Increasing demand on emergency departments has led to the development of different models of service delivery [1]. Qualitative research in emergency departments is crucial for understanding patients’ experiences and improving patient-centred care, and research is urgently needed to understand the outcomes of these new service models for patients [2]. However, there is little evidence in the literature about effective patient recruitment for qualitative research in emergency department settings [3].
Challenges to patient recruitment and engagement in research can occur at all stages of the process: initially identifying and inviting eligible patients; gaining their consent; and successfully engaging them in data collection [4]. The unscheduled nature of emergency department visits poses specific recruitment challenges, due to the urgent nature of emergency department patient conditions and the demanding work environment that the emergency department presents [5]. Limited success in identifying and inviting eligible patients for research has been associated with poor collaboration between hospital sites and researchers [4]. Hospital staff may have doubts about their involvement in the research if they are unsure of the purpose of the research or have concerns about their level of skill in identifying and inviting eligible patients [6]. Furthermore, narrow eligibility criteria may also contribute to insufficient numbers of patients being identified and invited to participate in research [7].
Once approached to take part, patient participation in research studies is an individual choice based on several factors, such as the purpose of the study, what participation involves, how the findings will be used and who will benefit from the findings [3]. Impersonal communication between researchers and patients (such as postal or email invitations, telephone interviews or online surveys) can hamper attempts to recruit patients, whereas sitting down with a patient and their family to explain the research conveys trust and openness, increasing the likelihood of patients engaging with a study [3, 5, 8]. However, there are practical difficulties associated with obtaining verbal consent in the emergency department setting due to both the nature of the patient’s condition and the busy environment [5]. Telephone reminders to patients following postal invitations have been found to increase patient recruitment [9]. While payment for participation in research is highly debated and can be viewed as presenting ethical challenges [4], a lack of monetary recognition for participation in research has also been identified as a reason for low recruitment rates [5, 8]. Despite these significant challenges in recruiting patients in emergency departments for research, obtaining patient perspectives on their care and experiences in strained settings such as the emergency department are crucial to improving patient care and safety [2].
The literature demonstrates a range of potential barriers and solutions to recruiting patients for research. However, existing research has generally focussed on patient recruitment into large clinical trials, as opposed to smaller-scale qualitative research in defined care settings. We aim to describe the factors which influenced patient recruitment in our study of different general practitioner models in the emergency department setting, by exploring the key challenges and consequent amendments made to our processes. From our learning, we propose recommendations for future research that seeks to recruit emergency department patients for qualitative research.
Context: Setting
Our UK National Institute for Healthcare Research Health Services and Delivery Research (NIHR DS&DR) funded study, “GPs in EDs” [10], recruited 13 hospital emergency departments in England and Wales as “case study sites”, whereby mixed methods were used to carry out an in-depth evaluation of the effectiveness of different models of general practitioners working in or alongside emergency departments. Three of these 10 case study sites did not have any model of using general practitioners in their emergency department and acted as “control sites” for comparison. We included patient data for this analysis from one further site which had initially been planned as a case study site, but following the research visit it was decided that it did not meet the eligibility criteria for all data to be included in the overall study.
One key objective was to understand the impact on patient experience, by conducting qualitative interviews with patients. Much consideration was given to effective recruitment methods for this qualitative research element, particularly in a hard-to-reach area such as an emergency department. In line with best practice, public and patient members are study Co-Applicants alongside multi-disciplinary and specialist partners [11]. Two public members are also members of our independent Study Steering Committee and have worked alongside stakeholder and academic colleagues to oversee study implementation. All colleagues contributed to decisions throughout the research about enhancing data collection through patient interviews.
Patient recruitment methods in the GPs in EDs study
We aimed to recruit a purposive sample of 60-120 patients from our case study sites, with specific conditions appropriate for management by either emergency department clinicians or general practitioners working in the emergency department setting. We planned to conduct semi-structured telephone interviews, of 20-30-minute duration, following the patients’ emergency department visits to explore patients’ reflections on their experiences. During the early phase of our study at a stakeholder event, a group of expert clinicians, policymakers, public contributors and researchers took part in a consensus exercise to choose five “marker” conditions which were deemed the most suitable for a comparative analysis. These marker conditions comprised of a presenting complaint (e.g. back pain) with associated exemplar diagnoses (e.g. sciatica) with a low acuity score (see Appendix 1). The aim of patient interviews was to understand how patients with certain symptoms or diagnoses were managed in the different services by different staff, in terms of use of acute investigations, observation times and referral to other acute hospital services. We aimed to recruit 5-10 patient participants at each participating case study site, covering the range of marker conditions. Our initial strategy included two recruitment methods to invite patients into the study, discussed below.
Before agreeing to be included as a case study site, departments stated that they were able to support our research, which included the capability and capacity to support patient recruitment. However, due to the demanding setting, researchers often had to negotiate the level of support for each aspect of the study, offering flexibility if departments were unable to give the ideal level of support needed for identifying and inviting patients. It was important that we were flexible with what we requested of departments, as we needed to recruit sufficient and appropriate departments as case study sites and collect a range of data via different research methods for all aspects of the study (e.g. observations and staff interviews).
Initial recruitment method 1: inviting patients via post
The first method aimed to recruit patients via postal invitations sent out by a member of hospital staff (i.e. a NHS-appointed delivery research nurse), who would use the electronic health record (EHR) system to identify up to 50 patients who had attended the emergency department in the last three months, with the marker conditions in our recruitment framework (see Appendix 1). Eligible patients were mailed a patient study pack containing: a study invitation letter, a participant information sheet two consent forms and a stamped and addressed envelope. The patient information sheet asked patients to sign and return their consent forms to the university if they wished to take part in a telephone interview. Once these were received, the study team would contact the patient by telephone to arrange an interview.
Initial recruitment method 2: inviting patients at the emergency department
The second method aimed to recruit patients during the research visit in the case study site emergency department. A member of hospital staff (i.e. a research nurse) would identify up to 50 eligible patients when they were in the emergency department, informing them of the study and providing them with the patient study pack. Patients would be asked to take home the materials they had been given and consider whether they would like to take part, returning the consent form (to the university) if they wished to participate. Once consent forms were received by the study team, the same process for contacting patients would be followed as method 1.
Amendments to patient recruitment processes
Due to low initial patient recruitment figures from both methods, the study team sought advice from study co-applicants, study steering committee members and public and patient involvement representatives, on potential changes to the recruitment methods. The following amendments were made in May 2018 to help with patient recruitment:
- Inviting up to 100 participants at each case study site rather than 50, to increase returns.
- Printing study invitation letters on hospital headed paper rather than Cardiff University headed paper so that patients were familiar with the sender.
- Giving participants a quicker and easy option of registering their interest by texting ‘yes’ to a mobile number, to then be followed up with a phone call from a member of the research team to request the consent form.
- Specifying the desired marker conditions on the participant information sheet so that patients could recognise their eligibility for the study.
- Offering an incentive of a £20 high-street shopping voucher to participants who were interviewed.