Research in Community Mental Health Settings: A Practicum Experience for Researchers

Abstract

Applying research findings to community mental health practices is slowed by provider concerns that research participants often differ from community populations in duration of illness, comorbid conditions, and illness severity. Selecting participants from community settings makes research results demonstrably relevant, but researchers and community providers can be mistrustful of one another, feeling that the other has little understanding of their needs and work. This mistrust impedes patient referrals for research. This column describes a program to increase researcher knowledge of community clinic procedures through structured interactions with clinic personnel. Follow-up interviews indicate improved attitudes and cooperation of researchers and community providers.

Several seminal reports have stressed the importance of community-based research on interventions and practices. Such research can facilitate uptake of evidence-based interventions developed in research settings, address real-world problems identified by community providers, and enhance generalizability of research findings by studying the patient populations that typically receive the intervention or practice (1–5). Federal support to develop and enhance community-based research has grown, including the National Institute of Mental Health’s Interventions and Practices Research Infrastructure Program (IP-RISP). This program seeks to improve community-based research via support for infrastructure-building projects.

The IP-RISP in San Antonio is a collaboration between the county community mental health agency (the Center for Health Care Services) and the Department of Psychiatry at the University of Texas Health Science Center at San Antonio. Sustaining Public-Academic Research Collaborations (SPARC), initially funded in 2006, has a specific aim to increase recruitment of consumers from the Center for Health Care Services into research studies, including intervention studies, to make study results more generalizable to the populations served by community mental health centers. Whereas many public-academic partnerships are based on a project of mutual interest, SPARC aims to create a platform for a broad range of research projects that involve the Center for Health Care Services at many levels. In our model, there are multiple levels of engagement between researchers and the agency. Some research projects are jointly conceived and carried out as active collaborations. At the broadest level, all research projects are enhanced by acceptance of research staff by clinic staff and vice versa. Most projects are improved by providing researchers access to participants and records and by providing clinic staff access to researchers and their protocols.

Several reports note barriers and impediments to conducting community-based research (2,3,6). One theme that consistently emerges is the issue of mutual trust and understanding between researchers and community representatives, whether from the general public or from community health agencies. Many of the attitudes of mistrust are seemingly rooted in lack of understanding of the roles and functions of the “other side.”

Before the funding of SPARC, our research group and other investigators from our Department of Psychiatry had for more than a decade conducted studies by recruiting participants from the Center for Health Care Services clinics, primarily for interventions at locations outside the center. The center’s management approved these studies and supported the concept of agency involvement with research. Research recruiters had frequent contact with clinic personnel, mostly involving access to medical records and potential participants at the times of their clinic visits. Investigators sometimes met with medical staff to describe particular studies and their inclusion and exclusion criteria. Thus there were many interactions between staff and research personnel.

As part of our IP-RISP, community mental health center management, clinical staff, and clerical staff were interviewed in focus groups or individually about their attitudes toward research in general and research being conducted with patients from their agency. A focus group of university-based research assistants was asked to comment on attitudes toward working at agency sites and experiences at these sites, and individual interviews were conducted with university investigators.

Several themes emerged from these groups and individual interviews, and a full report is in preparation. Agency personnel identified several problems. For example, they viewed researchers as having little knowledge or appreciation of their work demands, they thought that researchers had minimal awareness of when their research-related requests (such as pulling patients’ charts) were time-consuming or disruptive, and they expressed frustration that research personnel were not readily identifiable as such and were not introduced to them. Research personnel identified problems that included a major concern that agency staff gave researchers’ needs low priority. Related to this problem was a perceived lack of appreciation of research in general and lack of awareness of research projects carried out at the clinic on the part of agency staff. It was striking that at the level of frontline clinic and research staff, frequent interactions had not produced understanding and appreciation of the roles and functions of the “other side.”

To clarify Center for Health Care Services’ procedures and personnel, we designed and implemented a practicum for research personnel.

A practicum for researchers

Between August 2007 and March 2008, a total of 19 persons have participated in the Center for Health Care Services’ practicum. Of these, four were faculty investigators, two were clinical trainees, and 13 were nonfaculty research personnel.

The practicums were organized and run by an agency employee (LL) with three years of experience in its clinics; the employee is assigned to and paid for by the research infrastructure project. The position was created to familiarize practicum participants with the logistics and procedures involved in patient visits. This meant explaining the roles of clinic staff and the tasks they perform. Practicums took place in one of the agency clinics with a high volume of patients. Groups of two or three researchers were first given a 45-minute orientation to the agency, the workings of the clinic, and necessary documentation. These researchers then rotated individually to each of the clinic’s work stations: receptionist, case manager, intake clinician, physician, scheduler (appointments), and medical records. Time at each station was 15–30 minutes. The final period of the half-day in the clinic was spent with the practicum organizer, who addressed any unanswered questions. Within a week of practicum completion, two of us (ALM and LL) debriefed participants. In the debriefing, participants were asked to describe what they had learned from the experience and were invited to suggest ways of improving the practicum.

With feedback from practicum participants and clinic staff, we’ve made several modifications. Initially participants acted simply as observers as agency staff went about their tasks. This was particularly problematic with medical records; little was learned from watching charts being removed and replaced. Subsequently, at each station a designated staff member took on the orientation task, explaining the work to the participant and answering any questions. Also added was a brief test of knowledge of clinic procedures, taken before and after the practicum. One question, for example, was “How do you find out when a client/consumer is scheduled for a follow-up visit?”

Outcomes

Comments made by research personnel during the debriefing sessions fell into four general categories. First, participants noted the complexity of the processes and the amount of accompanying paperwork. They indicated that they were much more sympathetic to the workload carried by clinic staff as a result of this experience. Second, participants became aware of the patient’s perspective, in terms of the numbers of staff seen (typically at least five, including receptionist and scheduler) and the amount of time spent with each. Third, in relating the practicum to their own work needs, several researchers indicated that understanding the flow of the clinic enabled them to better coordinate their patient interactions with patients’ other activities during a visit. Fourth, the practicum experience facilitated interpersonal interactions that had not occurred in the ordinary course of the workday. Subsequent to the practicum, research personnel reported that they felt more comfortable approaching clinic staff about specific questions, both because they had learned whom to ask and because they felt that they had been officially introduced.

Clinic staff provided feedback to the practicum organizer about the experience from their perspectives. Most did not feel that the practicum was burdensome to them and welcomed the opportunity to inform others about their work. They also remarked on the value of getting to know the researchers under circumstances other than performing a task related to the needs of the researchers. Clinic staff also used the practicum interactions to ask research staff about their work, feeling that they had very little understanding of what the researchers did and why.

The introduction of pre- and posttesting was helpful. In completing the pretest, research staff discovered that they lacked critical information about clinic procedures. As a result, they tended to be more focused on learning about the tasks performed at the clinic. Once the test had been piloted and refined, it was administered to the final three persons taking the practicum. Scores increased from an average of 10.7 correct answers prepracticum to an average of 19.3 correct answers post-practicum (maximum score of 20).

Discussion and recommendations

As noted earlier, a major finding from the focus groups was that clinic staff and researchers each felt that the other group did not appreciate the nature and importance of their work. The program succeeded in helping researchers appreciate the workload faced by clinic staff and learn key details about work flow. The program was not structured to educate clinic staff about research, but it was evident from their comments to the practicum organizer that face-to-face interactions with research staff contributed to more positive attitudes toward them and their work.

When practicum development was completed and outcomes were reported to agency managers, they concluded that the program contributed to the acceptance and access goals and decided to make the practicum a required part of the orientation for research staff applying for research privileges at the agency. Because the practicum organizer is paid for by the grant, the cost in staff time to the agency is the few minutes a staff member at each work station spent to describe tasks. Frequency of practicums obviously depends on number of research projects and personnel, but even in our busy setting, one practicum per month has been sufficient. Exclusive of the practicum organizer’s time commitment, this requires 30–60 minutes of clinic staff time once a month. The half-day spent by the organizer is more consequential, in terms of resources. Without external funding, some agencies may decide this position is a worthwhile investment for smooth research operations and less intrusion in their clinics. Some research may bring added resources and benefits that more than compensate for clinic staff time spent on the practicums and other research-related activities. We also believe, however, that researchers and agencies should examine each protocol in terms of actual costs to the agency, including orientation of research personnel, and agree on whether and how compensation to the agency should be made.

When we first conducted the practicum, almost half of the participants were research staff who had two or more years of experience working at agency sites. Despite this prior experience, many of these persons commented that they had learned a great deal about clinic functions and that they found this information valuable. Hence, our recommendation for those who institute such a program is to have both current research staff and new staff participate in it. We also recommend that faculty investigators complete the practicum, even if they will not be working at the agency sites, because the knowledge gained may help them to supervise more effectively and plan studies more realistically. A practicum description was developed that emphasizes the benefits of the practicum program to planning and conducting research. This helps to overcome researcher resistance to having to cross yet another hurdle in getting approval for projects and personnel.

With regard to outcomes that can improve the conduct of research, learning the details of clinic functioning was the most helpful aspect of the experience. Knowing patient flow and work flow enabled research staff to better integrate their activities with those of the clinic and to reduce the burden of research-related requests on clinic staff by making the requests congruent with usual clinic procedures. It is important to note that these gains came specifically from practicum participation and had not occurred after years of working side by side.

In summary, an important aspect of conducting research in community settings is research staff knowledge of clinic logistics and staff roles. Often researchers negotiate and interact solely with clinic administrators on the assumption that these administrators will work out logistical details with their administrative and clinical staffs. In reality, however, neither investigators nor agency management are typically cognizant of the details of knowledge and working relationships that research staff need to do their jobs in the clinics. Successful implementation of a research project revolves around attention to logistic details. Thus knowledge of clinic procedures and personnel can be of inestimable value to researchers and their staffs.

The practicum described here improved knowledge and attitudes of research staff. It is recommended as a tool to improve implementation of community-based research in collaborations between community providers and academic researchers. This experience addresses acceptance and access components of the engagement model described above. These components form important bases for active and successful collaborations.