Successful recruitment strategies are key to recruiting appropriate people with different skills and experiences (Boivin et al. 2010). Research suggests that a barrier to recruitment for clinical guideline developers is not having the resources to implement recruitment strategies (Armstrong and Bloom 2017b). Therefore, this section provides advice on a range of recruitment methods, some of which are cost neutral.

Nomination and open recruitment

There are 2 key methods of recruitment: open recruitment and nomination. In open recruitment, guideline developers advertise the post using the role and person specification. Applications are reviewed against criteria and the developer is responsible for selecting people who meet the criteria. Nomination is used when developers approach patient organisations to nominate someone who, in their opinion, can reflect and understand patient or public issues relevant to the guideline. With nomination, the patient organisation is responsible for recruiting and the developer should not have any input. It is possible to combine elements of both approaches, but whatever method is selected it should be an accepted, transparent, and justifiable approach that can be documented. 

Advantages and disadvantages of each method

Each method has advantages and disadvantages to consider when deciding which to use. These are outlined in table 1. In summary, open recruitment enables a wider range of people to become involved and is transparent. It helps minimise bias by allowing developers to choose between people from different geographical locations, treatment centres, and groups in society. However, it can increase bias if the developer chooses people who appear to be more ‘compatible’ with the interests or culture of the guideline group. To help avoid that bias, involve a suitable person external to the guideline team in the selection and ratification process, such as a patient involvement specialist. Open recruitment can be costly in terms of human resources and time compared with nomination. Timescales should account for developing recruitment criteria, administering the recruitment process, and reviewing applications. Templates of application forms and person specifications can help speed up the process.

Alternatively, nomination is rapid but can narrow the pool of potential candidates. To prevent this, a predefined nomination process should be outlined from the outset and strategies should be implemented to ensure people are nominated from a broad pool of candidates. Sometimes patients and public members recruited from patient organisations can pursue their organisation’s agenda. This should be prevented through induction and training that emphasises that the individual is to represent their experiences and those of others living with the condition.

If developers choose nomination as a method, they need to consider how this might affect the status of the individual within the group if the professional members had to compete to ‘earn’ their place. Conversely, if health professionals are nominated there may be no perceived unfairness. Open recruitment can increase patient and public members’ confidence by knowing that they were selected from a pool of applicants. Regardless of the method selected, the way in which it was implemented needs to be documented and transparent.

Table 1 Advantages and disadvantages of open and nomination recruitment methods

	Open recruitment	Nomination
Advantages	– Attracts a wider range of people – Reduces bias by recruiting people who are unknown to rest of guideline development group, which lowers the chance of people agreeing with group in fear of disagreeing with their own doctor – Phone interviewing shortlisted applicants helps screen out people with narrow perspectives and those who cannot reflect on broader patient issues. Advice from a patient and public involvement specialist can be helpful in eliminating unsuitable applicants – Attracts people with broader perspectives – Transparent – can answer questions about why certain people were recruited and demonstrate where procedures have followed equality legislation	– Less resource demanding – The guideline developer has no influence on the choice of the group members and so no risk of influencing group composition through selective recruitment – Could increase the chance of recruiting individuals who you might not have considered because of the joint expertise of patient organisations and people with specific aspects of a disease – In most cases, patients nominated by a patient organisation are trained in championing patient perspectives – Can be faster than open recruitment although it depends on how long it takes the patient organisation to respond – Can recruit patients with a background in user-led research or known ability to work well in groups – Assures that patient organisations decide themselves who is best to provide their perspective (respects patient autonomy) – May facilitate reaching specific seldom heard groups, especially if there are barriers to patients or public engagement
Disadvantages	– Time consuming – Costs of advertising, if paying for advertising to be placed – Costs of preparing and processing paperwork and applications – Risk of biased choice, that is, a risk that the guideline developer actively influences group composition in a way that ‘easy to handle’ patients are recruited – Needs rigorous and transparent documentation of the selection process to avoid risk of bias or being selective – If relying on patient organisations to circulate the advert, this could be perceived as nomination – Risks of failed recruitment – if the condition is rare or the affected population is less likely to use recruitment channels like the internet – Ethical concerns if organisations persuade a vulnerable person to apply and they are unsuccessful	– Risk of missing people with a very unique expertise and experience – When nominating from patient organisations, there is a risk of recruiting people with biased perspectives, such as those who have only had negative experiences of healthcare systems  – Can exclude patients who have not had experience of similar work, but might still be able to make valuable contributions – May introduce bias. In some countries, nominated members from patient organisations could be associated with teaching hospitals, pharmaceutical companies or campaign organisations, and have different experiences from those in rural areas or general clinics – Risk of narrow patient perspectives if patients with a background in lobbying on one aspect of a condition are nominated – For some guideline topics (for example, rare conditions or symptom-based topics) there may not be any relevant patient organisations who can nominate patients – Some patient organisations may not have the capacity to identify appropriate nominees

Selection of methods in practice

The method to choose will depend on the developer’s requirements and resources. Local circumstances may dictate which approach would work best. For example, in countries with well-resourced or well-developed patient organisations, the nomination process can work well (especially for main condition areas like cancer). Open recruitment works well for well-resourced guideline development agencies with specialist patient or public involvement support (like NICE).

NICE uses open recruitment and has found that it leads to a range of individuals applying for the role, including many who are not associated with patient organisations. NICE advertises positions for patients and public members for 4 weeks thereby allowing patient organisations time to contact their members and for the advertisement to get maximum exposure through websites and other social networks.

The Dutch Institute for Healthcare Improvement (CBO) in the Netherlands, the German ÄZQ and SIGN in Scotland, recruit primarily through umbrella patient organisations, such as The Richmond Group of Charities or National Voices in the UK. The ÄZQ uses a predefined nomination method, which is outlined in detail in their manual (Sänger, 2008). It recruits from 4 umbrella organisations to ensure people are nominated from a broad pool of candidates. ÄZQ asks them to select all the patient organisations they think are appropriate for the condition in question, and then have a discussion with every organisation about the patients they want to nominate. This results in a list of members for the guideline development group for the developer, who then starts training and support for them. During the initial meeting, the guideline group is asked if there any expertise is missing from the group and the developer then seeks to fill any gaps in experience.

Advertising the role

Open recruitment works best when patient organisations, or healthcare professional organisations with public involvement functions, can inform their members of the vacancy by promoting it on their websites, through social media, email distribution or newsletters. Patient organisations can also provide advice on how to recruit people from seldom heard groups. 

Healthcare professionals in the development group may also be able to support recruitment, either by advertising the opportunity through their networks or by nominating a patient. However, this can increase the likelihood of recruiting a patient or public member who is treated by the same health professional on the panel. This should be avoided because it can prevent the patient from speaking freely during discussions.

If using social media to advertise, developers can reach a larger audience who are invested in the guidance topic by ‘tagging’ relevant patient organisations in any social media posts. Developers can engage seldom heard groups, such as black, Asian, and minority ethnic groups (BAME), on Twitter, Facebook or patient forums. Permission should be obtained before sharing any opportunities. Starting online conversations with public members who express interest in the recruitment opportunity can increase applications by addressing any concerns or queries that arise. This approach is relatively cost effective although time is required to build online relationships with the public. Not everyone has easy access to the internet, so additional methods of publicising the vacancy should still be used to reduce inequalities in the recruitment process. If seldom heard groups are not active on one form of social media (for example, Twitter) then they might be more active on another channel, such as Facebook. If not, it will be difficult to engage them through this means. 

When advertising the role, state explicitly the kinds of support that individuals can receive to encourage more people to apply. This should be realistic and deliverable in practice. The section on supporting individual patient and public members describes the types of support that can be provided.

Documents for recruitment

It is helpful to publish the role and person specification (in both open and nomination recruitment methods), either as a detailed advertisement or as additional information to help applicants decide if they are suitable for the role. The application or nomination form should be well structured, which will make it easier for people to provide the relevant information. NICE also includes an equality monitoring form for applicants in line with the UK’s Equality Act (2010). Guidance on this act can be found in the further reading section. The form collects personal information, such as age and gender, and can be used to evaluate and review the diversity of membership. The form is processed separately from the main application form to ensure anonymity.

To enable people with various disabilities to apply (for example, people with sight impairment), developers need to consider the accessibility of their information, such as ensuring documents can be read using a screen reader. Guideline developers should check government or organisation guidelines on accessibility for further information.

Interviewing candidates after open recruitment

Interviewing candidates after open recruitment can help overcome some of the known barriers to effective patient and public involvement. These include concerns over skills, breadth of experience and the ability to reflect on experience, objectively review the evidence, or work critically within a group. People who have had only negative experiences of care, or people who are opposed to the methodology behind evidence-based care, may not be appropriate candidates. Developers should consider how to interview people with specific health conditions or disabilities, or those who work full time. Interviewing over the phone or by video conference (for example, Skype or Zoom) are useful alternatives if some people cannot attend face-to-face interviews. Group interviews might also help assess communication and group working skills.

Making the appointment

Successful candidates should be notified in writing. Consider whether they should complete a declaration of interests form, to identify possible conflicts, and a contract. Some organisations designate alternate members at the interview stage in case the appointed member has a change in circumstance and cannot take up the role. But, in some cases, it may be better to re-advertise or get new nominations.

It is also important to ensure the recruitment process is fair and to document the process, including the reasons for who to recruit, to avoid any potential accusations about discriminatory practices. Unsuccessful candidates can be offered other involvement opportunities, such as being a peer reviewer. Candidates should have a named contact and details, so the developers know who contact for further information or to discuss the outcome of their application or interview.