The project had just moved from the observation phase into the interview recruitment phase at the first site of a research project on excellence in person-centred care at a long-term care home in an urban centre in Canada. It was puzzling why staff were not volunteering for interviews in larger numbers, even though administration had allowed staff to conduct the interview on work time. Several recruitment approaches had been invoked: presentations at nursing rounds and staff meetings, posters in staff areas and public areas such as hallway bulletin boards, encouragement to participate from administration and senior staff, email calls to participate, and in-person on-site requests from researchers. When asked about their non-participation, they cited lack of time as the main reason; too busy while on shift and too busy with home life to have the researcher come to their home during the off days. To accommodate respondents’ busy schedules, an interviewer was made available during all eight-hour work shifts, during breaks, and after-shift, in the day, evening, or night, mindful to provide options, given that shifts are very busy and to accommodate the different hours of shift work. The length of interview was made flexible, fifteen minutes to an hour and a half, whatever time respondents had to share. Accommodations were made for interviewing off-site, even to go to the respondent’s home. Still very few staff volunteered for the formal interviews; they responded that they were still ‘too busy’.
Given that it is not unusual for people to say, ‘I don’t have time’ rather than give more complicated reasons for not participating in something, it is not always clear if the ‘lack of time’ response from a potential participant means just that or something else. However, we could not pinpoint any hesitations other than time constraints. We had ensured that comfortable, trusting relationships had been established. Several months had been spent building trust and familiarity with staff, residents and families and gaining an in-depth understanding of the routines and institutional cultures. The project had a regular presence at the nursing home. There were posters on the walls and a research assistant chatted with residents and staff for a few hours daily over a period of several months in common areas and hallways, even helping pass snacks and attending recreational activities. The project had just completed an observation phase where the research assistant recruited sets of staff (e.g., health care aides, registered nurses) and residents, with appropriate permissions, to observe and asked questions of staff and residents as they provided intimate personal care to residents, such as toileting and other activities of daily living. Residents, staff and families were relaxed and forthcoming during the short, informal interactions. When we checked confidentially with staff, they did not indicate that fear of speaking out was an issue, nor had there been any previous bad experiences with researchers. No other barriers, such as cultural differences or communication difficulties seemed to be present. Staff seemed to find the project interesting and were not hesitant to participant in the observational portion of the study. After checking other potential reasons for not participating we concluded that time was indeed the factor preventing staff participation.
The research team had to get creative, given that the standard interview recruitment was not yielding the response rates required. The study had gathered only seven interviews with health care aides (HCAs) and two with nurses. The aim was approximately 25 interviews. Recruitment required a new approach. The team had to rethink and anticipate what might encourage the busy staff to participate meaningfully in the study was undertaken. It was imperative to keep participation time short and during staff break times so that responding to the study would not impinge on resident care or personal time outside of work. The team considered the needs of the staff and conditions of the field environment and then sent a redesigned recruitment event through ethics approval.
Methods - Overview of the Research Event
The redesign involved drop-in events where staff could take a bit of time on their breaks to participate in the research study. The research team organized three drop-in sessions in the nursing home for HCAs and nursing staff to respond to seven research questions; questions that had originally formed the interview guide to be used in the face-to-face interviews. The drop-in sessions were organized to correspond with break periods on all three shifts: day (1-3 pm), evening (8-11 pm), and night (1-3 am). Potential participants were made aware of the research events for a month prior to the events via event posters throughout the care home in areas accessible to the staff but not residents or visitors (i.e. behind the nursing desks, in staff rooms, stairwells, etc.). One of the research assistants and a number of enthusiastic staff members announced verbal reminders leading up to the event and during the first hour of each event when participation was slower. To provide extra incentives to participate, to make the event festive, and to thank staff for participating, the project provided pizza, snacks, refreshments, small promotional items (pens, hand sanitizer, etc.) and gift cards. Coincidentally, the timing of the event was in December and the recreation room on the main floor of the care home where the event was held had Christmas decorations up, which helped to add a festive atmosphere.
Staff on each shift came to the event during their breaks. They sometimes came with colleagues, in twos or threes. It had been conveyed in advance from the researchers through the senior staff who promoted the event, that this was an optional event. When potential participants arrived, the research team emphasized the voluntary nature of the study along with the consent form, that if they wished at any point in the event, participants could simply take some food and choose not to participate, to end their participation in the middle, or to withdraw the answers they had already provided.
Staff who agreed to participate completed the consent and demographic forms, received seven 4”x6” blank post-it notes and a pen. The research questions were written on large posters and placed atop tables set up in a u-shaped formation, with chairs for participants to sit and write. Staff were encouraged to circulate around the tables, prepare a written response on the 4” x 6” post-it note and adhere it to the corresponding poster question. Refreshments were provided at an adjacent table. A third table was set up near the door to hold the forms and cards. Upon completion, staff were encouraged to have refreshments, take some promotional items, a thank you card and a gift card. Two research assistants were available to provide direction and support to staff as needed throughout the event. The research questions are provided in Table 1.
Table 1: Research Questions
1) What makes a good health care aid [HCA]?
2) What makes a good nurse?
3) What kinds of things do you do that makes a resident feel cared for?
4) How do you manage your feelings when you see or smell things in the course of providing care that some people might consider smelly or disgusting?
5) What frustrates you about your job?
6) Often when providing care, there will be several residents who require your attention all at the same time. How do you decide whom to respond to first?
7) What would be on your “wish list” if you could change anything to enhance the care of residents at (this PCH) or to enhance the workplace?
Most participants took 2-3 minutes per question to read and prepare a response. At times, staff were observed to read existing peer written responses on the posters prior to formulating their individual response. They talked amongst themselves initially during the process then settled into writing their individual responses to the questions. No expressions of confusion or uncertainty were noted. There were a few requests for clarity and most participants answered all of the research questions; few post-it notes were returned blank. Staff often waited for their colleagues to finish and left the room together.