The role of PhD-prepared, hospital-based nurses: an inter-Nordic study

Abstract

Background

Little is known about PhD-prepared nurses employed at Nordic university hospitals, how they are organised, what their practices look like or what career pathway they have chosen.

Aims

The purpose was to investigate and compare the prevalence of PhD-prepared nurses employed at university hospitals in the Nordic countries, to investigate what functions they fulfil and what research activities they undertake and to document how they describe their ideal work life.

Methods

A descriptive cross-sectional study. An electronic questionnaire was sent to 245 PhD-prepared nurses working at a university hospital in one of six Nordic countries and 166 responses were achieved (response rate 67%). Descriptive analyses were performed using SPSS Statistics.

Results

The study found notable differences among PhD-prepared nurses employed at university hospitals with respect to work function; organisational structure; satisfaction about time split between research and practice; and the mean scores of time spend on research, clinical practice and teaching, supervision and administration.

Conclusions

In order to succeed with capacity building among the nursing workforce, collaboration and networking with other researchers and close contact to clinical practice is important. The role of the hospital-based, PhD-prepared nurse needs to be better described and defined to ensure that evidence-based care is provided.

Introduction

Changes in disease panorama, an aging population and shorter hospital stays are leading to more complex and advanced care situations. These changes challenge health professionals and put higher demands on their competence and their ability to work effectively. Hence, health professionals' roles and functions also need to be developed (Olsen and Hølge-Hazelton, 2016).

For the past 20 years, there has been a worldwide increase in clinical research, and the importance and worthwhileness of research has been recognised by the public, policymakers and health care professionals (Krzyzanowska et al., 2011). Research in clinical nursing has also increased significantly, however at different speeds related to educational curricula, possibilities for obtaining research training and degrees and research capacity building. Studies of clinical nursing have been shown to improve patient care by strengthening evidence-based clinical practice (Tingen et al., 2009); therefore, clinical nursing research capacity is crucial both to patients and society (Aiken et al., 2015; Tingen et al., 2009). Research has also shown a relationship between the number of nurses with higher education and lower patient mortality and failure to rescue rates (Aiken et al., 2003).

Sterling and McNally (1999) noted that PhD-prepared nurses contribute to the management of patient care, the development of interwoven partnerships and leadership positions. However, few differences were seen between the role of a PhD-prepared nurse and an advanced practice nurse (one without a PhD degree) (Sterling and McNally, 1999). By contrast, McNett (2006) observed that PhD-prepared nurses employed at hospitals tend to describe their roles as bridging the gap between research and practice and being a voice for the nursing practice within the organisation. She concluded that hospital-based PhD-prepared nurses are in a key position to advance both the clinical nursing research field and the delivery of patient care within healthcare systems (Jamerson and Vermeersch, 2012).

There may be both financial and clinical benefits to employing PhD-prepared nurses in hospitals (Staffileno et al., 2013). These nurses can initiate and facilitate research that is based in clinical practice, leading to more effective care and cost savings in the long term (Aiken et al., 2003). However, the literature on PhD-prepared nurses in clinical settings, their employment and functions and their impact on patient care is scarce (Jamerson and Vermeersch, 2012; McNett, 2006; Wilkes and Mohan, 2008).

Organisation and capacity building

There is little guidance in the literature regarding how clinical institutions, such as hospitals, can apply organisational models to meet the challenges of building research capacity in clinical nursing.

Research focusing on the roles of nurse researchers in clinical practice illustrates that the functions of the nurse research facilitator vary widely (Jamerson and Vermeersch, 2012; Kirchhoff and Mateo, 1996). Furthermore, there seem to be differences between those who are engaged part-time and those who are engaged full-time as researchers and between those in dual, collaborative and functional roles, such as, for example, those who work part-time in a university position and part-time in clinical practice (Jamerson and Vermeersch, 2012).

The lack of clear definitions, and the interchangeable use of different terms to describe these nurses, may also affect organisations’ and nursing research capacity building. Internationally, nurses with a PhD employed in clinical settings are, for example, described as ‘PhD-prepared nurses’ (McNett, 2006), ‘nurse research facilitators’ (Jamerson and Vermeersch, 2012) and ‘clinical nurse researchers’ (Kirchhoff and Mateo, 1996). From here onwards, the present study will use the term ‘hospital-based, PhD-prepared nurses’.

The Nordic area

The Nordic countries (Denmark, Finland, Iceland, Norway and Sweden, plus Greenland and the Faroe Islands) have a shared history and culture, with economic and political commonalities and similarities based on common values. The Nordic countries cover an area of approximately 1.322 million km² and have more than 27 million inhabitants. Sweden is the largest country, by population (Nordic Co-operation, 2016). Furthermore, the Nordic countries have comparable health care systems, and all countries now have PhD programmes in nursing (Råholm et al., 2010).

Despite the increasing number of registered nurses (RNs) with a PhD in the Nordic countries, there seem to be limited employment opportunities that combine clinical and university positions where nurse researchers can consolidate their clinical experiences and where a research career pathway is possible. Nurses who have achieved a PhD degree often take up academic positions in universities and colleges instead of remaining in clinical practice.

To date, there has been no overview of how many PhD-prepared nurses are employed at Nordic university hospitals, how they are organised, what their practices look like or what clinical nursing career pathway they have chosen (DAMVAD, 2014; Wilkes and Mohan, 2008). Neither hospitals, universities nor nurse unions/societies systematically gather information on education and PhD degrees. To make the matter more complicated, midwife training is built into the nursing education programmes in Finland, Norway and Sweden, but it is a stand-alone curriculum in the other Nordic countries. To investigate these differences further, six leading Nordic nurse researchers, with support from one research assistant, initiated a collaboration. To the best of the authors' knowledge, this is the first survey to study the prevalence, location and activities of PhD-prepared nurses employed at university hospitals in the Nordic countries.

The aim of this study was to investigate and compare the prevalence of PhD-prepared nurses employed at university hospitals in the Nordic countries, to investigate what functions they fulfil and what research activities they undertake and to document how they describe their ideal work life.

Methods

The study employed a cross-sectional survey based on a questionnaire with a descriptive design. Respondents were RNs who had obtained a PhD and were working at a university hospital in one of six Nordic countries: Sweden, Norway, Finland, Iceland, the Faroe Islands or Denmark. Representatives from the author group contacted the university hospitals in each country and gathered direct contact information and email addresses for all employed PhD-prepared nurses, or established a contact who forwarded emails to those nurses at their hospital of employment. The questionnaire was sent to 245 PhD-prepared nurses. After prolonging the response period by one month and dispatching two email reminders, 166 responses were included (response rate = 67%). The response rate per country was 100% from the Faroe Islands, 83% from Denmark, 71% from Norway, 71% from Iceland, 68% from Finland and 57% from Sweden.

Data collection

Data were self-reported via an electronic questionnaire administered by a commercial survey tool (SurveyXact) (Rambøll Management Consulting, 2012). Initially, four PhD-prepared nurses employed in different countries (Sweden, Norway and Denmark) read and accepted the questionnaire. In addition, a subsequent pilot study involving six PhD-prepared nurses identified misunderstandings or omissions in the questionnaire.

Data were collected between 1 September and 7 November 2016. The questionnaire consisted of 25 items, which have been developed based on earlier research (Lode et al., 2015) and from clinical experience. The first 10 items concerned demographic data and data about the locations of the hospitals where the respondents were employed. Another 15 items elicited information about the organisation of their work and their roles in their current positions. Finally, the respondents were asked: ‘If you could choose, what would your ideal work life look like?’. A research assistant from the author group distributed the questionnaire to the PhD-prepared nurses’ email addresses and automatically received the completed self-reports. The questionnaire was in the English language, to ensure equal comprehension among participants.

Data analysis

Statistical analysis was performed using SPSS Statistics (Version 22.00, IBM Corporation, Armonk, NY, USA). Only one PhD-prepared nurse from the Faroe Islands participated, therefore this response was pooled with responses from Denmark. Descriptive analyses were performed using mean and standard deviation (SD). Chi-square analyses were used to show differences in proportions. The level of significance was set to p < 0.05 for all analyses. The findings from the open-ended question were analysed by two of the authors until consensus was reached. The analysis was inspired by Braun and Clarke's six steps of thematic analysis, a widely used method for discerning patterns of meaning across a dataset (Clarke and Braun, 2017):

1. Familiarizing with the data, reading and re-reading

2. Preliminary coding, what is going on in the data?

3. Searching for themes

4. Naming and adjusting the themes, revising the data

5. Reviewing the themes, generating clear names for the themes.

Ethical considerations

The North Denmark Region Committee on Health Research Ethics (approval number: 2008-58-0028) approved the study. The study complied with all ethical principles for medical research described in the Helsinki Declaration (World Medical Association, 2013). The collected data were handled confidentially and stored safely according to regulations. Each of the included PhD-prepared nurses received a key, and as every reply was automatically returned to the research assistant from each participant's email address, the authors could be certain that the reply was from the invited nurse and no one else. The questionnaire was distributed to each prospective participant personally, and the returned answers were considered the participant's informed consent to be included in the investigation.

Results

The number of Nordic RNs with a PhD degree has increased significantly in recent years; Sweden stands out, with almost 1700 RNs/midwives with a PhD in 2017. In comparison, there were approximately 210 RNs with a PhD in Denmark and 430 RNs with the degree in Finland. There has also been an increase in the number of nurses choosing to become professors, although the number of professors of nursing, in relation to the number of RNs with a PhD, varies across the countries, with 37% professors in nursing in Norway (numbers from 2016), compared with 10% in Denmark, 7% in Sweden and 4% in Finland (Figure 1).

Figure 1.

Overview of milestones for the development of the academic development for nurses in the Nordic countries. (*No numbers for 2017 were available for Norway.). Note: The numbers are based on data from the nursing unions and from different educational institutions. As no exact numbers exists, they are only an estimate. The numbers present an overview and a trend of the development of scientific competence in each country and some variations between the Nordic countries.

Sample characteristics

Fifteen males (9%) and 151 (91%) females with an average age of 53 years (SD 7.5) participated in the survey (Table 1). In total, 113 (68%) of the nurses reported their main working position to be at a university hospital, 32 (19%) had their main working position at a university, and 21 (13%) had their main working position in other places. However, differences among countries were identified. All of the PhD-prepared nurses from Finland (100%) reported their main working position to be a university hospital, while the figures for the other countries were as follows: 79% (Denmark; n = 50), 58% (Iceland; n = 7), 54% (Norway; n = 20) and 51% (Sweden; n = 19). The majority of the respondents received their PhD or doctoral degree from a Faculty of Medicine (63.9%), while 6.6% received it from a Faculty of Social Sciences, 0.6% from a Faculty of Humanities, 1.8% from a Faculty of Engineering and Sciences and 27% from other places. Only 29% of the PhD-prepared nurses from Finland received their PhD degree from a Faculty of Medicine, compared with 92% from Sweden (p < 0.001). About half (52%) of all the respondents had attended a formal lecturer or postdoctoral course. In particular, PhD-prepared nurses from Iceland (67%, n = 8) and Sweden (68%, n = 25) seemed to be more likely to have attended a formal lecturer or postdoctoral course compared with participants from the other countries.

Table 1.

Descriptive characteristics of PhD-prepared nurses working in Denmark, Norway, Finland, Sweden and Iceland (*Several items could be marked).

	Denmark	Norway	Finland	Sweden	Iceland	Total
	n = 63	n = 37	n = 17	n = 37	n = 12	n = 166
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	X2 (p)
Male	2 (3.2)	6 (16.2)	2 (11.8)	5 (13.5)	0	15 (9.0)
Female	61 (96.8)	31 (83.8)	15 (88.2)	32 (86.5)	12 (100)	151 (91.0)
Main working position							48,557 (.000)
University hospital	50 (79.4)	20 (54.1)	17 (100)	19 (51.4)	7 (58.3)	113 (68.1)
University	1 (1.6)	9 (24.3)	0	17 (45.9)	5 (41.7)	32 (19.3)
Other	12 (19.0)	8 (21.6)	0	1 (2.7)	0	21 (12.7)
Do you have an additional position?							23,333 (.000)
Yes	26 (41.3)	27 (73.0)	8 (47.1)	29 (78.4)	11 (91.7)	101 (60.8)
No	37 (58.7)	10 (27.0)	9 (52.9)	8 (21.6)	1 (8.3)	65 (39.2)
PhD or Doctoral degree from							50,555 (.000)
The Faculty of Social Sciences	3 (4.8)	5 (13.5)	3 (17.6)	0	0	11 (6.6)
The Faculty of Humanities	1 (1.6)	0	0	0	0	1 (0.6)
The Faculty of Medicine	32 (50.8)	30 (81.1)	5 (29.4)	34 (91.9)	5 (41.7)	106 (63.9)
The Faculty of Engineering and Sciences	3 (4.8)	0	0	0	0	3 (1.8)
Other	24 (38.1)	2 (5.4)	9 (52.9)	3 (8.1)	7 (58.3)	45 (27.1)
Referring to							53,787 (.000)
Hospital director level	7 (11.3)	3 (8.1)	12 (70.6)	4 (10.8)	3 (25.0)	29 (17.6)
Ward management level	19 (30.6)	5 (13.5)	0	6 (16.2)	1 (8.3)	31 (18.8)
Unit management level	8 (12.9)	9 (24.3)	1 (5.9)	8 (21.6)	1 (8.3)	27 (16.4)
Research department level	19 (30.6)	14 (37.8)	2 (11.8)	10 (27.0)	2 (16.7)	47 (28.5)
Other	9 (14.5)	6 (1.2)	2 (11.8)	9 (24.3)	5 (41.7)	31 (18.8)
Main research collaborators*
Nurses	58 (92.1)	33 (8.2)	11 (64.7)	33 (89.2)	11 (91.7)	146 (88.0)	9,937 (.041)
Physicians	42 (66.7)	32 (86.5)	7 (41.2)	30 (81.1)	6 (50)	117 (70.5)	16,431 (.002)
Allied professionals	29 (46.0)	16 (43.2)	9 (52.9)	10 (27)	6 (50)	70 (42.2)	4,992 (.288)
Health economist	6 (9.5)	2 (5.4)	1 (5.9)	3 (8.1)	0	12 (7.2)	1,702 (.790)
Statisticians	24 (38.1)	15 (40.5)	6 (35.3)	8 (21.6)	5 (41.7)	58 (34.9)	3,913 (.418)
Sociologist	8 (12.7)	3 (8.1)	0	1 (2.7)	0	12 (7.2)	6,243 (.182)
Other	14 (22.2)	4 (10.8)	3 (17.6)	6 (16.2)	2 (16.7)	29 (17.5)	2,171 (.704)
Used research design*
Experimental	33 (52.4)	16 (43.2)	3 (17.6)	16 (43.2)	3 (25.0)	71 (42.8)	8,316 (.081)
Descriptive	30 (47.6)	23 (62.2)	9 (52.9)	27 (73)	11 (91.7)	100 (60.2)	12,028 (.017)
Qualitative	50 (79.4)	21 (56.8)	12 (70.6)	28 (75.7)	4 (33.3)	115 (69.3)	13,747 (.008)
Mixed Methods	38 (60.3)	21 (56.8)	10 (58.8)	22 (59.5)	9 (75)	100 (60.2)	1,303 (.861)
Other	11 (17.5)	8 (21.6)	1 (5.9)	1 (2.7)	1 (8.3)	22 (13.5)	7,862 (.097)
Formal lecturer or postdoctoral							6,824 (.145)
Yes	29 (46.0)	16 (43.2)	8 (47.1)	25 (67.6)	8 (66.7)	86 (51.8)
No	34 (54.0)	21 (56.8)	9 (52.9)	12 (32.4)	4 (33.3)	80 (48.2)
Budget responsibility							10,269 (.036)
Yes	29 (46.0)	17 (45.9)	7 (43.8)	15 (40.3)	11 (91.7)	79 (47.9)
No	34 (54.0)	20 (54.1)	9 (56.3)	22 (59.5)	1 (8.3)	86 (52.1)
Distribution of time between research and practice							10,314 (.035)
Yes	46 (73.0)	29 (78.9)	10 (58.8)	23 (62.2)	4 (33.3)	112 (67.5)
No	17 (27.0)	8 (21.6)	7 (41.2)	14 (37.8)	8 (66.7)	54 (32.5)
b) Mean (SD)
Age	52.6 (7.3)	53.3 (7.3)	53.1 (6.)	53.8 (8.2)	54.3 (7.9)	53.3 (7.47)
Time on research (range 0–100%)	46.7 (20.7)	50.8 (24)	20.1 (21.2)	27 (17.7)	29.4 (18.2)	39.3 (23.6)
Time on clinical settings (range 0–94%)	13.6 (15.6)	16.2 (20.7)	12.1 (14.3)	24.9 (20.6)	17.3 (24.3)	16.7 (18.9)
Time on supervision, teaching and   administration (range 0–99%)	40.9 (21.8)	43 (21.6)	54.8 (23.8)	47.9 (25.3)	59.8 (22.2)	45.8 (23.2)

Approximately 50% of the total group had budget responsibility, while almost all (90%) from Iceland had budget responsibility. Overall, two-thirds (68%) of the PhD-prepared nurses were satisfied with the distribution of their time between research and practice. However, the results varied by country, with 33% (n = 4) reporting being satisfied in Iceland, 59% (n = 10) in Finland, 62% (n = 23) in Sweden, 73% (n = 46) in Denmark and 79% (n = 29) in Norway.

Organisation of their work

PhD-prepared nurses employed in hospitals were, on average, spending nearly half of their time on supervision, teaching and administration (see Table 1). The mean scores were similar across the countries. In comparison, just 20% to 30% of the time was spent on research in Sweden, Iceland and Finland, which differed from Denmark and Norway, where it was 47% (SD 20.7) and 51% (SD 24.0), respectively. There was a significant difference across the countries regarding by whom the PhD-prepared nurses were employed and whether they report to the hospital director level, ward management level, unit management level, research department level or others. In Finland, the majority of PhD-prepared nurses (71%) referred to the hospital director level, unlike Denmark, Sweden, Norway and Iceland, where the nurses were referring to various organisational levels. Overall, 18% (n = 29) referred to the hospital director level, 19% (n = 31) to the ward management, 16% (n = 27) to the unit management level, 29% (n = 47) to research department level and 19% (n = 31) to others. Despite these differences in organisational structure, there was agreement across the countries about the importance of researchers who are responsible for leading research in clinical nursing having a nursing background.

Of the 166 PhD-prepared nurses surveyed, 61% had an additional position. Of these, the majority held their additional position at a university (55%), or in a specialist health care setting (38%). There were significant differences across the countries; 92% (n = 11) of the PhD-prepared nurses from Iceland had an additional position, whereas in Denmark just 41% (n = 26) reported an additional position.

In Sweden, Norway and Denmark, the main research collaborations were between nurses and physicians, whereas PhD-prepared nurses from Iceland seemed to collaborate equally with physicians (50%), allied professionals (50%) and statisticians (42%). The same distribution of PhD-prepared nurses' collaborators emerged from Finland. There seemed to be different research design traditions across the countries, where the descriptive design was the most commonly used design in Iceland (92%), unlike Denmark, Finland and Sweden, where the qualitative designs were the most common.

PhD nurses' work functions

Of eight different functional options, management, research, teaching, supervision, clinical practice, research utilisation, research grant seeking and others, respondents were asked to address all the functions that they performed. None of the respondents reported that they performed all of them; however, research, teaching, supervision and research utilisation functions were reported by at least 70% of the respondents. Figure 2 illustrates the differences in work functions across the countries. Interestingly, fewer than 60% of the PhD-prepared nurses from Finland worked in research, whereas in Denmark almost all of them did (97%). Relatively few of the PhD-prepared nurses worked in a clinical setting: 46% in Sweden and fewer than 35% in the rest of the countries. Most respondents from Norway (89.2%) and Denmark (83.9%) were involved in supervision. Approximately 65% of the respondents from Iceland worked in management, which differed from the rest of the countries, where the corresponding proportions were 36% in Denmark, 35% in Norway, 29% in Finland and 24% in Sweden. The proportion of PhD-prepared nurses who reported applying for research funding was significantly higher in Denmark (81%), compared with Norway (68%), Sweden (51%), Iceland (58%) and Finland (17%).

Figure 2.

Distribution of work functions across Denmark, Norway, Finland, Sweden and Iceland.

Ideal work life

The respondents were given the opportunity to describe what their ideal work life would look like in an open-ended question. Ninety respondents (55%) choose to use this opportunity; of these, 24 responded that they were satisfied with their current work life. The further analysis resulted in four broad themes: (1) time, (2) collaboration, (3) recognition and respect and (4) making a difference.

Time: Several (>20) respondents pointed out that more time for research and for practice, including clinical work, would be preferable, for example: ‘I want it to be almost like now with a mix of research, education activities [and] clinical work, but with more time allocated to research than today’ (Respondent 66, SE). Likewise, less time should be spent on administrative work, particularly grant seeking. Administrative and assessment work was highlighted as a potential negative factor in a more ideal working life, for example: ‘More time to do actual research and less time spent on research administration (budgets, payment of bills, HR in relation to staff, etc.)’ (Respondent 12, DK).

Collaboration: Some (>10) respondents mentioned that they would like to be a part of a network, for example: ‘It would be great to be part of a larger research group, focusing on a specific topic and to have a cooperative environment’ (Respondent 8, DK). Others mentioned that they work alone: ‘Now, I am the only nurse doing research among 200 clinical nurses’ (Respondent 22, DK). A few nurses mentioned explicitly that collaborating with a professor would improve their work, for example: ‘Being part of a dynamic research network within the ward and to have a professor within nursing as a supervisor’ (Respondent 16, DK). Factors of improvement, such as ‘A closer collaboration with clinical leaders and ward leaders’ (Respondent 3, DK), were also mentioned. Collaboration also included maintaining clinical skills and staying close to practice, for example: ‘From the start of my post-grad career, I would have appreciated being able to continuously develop my research career within a certain clinical specialty. Thus, being able to maintain some clinical skills so that I could be a part of a clinical team and contribute to direct patient care.’ (Respondent 28, DK).

Recognition and respect: Some mentioned that more recognition would improve their work: ‘I would prefer to work in a research unit where all disciplines and research approaches were respected equally’ (Respondent 4, DK), or: ‘I miss respect and recognition among researchers (physicians) at the clinical unit I refer to’ (Respondent 25, DK). Recognition could also come via a formal connection to a university: ‘I almost have an ideal work life, but I wish that our research department could be officially connected to the university’ (Respondent 10, DK). Further, they pointed out that improved and equal pay would be appreciated: ‘I am happy with the current one (position), but the payment could be better’ (Respondent 11, DK) and clear career progression: ‘Having a clear structure for positions and advancement within the hospital system for researchers, that is not [an] MD’ (Respondent 12, DK).

Making a difference: A few (<5) respondents mentioned that making a difference for patients and health care professionals mattered in an ideal work life: ‘My ideal work is working intersectorial[ly] between the hospital and municipality and through research to explore possibilities and to make coherent and safe pathways. Doing research that matters in real life—that makes a difference for patients and health care professionals—and that improves and challenges the health care system’ (Respondent 21, DK). Or: ‘I am quite content, but in an ideal world I would spend less time doing administrative work, have more close collaborators locally and see the results of my research eventually benefit patients and/or their relatives’ (Respondent 34, DK).

Discussion

The Nordic countries have comparable health care systems, and all six countries studied have PhD nursing degree programmes. Despite these similarities, this study found notable differences among PhD-prepared nurses employed at university hospitals with respect to work function; organisational structure; satisfaction about time split research and practice; and the mean scores of time spent on research, clinical practice and teaching, supervision and administration. Regardless of these differences, most PhD-prepared nurses reported being generally satisfied with their work life. The discussion is divided into three sections focusing on work functions, organisational structure and satisfaction.

Work functions

The fact that the presence of increasing numbers of PhD-prepared nurses in hospitals is a fairly new occurrence has probably influenced the results showing differences in how they distribute their tasks and spend their time. As outlined in Table 1, hospital-based nurses with a PhD in the Nordic countries only spend a part of their time on research. On average, they spend nearly half of their time on supervision, teaching and administration.

A majority of the respondents held positions shared between a university and a hospital. Shared positions are important for the development of clinical practice and the establishment of international cooperation, where an university affiliation is often required (Aalborg University, 2018). For this reason, there is a need for more PhD-prepared nurses in such positions. There are different ways to establish these positions, and one might speculate that those who hold these positions will more easily keep in contact with both institutions. One challenge can be that of dual roles and divided loyalties. Though PhD-prepared nurses must divide their loyalties and time between different institutions or programmes, that can make it easier to understand the institutions' research cultures, research capacity, resources and needs (Jamerson and Vermeersch, 2012). When nurses have closer contact with clinical practice there is reason to hope that their research will be more closely linked to patient-related research questions.

Organisational structure

Hospital-based nurses with a PhD in the Nordic countries are organised differently from one country to the next. For example, in Finland, the majority report to the hospital director level, unlike Denmark, Sweden, Norway and Iceland, where the nurses were referring to various organisational levels. Furthermore, all the Finish respondents' main positions were in hospitals, while this was the situation for only about half of the respondents from Denmark and Norway.

One might speculate that these differences reflect the nurses' organisational position, rather than their ability to conduct research. In order to succeed with research capacity building among the nursing workforce, Chan et al. (2010) suggest an organisational model that involves the design of the role, a support system for the role, and thorough evaluations of outcomes of the role.

Other topics the nurses in the present study mentioned were the wish to be part of a research group, to work more closely with other researchers and to share research ideas. In some university hospitals, it may be expected that a member of a research group would avoid working alone and would profit from sharing with and gaining from others (Aalborg University Hospital, 2017; Oslo University Hospital, 2016). Such expected inclusion in research groups should be established in other hospitals in the Nordic countries, to ensure that PhD-prepared nurses continue working in these settings and to enhance the quantity and quality of nursing research.

Satisfaction

In the nurses' open-ended replies concerning their thoughts about an ideal work life, some respondents mentioned that they would like to stay close to clinical practice, that they wished to maintain their clinical skills and that it was important that their research benefited patients. This feedback is important, as it has been documented that well-educated nurses have an impact on patient safety and on high quality of care (Krzyzanowska et al., 2011; Tingen et al., 2009). Furthermore, nursing practice has become more complex in recent years, and the demand for updated knowledge has not only increased but also become essential for patient care. Challenges like hospital infections, falls and other adverse events call for systematic surveillance and the implementation of interventions that increase the quality of nursing care (Olds et al., 2017). It is supposed that PhD-prepared nurses can teach bedside nurses to strengthen their clinical skills and to observe and document all events systematically, thus bringing down rates of malpractice (Jamerson and Vermeersch, 2012).

Some of the study's respondents reported that, for example, having a professor with a background in nursing as a supervisor or mentor could make their work life better. This may be due to the fact that many nurses work alone as researchers in today's hospitals. As there are few PhD-prepared nurses in the hospitals, they have few colleagues who share their professional background and with whom they can discuss research questions. Another challenge might be that, in Denmark, Finland and Sweden, the most common research methodology used by PhD-prepared nurses in hospitals was qualitative design. The gold standard of the medical research tradition is quantitative study (Malterud, 2001), so this difference in methodology can create a gap in collaborations, as participants may not always understand others' views. One way to increase levels of collaboration could be to identify research questions and plan projects that address different perspectives (i.e., encourage interdisciplinary collaboration) and methodological approaches.

Finally, research methodology on good clinical nursing pathways is inadequate, and further the PhD-prepared nurses is a significant perquisite for enhancing the capacity of research among clinical nurses. In addition, nurse leaders are essential for establishing a research culture, as they serve to enhance other nurses’ scientific attitudes and capacity (Lode et al., 2015).

Limitations

This study has some limitations. As there are no national registers of the total populations of PhD-prepared nurses working in hospitals, the number of nurses included in the survey might be less than the total population of such nurses in the different countries. However, the authors' intention was to present a picture of the situation today. Another limitation was that the authors had to create the questionnaire, as no validated or published questionnaire on this topic already existed. As all results are presented as single items, and the group consists of PhD-prepared nurses working in hospitals, we hope we have covered the most important areas. Finally, the numbers given in Figure 1 must be interpreted with caution related to the number of nurses with a PhD, or the number of nurses holding a professor position in the different countries, as no bodies have exact information about these numbers.

Although the Nordic countries' education and health care systems have similarities, there are also differences that may explain some of the results in the study. The findings related to these differences would be interesting to investigate further. It is also challenging to compare situations across countries due to non-identical organisations and systems.

Finally, as this survey of PhD-prepared nurses employed at university hospitals addresses work function, organisational structure and satisfaction about the time split between research and practice in six Nordic countries, it is an important piece of work related to nurse–researcher collaboration. Given the similarities of the health care systems and challenges related to PhD-prepared nurses, this kind of research (i.e., research across borders) should be more encouraged, and the findings could be used to strengthen Nordic collaboration centred on research.

Conclusion

Despite similarities among the six Nordic countries, this study found notable differences in the organisational structures that PhD-prepared nurses employed at university hospitals face. In order to succeed with capacity building among the nursing workforce, this study highlights the importance of an environment that allows collaboration and networking with other researchers and close contact to clinical practice. Moreover, the role of the hospital-based, PhD-prepared nurse should be better described and defined to enhance and contribute to evidence-based practice.

Key points for policy, practice and/or research

• This study has shown that in order to succeed with capacity building among the nursing workforce an environment that allows collaboration and networking with other researchers is important and necessary.

• The role of the hospital-based, PhD-prepared nurse should be better described and defined to enhance and contribute to evidence-based practice.

• Organisationally, there is a need for further work on establishing a uniform structure for employment of PhD-prepared nurses at university hospitals.

• There is a need for further research about the organisational structure of PhD-prepared nurses.

Biography

Erik Elgaard Sørensen is professor and Head of the Clinical Nursing Research Unit at Aalborg University and Aalborg University Hospital. EES worked in clinical nursing practice for 20 years, followed by a research career for the past 15 years. He moved from being a nurse to a nurse director and a researcher in clinical nursing. As a researcher, he worked on leadership and nursing, technology and nursing, research capacity building in clinical nursing and lately with fundamentals of care. In the last six years the workload has been heavy in research and doctoral supervision, academic publishing, service to the hospital, university, public and media work, editorial functions and service to the profession and international collaboration. A member of International Learning Collaborative (ILC) (since 2012) and the international group around Fundamentals of Care.

Kathrine Hoffmann Kusk is a sociologist and research assistant in the Clinical Nursing Research Unit at Aalborg University Hospital, Denmark. She has been working in the research unit since 2013 with a variety of different work assignments. Her main research area is public health with a special focus on alcohol.

Asa Muntlin Athlin has specialist training in emergency care and extensive clinical and research experience in emergency nursing. Her current research areas include health services research, pain management, emergency care, patient experiences, e-health, knowledge translation and fundamentals of care. AMA is the co-principal investigator and coordinator of a joint fundamental of care research programme between Sweden and Australia, and the principal investigator of a European study around fundamentals of care in clinical practice. She is also involved in different projects through the Nordic Health Research and Innovation Networks and Swedish Society of Nursing. In addition, as Associate Professor at Uppsala University, she is involved in teaching fundamentals of care to students at undergraduate and postgraduate levels.

Kirsten Lode is a nurse and Director of Health Care Sciences at Stavanger University Hospital and Assistant Professor at University of Stavanger. KL has been working in clinical nursing leadership for 24 years, followed by a 12 years research career. As a researcher, she has worked with coping with chronic diseases, qualitative research evaluation and research capacity building in clinical nursing. In the last five years she has supervised master and doctoral students, performed academic publishing and teaching, and supervised clinical projects. In addition, KL is a member of The Breast Cancer Research group at Stavanger University Hospital and Professional Relations in Welfare Research group at Stavanger University. She has both national and international research collaboration and is a member of ILC.

Tone Rustøen is a nurse, professor at the University of Oslo, and a researcher at Oslo University Hospital (OUH), Division of Emergencies and Critical Care. TR is head of nursing research in Health South East, and she leads a network about symptoms, symptom management and HRQoL in various patients groups (NORSMAN) funded by Health South East. She is a research group leader at OUH emergency clinic, and has been the principal investigator on 12 research projects. Her main research interests are in pain, other symptoms, how symptoms groups together, and how symptoms burden negatively influences patients with different medical conditions.

Susanne Salmela has been Director of Nursing Development at Vaasa Central Hospital since 2014. SS worked as Medical Laboratory Technologist for several years, and for 12 years in the research of the Botnia Study Group about diabetes (T2D). This was followed by a period of four and a half years as head of research at the Swedish Higher Vocational Education in Vaasa, and as Director of Nursing from 2006 to 2014. SS gained her Master of Caring Science in 1996 and PhD in Caring Science in 2012.

Bibi Hølge-Hazelton is professor in Clinical Nursing with special responsibilities and Head of Research Support Unit at the University of Southern Denmark and Zealand University Hospital. BHH worked in clinical palliative and cancer nursing practice in primary and secondary care and education for more than 10 years), followed by a research career for the past 20 years. As a researcher, she has worked with involvement of young cancer patients, professional development of nurses and of general practitioners, using on-line technologies in qualitative research, and capacity building in clinical nursing and allied health. Presently she is leading the research programme CAPAN, focusing on capacity building in nursing at a new university hospital.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics

The North Denmark Region Committee on Health Research Ethics (approval number: 2008-58-0028) approved the study. The study complied with all ethical principles for medical research described in the Helsinki Declaration (World Medical Association, 2013). The collected data were handled confidentially and stored safely according to regulations. Each of the included PhD-prepared nurses received a key, and as every reply was automatically returned to the research assistant from each participant's email address, the authors could be certain that the reply was from the invited nurse and no one else. The questionnaire was distributed to each prospective participant personally, and the returned answers were considered the participant's informed consent to be included in the investigation.