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Increasing nursing research capacity in the workplace

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Background: Engaging nurses in research remains extremely difficult.
Aim: This action-research project aimed to increase nursing research capacity in one hospital trust.
Method and initial results: A survey established levels of research knowledge, activity and experience among nurses. The response was low but participants expressed considerable interest. Two roadshows were organised. We then ran a series of four workshops, and the location of the second workshop was changed to increase staff involvement. By the fourth week, uptake was slow but sure and three or four valuable contacts had been made.
Discussion: Lack of understanding and accessibility of research emerged as key concerns. The initiatives described can help to support and develop nurses’ capacity and demystify research.
Conclusion: This initiative has highlighted the tensions between service demand, nursing capacity and nurses’ research confidence and capabilities. It is important to remain flexible, proactive, creative and enthusiastic in supporting nurses to develop skills.

Abstract

Purkis, J. et al (2008) Increasing nursing research capacity in the workplace. Nursing Times; 104: 37, 28–31

Authors
Judith Purkis, PhD, MA, BA, RM, RGN
, is senior research fellow, Institute of Health; Judith A. Jackson, PhD, BA, DipN, RHV, RM, RGN, is principal investigator, associate professor; Gillian Hundt, PhD, MPhil, MA, is professor of social sciences in health; all at University of Warwick; Carole Stockman, BSc, RGN, is specialist practitioner, district nurse, Warwickshire PCT (former research nurse).

Background

Engaging nurses in research – in terms of both carrying out research or using research findings – remains notoriously difficult (Gerrish and Lacey, 2006; Lacey, 1994).

Much research and therefore research funding has historically remained within either academic or medical institutions but there is an increasing impetus for this to change (Department of Health, 2006; Hutchinson and Johnston, 2004).

The DH’s (2006) Best Research for Best Health document clearly outlined the government’s vision for an efficient and effective health service underpinned by top-quality, cutting-edge research. It also advocated a clear and consistent focus on patients’ and the public’s needs.

Therefore nurses – especially those in clinical practice – should be in a prime position to maintain this focus and drive the research agenda.

This builds on the strategic objective of the DH’s (1999) policy document Making a Difference ‘to strengthen the capacity of the nursing profession to contribute to and to undertake health services research’.

As with many other allied health professions, research teaching is now an integral part of the nursing curriculum and, increasingly, post-qualification professional development requirements encourage a research orientation. Nevertheless, since nursing has an ageing demographic (NMC, 2007), research may remain a distant and daunting prospect for some practitioners.

This, along with many other factors, may mitigate against clinical nurses’ involvement in research. Factors range from ‘particular attributes of individuals at one end of the scale to widespread organisational difficulties at the other’ (Bryar et al, 2003).

This article describes how three nurse researchers at one hospital trust set out to investigate and encourage practitioner engagement in research, and describes the challenges met over an 18-month period.

Literature review

Much of the literature focuses on transfer of knowledge and/or using research findings to develop evidence-based practice. Much less is available regarding developing research capacity in clinical settings among practising nurses. This is despite an awareness of the problem for many years (Llorens and Gillette, 1985), and a critique of the paucity of the literature more recently (Segrott et al, 2006).

Engaging nurses in research and creating knowledge offers the opportunity for them to move beyond being purely ‘research consumers’ (Winter, 1990). By developing ownership of nurses’ own clinical concerns, consequent research may begin to reduce the research-practice gap. It is therefore crucial that opportunities are available for practising nurses to engage in research should they wish to do so.

However, creating a clinical research culture and increasing nursing research capacity is not necessarily straightforward.

Segrott et al (2006) identified a variety of important challenges to developing research capacity among nurse educators, albeit in academic departments. Their review of the literature suggested there are many challenges facing nurses and emphasised the need to understand the local context as well as possible. Some recurring and key themes may help guide future developments. The two main themes in this study were (Segrott et al, 2006):

  • Material constraints and organisational contexts;

  • The changing roles and expectations of nurses (or educators).

We will see these echoed as we later describe our findings.

Funk et al (1991) looked more specifically at research use but, inevitably, this required consideration of the local nursing context. This work looked at the challenges in trying to develop a research culture in nursing.

Funk’s model took its base from the work of Rogers (1983), who suggested there are four key factors in the adoption of change: the characteristics of the adopter; the organisation; the innovation; and the communication. Funk et al (1991) translated these for the purposes of application to a clinical setting as: the characteristics of the nurse; the setting; the research; and the presentation and accessibility of research.

Adams (2001) conducted a small phenomenological study exploring the research perceptions of qualified orthopaedic nurses. Specifically, the setting and the research were reported as being most important to this group of nurses.

Bryar et al (2003) suggested that, historically, organisational constraints have been paramount, which could add weight to the setting being a key factor.

Conversely, however, they indicated that for this cohort of nurses practising in the north of England, the main barriers to use were not necessarily reported as ‘organisational’ ones. Nurses reported issues of time, lack of individual authority, issues with the research itself and lack of peer support. This is important and is reflected later in our discussion.

Method and initial results

Funding was secured for a nurse-led research study in a district hospital. A component for building nursing research capacity was included in the funding, as this was a specific aim of the funding body, the Burdett Trust for Nursing.

The original research design planned for two or three nurses to be seconded with backfill to fund replacement clinical staff to enable them to work part-time on the study as practice-based researchers.

However, when advertised in the hospital, there were very few interested candidates so one registered nurse was seconded full-time and a plan developed to raise awareness of opportunities for practice-based research and stimulate interest in it.

The principal investigator had experience of developing health-improvement projects on wards with staff at another trust, which resulted in successful external funding.

On-site assessment
Initially the researchers developed a simple, short survey to map the level of research knowledge, activity and experience of nurses working in the trust. The survey also aimed to capture any areas of practice in which nurses were interested or involved. Approximately 400 were distributed by hand.

This one-page document offered the nurses a choice of research topics, including reviewing literature, simple statistics and qualitative interviewing. Nurses were asked to tick those of interest to them. We also collected data on the nurses’ experiences in clinical practice, audit and research.

While nurses verbally expressed interest in research and promised to complete the questionnaire, we received only 19 responses. This perhaps reflects the ongoing challenges of enhancing the nursing and midwifery contribution to research and truly engaging practitioners (Fitzsimons et al, 2006; Newman et al, 1998). Despite this low response rate, there was considerable interest in many areas of research among this group of nurses (Table 1).

Table 1. Nurse responses

Topics of interest:

  • Literature searching – 12

  • Writing for publication/journals – 13

  • Action research – 13

  • Simple statistical analysis – 11

  • Poster/abstract preparation – 8

  • Qualitative interviewing – 9

  • Other (please explain) – 3

Over half the nurses had previously been involved in audits or benchmarking activities. Their areas of interest generally related to their current areas of practice and spanned numerous specialist areas.

In order to reach more staff to identify their preferences in terms of training format and content, we organised two roadshow sessions for staff on site. Initially the venue of the ‘stall’ was in a purpose-built training centre, situated next to the main hospital site. This proved to be a poor choice as staff did not pass by incidentally and it was some distance from the clinical practice area. We relocated to a more central and visible position outside the staff canteen, ensuring we had a steady stream of all grades of staff passing by (including nurses and allied health professionals).

Fourteen members of staff from various disciplines contributed and advised on the most preferable arrangements. Most importantly, we decided that any future activities should be held in the main hospital in areas near the staff canteen, which has a high level of staff activity throughout the day. This made the team much more visible.

In terms of location, timing and advertising, opinion from the 14 respondents was inconsistent. This perhaps reflected the diversity of different practice areas with different clinical demands. There was more consistency regarding the time than anything else, with most suggesting afternoons were the most suitable.

Perceived challenges
As Table 1 demonstrates, of the initial 19 responses, 12 nurses identified they would like help with reviewing literature and 13 asked for more information about undertaking research and research methodologies and for support with writing for publication.

Verbal responses included ‘would like to be involved if I knew a bit more’ and ‘I am very interested to learn and update skills’. This provided the research team with a framework to plan the next stage.

Developing workshops
We designed workshops as informal drop-in sessions run across four consecutive weeks, ideally on the same day each week. The rationale for this was to try to develop some continuity and familiarity among staff.

Because the room was not always available, we were unable to book the same day each week, although eventually this was not important.

Before the workshops, a brightly coloured, eye-catching poster was designed and displayed all around the hospital. An advert was placed in the hospital bulletin, which is available to all staff on the hospital intranet. Furthermore, personal email invitations were sent to all heads of department, ward managers/team leaders and nurse specialists. We felt the workshops were well publicised and anticipated substantial interest.

In response to the concerns identified, the topics chosen for the four consecutive workshops were: ‘What is Research?’, ‘Literature Searching’, ‘Methodologies’ and ‘Writing a Paper’. We developed a short PowerPoint presentation for each topic, with each week’s topic following the previous one. We planned to use this as a rolling slide show throughout the workshops.

Additionally, there were display boards containing information, examples of research posters, the team’s contact numbers and details of the hospital’s own research and development department. Handouts were developed and, as an added incentive to encourage staff to approach the table, a large tin of chocolates was available.

Implementing the workshops
The first workshop was organised and set to run on a Tuesday in mid-November 2007, from noon–2pm, hoping to catch staff during their lunch break.

We set up the initial part of the PowerPoint presentation entitled ‘What is Research?’ to roll on the wall of the conference room. This room adjoins the main canteen via two sets of double doors. We arranged the display boards, set out handouts and sweets on a large table and waited for some interest.

However, using this room proved problematic. It was perceived as a separate area and we were effectively shut off from the public area, the canteen. The doors created a physical barrier despite being open. It had the feeling of an empty shop – no one wanting to be the first customer. So, despite all the publicity and invitations, we had virtually no interest and had to rethink our strategy.

The following week we decided to abandon the conference room and, with the canteen manager’s permission, moved directly into a corner of the canteen. We set up the display boards as before and added the next small presentation, ‘Literature Searching’, to the rolling display. This was projected onto the canteen wall for all to see.

The difference was immediately apparent as people appeared curious and seemed to be taking an interest in the display and slide show.

However, we continued to sit waiting for more specific enquiries. We knew there were nurses in the hospital with an interest in research and some feasible ideas circulating in practice but still virtually no one approached us for help or advice.

As our finish time of 2pm approached, two student physiotherapists came up very apologetically and asked for help as they were about to start their dissertations. They were unsure about how to start their literature review. While we seized the opportunity to help, we were fascinated and informed by their observation that they had thought we were ‘waiting for somebody important’. We – in their eyes at least – had not seemed approachable.

The third workshop went ahead as planned. Despite the poor level of interest to date, we hoped that by providing a consistent and eventually familiar presence, interest would gain momentum and this seemed to be the case. While we did not have an abundance of interest, one or two people approached us, asked simple questions and took away some of the handouts. There seemed to be a definite, if slight, improvement.

We were then approached by a consultant with an obvious interest in the slide show. She was very polite and keen but slightly concerned about the nature of some of the content in the slide show. As our own topic was about end-of-life care, we had used some of this as examples for research (that is, keywords such as ‘death’ and ‘dying’) and she felt this may distress some people in a public area.

While this is debatable, particularly in a hospital environment, it was also a valid observation and easily resolved. In order to avoid any potential distress or discomfort, we agreed to remove these examples and insert others. This was done in preparation for the fourth and final workshop.

The last workshop was again held in the canteen. The slide show had additional information on ‘How to write a paper’ and our displays and handouts were readily available as in previous weeks. The uptake was slow but sure and three or four valuable contacts were made.

Discussion

During this short time of contact, we undoubtedly established a trickle of interest.

While ‘time’, a characteristic of the setting, was repeatedly given as a reason for avoiding participation in research, this was less of a concern than a lack of understanding from individual nurses. The only other concern equal to lack of understanding was accessibility of the research itself.

While the setting remains crucial, fortunately these concerns may, in the short term, be more immediately and realistically addressed. Many nurses seemed to recognise that researching could be part of their day-to-day work and evolve from activities they were already doing, rather than requiring substantial extra time. However, they felt they needed a clearer understanding of how that could work in reality.

Initiatives such as those described here can be instrumental in supporting and developing the individual’s characteristics and demystifying research, which may also help with issues of accessibility. While in part the ideal answer may be to ensure some protected research time is built into nursing contracts, this may not be attainable in the current climate.

Subsequently, we emailed all clinical nurse specialists, ward sisters and charge nurses in the trust, reiterating the importance of research both as knowledge to inform practice and as a process and catalyst for change. We reminded them of our availability and the support already in house.

Two clinical nurse specialists have contacted us already, requesting advice on ideas for research.

Following liaison with the professional development nurses on site, a research element is being designed for inclusion in both the management training provided at the trust just before qualifying and in regular mandatory training.

In doing this, we hope to be able to maintain interest and dialogue with frontline staff regarding practitioner-based research. We hope that, ultimately, nursing research on site becomes integral to best clinical practice.

Conclusion

This initiative has, once again, highlighted the tensions between service demand, nursing capacity and nurses’ research confidence and capabilities.

An important learning point for this research team is the necessity to remain flexible, proactive, creative and enthusiastic in supporting nurses to develop skills. It is useful to summarise the lessons learnt for others considering a similar pursuit (Box 1).

Box 1. Lessons learnt from this project

  • Generating interest clinically is challenging and it is best to anticipate a slow build-up.

  • Consistency and familiarity seem important in provision.

  • Flexibility and adaptability are key.

  • To be well received, ideas need to be generated from clinicians themselves.

  • Support and information is more likely to be accessed if it is in the practice area.

  • Accessible information with take-home materials are popular.

  • While lack of time is seen as one of the main barriers to carrying out research, lack of understanding was found to be a key concern.

The process described here has resonance with much of the literature, in that reconciling the clinical demands of practice and the pressing urgency to foster research cultures remains one of the major challenges of the modern NHS (DH, 2006).

Undoubtedly the profession now stands at a crucial point in the history of nursing research. The policy is firmly in place and the public rightly anticipates healthcare based on the best possible research. The onus now lies not only with individual professionals and clinical leaders but also with managers and researchers alike to collaborate on finding the best possible ways of fostering dynamic and healthy research cultures.

Plans

Partly as a result of our brief period of visibility, we have been invited to continue our input in the management training and mandatory updating. This is intended to regularly remind nurses that a critical, analytical view of everyday practice forms the basis of research and the foundation of evidence-based practice (Fitzpatrick, 2007).

Furthermore, it is designed to ensure that the infrastructure of support is there to help practitioners when they are ready to develop their own ideas and practice.

Implications for practice

  • This project seems to present a microcosm of research dilemmas in practice. Nursing staff had the most imaginative, impressive and important ideas for research. They had even begun, at times, to suggest potentially simple and sometimes creative solutions to the problems they saw.

  • Few nurses recognised their daily challenges and observations as research material; fewer still had any idea how to go about developing these ideas into a proposal worthy of funding.

  • This research uncovered a lack of good, structured, practical support for clinicians in their own space.

  • While support was available in the teaching centre and the library, by the very nature of its location (away from the clinical area), it allowed research to disappear from everyday practice.

  • It is important to regularly remind nurses that critically reflecting on everyday practice forms the basis of research and evidence-based practice.

  • Visibility and accessibility are essential when trying to attract staff to take part
    in workshops.

References

Adams, D. (2001) Breaking down the barriers: perceptions of factors that influence the use of evidence in practice. Journal of Orthopaedic Nursing; 5: 170–175.

Bryar, R. et al (2003) The Yorkshire BARRIERS project: diagnostic analyisis of barriers to research utilisation. International Journal of Nursing Studies; 40: 73–84.

Department of Health (2006) BestResearch for Best Health: a New National Health Research Strategy. www.dh.gov.uk

Department of Health (1999) Making a Difference. Strengthening the Nursing and Midwifery Contribution to Health and Health Care. www.dh.gov.uk

Fitzpatrick, J. (2007) Finding the research for evidence-based practice – part one: the development of EBP. Nursing Times; 103: 17, 32–33.

Fitzsimons, D. et al (2006) Vision, leadership and partnership: how to enhance the nursing and midwifery contribution to research and development. Journal of Advanced Nursing; 55: 6, 748–756.

Funk, S.G. et al (1991) Barriers to using research findings in practice: the clinician’s perspective. Applied Nursing Research; 4: 90–95.

Gerrish, K., Lacey, A. (2006) The Research Process in Nursing. Oxford: Wiley-Blackwell.

Hutchinson, A., Johnston, L. (2004) Bridging the divide: a survey of nurses’ opinions regarding barriers to, and facilitators of, research utilisation in the practice setting. Journal of Clinical Nursing; 13: 304–315.

Lacey, A. (1994) Research utilization in nursing practice: a pilot study. Journal of Advanced Nursing; 19, 987–997.

Llorens, L.A., Gillette, N.P. (1985) The challenges for research in a practice profession. American Journal of Occupational Therapy; 39: 143–145.

Newman, M. et al (1998) Barriers to evidence based practice. Intensive and Critical Care Nursing; 14: 231–238.

NMC (2007) Statistical Analysis of the Register 1 April 2006 to 31 March 2007. www.nmc-uk.org

Rogers, E.M. (1983) The Diffusion of Innovations. New York, NY: Free Press.

Segrott, J. et al (2006) Challenges and strategies in developing nursing research capacity: a review of the literature. International Journal of Nursing Studies; 43: 637–651.

Winter, J.C. (1990) Relationship between sources of knowledge and use of research findings. Journal of Continuing Education in Nursing; 21: 138–140.

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