“I haven’t been in hospital for 40 years”: challenges and opportunities for recruiting older people into a qualitative study on shorter hospital stays
Right at the beginning of the COVID-19 pandemic I started to design a qualitative study to explore older people’s thoughts about being in hospital and the discharge process to understand the patient perspective on factors that might impact on delayed transfers of care (DToC) and help reduce the length of hospital stays (1). Older people tend to stay in hospital longer than they need to, for various reasons, and this sometimes impacts on their physical and emotional wellbeing. Reducing delayed transfers of care in older people, from hospital to home or other community setting, is an NHS England priority. There is also a new ‘discharge to assess’ policy (2) that provides the opportunity for swifter discharge processes, but it is not yet widely implemented and the implications for older people are unknown.
My initial concerns were about the adjustments I would need to make to conduct qualitative interviews effectively with people who would perhaps be living with a range of complex morbidities and impairments. I anticipated having to shorten the length of interviews to avoid participant fatigue, adapt my interview style to accommodate those hard of hearing and prepare information sheets and consent forms in larger font for those with visual impairments. However, what I did not anticipate was the difficulty I would have recruiting people aged over 75 years who had been in hospital in the last 6 months.
COVID-19 restrictions at the time meant I did not have approval to access hospital wards to interview older people face to face during a hospital stay. Fortunately, the Community Aging Research cohort study (CARE75+), led by Andy Clegg and colleagues in the Older People and Frailty theme (3) , provided an ideal source for recruiting participants for telephone interviews. With permission from the programme manager, I mailed out invitations to older people in the cohort who had consented to be approached about other research studies. After carefully filling envelopes and mailing out each batch of initiation letters I waited patiently for positive responses. The phone calls came thick and fast, and I spoke to many charming, interesting and engaging folk, most of whom politely declined to participate because they were fit and healthy and hadn’t been in hospital for years. One lady recounted that she hadn’t been in hospital “since I gave birth to my son, and that was 40 years ago”.
Whist I was thrilled that the CARE75+ cohort was full of fit and healthy older people (or at least those who responded to me were), many of whom were dancing and hill walking their way into their 90’s (not a frailty deficit in sight), this did leave me in a predicament about fulfilling my sample size requirements. I had managed to recruit a handful of older people (n=3) and family members (n=1) from the cohort, but the small sample lacked the range and depth of insight I needed to really understand hospital stays from the perspective of older people. On reflection, a limitation of using this method of speculative mail out was that any potentially eligible older people recently discharged from hospital may not have felt well enough to respond to the request.
My next stop was Care Opinion (4) , a website dedicated to sharing people’s experiences of health and care services in the UK; anonymised stories are published online and shared with relevant health and care providers. Care Opinion had recently established a ‘research community’ to create opportunities for patients and caregivers who have already shared online feedback to be involved in research (5). The Chief Executive (James Munro) agreed to identify patients and caregivers within the research community, who met my eligibility criteria, and invite them to participate in telephone interviews. This was an efficient process that resulted in another nine participants, all of whom were family members of older people who had been in hospital. This made a real difference to my sample; family members’ perspectives were important to capture, since they can often influence the length of hospital stays and the decisions made about discharge. The main drawback of recruiting from this source is that the stories shared tended to represent the extremes of care experiences, leading me to interview family members who were either full of praise for health and care services or very disillusioned with the care their family member had received. That said, their insights make a valuable contribution to the bigger picture of how to shorten hospital stays for older people.
As the UK government began implementing the roadmap out of lockdown in April 2021 restrictions started to ease and I explored options to recruit the final few older people into my study. The guidance at the time allowed for social contact indoors between members of a household only, which still precluded interviewing older people face to face. Luckily for me Bradford District was about to launch the City of Research website (6) , to encourage volunteers from across the region to sign up to take part in research. I didn’t hesitate when invited to offer up my study as one of the first to be advertised on the website. The portal aims to build on the success of the COVID-19 vaccine trials led by Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) which benefitted from hundreds of volunteers from the local community. My project is featured under the health services research call where the eligibility criteria are clearly outlined, and willing volunteers can get in touch (7) . This approach is a fantastic way of engaging and involving the community in the city’s research and facilitating ‘people-powered’ studies. However, an online portal may not be the best way to attract older people aged over 75, who may respond better to written invites or face to face recruitment; I didn’t manage to recruit any older people using this strategy.
My last-ditch attempt to recruit the remaining 5-10 older people needed for my study was to solicit help from the ‘virtual ward’ at Bradford Royal Infirmary. The virtual ward runs a well-established discharge to assess process, led by a multi-disciplinary team working across health and social care organisations to shift ongoing care closer to home and support older people at home. Approximately six older people per week are discharged from acute and elderly wards into the virtual ward and so it seemed like a good opportunity to recruit participants quickly. With the help of the lead nurse in charge (Andrea Allanach), older people being discharged from the virtual ward are being asked if they would consider being part of the study. I’m optimistic that being invited face to face by a nurse during the discharge process represents a more friendly and acceptable approach. This strategy is currently in process, and I have fingers crossed while I wait patiently for some positive responses.
This study is being conducted by the Improvement Science theme in collaboration with the Older People and Frailty theme and alongside a related project, led by York University (8), which is using a ‘systems thinking’ approach to examine the discharge process more broadly. We aim to use the findings to inform key messaging that could help address knowledge gaps or misconceptions, raise awareness of the discharge process, and may help drive older patients’ and families’ decisions to seek earlier discharge and shorter hospital stays.
Watch out for a future blog that will outline key findings from the study and pathways to impact.
For further information please contact the study investigator: Dr Helen Smith, Senior Research Fellow, NIHR Applied Research Collaboration Yorkshire & Humber (ARC Y&H), Improvement Science theme (Helen.Smith@btfht.nhs.uk)
This blog was written by Helen Smith, Senior Research Fellow, Improvement Science theme, Yorkshire and Humber ARC.
27 July 2021