Problem

Most health services research is conducted, or at least coordinated, by university departments, whereas the research participants (staff and/or patients) are recruited by the health service. This can create immense operational difficulties for the coordinating research team, particularly when the trust is not a local one.

Solution

A trust liaison person is needed. This person facilitates the operation of the study in the trust and acts as a contact point. The person needs to be enthusiastic, proactive and well known within the trust, as well as efficient and persuasive. Such people are difficult to find. Senior staff commonly fulfil these criteria, but they are frequently too busy to help and are not readily available to the research team. On the other hand, junior staff might not have enough influence among their colleagues. In spite of these difficulties, getting the right person on board is key to the smooth running of a study.

Problem

Any study requires a certain amount of telephone research, particularly in the planning stage, to make useful contacts and to raise the profile of the study. Reaching key people by telephone can be extremely time-consuming. Wards are busy and occasionally chaotic places and for clinicians patients’ needs are priority, not research. Consequently it can take around four phone calls to achieve one successful conversation with a busy ward manager. It can also be surprisingly difficult to find out who works where. Staff lists are often essential for a study, but can be extremely fluid, both for doctors and nursing staff. Owing to prevailing conditions, trusts sometimes rely heavily on locum and agency staff, making running a study highly problematic, since these people are often not informed about the research and are unlikely to have much interest in facilitating it. Face-to-face visits were the most effective method of raising the profile of our project, but they can be time-consuming, especially when long distances are involved.

Solution

Sufficient time should be allocated to the preparation stage for key contacts to be made. Personal visits by the liaison person to key staff can shorten this period. They must have comprehensive knowledge of the study in order to be able to impart information confidently.

It is useful to make sure that up-to-date staff lists are available and that any temporary staff are aware of the study. Telephone enquiries, as well as brief informative leaflets and large notices for ward offices, are a good idea.

It is often easier to attend local meetings (such as acute care forums) to get the message across rather than have individual meetings with busy staff (although this contact, if feasible, is invaluable).

Problem

In order to persuade a National Health Service (NHS) organisation to take on a project the research team needs to effectively ‘sell’ the benefits of the study both for the service and the patients.

Solution

This does require a degree of zeal on the part of the research team and it helps to have researchers with some knowledge of the stresses and time pressures experienced by the NHS staff. Basic marketing strategies such as designing a project logo or a slogan that can be used, for example on stationery, are useful. This makes the study immediately identifiable among the many project requests, letters and other mailings that trust employees receive. Pharmaceutical companies are expert in these techniques and may be able to share some ‘tools of the trade’ (e.g. by running a short seminar on ideas and techniques needed to ‘sell’ concepts to mental health trusts). We feel that this can be done without compromising the independence of the study.

Problem

It is usually necessary to obtain honorary contracts for researchers who are not employed by the trust where the research is to be carried out. This can be very time-consuming, especially when Criminal Records Bureau checks need to be made, and can hold up the launch of the study.

The Solution

This must be completed at the preparation stage, since the study cannot legally commence until all research staff have an honorary contract.

Problem 1

In order for the study to run smoothly, as many people as possible in the trust must be aware of its aims and objectives. It is often difficult to determine at which level this profile-raising exercise should be aimed. Should the information be targeted at those actually taking part in the study, or at senior management, with the hope that there will be efficient dissemination of information down the chain? The bottom-up approach is labour-intensive since there are far more people to speak to, and lower-grade staff often do not have protected time for such matters. A top-down approach can also be problematic since enthusiasm and consent to proceed from senior members of staff do not automatically translate to junior clinicians.

Solution

A detailed strategy of the timing and manner of making contacts within the trust must be drawn up. This is important so as to involve, rather than antagonise people. The ideal solution is a top-down and bottom-up approach. Medical and nursing directors as well as clinical governance leads need to be contacted to obtain consent for the involvement of their trust. Contacts also need to be built with junior staff since they will be more directly involved and their enthusiasm is as much, if not more important. Operational staff often also believe that senior managers have unrealistic ideas about what life on the ground is like and what is actually possible. Middle management staff such as ward managers, senior nursing officers or professional development nurses are a good source of contact with junior nursing staff. Consultants can be a useful lead-in to junior doctors. It should be stressed that there is no substitute for personal contact with key collaborators and that relationships should be carefully nurtured.

Problem 2

Owing to pressures associated with timing of baseline and post-intervention data collection, respondents are often given limited time to complete and return their questionnaires. This can result in a low response rate and therefore results that cannot be related to a wider population.

Solution

It is vital that enough time is allowed for participants to respond and for reminders to be sent out. Two reminders sent 2 weeks apart is usually sufficient.

Problem

Proper delivery of the study is impossible without an intimate knowledge of the structure of each trust, particularly with regard to clinical governance mechanisms. This knowledge is also important at the planning stage, but trusts can be reluctant to provide this information until extensive details about the research have been provided.

Ethical and research governance issues may also hinder the flow of information from the trust. Data protection is often a factor here. Trusts vary in their willingness to provide identifiable data about staff and patients.

Solution

The study should be run pragmatically and a certain degree of heterogeneity in clinical governance mechanisms between centres should be accepted as inevitable. These differences should be absorbed into study procedures as quickly as possible, without causing difficulties for the trust or the participants. Participation must be made as easy as possible. Finding out about the structure of each trust will also help to decide which members of staff to target.

Problem

Most health services research requires NHS staff to perform some study-related tasks. No study can run smoothly unless they are prepared to take a certain degree of responsibility for the project. As it is, there is often confusion over who should be implementing the trial within the clinical governance group.

Solution

Root the study within the clinical governance structure. This often requires much ‘oiling of the wheels’, but it gives the researcher some control over the process. It also means that, in theory at least, the clinical governance committee can strongly engage and motivate staff to contribute to the research. This will depend, however, on the degree of the committee's involvement in the project. To this end, the study must be relevant to the local agenda.

To achieve that, it is useful to find out whether any similar projects are running locally, and if so, how they relate to your project. The degree of support your project will get from the trust can depend both on the number of projects that the trust is already running and the attitude of the staff involved.

If the clinical governance committee is not directly engaged, it can be effective to intervene at middle management level. For instance, suggest that consultants mention the project during teaching sessions with their juniors. Alternatively, all junior staff could be sent a brief letter explaining the trial, signed by the principal investigator.