Lead With the Why: Research Recruitment of Older Adults With HF During COVID-19.

Recruitment of older adults with advanced heart failure is notoriously challenging, particularly for doctoral students conducting dissertation research studies with limited financial and personnel resources. Successful recruitment of participants requires a multifaceted recruitment strategy that is mindful of context and sensitive to the clinical partners who provide care in the recruitment setting. This article reflects on these challenges and proposes a practical framework to guide recruitment strategies in future research.

Following the death of both my close friend and my aunt from septic shock within a short time span, I became passionate about caring for patients and families facing critical illness. In my 5 years as a nurse in an intensive care unit, I cared for critically ill patients suffering from acute exacerbations of chronic diseases such as heart failure (HF), often resulting in long-term hospitalization, suffering or death. Many of these patients experienced chronic physical, psychological, social, and existential suffering throughout their disease trajectories.

As a nurse, I was uniquely positioned to identify the palliative-care needs, and I noticed that many patients with advanced HF, particularly those who were physically frail, had been experiencing these needs before hospitalization. Unfortunately, many opportunities to integrate palliative care earlier in the disease trajectory of these patients with chronic diseases were missed due to poor integration of palliative care into the community setting. I found myself deeply moved and distressed by the lack of evidence-based ways to provide early palliative care for people with serious chronic illnesses. Therefore, I decided to pursue a Ph.D. in nursing to become an independent nurse scientist so I could develop skills that would address these gaps. My dissertation research study aims to investigate the palliative-care needs of community-dwelling people with advanced HF and physical frailty.

One of the most important and nuanced skills I am currently developing as I conduct my dissertation research is participant recruitment. A robust approach to recruitment is critical in order to power research studies and provide recommendations grounded in data. Older adults with advanced chronic conditions such as HF can be difficult to recruit for research studies due to symptom severity and cognitive impairment, often leading to under-representation of older adults in HF research. However, older adults account for 80% of the 6 million people with HF, and HF is the leading cause of hospitalization for older adults in the United States. Therefore, it is critical to develop and use effective recruitment strategies in order to understand the impact of HF on the lives of older adults and to improve the care of those with HF.

Existing resources such as the Recruiting Older Adults into Research by the National Institute on Aging provide excellent recruitment resources for researchers and potential participants. However, the COVID-19 pandemic has created unique obstacles and challenges. During the pandemic, personnel restrictions created significant barriers for in-person recruitment by clinical researchers and halted some research studies entirely. When launching recruitment for my dissertation research study during the height of the pandemic, these restrictions required me and my mentorship team to iterate and innovate new strategies. As I approach the home stretch of recruitment, I want to share several key takeaways I've learned while recruiting older adults with advanced HF during a global pandemic.

Lead With the Why

While recruiting participants several years ago as a new Ph.D. student and research assistant at an HF clinic, I found myself frustrated by the lack of interested participants. Even more strongly during a pandemic, participation in research outside of COVID-19 has been a low priority for many. When reflecting on this challenge with a colleague who works in sales, he shared advice from business guru Simon Sinek, which transformed my recruitment strategies then and now: “Start with your WHY.” Sinek explains this approach, saying,

When most organizations or people think, act or communicate, they do so from the outside in, from WHAT to WHY.… We say WHAT we do, we sometimes say HOW we do it, but we rarely say WHY we do WHAT we do.… When communicating from the inside out, however, the WHY is offered as the reason to buy and the WHAT is serve as the tangible proof of that belief.

Although research recruitment does not attempt to “sell” anything, the heart of this model can be easily adapted to transform recruitment experiences for researchers and participants alike. For researchers, we need to connect with our participants by sharing WHY this research is so important to us and to those we hope to impact. Although I've cared for many people with HF, I am not an expert on what the actual experience of living with HF is like; my participants are the experts! For my study, I emphasize how sharing their expertise in my research study will, I hope, help to shape the future care we will provide. Sinek's approach adapted as a research recruitment framework may look something like that found in Fig. 1 .

Fig. 1

Practical Framework to Guide Research Recruitment of Older Adults with Heart Failure.

One Strategy Won't Fit All

If I could use 1 word to capture the essence of my Ph.D. research experience, it would be iteration. As the source of some of my greatest frustration and most fruitful growth, iterating ideas characterizes my daily work. Recruitment strategies are no exception. The COVID-19 pandemic forced me to think outside of my flyer-focused box due to personnel restrictions in the clinic where I planned to recruit. As a 1-person study team with limited funds for recruitment, this was a particularly unique challenge. However, it turned out to be one of the most valuable learning experiences during my Ph.D. education so far.

After lots of brainstorming and iterating with my advisors and Ph.D. colleagues, I partnered with the MyChart recruitment team at my institution to develop an online recruitment strategy using the electronic health record (EPIC) patient portal called MyChart. Key elements of success included strategic design of my data-management system, strong recruitment messaging (Fig. 1), and thorough testing of my recruitment pitch with people similar to my potential participants (thanks, Grandma!). However, this strategy would not work for all of my participants, which is why I use in-person recruitment, flyers, provider referral and online recruitment to reach as many participants as possible. It is critical to investigate how potential participants currently engage with information in order to tailor strategies for the population of interest. Additionally, reviewing the literature regarding best practices and strategies for participant recruitment in the population with HF provided actionable suggestions to strengthen my existing plan. For older adults with HF, some evidence-based strategies include involving recruitment and retention experts in the development of recruitment strategies, testing recruitment protocols and engaging HF clinicians at recruitment sites. Once strategies have been selected, streamline and simplify the recruitment process through iteration, testing and lots of practice! (Fig. 1)

Consider the Context

As one critic of Sinek's model pointed out, the “who” is also a critical component of any approach in business. In research, we must clearly understand our population of interest and any facilitators and barriers to recruiting potential participants (Fig. 1). In my case, there are 2 main barriers to recruitment: mistrust of researchers and HF symptom severity.

I needed to understand the repercussions of several historical instances of unethical research practices in my city, particularly among Black participants. In Baltimore City, people's deep-seated mistrust of researchers has the potential to impact my recruitment strongly. As a white researcher, it is critical for me to acknowledge and understand the origins of this mistrust and develop a culturally sensitive recruitment strategy. I completed several courses focused on research ethics and pursued mentorship from researchers with experience in recruiting among Black populations. This resulted in several key elements I include in my recruitment protocol. I always start recruitment interactions by having a provider introduce me and building rapport with the participant, a skill I learned in my work as an ICU nurse. While telling them about the study, I strongly emphasize the voluntary nature of participating in the research study and how we protect the participants’ data.

The HF clinic where I recruit caters to patients recently discharged from an HF hospitalization. Oftentimes, these patients continue to experience burdensome HF symptoms that interfere with their ability to participate in research. For example, several patients were too fatigued or short of breath to participate. Others experienced moderate cognitive impairment and could not answer the survey questions. For participants with burdensome symptoms, I asked if I could contact them at a later time when they were feeling better or send them the survey electronically to complete at their convenience.

The second essential part of the “who” are the HF clinicians and staff in the clinic where I recruit. Every clinical setting is unique in its complex environment, which consists of clinical personnel, patients and caregivers, physical space, volume of research studies recruiting from the clinic, and overall posture of the staff and institution toward participation in clinical research (Fig. 1). Clinical personnel will understand this complex interaction of factors, but research assistants and principal investigators must be mindful of the clinical staffs’ primary role–to care for patients and caregivers. Exploring the relevance of the research purpose to the clinic priorities provides opportunities to establish rapport and promotes “buy-in” of clinical partners. Aligning the “why” of the research with priorities of clinical partners was key in promoting collaboration with the clinic and access to potential participants.

In my experience as a research assistant and Ph.D. student, establishing relationships with the clinic personnel and observing the flow in the clinic over 3 years of recruitment for various studies allowed me to tailor my recruitment strategies to fit the context of the clinic. I regularly check in with the nurse practitioners, nurses and medical assistants to discuss any changes needed to accommodate their schedules.

During the period of time when research teams were not allowed in the clinic due to COVID-19, I met with clinic providers to understand their current modality of interaction with patients and, subsequently, I adapted my recruitment strategy. When in-person clinic visits were sparse, I focused on building a data-management workflow amenable to online or in-person data collection and primarily recruited potential participants by using the MyChart patient portal. As more patients returned to the clinic, I partnered with a clinic nurse and medical assistant to ask patients to fill out my eligibility form and provide contact information for me to follow up via phone or e-mail. The sample-size goal for this study is 250 participants. In 8 months of recruitment, we have enrolled more than 260 patients! This would not have been possible without partnership and collaboration among the research and clinical teams.

Conclusion

Conducting my dissertation research study during a global pandemic reinforced the importance of iteration, collaboration and perseverance. Recruitment of older adults with advanced HF requires a multifaceted recruitment strategy that is mindful of context and sensitive to the clinical partners who provide care in the setting of recruitment. I've grown to appreciate the art and science of recruitment in this population–most of the time. I am especially grateful to the participants I've met, my mentorship team and the amazing HF clinic for their collaboration and kindness. As I establish my research career, I will use insights learned from this experience to inform my future recruitment strategies and continue to tailor this simple framework so others may try it.