Review: Research excellence across clinical healthcare: a novel research capacity building programme for nurses and midwives in a large Irish region

A few months ago, in JRN Westwood et al. (2018) described their capacity-building work in the southwest of England. Key to the success of their systematic framework approach was commitment from ‘board to ward’. Fullam et al. have presented in the reviewed paper an excellent description of a scheme – Research Excellence Across Clinical Healthcare (REACH) – designed to engage frontline staff in research as a strategy for capacity building in a large Irish region. This research immersion opportunity for qualified staff also received investment from clinical partners. At the Royal College of Nursing Research Conference earlier this year a number of teams engaged in what is often in the UK referred to as clinical academic careers (Coad et al., 2018; Kenkre et al., 2018; Topping et al., 2018) described their endeavours in research capacity building in different regions and countries of the UK. They illuminated some of the barriers, constraints and levers for embedding and normalising research in nurses’ and midwives’ work. They also, like Fullam et al., emphasised the importance of providing expert support for those who sought to become fully-formed clinically-active health researchers. I have just returned from Australia, where I heard Professor Fiona Newell (2018) outline the work and infrastructure that she and colleagues had put in place in the Royal Children’s Hospital, Melbourne. What all these activities and evaluations have in common is how much potential we have in the nursing and midwifery workforce to make patient-focused and relevant research part of the toolkit of contemporary healthcare. Such activity encompasses the delivery of evidence-based practice through to knowledge creation and implementation, but also underscores the enormity of this ongoing challenge. We, the profession, would be remiss if all we did was invest in isolated small-scale studies that contribute little to a robust knowledge base (Greenhalgh et al., 2004; Thompson, 2003); likewise if nursing underperforms, in contrast to other non-medical professions, when applying for national research training awards (Baltruks and Callaghan, 2018; National Institute for Health Research Trainees Coordinating Centre, 2017).

In many countries worldwide, but particularly high-income countries such as the UK and Ireland, healthcare organisations are facing severe nursing and midwifery shortages (Association of UK University Hospitals (AUKUH), 2017; Lartey et al., 2014). There has been systematic disinvestment in funded continuing professional development and education beyond registration. This is despite the growing evidence that healthcare organisations that invest in staff development have a lower turnover and better staff satisfaction (Drenkard, 2013; Kelly et al., 2011). It is not difficult to make a connection between job satisfaction and employee commitment to an organisation (Cannaby et al., 2017; AUKUH, 2017). Nursing is the largest healthcare workforce, and in the recent past it has taken the brunt of blame for poor care and not being compassionate enough. That tarnished image has gone through something of a rehabilitation as nurses and midwives are increasingly seen in the media as the first contact for patients, on the frontline, performing much of the daily toil of unremitting healthcare demands from populations with ever more complex and challenging health and social care needs. Engagement in research can serve to ignite and replenish the enthusiasm for care delivery and improve care, but may also be seen as a distraction from the real work of healthcare where serving the needs of patients in the here and now takes priority (Henderson et al., 2009). Yet without long-term investment in knowledge creation, nursing will fail to disinvest in ineffective interventions and truly engage in the triple aim of improving health care experience, improving services and minimising costs. Capacity-building clinically-active health researchers should be part of any package for achieving those aims. The aims will not be achieved without local, regional and national investment, executive nursing leadership assuming responsibility, and a formalised career structure that truly enables sustainable clinical academic roles. Opportunities such as REACH provide a window into what could be, and for a few an entry into a clinical academic career, but schemes such as these are too often dependent on champions and are time and funding limited. They may be a real asset in the research capacity-building portfolio, but the level of variation means evaluating effectiveness, or even agreeing metrics, remains challenging.

One of the indicators of success used in education is the concept of added value. This commonly refers to the amount of improvement, or academic achievement, that can be attributed to the educational experience. The direction globally is for initial nurse registration to be at Bachelor (baccalaureate) level. Although not yet universally adopted, the Republic of Ireland was in historical terms a recent – if not as recent as the UK –adopter of graduate professional entry. What is also apparent from the growing body of evidence is that the concentration, or dose, of ‘graduateness’ in a nursing workforce makes a difference to patient outcomes (Aiken et al., 2011, 2014; Gkantaras et al., 2016; Mahfoud et al., 2018). The REACH initiative, described in this paper by Fullam and colleagues, targeted specialised and advanced grade nurses but was open to any grade as long as they were not currently engaged in Master’s or doctoral education. Although participants were experienced nurses, they may or may not have been exposed to adequate research education in their pre- or post-qualifying programmes. It is a pity that we, the readers, do not know more about the research education of the participants completing REACH as this would have allowed us to judge the height of the step up, or value added, achieved.

Most role specifications for specialised and advanced roles incorporate engagement with research and service improvement and audit-based activities and/or evaluation, interpretation of data, presentation of clinical findings in order to inform service delivery, monitor patient safety and instigate improvement. Although there is a growing body of evidence of what constitutes an appropriate dose of graduateness for patient safety, knowing what dose of research education and exposure to clinical research during training is adequate as a platform for contemporary registered practice is not. Whilst it may not be necessary for every nurse to be research active, all nurses should as a minimum be research literate and enabled to deliver evidence-based practice. A more effective strategy is needed for talent spotting those who have the interest and potential to engage in conducting research and developing a clinical academic career. I find it fascinating that nursing programmes often require students to identify the focus of research in project work, whereas non-nursing healthcare students often participate in, and write up some aspect of, ongoing frequently funded research. They work in effect as student research assistants, but this exposure does seem to function like a Hogwortian sorting hat (Rowling, 1997) allowing those with real interest, enthusiasm and potential for research to gain insight into the realities of being researchers and experience the team effort that goes into high-quality research.

So what does this paper bring to our understanding of research capacity building? It reinforces that a number of essential building blocks need to be in place, namely institutional support including executive leadership, expert mentoring and a focus on outputs of research to evidence well-spent investment. It reinforces that schemes of this type have a place and are transferable across healthcare organisations and possibly countries. What remains unknown is what dose of REACH or its equivalent is needed to kick-start a research career. Or what research skills and capabilities REACH-type interventions offer practising nurses or midwives to enable them to engage in research commensurate with role or grade expectations. If these aspects could be better defined, then it might be possible to align research expectations with job descriptions, evaluate performance in annual performance review, bring greater transparency, and importantly position and embed research in all its myriad manifestations as part of every nurse’s and midwife’s role and structure development more effectively.

Biography

Annie Topping (RGN, PhD, PGCE, BSc, FHEA) is Professor of Nursing at the University of Birmingham & University Hospitals Birmingham NHS Foundation Trust. She trained as a registered nurse at the Royal Free Hospital, and after working clinically in surgery and surgical oncology moved to higher education. Annie’s current interests include the use of technology to improve care delivery, new roles and systems for promoting transition across primary and secondary care to enhance patient outcomes, and the promotion of self-care.