HEALTH CARE CHOICES: A STUDENT'S PERSPECTIVE 44 HEALTH CARE CHOICES: A STUDENT'S PERSPECTIVE Kelly Coloff, RN1 1 Kalispell, MT, kellycoloff@yahoo.com Key Words: Nursing Research, Health Care, Complementary Therapies, Student ABSTRACT The purpose of this paper is to describe student experiences as a research assistant on the Health Care Choices Project, a study of the use of complementary therapy by older adults living in rural areas. The goal of this project, headed by a doctorally prepared nurse faculty member, was to “explore the use, cost, and satisfaction with complementary therapy by older adults in rural communities” (Shreffler, 1999). The research group recruited both undergraduate and graduate students from three university campuses to participate in the project. Undergraduate students were primarily recruited to assist with telephone interviewing, piloting, media campaigning, and to further their own academic experience. Graduate students participated in data collection, data processing, and data analysis and were able to apply their work to degree completion. INTRODUCTION The purpose of this paper is to describe student experiences as a research assistant on the Health Care Choices Project, a study of the use of complementary therapy by older adults living in rural areas. The goal of this project, headed by a doctorally prepared nurse faculty member, was to “explore the use, cost, and satisfaction with complementary therapy by older adults in rural communities” (Shreffler, 1999). The research group recruited both undergraduate and graduate students from three university campuses to participate in the project. Undergraduate students were primarily recruited to assist with telephone interviewing, piloting, media campaigning, and to further their own academic experience. Graduate students participated in data collection, data processing, and data analysis and were able to apply their work to degree completions. HEALTH CARE CHOICES STUDY Purpose As stated previously, the purpose of the HCC project was to better understand the use, cost, and satisfaction with complementary therapies in rural adults. The literature review and grant proposal were completed before student assistants became involved in the project. Although students involved in the project were not able to see this process first hand, review of the pertinent project literature and the proposal provided orientation to the applied research tools. The researchers worked constantly to maintain the project within the original aims presented in the approved grant. Standard reporting intervals were in place to ensure the funding agency that the project money was being spent appropriately and that the research was progressing in a timely manner. Rules based on ethical standards applied to all aspects of the research process from recruiting student 44Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 mailto:kellycoloff@yahoo.com 45 volunteers to ensuring confidentiality in human subjects testing. For example, student interviewers went through online training to ensure proper qualifications for involvement with human subjects. Interview questions were focused on types of complementary therapies, as well as estimated costs of each therapy. The study explored both provider- based complementary therapies such as chiropractors, physical therapy, acupuncture, accupressure, as well as self-directed practices not based on provider direction such as use of vitamins, herbs, and copper band. Researchers Researchers from two universities were involved in this research project giving the interpretation of the data a broader perspective for rural adults. Four nursing professors, two representing each university, collaborated on this project. All four researchers worked on the grant proposal, human subjects verification, research tool, data collection, data analysis, and conclusions. Study Population Although one university is an urban center in the state with a population of approximately 78,000, it is surrounded by very rural communities. This intermixing of urban and rural communities provided me with insight into a large and diverse nursing client base. The study population for the HCC project consisted of adults age 60 or older living in rural areas. Ten research sites in each state were randomly selected with the assistance of a statistician. Potential participant names were purchased from a national name supplier and then were randomly selected from each town for the study. This method of acquiring names proved to be only somewhat reliable. The pilot interviews revealed that many individuals called were under the age of 60 and did not meet the criteria for participation in the project. Several individuals contacted for the project were curious about how their names were chosen. Whereas, consumers often expect telemarketers to have lists of names, it is less common to have research groups contact a person via a home phone number for a lengthy interview. The study group included both males and females, married, single, or widowed. The primary criteria were that participants be age 60 or older and live in a rural area. As secondary criterion, all participants were required to have telephone service because telephone interviewing was the mode of data collection. The sample group consisted of 320 rural dwelling older adults, 160 living in each state. No assessment was made regarding the amount of time participants had lived in their communities. Initially, rural communities less than 20,000 residents were randomly selected equally from eastern and western portions of both states. From these communities, names of individuals older than 60 years of age were randomly selected to serve as possible participants in the project. An excess number of individuals were initially selected to allow for disqualification, refusal, and unavailability of participants. 45Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 46 Media Campaign Before piloting began, a media campaign using flyers was organized and it was used throughout the data collection process. The purpose of the media campaign was to increase community awareness of the HCC project. These flyers were meant to inform people of the study goals and process and to encourage participation to benefit their community. Flyers were sent to churches and senior citizen centers with letters encouraging these facilities to post the flyers. During the beginning stages of the project, creating the media campaign was the focus of this student’s involvement. The student assisted in writing letters to local newspapers which included a description of the study as well as a statement of implications of the study for the community. These letters inquired if the newspaper would consider publishing a short excerpt about the study in the local newspaper. Locating and contacting these newspapers was often a challenge because many of these rural communities did not have their own daily paper but rather a countywide newspaper. As a result of these letters, many of the newspapers published the entire description that was provided. The newspaper articles contained similar information to that in the flyers. Letters were also sent to the personal address of each randomly selected individual. These letters were sent out two to three weeks before the interview calling began. These letters were intended to provide advance notice to possible participants that they might be contacted for an interview. These letters also reviewed the process and purpose of the study and assured confidentiality. After interviewing was completed in each community, thank you letters were sent to all people contacted by telephone regardless of their decision to participate or decline. Project Piloting/Interview Tool Revision Initially, students piloted the interview tool with their own family members who were over the age of 60. The purpose of these pilot interviews was primarily to detect major problems with the wording and sequencing of questions. This process eliminated several questions and required laborious rewording of others. The second phase of piloting focused on an actual, randomly selected community. The appropriate number of interviews were completed with participants in this community. This piloting process was completed primarily by students. The most important aspect of this piloting was documenting each call and the difficulties encountered. During this phase of piloting, the age discrepancies (people in the sampling frame younger than 60 years old) were noted and the name supplier was notified to make the appropriate corrections before actual interviewing began. METHODS Telephone interviewing was the method of data collection used in the HCC study. The interview tool included a large section of questions on the use, cost, and satisfaction with complementary therapies. Many of these questions were developed by the research team, but some pre-written and tested scales were incorporated for questions specifically relating to spirituality and health-related quality of life. Demographic 46Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 47 questions were included at the beginning and end of the interview. As well as collecting necessary information, these questions provided a comfortable introduction and conclusion to the interview process. After initial piloting with family members and friends of the research group, the questions were revised, reworded, and rearranged to provide the optimal sequence of questions to reduce confusion and expedite the interviewing process. Since so many questions were deemed necessary in the interview, each interview took approximately 20- 30 minutes. The interview length proved to be a deterrent for a portion of the selected interviewees. The researchers expected that rural adults would be difficult to contact during mid-day hours, so evening hours were chosen for most interview calls. The researchers considered harvesting, planting, and other farming and ranching seasons when planning the timing for interviews. RESULTS Difficulties Encountered: The “Real World” of Research Student recruitment was extremely difficult for all four of the primary researchers. Interest seemed low to begin with and many students were not willing to stick with the project for any length of time. The busy schedules of nursing students may have made it difficult for these students to consider volunteer work on projects. With the diversity in the nursing field and the many opportunities for clinical learning, lack of interest in specific research topics may have been related to the student’s focus on another area of nursing. Lack of undergraduate student interest posed a significant problem in completing the required number of interviews. Eventually, a survey research service at one university was used to complete the interviews in both states for a set fee per interview. Due to the need for conference calling between three campuses, time restraints and scheduling also posed obstacles for this research team. Despite scheduling meetings with four very busy professors, the conference calling in itself was a major challenge. The principal investigator provided an agenda via e-mail prior to each meeting to focus the group and expedite the meetings. Due to the distance separating the investigators, they chose conference calling as their primary method for communication. Conference calling allowed more direct communication with all researchers at one time and was more cost effective than traveling between research sites. Problem solving was difficult in conference calls with four or more individuals voicing their opinions. Each person had to adapt to different cueing for these calls in order to prevent interruption and frustration of all members involved. By sticking to the agenda and supplementing the conference call meeting with e-mails and one-on-one phone calls, the study proceeded relatively smoothly. This use of technology showed the trend in nursing as well as other health-related research. Many difficulties were encountered using telephone interviewing as the data collection method. First, a machine answered many of the telephone numbers called and despite leaving several messages, no person was ever contacted. With new technology such as caller identification, people in general are more prone to screen their calls and ignore all unknown callers dismissing them as telemarketers. Even when individuals 47Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 48 were contacted by telephone, many were unwilling to participate especially when they were informed of the length of the interview. Some people were offended by receiving a call from a stranger requesting information from them. Another problem with telephone interviewing was the time required for each interview, which limited the number of interviews that could be completed within a time frame. One interesting fact is that the majority of people stated they had never received the informational letter or received it but did not remember the contents of the letter. Positive Aspects of the HCC Study The study in general focused on a group of individuals, rural adults, not previously singled out for study on this subject. The two-state involvement provided a broader rural perspective for information and improved generalization of results. Although telephone interviewing required patience and was both stressful and anxiety producing, talking with willing participants was quite rewarding. Many were very interested in the study, providing information that was accurate and more than the minimum that was requested. They asked questions and offered information of interest both useful to the study and helpful in inspiring the students’ future telephone calling efforts. Nursing students had a chance to understand the rewards of personal interaction with people in a different context than providing direct nursing care. DISCUSSION The benefits of working on this research project applied to the student experience as well as clinical practice after graduation. Although BSN programs typically include a research course, the main focus is on research as an adjunct to evidence-based practice. The emphasis in such courses is on the research process, critiquing research articles, and applying them to clinical practice. Although this is valuable, direct involvement in a university-based research project allows for an in depth look at the research process. Participation in the research experience promoted an increased awareness of research and how it can be applied to clinical practice. Also, being aware of complementary therapy use is very important in understanding all of the processes involved in sickness and healing for patients. For example, employment in a semi-rural setting has revealed that the vast number of people use complementary therapies, most often vitamins and herbal supplements. Often the use of these remedies is not disclosed unless addressed directly by the nurse. Understanding that there is high volume use of complementary therapies in all age groups highlighted the need for review of alternative therapy use when taking patient histories. Increased awareness of this topic will encourage nurses and nursing students to include questions about complementary health care use in patient history taking. In conclusion, undergraduate student participation in research projects is a valuable experience for both the student and the research team. The experience of being part of the Health Care Choices Project improved this student’s understanding of research and its application to practice. It also enriched the research project by adding the fresh and creative perspective that undergraduate students can offer. 48Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 49 ACKNOWLEDGMENTS I wish to extend my gratitude and thanks to Jean Shreffler-Grant, PhD, RN for her help in writing and editing this manuscript and for her encouragement in pursuing my nursing career. REFERENCES Shreffler, J., Weinert, C., Nichols, E., & Ide, B. (1999). Complementary therapies in rural areas. Grant 1R15-AT095-01, National Center for Complementary and Alternative Medicine, National Institutes of Health. 49Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003