Overcoming the challenges of recruiting and interviewing patients following critical illness
Intended for healthcare professionals
Evidence and practice    

Overcoming the challenges of recruiting and interviewing patients following critical illness

Alison James Senior lecturer, School of Health and Social Care, London South Bank University, London, England
Emily Boughton Patient experience facilitator (Hertfordshire Division), Central London Community Healthcare NHS Trust, London, England
Neeta Pattni Patient experience facilitator (North Central Division), Central London Community Healthcare NHS Trust, London, England
Nicola Thomas Professor of kidney care, School of Health and Social Care, London South Bank University, London, England
Suzanne Bench Professor of critical care nursing, School of Health and Social Care, London South Bank University, London, England

Why you should read this article:
  • To reflect on how best to recruit and interview participants in a virtual setting

  • To understand how other team members can assist in recruiting participants

  • To consider ways in which healthcare researchers should take care of themselves when interviewing virtually

Background The strict restrictions implemented in England during the COVID-19 pandemic meant it was no longer possible to recruit or interview participants in person. However, virtual recruitment and interviews are not without their challenges, particularly when exploring sensitive topics.

Aim To discuss how to overcome some of the challenges involved in recruiting and interviewing participants who have been critically ill with COVID-19.

Discussion An exploratory, descriptive study was conducted involving interviews with 20 people who had been critically ill with COVID-19 and had been discharged from two community-based healthcare settings in London, England. Participants were interviewed at home after being discharged from hospital after at least one month. The sensitivity of the research topic meant strategies for recruiting and interviewing needed to be adapted, including involving patient experience facilitators, using virtual interviews, managing the distress of participants and self-care for the researchers.

Conclusion The adaptations used in this study can be used in research involving people who have been critically ill.

Implications for practice Researchers can explore innovative ways to recruit participants using hospital or community staff who are not usually involved in research. Virtual interviews require additional skills, such as building rapport with participants, so may require additional training. A distress protocol for participants should always be considered when discussing sensitive topics. Self-care and debrief strategies for interviewers are also critical.

Nurse Researcher. doi: 10.7748/nr.2023.e1854

Peer review

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

Correspondence

jamesa23@lsbu.ac.uk

Conflict of interest

Suzanne Bench is a National Institute for Health Research (NIHR) 70@70 senior nurse and midwifery research leader – the views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care

James A, Boughton E, Pattni N et al (2023) Overcoming the challenges of recruiting and interviewing patients following critical illness. Nurse Researcher. doi: 10.7748/nr.2023.e1854

Acknowledgements

The authors would like to acknowledge the contributions of the following: Helen Cherry, patient and carer representative; Hilary Floyd, medical director, NHS Seacole Centre, Epsom and St Helier University Hospitals NHS Trust; Matthew Hodson, deputy director of nursing and therapies, Central London Community Healthcare NHS Trust (North Central Division); Nicola McGuinness, research assistant, Institute of Health and Social Care, London South Bank University; Gaby Parker, consultant clinical neuropsychologist, Central London Community Healthcare NHS Trust (Hertfordshire Division). They would also like to thank everyone who gave up their time to speak to them and participate in their research, as well as the staff at the data collection sites for supporting the study during the COVID-19 pandemic and the Burdett Trust for Nursing for awarding them the grant that enabled them to complete this work

Published online: 16 March 2023

Introduction

This paper discusses the challenges of using virtual interviews in a qualitative study conducted during the COVID-19 pandemic and the steps taken by the authors to overcome them (Bench 2021). The aim of our study was to understand the experiences and rehabilitation needs of people who had been critically ill with COVID-19 and needed respiratory support.

Virtual interviews are not a novel method of collecting data in qualitative nursing research and some of the concerns other researchers had raised were evident in our study. However, this paper adds to the existing body of knowledge by identifying specific issues concerning recruitment and collecting data when undertaking virtual interviews with participants who have been critically ill with COVID-19. It also identifies important learning points regarding recruitment, building rapport and managing interruptions during virtual interviews, as well as other special considerations, such as managing distress.

Background

Virtual interviews can be beneficial to researchers because they can recruit participants from a wider geographical area than they can for face-to-face interviews. However, there are additional issues in virtual qualitative research that require attention (Salmons 2011) and some best practices from in-person research may not transfer (Pocock et al 2021). Researchers using virtual interviews need to reflect on the effects of the ‘digital divide’, including inequality of access to the internet (Archibald et al 2019). Ethical considerations include different privacy and data protection laws; under-representation of underserved groups; and different visual, verbal and nonverbal cues, which may result in distress not being easily picked up.

Virtual interviews can also present logistical concerns, such as the potential for distractions when at home, the greater difficulty in maintaining confidentiality, poor or no internet connections preventing interviews from taking place, trying to obtain informed consent from participants without being able to obtain a signature in-person, how to collect demographic data and how to pay participants (Schlegel et al 2021).

But the literature concerning virtual qualitative research often only evaluates the technology required for virtual interviews. For example, Lobe et al (2020) reviewed the latest videoconferencing services, including the options available on various platforms as well as security issues and logistics.

The challenges of conducting research during the COVID-19 pandemic are also underexplored. A few papers on the topic have been published (Sy et al 2020). For example, Campbell (2021) highlighted how the pandemic had required the author to change his method of collecting data from face-to-face interviews to virtual interviews in a study involving participants who were lone parents. Campbell reflected on the effects of using digital platforms to conduct interviews away from neutral venues, such as community centres and cafés. He identified ‘a radical shift in interpersonal dynamics’, as the participants and he were sometimes exposed to each other’s homes and family situation, which he felt brought about ‘unexpected intimacy’ between them. In contrast, there is little work critically exploring recruitment strategies and how to establish rapport with participants (Sy et al 2020).

We will discuss recruitment strategies and the ethical considerations virtual interviewing raises, some of the practical issues involved with this method, and the learning points highlighted by our study concerning virtual interviewing and conducting research during the COVID-19 pandemic.

Design

Methods

We used a qualitative methodology in our exploratory study. We interviewed 20 patients following their discharge from hospital to find out how they were affected emotionally and physically by their illness, and to explore the support required to become well again following COVID-19.

Ethics

The Health Research Authority and London South Bank University’s Health and Social Care Ethics Panel granted ethics approval. Participants provided written or audio-recorded informed consent before their interviews.

We notified participants when we started and stopped audio-recording their interviews. Participants could terminate their interviews at any time and withdraw from the study without giving a reason. However, their interviews were transcribed approximately two weeks after taking place and their identifying details deleted from the data; this made it impossible to remove their interviews from the study after this point.

Patient representation

Involving patients and the public throughout a study enhances its quality and ensures the research is relevant and appropriate (Brett et al 2014). We therefore involved an experienced patient and public involvement representative, Helen Cherry, throughout our research, and her expertise was invaluable in representing the patient’s voice. She also contributed to the study’s participant information leaflet and helped to develop a distress protocol.

Recruitment

Ensuring patients and staff are involved and well engaged is critical to successful recruitment and a truly successful co-design approach. We involved two different groups of trust staff to assist us: ‘patient experience facilitators’ (PEFs) and discharge coordinators.

PEFs

PEFs engage with patients and staff every day to improve patients’ experience, which made them well-placed to assist with recruitment.

The PEFs identified patients who fitted the study’s inclusion criteria and then contacted them to see if they wanted to be involved. If they did, one of our two research assistants contacted them to ensure they understood the study and arrange a mutually suitable date for interview, with their consent.

One of the challenges was finding patients who met the inclusion criteria across the trust sites. The PEF team regularly liaised with front-line staff across multiple sites to identify patients who may have met the inclusion criteria before they were discharged from community services. The PEFs then approached these patients to inform them of the study, answer questions and ask for their consent to be contacted by one of the research assistants.

The PEFs also attended weekly research team meetings to discuss progress and the targets for the number of participants. This was extremely helpful, as it was a safe space to think freely, share challenges and discuss new ways to recruit participants during these challenging times. Senior management’s backing of the PEFs’ involvement in the study was seen as important and very supportive.

Engaging clinical staff was also harder when working virtually. We were aware front-line staff were facing extreme pressures and subsequent burnout and fatigue. Therefore, it was important to promote the benefits and importance of the research, to ensure they bought into the study.

The PEFs met with services and front-line staff to ensure there was continuous dialogue about the study at all meetings and to understand how to make the referral process as simple as possible. If staff came across any eligible patients, they provided them with the written information about the study, obtained verbal consent to be contacted and then passed the patients’ details to the research group. This system worked well.

Key points

  • Information is provided about how best to recruit and interview participants in a virtual setting

  • Other healthcare workers can assist in recruiting participants when researchers cannot directly access potential participants

  • Ways in which nurse researchers should take care of themselves when conducting virtual interviews are outlined

Discharge coordinators

Further into the study, discharge coordinators were involved. UK NHS discharge coordinators assist patients to transition from hospital to the community in a safe, timely and efficient manner. The discharge coordinators and the triage team notified the PEFs of any patients who met the inclusion criteria before they discharged them. The PEFs could then give the patients the participant information leaflet and discuss the study with them at an appropriate time before they were discharged.

Inclusion

The COVID-19 pandemic has provided further evidence of health inequalities in the UK (Patients Association 2020). A large proportion of participants in our study identified as white British. We discussed the need for a diverse sample, particularly as national mortality rates at that time were highest among all other ethnic groups (Public Health England 2020). We considered targeting this cohort for recruitment; however, we did so towards the end of the recruitment period, and so it was not a major influence on our recruitment plan. Ensuring that health disparities are considered early in the design of a study and as a main element when planning recruitment could prevent unconscious bias.

Virtual interviews

Most qualitative interviews are conducted face to face (Mealer and Jones 2013), as this is regarded as the gold standard in qualitative research (McCoyd and Kerson 2006, Krouwel et al 2019). However, the COVID-19 restrictions governing social contact and travel in England meant we conducted all the interviews for our study by phone or by using the virtual teleconferencing platforms Zoom and Microsoft Teams.

Interviews held on virtual platforms are known as ‘virtual face-to-face’ interviews. We preferred this method as we considered it to be the best option available – it enabled the interviewers to see participants’ non-verbal cues and record them during the interviews. However, providing participants with technological choice is important – specifically because of the effects of the digital divide – so we allowed participants to choose the technology with which they were most comfortable (Sy et al 2020). Most preferred Zoom, as many of them were using it to socialise during the pandemic; Archibald et al (2019) reported that most (69%) of its study’s participants preferred interviews to be conducted using Zoom rather than face to face or using the phone or other video platforms.

Discussion

We reflected on several issues in our study concerning the use of virtual interviews.

Building rapport

Developing a rapport with a participant is vital to the success of an interview (Gerrish and Lathlean 2015) and a crucial skill in collecting high-quality data (Mitchell 2015). It easier to create rapport in person, so virtual research requires greater consideration of how to develop rapport with participants (Carter et al 2021).

Despite our concerns that building rapport with participants virtually would be difficult, we experienced no issues in our study – something also reported by Archibald et al (2019). Overall, participants were happy to share their experiences and it was therapeutic for some. For example, one participant said: ‘It’s been really cathartic talking with you as another health professional. Thank you for listening and the kindness you showed me today – I know it will help me on my road to recovery.’

From the start of our study, we developed strategies to assist in building rapport with participants, to enable them to feel comfortable telling us their stories. We started interviews with small talk and asked interviewees if they were comfortable where they were sitting and whether they needed to get a drink. We also reemphasised that they could stop the interview at any point to have a break.

Pre-research briefings are a good way to ensure participants know what to expect and are comfortable with virtual technology (Carter et al 2021). We made initial phone calls to introduce themselves to participants and arrange the interviews. We provided time to answer any questions participants might have had and ensure they understood the interview’s structure. We also clarified which virtual platforms they preferred and any special considerations required for the interview.

These initial phone calls to participants also helped to create the ‘unintended intimacy’ between the interviewers and the participants that Campbell (2021) identified, as they were a welcome opportunity to interact with others during lockdown.

Verbal cues and nonverbal cues such as facial expression and gestures can aid discussion and engagement when using a videoconferencing platform (Archibald et al 2019). However, not all our interviewees wanted to be seen during interviews. In such cases, we did not switch off our own cameras, so participants could see we were listening to them and our body language and responsiveness could assist in developing good interview relationships with them (Gerrish and Lathlean 2015). The interviewers also paid extra attention to interviewees’ tone of voice and breathing, as well as how they answered the question.

Managing interruptions

It is always important to conduct interviews in a suitable environment. Ideally, the interview should take place in a private room that is quiet and free from interruptions (Holloway and Galvin 2016). Participants may become distracted if interviews take place in someone’s personal or professional setting (Gerrish and Lathlean 2015). However, it is harder when conducting interviews virtually for researchers and participants to locate such an environment, and the only settings available for interviews during the pandemic were either personal or professional. Researchers conducting interviews virtually must therefore be flexible, able to adapt to unpredictability, and able to manage interruptions and participants’ comfort levels (Carter et al 2021).

In our study, we asked participants to choose interview times that worked best for them and were most likely to be free of interruptions. We also needed to consider potential breaches of privacy, if other people from either the interviewers’ or the participants’ households were at home, too. For example, one participant chose to be interviewed when they were working from their office, away from their family, so that they could feel comfortable discussing their recovery in private. Nevertheless, there were interruptions to our interviews caused by doorbells, phone calls and other family members.

Technical considerations

Good quality internet connections and relatively high data usage are needed for online video platforms to work sufficiently well for virtual interviews (Carter et al 2021). Internet stability and computer problems posed a challenge in our study, and we had to troubleshoot these issues with participants. However, resolving technical issues together can assist an interviewer and interviewee in building rapport (Archibald et al 2019).

We used a separate audio recorder to record our interviews, with the microphone placed next to the computer’s speaker for optimal audio quality. Zoom can record the audio and video of a meeting, but the use of a separate audio recorder is recommended when researching sensitive topics, as this provides better security (Carter et al 2021). The dictaphones would not be leaving the interviewers’ homes due to COVID restrictions, so could not be lost or stolen.

Special considerations following critical illness

All our interviews took place at least a month after the participants had been discharged from hospital. Many were still recovering from the effects of being critically ill with COVID-19. It was therefore important to consider participants’ particular needs and health issues.

Zoom fatigue

‘Zoom fatigue’ can be described as feeling tired or burnout from overusing virtual platforms when communicating (Wolf 2020). We tried to prevent ‘Zoom fatigue’ by ensuring all our interviews lasted no more than one hour (Bailenson 2021).

Difficulty breathing and talking

Some participants had difficulty breathing and talking. One explained: ‘Physically, I feel weak sometimes and then even when I’m talking to you, I experience that in my breathing. I have difficulty even talking long – it affects my voice because I had the tracheostomy while I was in hospital.’

Lack of energy

Fatigue after COVID-19 and other critical illnesses is a well-recognised problem (Bench et al 2021) that also affected interviews: ‘I just haven’t got the energy… I don’t feel like bothering to do anything and I’m such an active person. This drains me.’

One participant required a support person to attend their interview to assist them in answering questions; we also broke the interview into two parts, with an adequate break between them for the participant to rest. This meant the total time required for the interview exceeded one hour, although the two combined parts of the interview did not last that long.

Some participants chose days for their interviews when they did not have any other appointments planned. Some wanted early interviews as they felt they were able to concentrate better in the morning. Others were experiencing insomnia, so requested late-morning interviews: ‘I don’t have nightmares as such often, but I have issues sleeping. The longest period I can sleep at night is about three hours.’

Managing distress

It is impossible to provide physical support in virtual interviews, so it is hard for interviewers to support interviewees reliving traumatic experiences such as COVID-19 who express strong emotions such as intense crying and shaking. Researchers should therefore develop strategies to support interviewees who become distressed during their interviews (Carter 2021).

Our clinical psychologist and our patient representative developed a protocol for our interviewers to follow (Figure 1) (Carter et al 2021). The interviewers regularly checked how interviewees were feeling and whether they needed a break. They reminded interviewees they could pause or stop their interviews at any point. They also assessed them for signs of distress, such as crying, shaking, dissociating or hyperventilating (Draucker et al 2009), although this was harder during phone interviews.

Figure 1.

The distress protocols for interviewees and researchers

nr.2023.e1854_0001.jpg

If an interviewee showed signs of distress, the interviewers paused the interview, provided empathy and concern, and evaluated the interviewee’s emotional state. They asked questions such as ‘How are you feeling right now?’, ‘What can I do to help you right now?’ and ‘Would you like to stop the interview?’ The interviewers would only resume the interview if the interviewee said they were happy to do so.

The interviewers ended each interview with some light conversation, to find out how the interviewee was feeling and whether they needed support. If they felt it necessary, they signposted the interviewees to professional support and asked if they would like the clinical psychologist to contact them to provide further emotional support.

Self-care

Discussions of sensitive topics can be traumatic, so it is important for researchers to manage their own well-being (Woodby et al 2011). A range of strategies is recommended, including reflective journals, peer and supervisory support, and maintaining a healthy lifestyle (McCallum et al 2020). They should also seek support from colleagues or a professional counsellor if necessary (Green and Thorogood 2013).

Our study took place when COVID-19 restrictions were in place, so we had less support from our usual social networks. One of us scheduled her permitted daily walks to follow interviews, using the time to reflect on the interview and how to manage her own well-being. We kept diaries to reflect and to review themes arising from the interviews. We also scheduled our weekly virtual meetings to follow interviews, so we could ‘check in’ and debrief, as well as discuss the themes arising from the interviews. The clinical psychologist also included self-care measures in the distress protocol (Figure 1).

Implications for practice

Nurse researchers can use our findings to navigate the challenges caused by the pandemic and sensitive topics. Researchers can explore innovative ways to recruit participants through hospital or community staff not usually involved in research.

The involvement of the PEFs was crucial in our study. They supported front-line staff in identifying potential participants, creating a link between the participant and the researchers. We recommend their inclusion in recruitment for future studies.

Virtual interviews require additional skills, such as building rapport with participants, which helps interviewees to feel comfortable in sharing traumatic experiences of their critical illness. Interviewers conducting virtual interviews may therefore require additional training.

Researchers should always consider creating a distress protocol to follow in case a participant, researcher or transcriber experiences high levels of emotional distress because of the sensitive topics being discussed. This was particularly important during the COVID-19 pandemic.

Self-care and debrief strategies are also critical for interviewers when working virtually during highly emotional, uncertain and unpredictable times such as during COVID-19.

Conclusion

Qualitative research traditionally involves recruiting participants and interviewing in-person. However, we had to use virtual methods to recruit and interview participants in our study because of restrictions brought about by the COVID-19 pandemic. This paper has identified some of the challenges associated with virtual methods and interviewing participants who have been critically ill, and has offered solutions based on our experiences for ensuring rigour is maintained.

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