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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Res Nurs. Author manuscript; available in PMC Jul 1, 2012.
Published in final edited form as:
J Res Nurs. Jul 1, 2011; 16(4): 321–332.
doi:  10.1177/1744987110387475
PMCID: PMC3159163
NIHMSID: NIHMS292216

Strategies to engage clinical staff in subject recruitment

Lisa S. Segre, Assistant Professor, Kathleen C. Buckwalter, Professor, and Marie-Luise Friedemann, Professor Emerita

Abstract

Purpose

In many countries, meeting subject recruitment goals is challenging for researchers relying on clinical staff members (CSMs) to identify or recruit subjects. This paper describes research strategies that improved staff engagement in three different studies conducted in US clinical settings.

Method

The recruitment strategies described in this paper were identified during the process of consultation among three US researchers recruiting via CSMs. Strategies which successfully engaged CSMs are described.

Results

Our approach improved engagement with CSMs in three different US studies. Early engagement strategies included establishing trust, gathering input from CSMs, and using succinct training procedures as well as a study logo. Middle phase strategies included assigning recruitment, publishing a study newsletter, giving the CSMs compensation and appreciation for their participation, and expanding the subject pool. Completion strategies included closing with an appreciation meeting and adding merit letters to personnel files.

Conclusion

Recruitment of an adequate number of subjects is often challenging, even within clinical settings where subject populations are abundant. CSMs have rightly prioritised clinical care over directing subjects to research studies. It is therefore critical that researchers recruiting in such clinical settings anticipate recruitment challenges and plan to implement appropriate engagement strategies in all phases of research.

Keywords: Clinical staff members, strategies, subject recruitment

Introduction

The implementation of evidence-based practice relies on the successful completion of evaluative clinical research. Yet, a review of literature indicates that subject recruitment challenges are common, with reports of stalled enrolment in the US, Canada, Denmark, Sweden, Netherlands, Italy, France, and Australia (Ross et al., 1999). Barriers to recruitment are not universal: indeed, reports from Asian countries never cite such problems. Nevertheless, where it does exist, endemic recruitment stalling can be difficult to overcome. For example, a review of trials funded by two UK funding agencies revealed that less than one-third of studies had enrolled the required number of subjects within the time frame projected (McDonald et al., 2006). Problems with subject recruitment are critical because insufficient sample size makes a study underpowered, leading to spurious findings that are not statistically significant, and the premature abandonment of an effective intervention (Treweek et al., 2010).

In studies where investigators directly contact potential subjects, strategies for improving subject enrolment are well documented (Lovato et al., 1997; Davis et al., 2002). Some researchers, however, cannot employ these recruitment strategies because they do not have direct access to research participants. Instead, researchers who recruit participants from community agencies (e.g. caregiver facilities for the elderly, hospitals, or social service agencies) must typically rely on clinical staff members (CSMs) to direct potential research participants to the research team. Clinical staff members (e.g. physicians, nurses, social workers, case managers, and home caregivers) are well positioned to identify and facilitate connections between researchers and potential subjects; however, because their primary role is patient care, facilitating research is necessarily secondary.

The degree to which researchers experience recruitment challenges in studies relying on CSMs depends in part upon the cultural context. For example, in Sweden if healthcare management permits a research project, then it is expected that, as part of their job, the staff nurses will recruit subjects (B Wickberg, 2010, personal communication). Furthermore, one researcher from Hong Kong noted that even when research funding is not available, in many parts of Asia physicians and nurses are commonly asked to refer/enrol patients into a study. This practice seems to improve the recruitment rate as patients generally believe that nurses are trustworthy (D Lee, 2010, personal communication). Similarly, one UK qualitative study reported that nurses were fully engaged in their facilitative role: they developed useful reminder strategies to ensure consistent recruitment, expressed disappointment when recruitment rates were low, and attributed these low rates to patients’ reluctance to enrol (Potter et al., 2009).

Nevertheless, in the remaining published reports from the UK and the US, researchers cited numerous barriers that make it difficult for CSMs to facilitate subject recruitment: competing demands for staff time (Lovato et al., 1997; Brooker et al., 1999; Ross and Cornbleet, 2003; Sullivan-Bolyai et al., 2007; Kirchhoff and Kehl, 2008); gatekeeping by CSMs who believe they are protecting patients from research procedures they perceive as burdensome or undesirable (Moore and Miller, 1999; Ross and Cornbleet, 2003; Kirchhoff and Kehl, 2008; Potter et al., 2009); scepticism about the usefulness of research interventions (Sullivan-Bolyai et al., 2007); and a high turnover of staff and administrative personnel (Buckwalter et al., 2009). Indeed, one report from Australia indicated that it is increasingly more difficult to gain access to care facilities and acute care hospitals to conduct research because these agencies will not approve research studies that do not in some way meet their objectives or have direct benefit for them (E Beattie, 2010, personal communication).

In response to the challenges of indirect recruitment via CSMs, British and American researchers have described two categories of strategies for enhancing enrolment rates when recruitment is done via CSMs. This first category describes strategies that should be used before research in clinical settings begins:

  • Assess the suitability of the clinical setting in terms of stability (Buckwalter et al., 2009).
  • Negotiate the commitment of CSMs to the research process by assessing and engaging all stakeholders in the entry process (Murphy et al., 1992).
  • Market the study to enhance the relevance of the research to the clinical practice of CSMs (Foy et al., 2003).
  • Provide printed educational materials to enhance each CSM’s understanding of the research (Foy et al., 2003).

A second category of reports lists strategies that directly engage CSM participation in subject recruitment once the study is underway:

It is challenging for clinical researchers to implement these engagement strategies based on the brief descriptions provided in the literature. This paper presents CSM engagement strategies that succeeded in three different US settings, presenting the strategies in sufficient detail to facilitate their use by others relying on CSMs to recruit research subjects. To increase the utility of the suggested strategies, they have been arranged by phase of research. Although the strategies described in this paper have not been empirically evaluated in controlled studies, they represent the collective wisdom and research experiences of three investigators with over 60 years of experience conducting research in a variety of US clinical settings. These strategies are thus offered as research tools that have been useful in US studies, rather than as validated techniques for enhancing subject recruitment, which are universally applicable. These strategies are, however, particularly well suited to any studies (clinical trials, qualitative studies) in which researchers are relying on CSMs to direct potential subjects to the research team.

Method

The strategies described in this paper emerged from consultations between three researchers discussing ‘recruitment woes’ in the conduct of three different studies in US settings (Table 1). Specifically, through trial and error, the second author (KCB) successfully completed enrolment for the Communication study which relied on CSMs to facilitate her contact with research subjects. On the basis of this experience, the second author advised both co-authors (LSS and M-L F) while conducting their own studies in which CSMs directed potential participants to members of the research team. The strategies described in this paper are those which facilitated the engagement of CSMs in the subject recruitment process in at least one or more of the three studies.

Table 1
Description of the three studies

Results

Introductory phase engagement strategies

It can be difficult to initiate subject enrolment in settings where CSMs hold negative preconceptions about research, perceiving it as a burden, questioning feasibility, and appropriately giving it low priority compared to clinical care (Moore and Miller, 1999; Ross and Cornbleet, 2003; Sullivan-Bolyai et al., 2007; Kirchhoff and Kehl, 2008). Providing CSMs with training, describing the importance of the research, and providing adequate training on research procedures as well as the protection of human subjects can help to ameliorate some engagement barriers. Although CSM training was incorporated into all three of the studies described in this paper, training alone was insufficient to fully engage CSMs throughout subject recruitment. The following additional strategies were therefore used to both overcome the engagement challenges characteristic of the initial research phase and to prompt CSMs to appreciate the value of the research being conducted in their workplace.

Establishment of trust

Mistrust of the research process is a potential barrier for CSMs which can be exacerbated by previous negative experiences. In the Communication study, for example, a prior researcher in the same clinical setting had complained to administrative staff about CSMs, leading to negative notes in personnel files which affected the merit reviews of CSMs. Placing commendatory notes in staff’s personnel files is a common practice in the US Veterans Administration system as well as in clinical settings where participation in research is a job expectation. However, the use of negative notes is not expected. Thus, the researchers in the Communication study had to devote a considerable amount of time reassuring the understandably reluctant CSMs that their participation would be rewarded, and recruitment performance problems would remain confidential. Early in the study period, this reassurance required extra meetings with CSMs and ongoing staff encouragement, reminding them of their crucial role in gaining valid results and by periodically adding positive notes of study involvement to their personnel files. To strengthen trust in the Caregiver study, quarterly staff meetings directly addressed any CSM’s concerns and the resulting procedural adjustments were reported at the following staff meeting as well as in the study newsletter.

Staff input

Input from CSMs to the study research protocol both facilitates staff engagement and helps the principal investigator (PI) to design a feasible study. Further, if CSMs can control some aspects of the study they are more likely to accept the project and refer potential subjects. For example, in the Communication study, CSMs remarked that the speech intervention (Speech Therapy Enhancement Program, STEP) might go unnoticed in a patient’s chart. In response, researchers devised a clipboard containing laminated copies of the STEP tasks, marked by a Band-Aid logo. This clipboard was hung at the foot of the bed of each study participant, providing a visual reminder and an easy way to ensure that CSMs consistently performed the STEP tasks. In the Listening Visits (LV) study, CSMs rightly advised that recruiting Spanish-speaking subjects would boost subject enrolment (see the ‘Subject pool expansion’ section of this paper).

Succinct research training procedures

Initially, the myriad of procedural details associated with a research project may be perceived by CSMs as overwhelming. The following strategies improved the way CSMs were introduced to research procedures to facilitate their understanding and adherence.

Flow chart

Rather than requiring CSMs to read through lengthy procedural details, or listen to a long presentation, a flow chart can succinctly depict research procedures. Because of their brevity, these visual summaries also facilitate the standardisation and integrity of the recruitment process by serving as handy reminders. Finally, CSMs that miss the introductory training can use these visual summaries to acquaint themselves with the research procedures (see the LV study flow chart in Figure 1).

Figure 1
Listening Visits (LV) study recruitment procedures flow chart.

Recruitment scripts and role-play

CSMs may initially feel uncomfortable inviting individuals to participate in a research project. Recruitment scripts, often required by institutional review boards (IRBs), provide useful guidance. Practising recruitment procedures through role-play exercises also increases the understanding of procedural details. In the Caregiver study, researchers developed a script to assist CSMs in presenting the study to potential family participants and the elderly. Together, CSMs and the research team engaged in role-play to promote ease with the recruitment approach.

Study logo

Logos provide a visual reminder and an easy way to identify study-related materials, so the LV, Communication, and Caregiver studies each employed a logo. The PIs of the LV and Caregiver studies chose their logos (sunflowers and stick figure, respectively). However, in the Communication study, allowing the CSMs to choose the logo also solved a minor problem. Here, the study was funded by the Robert Wood Johnson Foundation (RWJF), but despite repeated clarification from the research team, CSMs continued to refer to the project as the ‘Johnson and Johnson Study’. The CSMs suggested that a Band-Aid logo would trigger research reminders; and although this symbol was unrelated to communication or the STEP intervention, the Band-Aid became a ubiquitous and effective project logo.

Data collection phase

Maintaining the ongoing commitment of CSMs to subject recruitment may require additional engagement strategies during the data collection phase. In cases where there is still insufficient subject enrolment at one site, it may also be necessary to add a site or expand the pool of CSMs eligible to recruit.

Assigned recruitment

Assigning CSMs to recruit specific individuals increases the personal responsibility of individual CSMs. In the Caregiver study, for example, once a month CSM leaders (usually directors) selected active cases that met the study’s inclusion criteria, and assigned specific CSMs to recruit the caregivers of these patients during their home visits.

Study newsletter

Newsletters serve as regular reminders about the study and provide a useful venue for reporting study progress, recognising contributions of CSMs, summarising results, and sharing stories highlighting the significance of the research findings for ongoing CSM clinical practice. Several features of newsletters are especially useful in engaging CSMs. For example, a subject recruitment thermometer – an image of a thermometer gauging enrolment – provides tangible feedback about recruitment efforts. In the Caregiver study, it even prompted a recruitment competition between two groups. Additionally, newsletters can also be utilised to convey how the research benefits research participants. For example, the Caregiver study newsletter contained a regular column, ‘Caregiving Families’, relaying compelling stories about the hardships experienced by caregivers in providing home care for their elderly family members. The LV study newsletter periodically featured comments about the benefits of Listening Visits from both the women who received this treatment and the CSMs who provided the intervention. Some of the LV study newsletters also featured preliminary study results demonstrating the effectiveness of the intervention. Finally, newsletters in both the LV and Caregiver studies regularly recognised the recruitment efforts of CSMs.

Staff compensation and appreciation

Compensating CSMs for time spent recruiting study participants and providing key information sends an important message: ‘Your time and expertise is valuable, so we appreciate your help in achieving our study goals’. Despite the low salaries characteristic of US long-term care and social service settings, often it is not possible or even desirable to pay CSMs for their efforts, as this compensation may be coercive and unethical. However, alternative compensation, a procedure which must be approved by ethics review boards (ERBs) in the US, can be equally effective.

Professional development

Researchers can often compensate CSMs by providing expertise or new information. For example, the Communication study gave the facility books for the staff library, a one-year subscription to a clinical nursing journal, relevant evidence-based protocols, screening/assessment tools, and reprints of articles on study-related topics. Both the Communication and Caregiver studies provided in-service education programmes and consultation to CSMs who were having a particular resident care problem.

Individual recognition

Clinical staff members who participate in research go ‘above and beyond the call of duty’. Recognising their individual efforts proved to be a successful engagement strategy. In the Communication study, researchers placed notes of thanks in CSM files, made certificates of appreciation, which were awarded at a staff luncheon and framed for display for visitors and other staff members. In the Caregiver study, top CSM recruiters were noted in the newsletter and invited to lunch in a restaurant twice a year. In the LV study, CSMs who facilitated contact with a potential research subject received a handwritten thank you note from the PI and a token of appreciation (gift certificate to a coffee shop, key ring, etc.). When a LV subject completed the three study interviews, the CSMs who facilitated their recruitment received a second thank you note and token of appreciation in recognition of both their initial recruitment efforts as well as their efforts to help the PI to maintain contact with the LV subject.

Subject pool expansion

Even when all of these strategies are employed, and even when CSMs are fully engaged, lagging recruitment rates may still necessitate alternative ways to expand the subject pool. Single sites may not have sufficient patient flow to meet subject recruitment goals. ‘Failing’ to meet the projected enrolment rate can create negative or despondent feelings among CSMs about the study which may, in turn, result in their disengagement. It is important therefore for researchers to recognise CSMs for their hard work even when subject enrolment is slower than expected, and engage them as collaborators in generating new ideas for expanding the subject pool. This tactic was used in all three studies. Although the researchers may not have purposefully asked for the help of CSMs, in the end it was the suggestions of CSMs that resulted in helpful ideas.

Broadening definitions of subjects and CSMs

In the LV study, after only one enrolment in the first 2 months, CSMs suggested including Spanish-speaking subjects. This suggestion required considerable additional effort and expense: the PI hired a Spanish-speaking interviewer, had the research instruments translated into Spanish, and obtained approval from the IRB. However, the pay-off was significant: 63.6% of the final study sample were Spanish-speaking. A variant of expanding subject eligibility criteria is broadening the pool of recruiters. In the Communication study, at the suggestion of CSMs already involved in the study, the PI expanded beyond nursing staff, inviting National Institute of Mental Health (NIMH)-supported postdoctoral fellows who were available in this particular Veterans Administration setting. This supportive cadre of research-savvy providers was an excellent source of study referrals. Similarly, in the Caregiver study, expansion among study interviewers also resulted in increased subject recruitment. In this study, minority recruitment presented a serious challenge. Caribbean caregivers consistently refused to participate unless another Caribbean person could convince them of the merit of the study. So, the researchers made connections with ethnic community leaders who were engaged in neighbourhood organisations and with ethnic graduate students who were active in service agencies in the community to work with the CSMs of these agencies in recruiting participants. This effort eventually provided about 25% of the sample.

Adding additional sites

If all else fails, it may be necessary to recruit a new research site. Expansion to a new site can present numerous, and sometimes seemingly insurmountable challenges, including finding a new and willing site, completing IRB applications, and training new CSMs. This effort may seem especially difficult to justify to the researcher who has already expended considerable effort at one site without success, but may be necessary. Again, CSMs can facilitate this process. Upon the recommendation of CSMs,the Communication study added another Veterans Administration unit with similar resident and staff characteristics, to achieve the desired sample size. Clinical staff members on the original unit agreed to support and assist CSMs on the more recently added unit, which gave them a sense of increased pride and engagement in the study.

Study completion phase

Once subject enrolment is met, a final meeting provides CSMs with a sense of accomplishment with their research experience. It also allows the researcher to acknowledge the importance of contributions by CSMs and to summarise the results of the study. Descriptions of the results should be succinct and highlight findings particularly relevant to CSMs. All three studies accomplished these tasks in a closing luncheon that had a festive atmosphere, complete with CSM recognition certificates.

Discussion

As researchers, we each began our research projects with a naive expectation that if we simply introduce our studies to CSMs, then subject recruitment and the conduct of research would unfold smoothly. When faced with unexpected recruitment challenges, our consultations identified the successful strategies described in this paper. Most importantly, the realisation that our recruitment challenges were not isolated experiences revealed a critical underlying perspective: staff acceptance and sustained support are crucial when researchers rely on CSMs for subject recruitment. Moreover, CSM acceptance is not automatic.

Barriers to subject recruitment must be overcome. Some CSMs may feel burdened by the demands of research if they perceive it as not directly benefiting their work or feel ‘over-examined’ and ‘abused’ by researchers who ‘get their data and run’. Clinical staff members may also fear problems will be uncovered and reported, prompting surveyor visits and the potential issuance of deficiencies. Adequately engaging, reassuring, and recognising CSMs, as well as providing a full description of study procedures alleviates fears and engenders a strong working alliance that benefits both researchers and CSMs. This perspective that CSMs may have doubts about participating in research, in turn, unveiled an unanticipated additional layer to conducting research in clinical settings – the need to actively engage CSMs on an ongoing basis.

These strategies were successful in our US-based studies; however, their applicability and suitability will depend on cultural context. For example, an underlying assumption in the US context – where all three of the described studies took place – is that nurses assume leadership roles in conducting research. Directing research is common practice for US nursing faculty, who are expected to develop a funded programme of research and are supported by nurse-specific funding agencies and research dissemination venues. While an independent research role is only recently becoming increasingly more common for nurses in some European (Workgroup of European Nurse Researchers, 2009) and Asian countries (Kim, 1998), these strategies may also be useful in studies where nurses are part of an interdisciplinary research team. Similarly, strategies that are permissible/ethical in US clinical settings may not be well-suited or permissible in other cultural contexts. As is mandatory in the US, the procedures for all three studies described, including the strategies described in this paper, were reviewed and approved by an IRB. The suitability of these strategies for other cultural contexts needs to be carefully evaluated by researchers as well as local independent ERBs.

Important conclusions regarding the engagement of CSMs are listed in Table 2. We stress three take-away points. First, be aware of the potential engagement barriers when relying on CSMs for subject recruitment. The naive expectation that the availability of subjects in clinical settings will make subject enrolment easy does not prepare researchers to assume the necessary problem solving stance. Second, the strategies described here provide researchers with possible solutions, distilled from the experiences of three researchers recruiting for very different US studies. Third, recruitment challenges are a common problem endemic to some clinical settings, and not always the result of inept planning. Adopting this perspective can inoculate the researcher against feelings of failure and support the essential problem solving approach. Although this article was written from the perspective of nursing research faculty conducting studies in three different US settings, we believe the strategies would also be of benefit to nurses in international contexts.

Table 2
Conclusions about the engagement of CSMs

Key points

  • The recruitment of an adequate number of research participants is not ensured in the context of clinical settings.
  • Clinical staff members have rightly prioritised clinical care over research.
  • Researchers should be prepared to take an active problem solving stance with regard to the engagement of CSMs at all stages of research.
  • It is important to realise that recruitment challenges are a common problem endemic to clinical settings and are not necessarily the result of inept planning.

Acknowledgments

Funding The Listening Visits Study is funded by the National Institutes of Mental Health (MH075964). Lisa Segre was also funded by this grant during the time she wrote the paper. The Communication Study was funded by a grant from the Robert Wood Johnson Foundation. The Caregiver Study was funded by Florida International University MBRS grant, SCORE Project NIHSO6GM08205, National Institutes of Health, National Institute of General Medical Sciences, Washington D.C., USA.

Biography

• 

Lisa S Segre (PhD), Assistant Professor in the College of Nursing at the University of Iowa, in Iowa City, specialises in the development of maternal depression screening and treatment programmes for low-income and ethnic minority women. Dr Segre is the recipient of a Mentored Patient-Oriented Research Career Development Award (K-23) from the National Institute of Mental Health. Her current research projects include: (1) the importation/evaluation of British ‘Listening Visits’ in a US social service programme; and (2) evaluation of a train-the-trainer model of disseminating maternal depression screening in social service/primary care settings.

Kathleen Coen Buckwalter (PhD, RN, FAAN), University of Iowa Sally Mathis Hartwig Professor of Gerontological Nursing Research, was named Associate Provost for Health Sciences (1997–2004). She is the Director of the John A Hartford Center of Geriatric Nursing Excellence and the Codirector of the University’s Center on Aging and the National Health Policy and Resource Center. She has secondary appointments in the Colleges of Medicine, Public Health, and Law. She was appointed to the State of Iowa Commission of Elder Affairs (2004) and the Judicial Nominating Commission (2007). Dr Buckwalter, who is recognised internationally for her research in psychiatric nursing, ageing and long-term care, has a sustained record of private and federal support for the evaluation of clinical nursing interventions for geropsychiatric populations. Her particularinterest is in behavioural management strategies for rural caregivers of persons with dementia and the effectiveness of community programmes to prevent, minimise, and treat psychiatric problems in the rural elderly. ude.awoiu@retlawkcub-neelhtaK

Marie-Luise Friedemann is Professor Emeritus at Florida International University, College of Nursing and Health Sciences. She has a doctorate and a Master’s degree in psychiatric nursing from the University of Michigan. She has held faculty and administrative positions at Wayne State University and Florida International University (FIU). At the present, she is a researcher at FIU, and is involved in foreign student exchange programmes. Family nursing is her speciality and research projects involve family caregiving. Dr Friedemann has developed a theoretical framework, the Framework of Systemic Organization, taught and applied in practice in many countries. She also developed a theory-based family assessment instrument, the Assessment of Strategies in Families, which has been translated into five other languages and is used worldwide. She is the author of many journal articles and several books and serves as consultant for research and curriculum development in Europe and Latin America. ude.uif@mmedeirf

Contributor Information

Lisa S. Segre, University of Iowa, Iowa City, Iowa, USA.

Kathleen C. Buckwalter, University of Iowa, Iowa City, Iowa, USA.

Marie-Luise Friedemann, Florida International University, Miami, Florida, USA.

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