[Benefit assessment in nursing research: illustrative examples and questions left unanswered]

Questions in nursing research are often studied in heterogeneous and instable fields such as nursing homes and use highly complex interventions. With the usual designs the mechanisms of their effects are difficult to evaluate. These interventions usually cannot be completely standardised. Comparison with 'care as usual' is hardly possible, since 'care as usual' can vary a lot. Moreover, the motivation to participate in a study with the chance of not getting an intervention is very low. Control groups with an active intervention, however, involve the risk that effects cannot be distinguished. This is why process evaluation and implementation research using multi-method approaches and triangulation are central to evaluating the effects of complex interventions. A solid theoretical foundation is the key to the proper interpretation of empirical results. (As supplied by publisher).

[Quantitative methodology and experimental studies 2/2]

Experimental studies potentially produce scientific evidence. To achieve this goal, it is necessary to pay particular attention to three elements essential for the validity of the study: randomisation, manipulation and control.

The importance of piloting an RCT intervention

The pilot study provides a unique opportunity to identify and prepare for the challenges of evaluating an intervention. Ultimately, it will enhance the scientific rigour and value of the full-scale study. Although some journals publish reports of pilot studies, little attention has been given to the types of research questions and issues specific to these studies. This article focuses on the utility of a pilot randomized controlled trial (RCT) as a first step towards conducting an RCT. Three major objectives of a pilot RCT are discussed: assessing the feasibility and acceptability of the intervention, assessing the feasibility and acceptability of the design and procedures, and facilitating the determination of effect sizes for use in sample-size calculations.

The soft option. Interview by Louise Hunt

A study is recruiting 310 children in hard water areas of England to test anecdotal evidence that water softeners reduce the symptoms of eczema.

Enhancing Recruitment and Retention in Randomized Clinical Trials of Cancer Symptom Management

PURPOSE/OBJECTIVES

To describe techniques to overcome challenges of collaborating with multiple clinical sites and participants to enhance recruitment and retention for cancer symptom management randomized clinical trials (RCTs).

DATA SOURCES

Personal experiences and publications related to recruitment and retention of sites and participants in RCTs, which were found by searching MEDLINE, CINAHL, and PsycINFO records.

DATA SYNTHESIS

Techniques to overcome challenges related to multisite research, patient confidentiality guidelines, and work with an at-risk population were identified and applied successfully in an RCT designed to modify fatigue during and following adjuvant breast cancer chemotherapy.

CONCLUSIONS

Successful recruitment and retention depended on the value that site personnel placed on symptom management research, identification of a designated contact person at each site, and flexibility in maintaining communication among the project director, contact individuals, and participants.

IMPLICATIONS FOR NURSING

Initial and ongoing collaboration with participants and a contact person at each site, assurance of privacy of protected health information, and emotional support are critical to recruitment and retention throughout cancer symptom management RCTs.

Implementing Randomized Assignment in a Nursing Clinical Randomized Control Trial

During the design phase of any research, an investigator addresses internal and external threats to validity and develops mechanisms to minimize these threats. Controlling for threats to study validity enhances the meaningfulness and generalizability of study outcomes. Representativeness of the study sample is one key design feature undertaken to ensure study validity; however, during clinical trials the investigator must stay attuned to ongoing situations that can alter sample representativeness. In the context of an ongoing nursing-led randomized control trial, threats to sample representativeness are discussed. These threats can occur in any study and may require modification of the study design to maintain validity of research outcomes. This article provides insight regarding threats to study validity encountered by one research team and the modifications undertaken to address them.

The role and potential contribution of clinical research nurses to clinical trials

AIMS AND OBJECTIVES

This study explores the scope and potential contribution of the Clinical Research Nurse (CRN) role to clinical trials of a nursing-specific topic.

BACKGROUND

Over the past two decades, there have been increases in the numbers of nurses working as CRNs because of the increasing global demand for clinical trials. CRNs can influence the quality of clinical trials but the scope and contribution of the role to clinical trials is not known.

DESIGN

Qualitative focus group study.

METHODS

A focus group interview was carried out with CRNs (n = 9) employed on a large, multi-centre (six NHS Trusts) randomized controlled trial of pressure area care. The focus group interview was recorded, alongside field notes of participant interactions and behaviours, and transcribed verbatim. Data were analysed for thematic content and process.

FINDINGS

CRNs described their transition to a clinical research role. They reported a lack of confidence, role conflict as researcher and nurse, the challenges of gaining cooperation of clinical nursing staff to comply with trial protocols and difficulties maintaining their own motivation. CRNs provided their perceptions and observations of pressure area care and prevention. They identified areas of inadequate treatment, management and care, influenced by organizational and clinical aspects of care delivery.

CONCLUSIONS

The study reveals challenges associated with training and management of CRNs. CRNs are usually associated with trial recruitment and data collection. This study highlights the additional contributions of CRNs for the study of topics specific to nursing as the result of their unique placement in the research centres as informal 'participant observers.' Such observations enhance understanding of the contexts being studied.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant to the design and conduct of research studies of nursing care and practice and present ways for investigators to optimize the skills and knowledge of nurses working as CRNs.

Home visiting for intervention delivery to improve rural family asthma management

The focus of this article is on the use of home visits in an asthma self-management intervention study with rural families who have a school-aged child with asthma. The study design involved randomization of the sample by elementary schools, then baseline (pretest) and postintervention data collection.(1) The purpose of this article is to describe challenges with, and pose solutions for, implementing home visits for asthma self-management in rural areas. Home visiting is a strategy for program delivery that takes advantage of the home context for tailoring services to address the family's individual needs. The advantages of intervening in the home include being able to (a) use actual home conditions for individualizing the asthma education to meet families' needs; (b) match home visitors with family in terms of ethnicity and language; (c) retain a high percentage of families over the year-long duration of the study; and (d) not add to family burden of managing asthma.

Retention of survivors of acute lymphoblastic leukemia in a longitudinal study of bone mineral density

Attrition in longitudinal studies of survivors of childhood cancer reduces these studies' statistical power, introduces bias and threatens internal and external validity. This study investigated the variables associated with dropout of survivors of acute lymphoblastic leukemia in a trial investigating the effect of vitamin D and calcium supplementation and nutritional counseling on bone mineral density (BMD). Twenty-five participants withdrew from the study. Common reasons given for withdrawing were intolerance of the study drug, family hardship and schedule conflicts. Few statistically and clinically significant differences identified participants who completed the study. Nurses need to be aware of the reasons that participants withdraw from clinical trials, as they are in a strategic position to encourage patients to participate in health promotion studies.

The nurse clinician as research participant recruiter: experience from a longitudinal intervention study

One of the most critical phases involved in carrying out a research project is participant recruitment. Recruitment into clinical trials and health programs is a primary public health challenge, particularly among adolescents. Special skills and abilities are needed to successfully recruit participants from this developmental age group. This paper describes the similarities found between the recruitment process developed for a randomized controlled trial with adolescents and the steps of the nursing process, and demonstrates that knowledge of the nursing process can assist in successfully recruiting individuals for a research study. Even without research training, clinical nurses can play a significant role in research studies because of their skills and experiences with the nursing process. Thus, nurse scientists and clinicians can work together successfully to conduct research studies and health projects that involve challenging recruitment efforts.

Data and safety monitoring during randomized controlled trials of nursing interventions

BACKGROUND

Principal investigators have a responsibility to ensure and maintain the scientific integrity of their research studies and to protect the safety of the participants. Data and safety monitoring is required for all types of clinical trials, and the nature and degree of the monitoring must be related to the degree of risk involved.

OBJECTIVES

This article aims to define the purpose of a data and safety monitoring board (DSMB), to describe the functions of a DSMB and distinguish them from the activities of an institutional review board, and to discuss the development and implementation of a DSMB plan.

METHODS

The literature on data and safety monitoring is reviewed, and the process and key issues are illustrated with examples from the authors' clinical trial and others.

RESULTS

The principal role of the DSMB is to monitor the data from the trial periodically, to review and assess the performance of its operations, and to make recommendations based on interim results (e.g., modification of the study protocol, or possible early termination of the study). Although the roles of a DSMB and institutional review board complement one another, the main focus of their responsibilities is different and carried out independently of one another. The members of a DSMB are selected on the basis of their methodologic, statistical, or clinical expertise.

CONCLUSION

The multiple scientific, ethical, safety, recruitment, intervention, and budgetary responsibilities of a principal investigator can be complex. The role of the DSMB is crucial and offers independent evaluation to ensure participant safety and good science.

Barriers to conducting randomised controlled trials: lessons learnt from the Horsechestnut & Venous Leg Ulcer Trial (HAVLUT)

The RCT is considered the gold standard for testing a therapeutic intervention. However, the conduct of an RCT is not without numerous obstacles. As illustrated through the recent Horsechestnut and Venous Leg Ulcer Trial (HAVLUT), these barriers can be attributed to randomisation, recruitment, retention, blinding and sampling procedures, and to gate keeping. These obstacles, together with strategies to prevent and overcome them, are detailed throughout this article, and are aimed at ameliorating the future design and conduct of RCTs.

Conduct of multisite clinical studies by professional organizations

ISSUES AND PURPOSE

Professional organizations are embracing collaborative multisite research and research utilization projects. This report describes the strategies undertaken and lessons learned from SPN's first multisite study.

CONCLUSIONS

Infrastructure concerns (e.g., vision, communication, dissemination of results, resources, and human rights protections) and methodological issues specific to multisite research must be addressed to ensure a successful study.

PRACTICE IMPLICATIONS

Multisite studies are an effective mechanism for more rapidly advancing nursing theory and evidence-based nursing practice.

Randomised controlled trials in nursing and midwifery: an interview with Maralyn Foureur. Interview by Pamela J. Wood

Randomised controlled trials are considered to be one of the best research designs for determining effective care in the clinical setting. Relatively few randomised controlled trials, however, have been carried out in nursing or midwifery practice, so few examples of the practical realities of this research methodology are readily accessible. This is the sixth article in a series based on interviews with nursing and midwifery researchers, designed to offer the beginning researcher a first-hand account of the experience of using particular methodologies. This article focuses on the randomised controlled trial as experienced by Maralyn Foureur (RGON, RM, BA, Grad Dip Clin Epidem, PhD) who used this methodology to demonstrate the effectiveness of a continuity of care model in midwifery practice.

Developing a model of collaborative research: the complexities and challenges of implementation

While the benefits of collaborative research have been well documented, fewer publications exist regarding the complex, problematic issues involved in these undertakings. This paper offers an integrated collaborative research model to depict the complexities and challenges of initiation and implementation of a 2 1/2 year joint research project between a community hospital and a university school of nursing in Southern Ontario, Canada. A sampling of the experiences of the researchers are analyzed to clarify the dynamic and often competing issues and interactions involved in encouraging hospital-wide research involvement during periods of organizational growth and change. The model reflects the simultaneous interaction of organizational, change and collaborative processes while maintaining the rigor of the research (RCT), and ensuring minimal disruption to the service agency. Quantitative outcomes of this collaboration are presented through an analysis of participant involvement on multiple organizational levels. Recommendations for future collaborative research, including design and methodological issues and collaborative and change strategies are offered. The complexity of balancing the necessary trade-offs required of successful collaborative research are highlighted and will be useful to those considering and planning future collaborations.