findings are difficult to estimate due to minimal information regarding method of analysis coupled with the retrospective nature of the study.

Seers (1987) examined both the relationship between and the factors affecting pain relief, anxiety and recovery, in patients undergoing elective abdominal surgery. Data were


collected using a structured interview technique. Participants (n = 80) were interviewed pre- operatively and twice a day post-operatively for seven consecutive days. At the end of the data collection period, trained nurses on the study wards were asked to complete a questionnaire seeking their opinion about various aspects of post-operative pain relief. The findings revealed amongst other things, that nurses ratings of patients’ pain were con- sistently lower than patients’ own ratings, a difference which was significant (P<O.OOl). These findings are consistent with those of other studies (Camp and O’Sullivan, 1987; Teske et al., 1983; Camp, 1988; Bondestam et al., 1987).

The reason for such error is open to question. Harrison (1991) has suggested that in certain cases errors are linked with the very personal nature of the pain experience, while other errors may be associated with the type of cues available, resulting in discrepancies between the patients’ pain assessment and that of nurses. A further reason for error suggested by Harrison (1991) is poor information gathering and reporting on the part of nurses. Nurses depend upon their own and colleagues’ data gathering when monitoring pain and yet studies show how poorly this key information is gathered (Donovan et al., 1987; Camp, 1988). Donovan et al. (1987) in one hospital survey reported that over half of the patients could not remember being asked by a nurse about their pain and in only half of the medical charts was any note made of pain progress. Furthermore, Camp (1988) has reported that half of the pain information available from patients was not noted, and in over a third the information recorded did not accord with that from the patient. Whether the margin of error decreases with experience remains however uncertain (Halfens et al., 1990; Jacavone and Dorstal, 1992).

Jacavone and Dorstal’s (1992) small qualitative study investigated clinical knowledge derived from practice along with the thought processes of expert nurses as they assessed and treated patients with cardiac pain. The small sample consisted of nurses with at least 5 years experience (n = 4) and those with under 1 year of experience (n = 4). Participants were interviewed on three occasions and observed while caring for patients. The initial formal interview focused upon a paradigm case identified by the nurse as influencing his or her practice. It is from such cases that cognitive schema are developed (De Groot, 1966; Egan and Schwartz, 1979; Jeffries et al., 1981; Sweller, 1988; Gitlin and Smyth, 1989). Each of the two subsequent interviews dealt with a recent event related to caring for a specific patient in pain. Questions focused on the nurses’ concerns, thoughts and interventions in the assessment and treatment of cardiac pain. Extensive field notes from the observations and transcribed interviews were analysed through several stages of qualitative analysis. Results showed a qualitative distinction in pain assessment between the two groups with experts demonstrating greater involvement with the patient, a keener sense of saliency and the employment of intuitive judgement. The study’s small sample size however precludes generalisations.

Studies have indicated therefore that despite advances in available methods of pain management, deficiencies exist in the ability of nurses to both accurately assess patients’ pain and provide appropriate relief (Hammond et al., 1966; Seers, 1987; Taylor, 1987; Graffam, 1990; Puntillo, 1990; Harrison, 1991; Scott, 1992). The problem appears to lie in part in the clinicians’ inability to seek relevant information (Camp, 1988; Donovan et al., 1987; Taylor, 1987) and once acquired, to use it effectively. The effects of experience upon clinicians’ performance in this domain remains uncertain (Jacavone and Dorstal, 1992) but given the results of research into expert practice in other areas of nursing (Tanner et al., 1987; Holden and Klinger, 1988) further empirical study is warranted.


Implications for nurse education and practice in the United Kingdom

The prime role played by problem-solving in contemporary nursing practice is widely acknowledged in the literature (McCarthy, 1981; Berger, 1984; Tanner et al., 1987; Hurst et al., 1991; Roberts et al., 1993). Both information-seeking and the subsequent utilisation of acquired data are critical stages within the problem-solving process. Research however shows that nurses’ problem-solving skills are variable (Sherman et al., 1979; Hunt and Marks-Maran, 1981) as are the specific information-seeking strategies used (Hammond et al., 1966; Johnston, 1982; Openhaw, 1985). The implications of such varying degrees of skill and efficiency are apparent in clinical practice as highlighted in the literature examining pain assessment and management (Hammond et al., 1966; Cohen, 1980; Taylor, 1987; Graffam, 1990; Puntillo, 1990; Harrison, 1991; Scott, 1992).

Research into expert practice in several disciplines has grown in recent years (Gale and Marsden, 1982; Shulman, 1987; Peterson and Commeaux, 1988; Gitlin and Smyth, 1989) and studies examining the problem-solving skills of experienced nurses have yielded interesting results (Tanner et al., 1987; Holden and Klinger, 1988). The importance of effective data acquisition as well as the significance of well-developed problem-solving strategies in the form of appropriate schema has been highlighted. It is suggested however that the current use of the nursing process in both clinical practice and nurse education requires review if the development of problem-solving skills is to be better facilitated. Greater emphasis needs to be placed upon the data acquisition phase of the process. Equally, in nursing curricula problem-solving needs to assume a higher priority coupled with a revision of teaching methods, with the move away from a simple emphasis upon goal attainment and a shift towards the development of those features such as schema acquisition, now known to characterise the effective performance of higher cognitive skills (Broderick and Ammentorp, 1979; Sternberg, 1985; Sweller, 1988). The nursing process was introduced into the United Kingdom over two decades ago and while the intervening years have seen significant advances in our knowledge of the problem-solving process there has been no evidence to suggest that problem-solving skills have improved. An urgent review of the use of the nursing process is required therefore if much of the trial and error which currently characterises nurse learning is to be overcome. Equally important is the need for further empirical study into the cognitive processes characteristic of experts if performance in this key skill is to be enhanced and acknowledged deficits are to be remedied.

A~kno~~le~~~mpnIs-The authors are currently engaged in a comparative study of outcomes of pre-registration nurse education programmes funded by the English National Board for Nursing, Midwifery and Health Visiting. This paper draws upon current project work. Responsibility for the views expressed, interpretation of issues, questions of inclusion and omission, remain as always with the research team and do not necessarily reflect the views of the English National Board for Nursing, Midwifery and Health Visiting.

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(Received 28 April 1994; accepted,for publication 27 February 1995)

Information-seeking strategies and data utilisation: theory and practice

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