A nurse's primer on recruiting participants for clinical trials

Documenting patients’ and providers’ preferences when proposing a randomized controlled trial: a qualitative exploration

Background

With advances in cancer diagnosis and treatment, women with early-stage breast cancer (ESBC) are living longer, increasing the number of patients receiving post-treatment follow-up care. Best-practice survivorship models recommend transitioning ESBC patients from oncology-provider (OP) care to community-based care. While developing materials for a future randomized controlled trial (RCT) to test the feasibility of a nurse-led Telephone Survivorship Clinic (TSC) for a smooth transition of ESBC survivors to follow-up care, we explored patients’ and OPs’ reactions to several of our proposed methods.

Methods

We used a qualitative study design with thematic analysis and a two-pronged approach. We interviewed OPs, seeking feedback on ways to recruit their ESBC patients for the trial, and ESBC patients, seeking input on a questionnaire package assessing outcomes and processes in the trial.

Results

OPs identified facilitators and barriers and offered suggestions for study design and recruitment process improvement. Facilitators included the novelty and utility of the study and simplicity of methods; barriers included lack of coordination between treating and discharging clinicians, time constraints, language barriers, motivation, and using a paper-based referral letter. OPs suggested using a combination of electronic and paper referral letters and supporting clinicians to help with recruitment. Patient advisors reported satisfaction with the content and length of the assessment package. However, they questioned the relevance of some questions (childhood trauma) while adding questions about trust in physicians and proximity to primary-care providers.

Conclusions

OPs and patient advisors rated our methods for the proposed trial highly for their simplicity and relevance then suggested changes. These findings document processes that could be effective for cancer-patient recruitment in survivorship clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01549-1.

Ethical Challenges Encountered by Clinical Trials Nurses: A Grounded Theory Study

OBJECTIVES

To investigate the ethical challenges experienced by oncology clinical trials nurses (OCTNs) during the management of CTs and to examine how they resolve those conflicts.

SAMPLE & SETTING

12 licensed RNs who had been practicing as full- or part-time OCTNs for a minimum of two years at various academic medical centers in the United States.

METHODS & VARIABLES

Classical grounded theory (CGT), an inductive methodology used to explore a social process in which little is known and to develop a theory grounded in the data, was used, in addition to CGT data analysis strategies.

RESULTS

CGT data analysis revealed the OCTNs' main concern (implementing an undefined job) and the way in which the OCTNs resolve this concern through the process of figuring it out. Figuring it out consists of learning as they go, utilizing their assets, standing their ground, and managing hope.

IMPLICATIONS FOR NURSING

Although some nursing research provides examples of ethical challenges OCTNs might encounter in practice, there is little information regarding how nurses manage those encounters. A theoretical understanding of the OCTNs' experiences managing ethical challenges fills a gap in the nursing literature and provides a framework for how OCTNs manage and respond to challenges in professional practice.

The State of Lupus Clinical Trials: Minority Participation Needed

In the United States, the reported prevalence of lupus is 100,000 to 500,000 patients. Lupus disproportionately affects minority populations, including African Americans and Latinos, and the associated health disparities are substantial. Women are at a higher risk of lupus than men and lupus prevalence is the highest in African Americans and Latinos compared to non-Hispanic whites. African Americans and Latinos also have increased disease symptom severity, experience more lupus-related complications, and have a two- to three-fold mortality rate compared to non-Hispanic Whites. Lupus clinical trials offer opportunities for quality care and can result in new treatment options, but African Americans and Latinos are underrepresented in clinical trials because of substantial patient- and provider-side barriers. In conjunction with the limited knowledge of clinical trials that potential participants may have, the healthcare staff approaching participants have limited time to adequately educate and explain the aspects of clinical trials. Indeed, ninety percent of clinical trials fail to meet their recruitment goals on time, so a multi-faceted approach is necessary to address the issue of low minority participation in clinical trials.

Social Determinants of Health: A Framework for Studying Cancer Health Disparities and Minority Participation in Research

The theory of social determinants of health (SDH) posits that the health of people and communities is affected by social and economic factors (i.e., economic stability, education, neighborhood and built environment, health and health care, and social and community context). These interrelated constructs may negatively affect minority patients’ ability to participate in cancer research. Understanding SDH can help nurse researchers assess and address barriers to research participation, as well as design trials to improve minority patients’ cancer-related health.

Barriers to participation in a randomized controlled trial of Qigong exercises amongst cancer survivors: lessons learnt

BACKGROUND

Clinical trials on cancer subjects have one of the highest dropout rates. Barriers to recruitment range from patient-related, through institutional-related to staff-related factors. This paper highlights the low response rate and the recruitment barriers faced in our Qigong exercises trial.

MATERIALS AND METHOD

The Qigong trial is a three-arm trial with a priori power size of 114 patients for 80% power. The University Malaya Medical Centre database showed a total of 1,933 patients from 2006-2010 and 751 patients met our inclusion criteria. These patients were approached via telephone interview. 131 out of 197 patients attended the trial and the final response rate was 48% (n=95/197).

RESULTS

Multiple barriers were identified, and were regrouped as patient- related, clinician-related and/or institutional related. A major consistent barrier was logistic difficulty related to transportation and car parking at the Medical Centre. conclusions: All clinical trials must pay considerable attention to the recruitment process and it should even be piloted to identify potential barriers and facilitators to reduce attrition rate in trials.

Psychosocial barriers and facilitators to clinical trial enrollment and adherence for adolescents with cancer

Adolescents (aged 15-19 years) have not experienced the same survival gains as children and older adults diagnosed with cancer. Poor clinical trial enrollment and adherence rates among adolescents may account for some of this disparity. Although biological, regulatory, systemic, and practice-related challenges to clinical trial enrollment and adherence have been examined, studies of psychosocial factors, which can serve as barriers or facilitators to enrollment and adherence, are limited. To bring attention to these psychological factors, we reviewed existing literature on psychosocial barriers and facilitators that can affect an adolescent's decision to enroll and adhere to a clinical trial. We also provide potential strategies to address psychosocial factors affecting clinical trial accrual and adherence.

The clinical trials nurse as subject advocate for minority and culturally diverse research subjects

Minority involvement in clinical trials is necessary to promote diversification in health-related research. The clinical trials nurse is uniquely qualified to advocate for and ensure the success of the minority participant in clinical trials research during the processes of recruitment, informed consent, and retention of subjects. This article incorporates a review of literature in conjunction with the American Nurses Association's standard of practice number 7 regarding ethics to demonstrate how the role of the clinical trials nurse as subject advocate can facilitate successful participation of minorities in clinical trial research.

The impact of a community-based clinical trial educational intervention among underrepresented Chinese Americans

BACKGROUND

Clinical trials are a critical resource for the discovery of new prevention, diagnostic, and treatment methods for cancer. The most effective prevention and treatment modalities are based on previous clinical trial results. However, participation in clinical trials is underrepresented by racial/ethnic minority populations, Asian Americans in particular. Asian Americans are the least represented of any ethnic groups in clinical trials. The purpose of this study is to develop and evaluate a culturally and linguistically appropriate community-based educational intervention to increase knowledge of and intent to participate in cancer clinical trials among underrepresented Chinese Americans.

METHODS

Community-Based Participatory Research approach was used to guide the development, cultural tailoring, implementation, and evaluation of clinical trial intervention. First, 22 Asian community representatives were recruited as community health educators (CHE) who received 12-hour training on clinical trial education. Second, 262 members were recruited from 11 Chinese community organizations. Of those recruited, a total of 247 eligible Chinese enrolled and participated in the clinical trial education delivered by trained CHEs. Participants completed pretest before and posttest after the intervention.

RESULTS

Fifteen of 21 measures of clinical trial knowledge showed significant changes post the intervention (P < 0.05). Education remained the sole demographic factor increasing clinical trial knowledge in multivariate analysis.

CONCLUSION

Clinical trial education should emphasize both benefits to science and the larger Asian community. This community-based clinical trial intervention demonstrated promising results and has potential to enhance recruitment and participation in clinical trial research among the underrepresented Asian Americans.

IMPACT

Improving clinical trial participation in the fast-growing Asian American population is key to dissemination of health innovations targeted to diminish health disparities.

From information processing to behavioral intentions: exploring cancer patients' motivations for clinical trial enrollment

OBJECTIVE

To investigate cancer patients' motivations for clinical trial enrollment, this study tests the proposition that a model of Risk Information Seeking and Processing (RISP) could serve as an antecedent to the Theory of Planned Behavior (TPB).

METHODS

With data from a telephone survey, we examined whether components of the RISP model had significant impact on belief-based attitudes and behavioral intentions.

RESULTS

Risk judgment and affective responses, especially optimistic feelings, consistently related to attitudes and behavioral intentions. Trust in doctors also significantly related to our respondents' positive attitudes toward clinical trials.

CONCLUSION

The RISP model might have more constrained applicability as compared to the TPB in explaining cancer patients' motivations for clinical trial enrollment. However, certain components of the RISP model seemed to contribute to our respondents' attitude formation as interesting additions to the TPB.

PRACTICE IMPLICATIONS

Communication about clinical trials is a balance act between providing sufficient information about the potential risks and benefits involved in a clinical trial and managing emotional responses that cancer patients associate with participation. Both acts contribute to the formation of positive attitudes toward clinical trials among cancer patients, which is the driving force behind their intentions for clinical trial enrollment.

Validating a measure to delineate the clinical trials nursing role in Italy

In Italy, the role of a nurse in cancer research is beginning to develop, but instruments developed to delineate the dimensions of the Italian clinical trials nursing role are lacking. This study aimed to translate into Italian the Clinical Trials Nursing Questionnaire (CTNQ) and assess its content validity, internal consistency, and stability reliability. Forward-backward translation and review by experts were performed to assess linguistic and content validation. Internal consistency reliability was computed using Cronbach alpha and by administering the translated CTNQ to a sample of 30 research nurses coming from different Italian districts. To determine the test-retest reliability, a copy of the questionnaire was given again to a subgroup of 10 research nurses. The pretest and posttest scores were compared using kappa coefficient. The comparison of the target language version with the original version allowed us to consider the translation of CTNQ as acceptable. The analyses revealed a Cronbach alpha coefficient of .98 for the frequency scale and .96 for the importance scale. The overall kappa coefficient was 0.98 for the frequency scale and 0.99 for the importance scale. The CTNQ is a valid and reliable instrument for the assessment of the research nurse's role in Italy.

Patient understanding of research: developing and testing of a new questionnaire

Lack of understanding or knowledge of research among patients participating in randomized clinical trials (RCTs) is common. However, there is a lack of validated measures to assess the extent of the problem. The aim of this study was to develop and pilot a questionnaire to assess knowledge and understanding of RCTs in the cancer setting. A 13-item four-part questionnaire was developed and piloted with three groups: patients with cancer who had no experience of clinical trials (n=26); patients with cancer who had previously participated in an RCT (n=26) and research nurses (n=26). The groups were compared using non-parametric anova techniques which showed a highly statistically significant difference between the nurses and both patient groups (P<0.001). The difference between the patient groups was not significant (P=0.231). Cronbach's alpha was computed at 0.77. After studying correlation of individual questions and verbatim comments from respondents, one question was removed from the questionnaire, but this did not have a major effect on the properties of the tool. Minor changes were made to six other questions and the revised tool will now be used and further tested in a large randomized controlled trial to improve informed consent in trial participation.

Clinical nurse specialist influence in the conduct of research in a clinical agency

Clinical nurse specialists (CNSs) have a unique view and understanding of patients in their environment and are a valuable resource that has not been adequately engaged in research, even when CNSs assist researchers in the conduct of research. The purpose of this article is to outline activities for supporting the conduct of research that capitalize on the clinical strengths of the CNS from an ecological framework. To illustrate the contributions of CNSs in the conduct of research, 3 clinical research studies are described. Discussion of these studies within the context of an ecological framework offers a systematic approach to describing the potential involvement of the CNS in the implementation of nursing research.

Recruiting participants to cancer prevention clinical trials: lessons from successful community oncology networks

PURPOSE/OBJECTIVES

To describe the organizational designs and task environments of community oncology networks with high accrual rates to cancer prevention clinical trials.

DESIGN

Replicated case study design; structural contingency theory.

SETTING

Local Community Clinical Oncology Programs (CCOPs) funded by the National Cancer Institute to test preventive and therapeutic interventions in community settings.

SAMPLE

Primary sample: oncology professionals affiliated with four CCOPs ranking among the top 10 in earned cancer control accrual credits in fiscal years 1999-2003. Secondary sample: oncology professionals affiliated with three CCOPs ranking among the top 10 three to four times during the study period. A total of 63 people participated in the interviews.

METHODS

Primary sample: on-site interviews with CCOP investigators, clinical research staff, and nononcology physicians. Secondary sample: telephone interviews with each CCOP's nurse administrator and at least one prevention research nurse.

MAIN RESEARCH VARIABLES

Staffing patterns, organizational processes, recruitment strategies, and environmental characteristics.

FINDINGS

All of the CCOPs employed dedicated prevention research staff. Recruitment through media publicity, mass mailings, or group information sessions worked best when prevention trials had flexible eligibility requirements and evaluated interventions with few health risks. Prevention trials evaluating agents with known toxicities in high-risk populations required more targeted recruitment through cancer screening programs, physician referral networks, and one-on-one discussions with protocol candidates.

CONCLUSIONS

High-performing CCOPs configured their structures, processes, and recruitment strategies to fit with accrual goals. They also benefited from stable and supportive task environments.

IMPLICATIONS FOR NURSING

Nurse-coordinated research networks have great potential to generate new knowledge about cancer prevention that can reduce cancer incidence and mortality significantly.

A Comparison of Methodologies from Two Longitudinal Community-Based Randomized Controlled Trials of Similar Interventions in Palliative Care: What Worked and What Did Not?

BACKGROUND

Methodological challenges such as recruitment problems and participant burden make clinical trials in palliative care difficult. In 2001-2004, two community-based randomized controlled trials (RCTs) of case conferences in palliative care settings were independently conducted in Australia--the Queensland Case Conferences trial (QCC) and the Palliative Care Trial (PCT).

DESIGN

A structured comparative study of the QCC and PCT was conducted, organized by known practical and organizational barriers to clinical trials in palliative care.

RESULTS

Differences in funding dictated study designs and recruitment success; PCT had 6 times the budget of QCC. Sample size attainment. Only PCT achieved the sample size goal. QCC focused on reducing attrition through gate-keeping while PCT maximized participation through detailed recruitment strategies and planned for significant attrition. Testing sustainable interventions. QCC achieved a higher percentage of planned case conferences; the QCC strategy required minimal extra work for clinicians while PCT superimposed conferences on normal work schedules. Minimizing participant burden. Differing strategies of data collection were implemented to reduce participant burden. QCC had short survey instruments. PCT incorporated all data collection into normal clinical nursing encounters. Other. Both studies had acceptable withdrawal rates. Intention-to-treat analyses are planned. Both studies included sub-studies to validate new outcome measures.

CONCLUSIONS

Health service interventions in palliative care can be studied using RCTs. Detailed comparative information of strategies, successes and challenges can inform the design of future trials. Key lessons include adequate funding, recruitment focus, sustainable interventions, and mechanisms to minimize participant burden.

Improving enrollment in cancer clinical trials

PURPOSE/OBJECTIVES

To identify successful strategies for clinical trial recruitment.

DESIGN

Survey research.

SETTING

New Jersey institutions actively recruiting patients for clinical trials.

SAMPLE

84 clinical research nurses directly involved with patient recruitment were surveyed, and 50 responded (60% response rate).

METHODS

Focus group; 34-item, direct mail questionnaire; follow-up telephone interviews; and descriptive statistics.

MAIN RESEARCH VARIABLES

Strategies for patient recruitment and retention.

FINDINGS

Respondents agreed most strongly about the importance of emphasizing to patients that treatment would not be compromised and keeping physicians informed of available protocols. Respondents felt the most effective strategies for increasing public awareness of clinical trials were to highlight participants in past trials and to stress the value of clinical trials through campaigns sponsored by nonprofit organizations. Compared to other respondents, those from cancer centers were significantly less concerned about educating physicians on the value of clinical trials. Focus group and telephone interview participants reported that patient retention in cancer trials was a lesser issue because enrollees tend to be motivated to continue.

CONCLUSIONS

Successful recruitment may depend on how a patient is approached about participation, keeping physicians abreast of available trials, and the level of awareness the public or a patient has about clinical research prior to considering it as a treatment option.

IMPLICATIONS FOR NURSING

Research nurses often are the first to interact with patients considering clinical trial participation and remain involved throughout the trial experience. Depending on the research setting, they are likely to be more informed about available protocols than physicians. Research nurses are in a position to build rapport with and advocate for patients. Strategies to increase enrollment and retention should actively involve these key personnel.