Engaging nurses in patient recruitment to research trials in the emergency department
Intended for healthcare professionals
Evidence and practice    

Engaging nurses in patient recruitment to research trials in the emergency department

Sarah Wait Sister, emergency department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England

Why you should read this article:
  • To recognise the challenges of undertaking clinical research in the emergency department setting

  • To learn about various strategies that could be used to support patient recruitment to research trials

  • To consider the role of nurses in recruiting patients to clinical research

Research is essential for the implementation of evidence-based practice and can lead to improvements and innovations in care delivery. Although ultimately beneficial for patients and staff, the data collection involved in research often presents challenges, particularly in the emergency department (ED) setting.

This article describes the challenges of undertaking a feasibility trial in a city centre ED. The target research population were adult patients who presented to the ED with an issue related to opioid misuse, for example opioid overdose, injection site wounds and/or abscess, or injury sustained during opioid intoxication. Challenges experienced during this trial included a demanding work environment, ED attendees not being suitable for recruitment into research, and suspension of the trial during the coronavirus disease 2019 (COVID-19) pandemic.

The author details the strategies introduced to ensure effective patient recruitment to the trial, including nurse secondment onto the research team, offering incentives, raising awareness of the trial among ED staff and implementing flexible training. These strategies continued to be effective after a period of suspension due to the COVID-19 pandemic.

Emergency Nurse. doi: 10.7748/en.2022.e2137

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

Sarah.Wait@uhbw.nhs.uk

Conflict of interest

The Take-home naloxone In Multicentre Emergency settings (TIME) trial referred to in this article was funded by the National Institute for Health and Care Research’s Health Technology Assessment Programme. The trial was also sponsored by Swansea University

Wait S (2022) Engaging nurses in patient recruitment to research trials in the emergency department. Emergency Nurse. doi: 10.7748/en.2022.e2137

Acknowledgements

The author would like to thank Helen Snooks, professor of health services research at Swansea University, and Rebecca Hoskins, consultant nurse and faculty strategic lead for advanced practice at University Hospitals Bristol and Weston NHS Foundation Trust and the University of the West of England, Bristol, for their guidance in writing this article

Published online: 15 August 2022

Research is essential for the implementation of evidence-based practice and can lead to improvements and innovations in care delivery. Organisations that undertake clinical research and introduce changes according to the subsequent findings offer improved care outcomes for patients and career development for staff (NHS Health Research Authority 2022). Research studies are undertaken in a variety of settings in the NHS, and although they are often beneficial for staff and patients, data collection in particular can be challenging, especially in the fast-paced and unpredictable environment of the emergency department (ED) (Rowlands et al 2018, Price et al 2020).

This article describes some of the challenges associated with undertaking a feasibility trial in an ED (Jones et al 2020), and the strategies used to ensure effective patient recruitment to the trial. The author was an ED nurse who was seconded as a research nurse for 12 hours. The rest of her time was spent working clinically in the ED, where she could recruit suitable patients as part of her normal role. The article does not focus on the trial itself, rather the author uses her experience of the trial to offer some practical strategies for recruiting patients to clinical research in challenging environments. The trial faced the additional challenge of suspension during the coronavirus disease 2019 (COVID-19) pandemic, then was restarted after a five-month break.

Take-home naloxone In Multicentre Emergency settings trial

The Take-home naloxone In Multicentre Emergency settings (TIME) trial referred to in this article was a feasibility study that aimed to determine whether it would be useful and practical to undertake a much larger subsequent study (Jones et al 2020). The purpose of the TIME trial was to investigate whether take-home naloxone hydrochloride, an opioid receptor antagonist, was a beneficial treatment for people attending emergency settings who were at risk of opioid overdose. Box 1 details the potential use of take-home naloxone in the ED.

Box 1.

Potential use of take-home naloxone hydrochloride in the emergency department

  • Recreational use of opioids can cause fatal overdoses, which in 2020 had reached record levels in the UK (Office for National Statistics 2021)

  • Naloxone is an opioid receptor antagonist used to treat life-threatening opioid overdose in emergency settings (Joint Formulary Committee 2022)

  • The World Health Organization (WHO) (2021a) has recommended that naloxone be provided to people deemed at risk of opioid overdose as part of a ‘take-home kit’

  • Research has shown that the use of naloxone in this way can prevent deaths from opioid overdose (WHO 2021b)

The TIME trial involved four EDs – two intervention sites and two control sites – and their associated ambulance services, each in a different trust. One of the four EDs was in the Bristol Royal Infirmary (where the author works), which is part of the University Hospitals Bristol and Weston NHS Foundation Trust. At the two intervention sites, paramedics and ED clinical staff distributed take-home naloxone with educational support to adult patients who were identified as being at risk of opioid overdose. At the two control sites, practice continued as usual.

The target participant population were adult patients who presented to the ED with an issue relating to opioid misuse, for example opioid overdose, injection site wounds and/or abscesses, or injury sustained during opioid intoxication. Eligible patients were offered the intervention (take-home naloxone) following standard treatment for issues relating to opioid misuse by a participating ED clinician, for example a nurse, emergency nurse practitioner or doctor.

In the TIME Trial, the intervention was a take-home naloxone kit (Jones et al 2020). The kit contained 2mg of naloxone 1mg/mL solution for intramuscular injection, designed to be given in five doses of 400 micrograms at intervals of one minute in the event of an opioid overdose. This injection can be administered by a person who does not have formal medical training in the event of an opioid overdose, alongside basic life support.

The TIME trial started in June 2019 and was suspended in March 2020 due to the COVID-19 pandemic. The trial was subsequently restarted in August 2020 and ran until February 2021. In total, 36 patients were recruited to the trial. During this trial, nurses or doctors who attended to a patient offered them the naloxone take-home kit after finishing their treatment, and at the same time asked the patient if they would take part in the trial (Jones et al 2020).

The trial was funded by the National Institute for Health and Care Research’s Health Technology Assessment Programme (www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm), and was approved by the NHS Health Research Authority (England), the Confidentiality Advisory Group (England and Wales) and the Research Ethics Committee (Wales).

Challenges of undertaking research in the emergency department

Key points

  • While research studies undertaken in the NHS are often beneficial for staff and patients, data collection can be challenging, particularly in the emergency department (ED) setting

  • ED staff often experience demanding workloads and competing priorities, and recruiting patients to a research trial can be a further demand on their limited time

  • Strategies that could be used to support recruitment to research trials include nurse secondment, engaging with patients, training staff, raising awareness and offering incentives

Staff in EDs can experience large numbers of attending patients with a wide variety of conditions, which can be an advantage for those seeking to undertake clinical research and recruit patients to trials. However, the ED is a highly demanding working environment, which is unpredictable and can see large surges in patient numbers (Rowlands et al 2018, Price et al 2020). This can lead to challenges when undertaking clinical research in this setting.

During the period of the TIME trial, the ED at the Bristol Royal Infirmary was processing approximately 74,000 patients per year and often experienced overcrowding alongside year-round service pressures. Subsequently, staff often experienced demanding workloads and competing priorities, and recruiting patients to a research trial was a further demand on their limited time. Box 2 provides contextual information about the ED at the Bristol Royal Infirmary.

Box 2.

Contextual information about the emergency department (ED) at the Bristol Royal Infirmary

  • The ED at the Bristol Royal Infirmary is situated in the centre of Bristol, a city in south west England. The Bristol Royal Infirmary is part of the University Hospitals Bristol and Weston NHS Foundation Trust

  • At the start of the Take-home naloxone hydrochloride In Multicentre Emergency settings (TIME) trial, the ED was seeing approximately 74,000 patients per year

  • The ED staff comprises: 100 nurses, including 19 emergency nurse practitioners; 41 unregistered support staff, including healthcare support workers; and 70 medical staff

  • The University Hospitals Bristol and Weston NHS Foundation Trust carries out a wide range of clinical research, averaging approximately 600 trials per year

Patients attending EDs can be challenging to recruit to research studies due to the circumstances of their attendance. For example, they may be experiencing an unscheduled hospital admission, undergoing a sudden illness, injury or traumatic event, or facing a new diagnosis. This can lead to patients being distressed while in the ED and not in an appropriate condition to discuss possible involvement in research (Rowlands et al 2018).

Strategies used to support recruitment to the trial

Various strategies were used to support recruitment to the trial, including nurse secondment, engaging with patients, training staff, raising awareness and offering incentives.

Nurse secondment

Price et al (2020) identified several barriers to undertaking research in the ED, including lack of support for nurses who are attempting to recruit to research studies and a lack of face-to-face communication with researchers. This lack of support can cause ED staff such as nurses to have doubts about their involvement in research, be unsure of the purpose of the research, and be concerned about their level of confidence and skill in identifying and recruiting eligible patients (Price et al 2020, Roper et al 2021). Another potential issue is that team cultures can differ significantly, since the ED staff are focused on managing the patients and the researchers are focused on trial recruitment (Roper et al 2021).

In the Bristol Royal Infirmary, nurses in the ED are offered the opportunity to be seconded to work on research trials, either focusing on the research alone or alongside their usual roles. Having a member of staff from the ED seconded into the role of research nurse can be beneficial for several reasons. Where a familiar member of staff has been seconded from the ED to the research team, their knowledge about the research trial can reassure the members of the ED team. They can also contribute to the recruitment of patients (Newington and Metcalfe 2014, Price et al 2020). A seconded member of staff can also act as a research advocate, providing updates and maintaining awareness of research trials, and providing regular training on aspects of the trial (Roper et al 2021).

During the TIME trial, the seconded nurse adopted a dual role, working on the trial part-time in conjunction with their clinical shifts. This was beneficial because during the seconded nurse’s clinical shifts they were able to observe how the trial worked in practice from the perspective of the ED nurses, as well as identifying and addressing any barriers that the ED nurses were experiencing in recruiting patients. In addition, the seconded member of staff was able to ‘bridge the gap’ between the clinicians in the ED and members of the research team.

Engaging with patients

Previous evidence has shown that face-to-face verbal exchanges are preferable to other approaches such as telephone calls and written leaflets when delivering research information to patients (Newington and Metcalfe 2014). It has also been shown that research participation increases when the clinician who treats the patient is also the person who attempts to recruit them to a research trial, since this can enable the patient to view the recruitment process as a normal and accepted part of care (Rowlands et al 2018).

In the TIME trial, it was decided that the optimal approach was for the clinician who saw and treated the patient to discuss the trial towards the end of the consultation.

Training staff

At the author’s trust, staff were initially trained in trial recruitment in large groups. For example, doctors new to the ED had a weekly teaching session, in which the seconded nurse gave a short teaching session about any new trial. While the large groups meant that a number of staff could be trained in trial recruitment at one time, eventually smaller groups and one-to-one sessions became preferable because staff trained in this way appeared to have a better understanding of the training and appeared more motivated to recruit patients to the trial.

Training staff was challenging at times because the ED was often busy, and staff could not be released from their duties to receive the trial recruitment training. The solution to this challenge was to identify a time when the ED was not as busy, for example 8am. This coincided with the doctors’ change of shift, so doctors coming on to the day shift could be reminded about the trial, and any staff available were trained during this quieter period. Using this strategy, more than 100 members of staff were eventually trained in the TIME trial. Undertaking the training on a one-to-one basis also meant that it had a relaxed feel, and there were greater opportunities for discussion.

Raising awareness

It was crucial to continually raise awareness of the TIME trial among clinicians in the ED, and several strategies were used to do this. A series of posters that provided accessible information about the trial were placed in staff areas and clinical areas. The TIME acronym was printed on stickers and these were placed on the edge of all the computer screens throughout the ED, where staff were likely to see them. The trial team also provided materials such as pens, sticky notes, posters and mugs that featured the TIME trial logo, which were useful in reinforcing awareness of the trial.

As the trial progressed, posters that incorporated the name of the trial into well-known songs were repeatedly placed in the staff areas. This humorous and light-hearted approach aimed to engage staff members’ ongoing interest and engagement with the trial. Regular emails were also sent out to the staff using the same humorous tone, focusing on positive developments in the trial such as how many people had been recruited that week, to assist in motivating staff.

Offering incentives

Incentives can be an effective way to engage staff with research studies (Newington and Metcalfe 2014, Roper et al 2021). Some low-cost incentives were used in the TIME trial to reward staff for their efforts in recruiting patients. Any member of staff who recruited a patient received a pen with the trial logo on it and a badge. The badges were a talking point for staff and assisted in fostering a good-natured competitive atmosphere in the team with regard to the recruitment of patients, as well as raising awareness of the trial. In addition, the first staff member to recruit a patient received an inexpensive prize, and throughout the trial similar prizes were awarded.

Another element of competition was introduced, whereby the staff member who recruited the most patients during a limited time period would win a prize. If a staff member attempted to recruit a patient but was unsuccessful, or considered recruiting a patient who was then found to be unsuitable, a light-hearted message was sent to them by email, thanking them for their efforts and encouraging them to continue trying. The use of incentives for staff has obvious ethical considerations, for example offering inducements to staff to recruit might introduce bias into the trial. Therefore, all prizes given to staff during the TIME Trial were inexpensive (up to £10 in value), or were items included in the trial materials, such as pens and mugs.

Re-introduction of the trial after the COVID-19 pandemic

The recruitment period for this trial was one year, and it had been running successfully in the department for eight months when the COVID-19 pandemic began. The decision was made by the trial leads to suspend the trial during this period of unprecedented upheaval and widespread refocusing of NHS resources. The trial then resumed five months later, after the ED had undergone significant restructuring and the pandemic was still ongoing.

During this unpredictable period, restarting the trial involved training large numbers of new ED staff in the trial over a short time. In addition, due to the widespread focus on COVID-19, the trial faced the possibility of being overlooked by staff members who were distracted by the pressures of working through the pandemic. However, all of the training approaches that had been used before the pandemic continued to be effective, and the ED staff members – who had become used to working in the context of competing priorities and constant disruption – were still able to recruit patients in the ED as the trial continued.

Outcomes and future developments

Using a combination of the strategies detailed in this article, staff members in the Bristol Royal Infirmary ED were able to recruit the largest number of patients in comparison with the other sites involved in the trial. The strategies were effective in engaging the ED staff, who subsequently recruited a large number of patients to the TIME trial despite the demands on their time and a challenging workload. These strategies could be adapted to other clinical areas, where they might be useful in engaging staff to participate in patient recruitment to research studies.

Conclusion

The research team involved in the TIME trial at the Bristol Royal Infirmary ED used a range of strategies to assist staff to overcome some of the challenges of undertaking clinical research. Using strategies such as nurse secondment, staff training and offering incentives, the research team identified a sustainable approach to recruiting patients to a research trial. This approach was shown to be effective in the ED, and these strategies could also be adapted for use in other clinical settings.

References

  1. Joint Formulary Committee (2022) British National Formulary. No. 83. BMJ Group and the Royal Pharmaceutical Society of Great Britain, London.
  2. Jones M, Bell F, Benger J  et al (2020) Protocol for Take-home naloxone In Multicentre Emergency (TIME) settings: feasibility study.  Pilot Feasibility Studies. 6, 96. doi: 10.1186/s40814-020-00626-w
  3. Newington L, Metcalfe A (2014) Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams. BMC Medical Research Methodology. 14, 10. doi: 10.1186/1471-2288-14-10
  4. NHS Health Research Authority (2022) UK Policy Framework for Health and Social Care Research. http://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/uk-policy-framework-health-and-social-care-research (Last accessed: 25 July 2022.)
  5. Office for National Statistics (2021) Deaths Related to Drug Poisoning in England and Wales: 2020 Registrations. http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2020 (Last accessed: 25 July 2022.)
  6. Price D, Edwards M, Carson-Stevens A et al (2020) Challenges of recruiting emergency department patients to a qualitative study: a thematic analysis of researchers’ experiences. BMC Medical Research Methodology. 20, 1, 151. doi: 10.1186/s12874-020-01039-2
  7. Roper L, Lyttle MD, Gamble C et al (2021) Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial. Emergency Medicine Journal. 38, 3, 191-197. doi: 10.1136/emermed-2020-209487
  8. Rowlands C, Rooshenas L, Fairhurst K et al (2018) Detailed systematic analysis of recruitment strategies in randomised controlled trials in patients with an unscheduled admission to hospital. BMJ Open. 8, 2, e018581. doi: 10.1136/bmjopen-2017-018581
  9. World Health Organization (2021a) Opioid Overdose. http://www.who.int/news-room/fact-sheets/detail/opioid-overdose (Last accessed: 25 July 2022.)
  10. World Health Organization (2021b) Study to Prevent Deaths from Opioid Overdose Shows Promising Results. http://www.who.int/news/item/06-08-2021-study-to-prevent-deaths-from-opioid-overdose-shows-promising-results (Last accessed: 25 July 2022.)

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