Research governance: ethical issues

Baseline Assessment of Health Research Systems in Saudi Arabia: Harnessing Efforts and Mobilizing Actions

Major transformations are taking place in the Kingdom of Saudi Arabia (KSA) to achieve the 2030 vision for the health sector. A key component in strengthening the health system is a strong research governance strategy that can support the decision-making process by providing timely and accurate evidence that reflects local context and needs. This paper sought to better understand governance structures and policies for health research systems and support clusters so that they function effectively. This paper outlines the findings of an in-depth baseline assessment of existing health research efforts, activities, and plans of eight research clusters in the KSA and identifies key gaps and strengths in health research governance and capabilities. A cross-sectional design was used to survey research clusters in KSA. A six-part survey was developed to better understand the research clusters' health research governance and capacities. The survey was sent to all KSA clusters and was completed in a group setting during meetings. Findings clearly show strong efforts to support research governance initiatives in health clusters in KSA. While some clusters are more advanced than others, there are plenty of opportunities to share knowledge and combine efforts to help achieve the goals set out for KSA health transformation. This baseline assessment also reflects the first attempt of its kind to understand the KSA experience and provide much-needed lessons on country-wide efforts to support the health system given the trickling effect of this sector on all others, enhancing and advancing national growth.

Organizational arrangements as a key to enhancing innovativeness and efficiency - analysis of a restructuring hospital in Finland

Background

Challenged to innovate and improve efficiency both at the policy level and in everyday work, many health care organizations are undergoing radical change. However, in many earlier studies, the significance of individuals’ perceptions of their organization and its innovativeness and efficiency during restructuring is not well acknowledged. Our study examines how various organizational arrangements; performance-, hierarchy-, tradition-, and leader-focused types, as well as collaborative and fragmented ones, connect to reaching innovativeness and efficiency in health care during restructuring.

Method

We built on previous organization and management research, innovation studies, and on research focusing in health care restructuring, and conducted an exploratory quantitative case study in a public sector hospital in Finland. Data comprising 447 responses from 19 professional groups across the hospital was analyzed using hierarchical regression analysis.

Results

Our results demonstrate that multiple, co-existing organizational arrangements can promote innovation and efficiency. The perceptions of the organizational members of the nature of their organization need to be generally positive and reflect future-orientation to show positive connections with efficiency and innovativeness; fragmentation in the members’ perceptions of the character of their organization and their inability to go beyond established organizational traditions pose risks of inefficiency and stagnation rather than fruitful exploration. Our study further shows, somewhat surprisingly, that while collaborative organizational arrangements are positively related to increases in perceived efficiency, the same does not apply to innovativeness.

Conclusions

Our study addresses understudied, yet inherently important aspects in providing high-quality health care: the relationships between different organizational arrangements and exploitation and exploration-related outcomes. In particular, examination of individuals’ perceptions (that may have even more weight for the subsequent developments than the actual situation) adds insight to the existing knowledge that has addressed more objective factors. Implications on how to support high levels of performance are drawn for management of professional and pluralistic organizations undergoing restructuring. Our findings also generate information that is useful for policy making concerned with public sector health care.

Outsourcing Transcription: Extending Ethical Considerations in Qualitative Research

Research ethics considerations foreground minimising harm to participants. Whilst increasing attention is being paid to researcher vulnerabilities, little has been written about transcriptionists, who can potentially experience emotional distress and vicarious trauma. In this article, we highlight ethical considerations when outsourcing audio for transcription as part of the RE:CURRENT (REcurrent miscarriage: evaluating CURRENT services) Project. Through qualitative interviews, we explored the perspectives of those involved in the management/delivery of services, and women and men who experienced recurrent miscarriage (N = 62). We put distress protocols in place for participants, researchers and the transcriptionist, and adopted a research team approach with the professional transcriber. The transcriptionist highlighted the isolated nature of the role; how researchers often did not brief her when commissioning work, and how the personal impacts of this work were rarely considered. Researchers and ethics committees should consider ethical responsibilities to 'do no harm' when it comes to transcriptionist wellbeing.

Research skills and the data spreadsheet: A research primer for low- and middle-income countries

The specialty of Emergency Medicine continues to expand and mature worldwide. As a relatively new specialty, the body of research that underpins patient management in the emergency department (ED) setting needs to be expanded for optimum patient care. Research in the ED, however, is complicated by a number of issues including limited time and resources, urgency for some therapeutic investigations and interventions, and difficulties in obtaining truly informed patient consent. Notwithstanding these issues, many of the fundamental principles of medical research apply equally to ED research. In all medical disciplines, data needs to be collected, collated and stored for analysis and a data spreadsheet is employed for this purpose. Like other aspects of clinical research, the use of the data spreadsheet needs to be exacting and appropriate. This research primer explores the choice of available spreadsheets and a range of principles for their best-practice use. It is deliberately, not an exhaustive review of the subject. However, we aim to explore basic principles and some of the most accessible and widely used data spreadsheets.

Qualitative exploration of patient flow in a Caribbean emergency department

OBJECTIVES

Emergency departments (EDs) are complex adaptive systems and improving patient flow requires understanding how ED processes work. This study aimed to explore the patient flow process in an ED in Trinidad and Tobago, identifying organisational factors influencing patient flow.

METHODS

Multiple qualitative methods, including non-participant observations, observational process mapping and informal conversational interviews were used to explore patient flow. The process maps were generated from the observational process mapping. Thematic analysis was used to analyse the data.

SETTING

The study was conducted at a major tertiary level ED in Trinidad and Tobago.

PARTICIPANTS

Patient and staff journeys in the ED were directly observed.

RESULTS

Six broad categories were identified: (1) ED organisational work processes, (2) ED design and layout, (3) material resources, (4) nursing staff levels, roles, skill mix and use, (5) non-clinical ED staff and (6) external clinical and non-clinical departments. Within each category there were individual factors that appeared to either facilitate or hinder patient flow. Organisational processes such as streaming, front loading of investigations and the transfer process were pre-existing strategies in the ED while staff actions to compensate for limitations with flow were more intuitive. A conceptual framework of factors influencing ED patient flow is also presented.

CONCLUSION

The knowledge gained may be used to strengthen the emergency care system in the local context. However, the study findings should be validated in other settings.

To What did They Consent? Understanding Consent Among Low Literacy Participants in a Microbicide Feasibility Study in Mazabuka, Zambia

We conducted a study to review the consenting process in a vaginal microbicide feasibility study conducted in Mazabuka, Zambia. Participants were drawn from those participating in the microbicide study. A questionnaire and focus group discussion were used to collect information on participants' understanding of study aims, risks and benefits. Altogether, 200 participants took part in this study. The results of the study showed that while all participants signed or endorsed their thumbprints to the consent forms, full informed consent was not attained from most of the participants since 77% (n = 154) of the participants had numerous questions about the study and 34% (n = 68) did not know who to get in touch with concerning the study. Study objectives were not fully understood by over 61% of the participants. Sixty four percent of the participants were not sure of the risks of taking part in the microbicide study. A significant number thought the study was all about determining their HIV status. Some participants were concerned that their partners were not on the trial as they were convinced that being on the study meant that that they had a lifetime protection from HIV infection. The process of obtaining consent was inadequate as various phases of the study were not fully understood. We recommend the need for researchers to reinforce the consenting process in all studies and more so when studies are conducted in low literacy populations.

Increasing value and reducing waste in biomedical research regulation and management

After identification of an important research question and selection of an appropriate study design, waste can arise from the regulation, governance, and management of biomedical research. Obtaining regulatory and governance approval has become increasingly burdensome and disproportionate to the conceivable risks to research participants. Regulation and governance involve interventions that are assumed to be justified in the interests of patients and the public, but they can actually compromise these interests. Inefficient management of the procedural conduct of research is wasteful, especially if it results in poor recruitment and retention of participants in well designed studies addressing important questions. These sources of waste can be minimised if the following four recommendations are addressed. First, regulators should use their influence to reduce other causes of waste and inefficiency in research. Second, regulators and policy makers should work with researchers, patients, and health professionals to streamline and harmonise the laws, regulations, guidelines, and processes that govern whether and how research can be done, and ensure that they are proportionate to the plausible risks associated with the research. Third, researchers and research managers should increase the efficiency of recruitment, retention, data monitoring, and data sharing in research through use of research designs known to reduce inefficiencies, and further research should be done to learn how efficiency can be increased. Finally, everyone, particularly those responsible for health-care systems, should promote integration of research into everyday clinical practice. Regulators and researchers should monitor adherence to each of these recommendations and publish metrics.

Effects of cinnamon granules on pharmacokinetics of berberine in Rhizoma Coptidis granules in healthy male volunteers

The effects of Cinnamon granules on pharmacokinetics of berberine in Rhizoma Coptidis granules in healthy male volunteers, and the compatibility mechanism of Jiao-Tai-Wan (JTW) composed of Rhizoma Coptidis granules and Cinnamon granules were investigated. The concentration of berberine in plasma of healthy male volunteers was determined directly by high performance liquid chromatography (HPLC) after an oral administration of Rhizoma Coptidis granules alone or combined with Cinnamon granules (JTW). The plasma concentration-time curves of berberine were plotted. The data were analyzed with Drug and Statistics (DAS) 2.0 pharmacokinetic program (Chinese Pharmacology Society) to obtain the main pharmacokinetic parameters. The results showed that the plasma concentration-time curve of berberine was described by a two-compartment model. The C(max), T(max), t(1/2) and CLz/F of berberine in Rhizoma Coptidis granules were 360.883 μg/L, 2.0 h, 3.882 h, 119.320 L·h(-1)·kg(-1) respectively, and those of berberine in JTW were 396.124 μg/L, 1.5 h, 4.727 h, 57.709 L·h(-1)·kg(-1) respectively. It was suggested that Rhizoma Coptidis granules combined with Cinnamon granules could increase the plasma concentration of berberine, promote berberine absorption and lengthen the detention time of berberine in healthy male volunteers.

The OPERA trial: protocol for a randomised trial of an exercise intervention for older people in residential and nursing accommodation

Abstract

Trial Registration

[ISRCTN: ISRCTN43769277]

The Department of Health's research governance framework remains an impediment to multi-centre studies: findings from a national descriptive study

OBJECTIVE

We describe our experience of using the standard application form, designed to streamline applications for multi-centre research, to seek approval from all primary care organizations (PCOs) in England and Wales to undertake a single telephone interview with a health service manager.

DESIGN

We sent applications (n=316), by email to each PCO, or consortium of PCOs, attaching a completed standard application form, the 15 required documents, and the approval we had been granted by the lead NHS organization. We maintained detailed records of the responses to our application, subsequent correspondence, additional paperwork requested, and time spent on the approval process.

SETTING

The UK Research Governance Framework, which regulates all research conducted in health and social care settings.

PARTICIPANTS

All PCOs in England and Wales.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Time taken to obtain approval to undertake a telephone interview with a health service manager.

RESULTS

We were unable to establish contact with 13 (4%) PCOs. Six months after submitting our application we had received approval from 259/316 (82%) PCOs and were still awaiting a verdict from 41 (13%). The median time to approval was 56 days (IQR 42-72). Overall, an estimated 318 staff-hours were spent completing supplementary forms, providing additional information and chasing up dormant applications.

CONCLUSIONS

Recent initiatives to 'streamline' research governance approval have failed to address the problems that face researchers undertaking multi-centre studies. There is an urgent need to develop a simpler process that allows low risk research to take place without threatening staff morale and endangering the quality of the research outputs. In the meantime, we advise researchers to allow far greater time than might reasonably be envisioned to obtain research governance approval.

Process development for ethical recruitment of patients into simultaneous clinical studies in a chiropractic research clinic

OBJECTIVE

To develop a process at one institution that creates an ethical means to bring other research projects to the attention of an individual who was excluded from the project for which they originally expressed interest, and to discuss the ethical issues surrounding patient recruitment and enrollment.

METHOD

General consensus process via meetings of investigators involved in the ongoing trials at one institution.

RESULTS

A process and flow sheet for offering new study information to individuals who did not meet the criteria for participation was developed. Once rejected, an individual can be asked if they wish to learn about other studies, are sent home with information, and are instructed to call back if they wish to volunteer. Consent can be used to take baseline information from the first study and apply it to the second.

CONCLUSION

This process was developed and implemented for use in this research center.

Research governance impediments to clinical trials: a retrospective survey

OBJECTIVE

We sought to evaluate the delays, between-centre variations in practice, and opportunity costs attributable to delays in research governance approval of clinical trials in the United Kingdom.

DESIGN

Retrospective survey.

SETTING

Research and Development (R&D) departments at 50 UK National Health Service hospital trusts governing 57 hospital sites.

PARTICIPANTS

R&D departments participating in four randomized multicentre clinical trials coordinated by our Neurosciences Trials Unit.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Median delay between application and research governance approval.

RESULTS

Only half of the R&D departments used the UK online R&D form. Only a single copy of the application was required by 96% of R&D departments. The median delay between application and research governance approval was 44 working days (inter-quartile range 23-80). A delay of >20 working days was incurred by 43 applications (75%), of which 24 (56%) were not explicable and 11 (20%) were attributable to local funding negotiations. Based on the trial randomization rates at each centre, 108 patients (17% of all patients randomized) could have been randomized during the delay, at a crude cost to funding agencies of 53,743 pounds; if a four week delay was deemed acceptable, 75 patients (12% of all patients randomized) could have been randomized during unacceptable delays, at a crude cost to funding agencies of 37,700 pounds.

CONCLUSIONS

The UK research governance system incurs unacceptably long and costly delays for clinical trials. Urgent reform is needed, including rapid design and uniform implementation of the 'bureaucracy busting' measures in Best Research for Best Health.

Research governance impediments to clinical trials: a retrospective survey

OBJECTIVE

We sought to evaluate the delays, between-centre variations in practice, and opportunity costs attributable to delays in research governance approval of clinical trials in the United Kingdom.

DESIGN

Retrospective survey.

SETTING

Research and Development (R&D) departments at 50 UK National Health Service hospital trusts governing 57 hospital sites.

PARTICIPANTS

R&D departments participating in four randomized multicentre clinical trials coordinated by our Neurosciences Trials Unit.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Median delay between application and research governance approval.

RESULTS

Only half of the R&D departments used the UK online R&D form. Only a single copy of the application was required by 96% of R&D departments. The median delay between application and research governance approval was 44 working days (inter-quartile range 23-80). A delay of >20 working days was incurred by 43 applications (75%), of which 24 (56%) were not explicable and 11 (20%) were attributable to local funding negotiations. Based on the trial randomization rates at each centre, 108 patients (17% of all patients randomized) could have been randomized during the delay, at a crude cost to funding agencies of 53,743 pounds; if a four week delay was deemed acceptable, 75 patients (12% of all patients randomized) could have been randomized during unacceptable delays, at a crude cost to funding agencies of 37,700 pounds.

CONCLUSIONS

The UK research governance system incurs unacceptably long and costly delays for clinical trials. Urgent reform is needed, including rapid design and uniform implementation of the 'bureaucracy busting' measures in Best Research for Best Health.