Abstract
Clinical research improves patient care and is a government priority. We sought the opinions of genito-urinary medicine clinic staff regarding undertaking research, any barriers they perceived, and methods to optimise study recruitment. Questionnaires were offered to everyone working in the genito-urinary medicine clinic over a one-week period. In addition, four focus groups were held with genito-urinary medicine clinic staff. Forty-three questionnaires were completed. All respondents stated that research was important; however, 14.0% worried that it affected patient care and 16.3% would rather see patients without having to consider research. Doctors were more likely to enjoy discussing studies than other healthcare staff (p = 0.029) and were less likely to think that too many studies were being conducted at one time (p = 0.027). Forty staff attended the focus groups. Time, knowledge of studies, difficulty in broaching the topic of research and patient factors were cited as barriers to recruitment. Suggestions to improve recruitment included: greater multi-disciplinary team involvement; improving staff research knowledge; streamlining the research process; and patient education. Reasons for different attitudes between staff disciplines towards research included different training pathways and incentives to conduct research. The recommendations staff have made to help drive recruitment should be implemented in the genito-urinary medicine clinic.
Keywords
Introduction
Clinical research improves patient care and should be embedded in daily medical practice.1,2 There is currently a national drive to increase research activity to improve quality of care, particularly in clinical settings.2,3 However, there are several perceived barriers to undertaking research in a clinical setting. Previous studies have cited the main problems to be a lack of funding, time and resources in a currently financially overstretched health system.4–10 At a higher level, complex application systems and a disconnect between Trust R&D departments and the clinical research network further hamper the initiation of studies. 11
The specialty of genito-urinary medicine (GUM) has undergone huge change over recent years and the scope for research in this field is rapidly increasing. In a time of economic recession, it is even more important to use research to find better, more cost-effective ways of treating patients, 2 and to conduct research studies as efficiently as possible. Yet, there is a paucity of literature that reports on the barriers to research specifically in GUM clinics. Our clinic is research-active and, over recent years, has seen mixed results with respect to recruitment to different studies. When recruitment has proved difficult, studies have overrun their allocated time or participation has been lower than expected. We explored the opinions of some of the key players in GUM research – GUM clinic staff – to find ways to optimise study recruitment.
Aims and objectives
This study aimed to:
Examine the attitudes of members of a GUM multi-disciplinary team (MDT) towards conducting clinical research; Explore staff ideas about barriers to undertaking research; Gain recommendations from the team on how better to facilitate research in a GUM centre.
To our knowledge, this type of study has not previously been undertaken in a GUM clinic setting, nor with all members of the MDT.
Materials and methods
Participants
All staff members in the GUM centre over a one-week period were approached to take part in the questionnaire, excluding HIV nurses and research nurses. All staff (including HIV and research nurses) were invited to participate in the focus groups. The grade of staff was not recorded, and nurses and healthcare assistants (HCAs) were grouped together, to provide anonymity. There are 14 doctors, 17 GUM nurses, seven HIV nurses, five research nurses, three HCAs, eight health advisors (HAs) and seven members of the clinical support team (receptionists and administrators) in total working at the GUM centre.
Staff questionnaire
The staff questionnaire was developed by two consultants, two research nurses and a medical student. It was then validated by two GUM nurses before being disseminated to the rest of the team.
Focus groups
All staff members were invited to attend a focus group. Three focus groups were held in parallel during one morning, each consisting of at least one member from every staff discipline, excluding HAs. An additional group was held consisting of two HAs.
The groups were asked to focus their discussion around the following questions:
What are the barriers to carrying out research (in the GUM clinic)? Why might different staff disciplines have different views on research? What could be done to facilitate research (in the GUM clinic)?
Important points from the discussions were transcribed and discussed with all the groups together. Later, recurring themes were identified by the researchers. The focus groups were not recorded.
Statistical analysis
Pearson’s Chi square tests were used in Analyse-It for Excel to test for differences in attitudes to research between doctors and other staff disciplines.
Results
Staff questionnaire
Forty-three completed questionnaires were available for analysis. This is an 87.8% response rate of the total 49 staff members (excluding HIV and research nurses) at the GUM centre. Thirteen questionnaires (30.2%) were returned by doctors, 14 (32.6%) from nurses or HCAs, seven (16.3%) from HAs and seven (16.3%) from the clinical support team. Two questionnaires with missing job titles were returned; these responses were included in the overall analysis, but excluded from the analysis between staff disciplines.
Staff attitudes towards conducting research
Responses to staff questionnaire about attitudes towards research.
Differences in attitudes towards research between staff disciplines
Differences in attitudes between doctors and other staff disciplines in the GUM clinic (nurses, HCAs, health advisors and clinical support team) towards undertaking research.
*Pearson’s Chi square test.
GUM: genito-urinary medicine.
Focus groups
Forty staff members participated in focus groups: 11 (27.5%) were doctors, 22 (55%) were nurses or HCAs, five (12.5%) were members of the clinical support team and two (5%) were HAs.
The following themes emerged from the focus group discussions.
Barriers to carrying out research
Lack of time: Staff felt that time pressures in the clinics often precluded them from conducting research; they felt that adding more discussion points to a consultation that is already running late created a stressful clinical environment and might not be appropriate for the patient. Lack of knowledge: Staff perceived a lack of personal knowledge about specific studies and their eligibility criteria to be an important barrier, making it difficult to have clear discussions with patients about studies. In addition to this, a lack of knowledge about research methodology in general meant that many staff members were not comfortable in explaining the principles of research and ethics to patients. The way in which information was communicated to staff about studies was through a pre-study meeting which everyone was invited to. However, it was at a time that not all staff members could always attend, and some staff members felt that the brief meeting was not enough for them to completely grasp the methodology and purpose of the study. Broaching the topic of research: Staff gave several reasons why they may feel unwilling to initiate conversations about research with patients. Patients may attend clinic feeling embarrassed or distressed; staff felt that suggesting participation in a research study at these times would sometimes be inappropriate. ‘Information overload’ was a concern among staff members; if they perceived this to be a risk, then their priority was to focus on information about the patient’s reason for attending rather than research information. Reception staff reported that in mentioning certain studies to patients, it might appear that they are making assumptions about patients’ sexual behaviour; for example, if a study was being conducted only in men who have sex with men. Patient factors: Patients may be unwilling to consider research at their initial appointment. It was felt that patients consider the GUM clinic as a ‘one-stop shop’, thereby preventing them from considering participation in research studies that would require them to return to the clinic. Vulnerable, distressed or non-English speaking patients were cited as patients for whom staff often felt that research is inappropriate.
Reasons for different attitudes towards conducting research between different staff disciplines
Incentives: Doctors were perceived to have more incentives to conduct research; they often have more defined roles in the conduct of a study and dissemination of data. They are more likely to attend conferences, be an author on publications and research is seen as an enhancement of their work portfolio. Training differences: Doctors are more likely to encounter research opportunities and training earlier in their careers than other staff disciplines. Ongoing education in research methodology, ethics and an emphasis on the importance of research is evident throughout their continuing professional development. Different patient groups: It was mentioned that HAs often deal with patients with complex problems, for whom research may not be appropriate.
Methods to facilitate carrying out research in the GUM clinic
Increase MDT involvement in research studies: Ideas included (i) increased feedback from researchers to the MDT and vice versa on study progress and any associated problems; (ii) having one study ‘champion’ from each staff discipline to promote every ongoing study and (iii) organising a visit to the department’s research unit as part of staff induction to help reinforce the idea that research is an integral part of work for all staff members. Improve understanding of research: Research training days were suggested as a method to improve general staff awareness of research methodology. Methods suggested to improve understanding of specific studies included a pre-study meeting for the MDT to explain the purpose and methods of the study, and short summaries available in each clinic room with clear information and exact wording that can be used to explain the purpose of the study to patients. Streamline recruitment process: Ideas included a clinic coordinator identifying patients who may be eligible for research, and including a tick-box prompt on the patient clerking proforma to remind clinicians to assess whether the patient is eligible for any studies. Normalise research for patients: Posters in the waiting room and notices on the website explaining and encouraging participation in research studies were suggested to promote the idea of research in GUM clinics to patients.
Discussion
All members of the MDT in the GUM clinic agreed that research is important. However, it emerged that doctors have more positive views than colleagues from other disciplines about conducting research, and are more likely to perceive that staff, in general, are happy to carry out research. This may mean that doctors have unrealistic expectations of the level of enthusiasm other staff members have about research. The results from the focus groups found that staff members believe this difference in attitudes to be due to a difference in the incentives to conduct research and the level of training in research skills between disciplines.
Greater emphasis in now being placed on research in nursing education10,12 and involvement of the whole MDT in research. 13 Providing all staff members with similar incentives and research training as doctors may foster more enthusiasm for conducting research.10,12,13 Non-doctor personnel need to be more involved in the planning and conduct of a study and may require additional support and training.14,15
Lack of time and lack of knowledge were cited as the main barriers to recruiting patients to studies, which is consistent with many previous studies in non-GUM specialties.4–7 One new finding was that difficulty in finding ways to broach the topic of research with the patient was cited as a barrier. Patients may not associate attendance at a GUM clinic with research and as they hope not to return to the clinic, may decline participation on this basis. 16 Patients often experience high levels of anxiety in GUM clinics 17 are attending for sensitive reasons and may have other vulnerability factors. Despite these factors, research has shown that patients often maintain high levels of interest in participating in research, strengthening the argument for better and more thorough patient education.16,18
The main limitation of this study was the small sample size, representing a single centre; therefore, the results may not be generalisable to other centres in the country, and similar studies should be conducted elsewhere. A possible confounder was a difference in work exposure between doctors and other healthcare staff: the doctors in our centre also provide HIV care and are used to discussing the numerous clinical trials undertaken in the HIV department. This may have counted for their more positive attitudes towards research in GUM. However, as research nurses and HIV nurses were included in the focus groups, this would not fully account for the difference.
Ten top tips to facilitate recruitment to research studies in the GUM centre.
Conclusion
Research remains an important part of our working lives and to improve patient care, it is vital we continue to conduct well-designed studies. GUM clinics should look closely at how best to involve all members of the MDT in the conduct of studies to facilitate clinical research in their departments.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.