Sample characteristics
347 community midwives and health visitors were informed of the survey by their employer and 114 completed the survey. Of these, sixty one respondents (54%) had experience of approaching service users about participation in research; this figure was higher among community midwives (N=22, 76% of all community midwife respondents) than among health visitors (N=39, 51% of all health visitor respondents). We did not calculate a response rate for health visitors and community midwives with experience of service user approach, as the employing organisations did not have data on the numbers of staff with that experience. Table 1 presents the demographic and other characteristics of the health visitor and community midwife respondents with experience of service user approach.
Table 1. Demographic and other characteristics of health visitor (HV) and community midwife (CM) participants who had experience of approaching service users about participation in research.
Participant characteristics
|
HV (n=39)
|
CM (n=22)
|
Gender
|
|
|
Female
|
37 (95%)
|
22 (100%)
|
Male
|
1 (3%)
|
0 (0%)
|
Prefer not to say
|
1 (3%)
|
0 (0%)
|
Ethnicity
|
|
|
Other than white British
|
8 (21%)
|
11 (50%)
|
White British
|
31 (79%)
|
11 (50%)
|
Years of experience
|
|
|
Less than 2 years
|
6 (15%)
|
2 (9%)
|
2-5 years
|
10 (26%)
|
5 (23%)
|
5-10 years
|
5 (13%)
|
1 (5%)
|
More than 10 years
|
18 (46%)
|
14 (64%)
|
Description of current practice environment1
|
|
|
Urban
|
28 (72%)
|
11 (50%)
|
Rural
|
9 (23%)
|
7 (32%)
|
Ethnically diverse
|
21(54%)
|
8 (36%)
|
Economically deprived
|
27 (69%)
|
4 (18%)
|
Affluent
|
7 (18%)
|
6 (27%)
|
1 Participants could choose more than one option, so % does not add up to 100.
Behavioural analysis of factors influencing the desired behaviours using the TDF
Across the dataset, 408 responses were mapped to 14 TDF domains and forty five specific barriers/enablers. Table 2 shows the number of responses coded to each of the TDF domains and the rank order of the TDF Domains for health visitors and community midwives. The same six domains dominated for both professional groups, and responses coded to these six domains accounted for 81% of all coded responses for health visitors and community midwives alike. These were: (a) environmental context and resources (b) goals (c) social/professional role and identity (d) social influences (e) beliefs about capabilities and (f) knowledge. The barriers and enablers for these key domains are outlined below, with example quotations.
Table 2. The frequency and rank order of responses coded to each of the TDF Domains for health visitors (HV) and community midwives (CM)
|
HV (n=39)
|
CM (n=22).
|
TDF Domain
|
Frequency
|
Rank
|
Frequency
|
Rank
|
Environmental context & resources
|
50
|
1
|
40
|
1
|
Social/professional role and identity
|
37
|
2
|
21
|
2
|
Social influences
|
37
|
2
|
14
|
5
|
Goals
|
29
|
4
|
16
|
4
|
Beliefs about capabilities
|
29
|
4
|
19
|
3
|
Knowledge
|
27
|
6
|
11
|
6
|
Beliefs about consequences
|
19
|
7
|
8
|
7
|
Emotion
|
14
|
8
|
6
|
8
|
Reinforcement
|
5
|
9
|
5
|
9
|
Intentions
|
5
|
9
|
3
|
10
|
Skills
|
3
|
11
|
2
|
11
|
Optimism
|
2
|
12
|
2
|
11
|
Memory, attention & decision processes
|
2
|
12
|
1
|
13
|
Behavioural regulation
|
0
|
14
|
1
|
13
|
(a) Environmental context and resources
Across the dataset, environmental context and resources was the most frequently identified domain. This domain was apparent in the responses of 27 (68%) health visitors and 18 community midwives (78%). Specific barriers identified were heavy caseloads and insufficient time, staff resource, inadequate study materials, and language barriers. Specific enablers were additional time, additional staff resource, and concise and accessible information.
Within this domain the most frequently cited barrier was heavy caseloads. Respondents felt they had insufficient time to talk to service users about research opportunities. This barrier was evident in the responses of 48% of health visitors and 61% of community midwives. Staff shortages, leading to increased individual workloads, compounded the challenge of workload pressures, making it more difficult for health visitors and community midwives to find the time to talk to service users about research opportunities.
It is difficult when the unit is busy and the time constraint, workload is high and staffing levels are poor (CM39)
The quality of supporting information (physical resources) about a particular study was mentioned by both health visitors and community midwives as influencing their service user approach behaviour. The need for comprehensive and accessible study information was particularly important given the workloads and time constraints of these staff. They needed to feel equipped to answer the questions of service users about the research without having to find additional time in their schedules to better inform themselves.
A lot of the time due to time constraints and pressure from management we have little time to find out information so that we are able to answer questions that families may have. I also find it difficult to find the time to enrol families for research due to busy workload (HV38)
It’s fine as long as I have been given appropriate info myself in a concise form (CM18)
Some respondents suggested that additional staff, or staff with specific responsibility for research, could facilitate approaches to service users about research opportunities. Others felt that research funding should, but often didn’t, cover the financial cost of staff time needed to approach service users about research participation. These respondents felt that the cost was being borne by themselves, as it was added to their existing duties without the allocation of additional staff time to cover this work.
Banging on again... TIME resource explicit and funded up front whether through bid process or combination of NHS Trust and monies from bid and CRN as required. But key weakness as appears Chief Investigators do not acknowledge the 'cost' of what NHS 'jobbing' clinical midwives need to be able to freely enjoy and support consistent good quality research recruitment (CM4)
There should be payment to providers of care for payment of additional time for the research study recruitment (HV85)
Another barrier mentioned by health visitors and community midwives alike was language, encountered when attempting to inform service users who spoke little or no English about potential research opportunities.
It is a difficulty when English isn't their first language (HV87)
(b) Social and professional role and identity
The second most frequently identified domain for both professional groups was professional role and identity. Across the dataset there were different ways in which the respondents’ professional role and identity influenced their participant recruitment behaviour. There was an enabling belief expressed by community midwives and health visitors that supporting research is integral to their professional role. However, some health visitors felt strongly that it was not part of their professional role to mention research opportunities to service users. Rather, they felt that this should be the researchers’ responsibility. A different subset of the health visitors were somewhat ambivalent, suggesting that the research topic needed to relate to their role and practice, and noting there was potential for conflict with their professional role.
I see it as a professional endeavour and one avenue into understanding the need of clients (HV85)
It is part of my job description (CM49)
Researchers should stop imposing on us and sort it out themselves (HV20)
I approve of encouraging participation in research as a general rule but am very respectful of the boundaries of roles, expectations and service policy (HV59)
(c) Social influences
There was strong evidence that social influences could act as both barriers and enablers to service user approach. Service users’ influence could act as a barrier to the health visitors and community midwives approaching service users about research recruitment, and there was evidence that these respondents actively chose whether to inform an eligible service user about a research study; it was a judgement based on the practitioner’s perception of the service user’s situation
I feel that you have to pick clients who you know would be willing to participate (HV55)
I wouldn’t ask them if I thought the client's reaction might not be positive. (CM35)
There was also evidence for the social influence of researchers on the respondents’ service user approach behaviour. Researchers who fail to engage with and support the health professionals appear to be a particular barrier to the involvement of health visitors, whereas community midwives identified communicative and supportive researchers as an enabler. These practitioners felt that it was the researchers’ responsibility not only to provide the information and physical resources for recruitment, but also to provide support and encouragement in person.
We need more involvement from the researchers rather than just handing it to us! (HV27)
Researchers being visible and approachable, using easy to- understand language and making it relevant to our clinical area, and help in the recruitment process is important (CM102)
A desire to contribute to the team was an enabler for both health visitors and community midwives. However, only health visitors mentioned that the influence of managers could act as both an enabler and a barrier to service user approach.
I do this as it supports my colleagues (CM106)
We share enthusiasm about research and how it impacts on all of us, practitioner and patient alike (HV50)
Some managers encourage participation whereas others are mindful of time restraints (HV91)
(d) Goals
Across both professional groups it was apparent that introducing research opportunities to service users was not a high priority. This posed a significant barrier to some, but not all respondents, and was the fourth most frequently identified TDF Domain for both professional groups (Table 2). Both health visitors and community midwives emphasised that service users’ needs always take precedence, yet this evidently did not include the service user’s right to be informed of research opportunities. Rather, the commissioned targets took precedence. Since commissioned targets did not include contributing to research, supporting research by approaching service users about research opportunities fell to the bottom of the list of activities to be completed during a busy clinical encounter.
I just about have time to do the job of health visiting. We have targets to meet. A very demanding caseload. Extensive safeguarding. Typing up complex patient notes. Worrying about the lack of resources to actually support the dire needs of my caseload. Sorting out other people’s research is the last thing I need or want to do (HV 20)
Due to the volume of topics we already have to discuss within a limited time, research would likely slip to the bottom (CM105)
However, other respondents commented that even in the face of competing clinical targets, they considered approaching service users about research participation to be a priority because practice and care is improved by research, and good research evidence requires participation by their service users. Thus, a belief that research underpins high quality care meant that the goals domain could also act as a counterbalancing enabler to research recruitment behaviour.
Research into maternity services is a growing area and it is important that all are involved to ensure the service moves forward with robust clinical findings to support out work (CM5)
Despite the time constraints, in order to gather evidence of effective interventions, good practice etc., we need to be doing research. (HV59)
(e) Beliefs about capabilities
For the most part, beliefs about capabilities acted as an enabler for both professional groups. However, this domain overlapped with the domain of environmental context and resources, and the domain of knowledge. Thus, some respondents expressed a lack of confidence in approaching service users in certain situations, such as more challenging clinical situations or when time was short. Others explained that their confidence in approaching service users about research participation was contingent on their knowledge about the study.
I feel competent and confident and know where to access support (CM4)
I am confident, if I was allocated time and resources (HV6)
I am relatively confident, except in labour (CM2)
I am confident if I know enough to offer a brief explanation or can signpost (HV47)
(f) Knowledge
Knowledge could act as a barrier or enabler for both health visitors and community midwives. In particular both professional groups emphasised the need for good procedural knowledge about the study, and knowledge of the scientific rationale for the study. A few participants also mentioned needing knowledge of the research topic.
It must be with midwives who have the relevant knowledge (CM4).
Knowing that participation is voluntary and that participants can with-draw within defined boundaries gives me greater confidence in approaching service users. Understanding the process of ethical approval and how research projects are planned, their protocols laid out etc. gives me greater confidence in explaining participation to others. I would also want to understand the research project objectives and the implication/commitment required from participants to feel confident that I could then 'sell' this to a patient (HV59).
Development of an intervention strategy
The intervention functions which map to the salient TDF Domains are shown in Table 3, together with example behaviour change techniques (BCTs) and policies for inclusion in a complex intervention to support health visitors and community midwives to approach eligible service users offering them the choice to take part in a research study. How these could combine into a complex intervention is depicted in Figure 1.
[INSERT TABLE 3]
Figure 1. Outline of a complex intervention to support health visitors and community midwives to approach service users about research participation.
[INSERT FIGURE 1]
The white boxes surround selected behaviour change techniques, and the surrounding blue boxes indicate supporting policies.