Supporting healthcare professionals from ethnic minority backgrounds to ‘Step Into’ a clinical academic career

Abstract

Background:

There is a need to develop research focussed healthcare professionals with the clinical experience and academic skills to meet the needs of a diverse population. Yet, healthcare professionals from ethnic minority backgrounds are often faced with personal, structural or organisational barriers, which prevent them from accessing and applying for development opportunities.

Aim:

To undertake an evaluation of the Step into Clinical Academic Careers’ programme. The programme was designed specifically for nurses, midwives and allied healthcare professionals (NMAHPs) working in NHS organisations, from ethnic minority backgrounds, who had the ambition to pursue a research or clinical academic career.

Methods:

Qualitative individual interviews and online evaluations were conducted to identify the views, perspectives and experiences of participants who undertook the programme. Participants were also followed up after 6 months.

Results:

Participants provided insights into four key areas relating to outcomes of the programme. These were (1) increased confidence, (2) increased motivation, (3) developing networks and (4) inspiring people.

Conclusions:

Organisations must work purposefully and collaboratively to realise equitable support for individuals from ethnic minority backgrounds, through targeted mentoring and leadership development training. Failure to do this will result in a continuation of limited diversity amongst clinical academic and clinical research leaders.

Introduction

Nurses, midwives and allied healthcare professionals (NMAHPs) globally are increasingly required to take on more complex, expert, autonomous roles (Carrick-Sen et al., 2019). In the United Kingdom, and where NMAHPs seek to advance their practice, there is an expectation that individuals will work towards gaining the skills needed to evidence their increasing competency across four areas: ‘clinical practice’, ‘leadership and management’, ‘education’ and ‘research’ (Health Education England, 2017). When positioned as clinical leaders, who are also competent researchers, the NMAHPs’ is considered critical for the development and delivery of clinically focussed, patient-centred research (Olive et al., 2022). More broadly, research-active healthcare organisations are important for improving patient satisfaction and perceived quality care experiences (Jonker et al., 2020; NHS England, 2019). Where clinical academics ¹ are employed in healthcare teams, enhanced health outcomes are often the result of clinical activities that are underpinned by up-to-date evidence-based practice (Newington et al., 2021). Therefore, in order to continue to deliver excellent healthcare, there is a need to develop research focussed healthcare professionals with the clinical experience and research skills to meet the needs of the general population (Cooper et al., 2019). Hence, NMAHPs hold a critical position in the health and social care workforce, providing clinical expertise and leadership.

Over recent years, there have been several successful programmes employed by organisations with the aim of providing opportunities for NMAHPs to gain the necessary experience required for clinical academic roles (Bramley et al., 2018; Strickland, 2017). These programmes include the nationally recognised Integrated Clinical and Practitioner Academic Programme, which is managed by the National Institute for Health Research (NIHR) and funded by Health Education England (HEE).

However, contemporary evidence indicates that NMAHPs from ethnic minority (EM) ² backgrounds are overlooked for this type of continuing professional development opportunities and/or promotion (or they do not put themselves forward for promotion) comparative to their White counterparts (NHS Workforce Race Equality Standard, 2021; Priest et al., 2015; Ross et al., 2020). Similar disparities are known to exist within higher education institutions (HEIs), for example, data from the UK Higher Education Staff Statistics showed that in 2019/2020, there was a much higher number of White academics (at various levels of seniority) compared to the combined total of individuals from Black, Asian and Mixed ethnicities (Higher Education Statistics Agency, 2021). It is important, therefore, that healthcare organisations and HEIs work together to purposefully support individuals from EM backgrounds, who are working in clinical practice, to undertake research activities (Messenger and Pollard, 2022). Despite local success in NMAHPs gaining access to national (and regional) programmes, as well as developing and running internal programmes to build research capacity, we noted (anecdotally) that NMAHP colleagues from EM backgrounds did not appear to be accessing research training (or taking up opportunities) to develop clinical academic careers. This research picture, alongside noted observations, led us to take action to ensure that steps could be taken to embed targeted programmes that might enhance inclusion and promote diversity among future healthcare leaders. As there is an increasingly diverse population in the United Kingdom it is imperative that clinical research and healthcare leadership is representative of the population it seeks to address (For Equity, 2022); this will be central to reducing health inequalities in the future (Saizan et al., 2021).

Background of the ‘Ethnic Minority (EM) Step into Clinical Academic Careers’ programme

The EM Step into Clinical Academic Career Development Programme, launched in November 2021, was developed in response to a regionally acknowledged lack of representation from NMAHPs from EM backgrounds. The programme was designed in collaboration between a large National Health Service (NHS) in the north of England and a leading national third-sector provider of leadership development. Delivered over 6 days, from November 2021 to March 2022, the programme was designed to bring together support for participants in the form of mentorship and various clinical/research and leadership expertise. This aimed to help to support participants to pursue clinical academic careers, as well as develop expertise in leadership development. The programme covered: research design skills, preparing applications and networking across the research community with leadership development (based on the highly successful Florence Nightingale Foundation Windrush programme; see Nursing Standard, 2021).

It was anticipated that participants would achieve the following:

• Develop skills in designing research and developing a research question and produce a high-quality application for HEE/NIHR Pre-Doctoral Clinical Academic Fellowship (PCAF)/Masters in Research.

• Critically identify future training needs and strengths and weaknesses relating to research and clinical practice and develop relationships with potential research supervisors and international experts.

• Demonstrate enhanced awareness of how personality influences personal effectiveness and performance in teams.

• Identify and critically appraise opportunities to influence through personal and collective authority.

• Develop strategies to express self in a manner which communicates presence, enables influence and has impact.

• Explore personal resilience and develop tools for staying effective under pressure.

The aim of the leadership aspect of the programme was to position individuals from EM backgrounds to develop leadership knowledge and skills. Therefore, individuals were provided with the opportunity to emerge from the training with a greater sense of themselves as future healthcare research leaders.

Participants were recruited from across the East Midlands via a competitive process. The programme received 48 inquiries, leading to 17 applications from multiple provider organisations from across health and social care. All applications were double-blind peer-reviewed and eight successful candidates selected. The team also received enquiries from five NMAHPs across the United Kingdom who learned about the programme during the application period.

Purpose

To explore the experiences of people from EM groups after engaging in a programme designed to support them to develop a clinical academic career.

Methods

Evaluation approach

The programme was evaluated using qualitative methods (see data analysis section below) focusing on participants’ progress though the programme and outcomes of the programme, to establish the impact of the programme for participants. Before commencing the programme, participants were asked to complete an online demographics form (Table 1). The following information was collected from participants: profession; NHS Agenda for Change banding (according to the National Health Service, 2022); highest educational qualification; self-reported ethnicity; details of any previous clinical academic research training they had applied for.

Table 1.

Participant characteristics/demographics.

Question	Responses	Results
		N
What is your profession?	Registered nurse Physiotherapist Research nurse Therapeutic radiographer	4 2 1 1
Agenda for Change (AfC) band (NHS, 2023)	2–4 5 6 7	1 2 4 1
What is your highest educational qualification?	BSc PGDip MSc	4 1 3
How would you describe your ethnic origin?	African Black African Malaysian Indian Mixed Mixed: Caribbean and white British	1 2 1 2 1 1

Semi-structured interviews were conducted after 6 weeks to explore, and capture, individual participant’s experiences; learning from the taught element(s) of the course (in line with the programme’s aim); perceived impact on participant’s future career choices and plans. A further qualitative interview was offered at 12 weeks to evaluate any additional impact, and changes in individual participant’s practice.

Participant recruitment

All those participating in the programme were invited by email to take part in the evaluation study. All eight participants consented to take part. Interviews were conducted online, and audio recorded with consent. Eight participants took part in one interview, and three agreed to a second (follow-up) interview. To mitigate potential influence, a researcher who was independent from the delivery of the programme conducted the interviews and completed the analysis. During the interview, participants were asked about their background, reasons for joining the programme and experiences on the programme (see Supplemental Appendix 1).

Data analysis

Interview recordings were transcribed verbatim and anonymised. Thematic analysis was carried out according to Braun and Clarke’s (2006) six-stage approach: (1) familiarisation with data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes and (6) producing the report (Clarke and Braun, 2013). This allowed for aggregation of responses and provided the ability to perform an in-depth investigation of participants’ perspectives. Once themes had been identified, these were aligned with the Kirkpatrick evaluation model [KP-model (Kirkpatrick, 1994)] to assess the potential impact of the programme.

The KP-model has four levels of assessment:

• 1. Reaction: The degree to which participants find the training favourable, engaging and relevant to their jobs.

• 2. Learning: The degree to which participants acquire the intended knowledge, skills, attitude, confidence and commitment based on their participation.

• 3. Behaviour: The degree to which participants apply what they learned during the training when they are back on the job.

• 4. Results: The degree to which targeted outcomes occur because of the training and the support and accountability.

The above criteria assume a causal link between positive learning experiences and increased learning, which leads to a transfer of learning into the organisational context. This is considered to result in positive outcomes for the organisation. Hence, Kirkpatrick (1994) has argued that for training to be effective, trainees must react positively to the learning opportunities provided.

The rationale for this analytical approach was underpinned by two things. Firstly, it provided a straightforward way to evaluate the programme based on the outcomes reported by participants (Bates, 2004). Secondly, the authors acknowledge that human concepts and models can be utilised to understand aspects of the world (Bhaskar, 1978, 2013) and that, according to Patton (1999) using more than one method for data analysis enhances reliability.

Ethical considerations

As this was an evaluation of an education initiative designed to understand its acceptability and impact, Research Ethics Committee approval was not required. However, ethical principles were followed. When joining the programme, and as part of the consenting process, participants were informed that (if they agreed to take part) their names and contact details would remain anonymous in any data collection or feedback provided. As such, implicit informed consent was obtained from all participants. All the data used in this study have been consented to and anonymised. Data were stored on a secure cloud server in accordance with the General Data Protection Regulation 2016.

Results

Participants (n = 8) provided insights into four key areas relating to the programme. Participants reported a number of positive learning experiences including, increased confidence and motivation, developing their networks and feeling supported and inspired. Qualitative results have been arranged according to Kirkpatrick’s (1994) four-level criteria for training outcomes.

Level 1: Reaction

Building confidence

Participants who joined the programme had varying degrees of clinical experience, with some having substantial experience. All participants held a longstanding interest in contributing to and getting involved in research relating to improving patient care and clinical practice. However, some participants described how they had not applied previously due to a perceived lack of support.

Initially, I wasn’t confident, because. . .I didn’t know how to find funding, and because I thought I’m from a different ethnic minority group, will I be supported by others? That was my main worry, that’s why I didn’t have confidence to approach this, and I didn’t know how to approach. But now, I’m okay [P2]

The targeted support and encouragement offered by the programme delivery team had a clear impact on building self-confidence for participants. Participants’ initial reaction to the programme was exceptionally positive, particularly in terms of increasing motivation and broadening thinking.

I think it’s really motivational. . ..it’s been really a culture and a bit of a communication of you can actually do this, you actually have got this and this is what we are trying to promote and trying to get out of you. [P1]

It’s just broadened and refreshed my mind on things I used to know that I wasn’t getting used. And it offers me the opportunity to look forward . . .. . .now I can approach them if I have any problems. It’s also given me somethings that I'm able to approach for help as well [P3]

They made me believe in myself. . .it was a huge boost to my confidence [P6]

A growth in confidence helped participants to realise that being from a different background, and in some cases, having trained outside of the United Kingdom did not mean that their contributions to the UK system were of less value. Many participants commented on how the delivery team had nurtured these beliefs which was appreciated. This support from the delivery team was transformational because some participants had an understanding that being from an EM background meant that funding for research would be difficult to obtain.

Level 2: Learning

Potential impact of the clinical academic role and understanding the self as leader

Participant learning involved a process of critical reflection on the self. Participants developed a greater understanding of the role of the clinical academic and reflected on what this meant for them.

The main thing about being a clinical academic for me is seeing a patient in front of you and being frustrated because they’re not getting the care that you think they should. So, then the main thing for me is trying to enact change [P7]

Participants talked about how the programme had enabled them to develop networks of clinicians and academics. This had opened up conversations which they felt they would have not otherwise had the confidence to initiate. Having those wider conversations outside of their everyday clinical practice had led to ideas of quality improvement and research and the potential to add benefit to patient care in the future.

Listening to the conversations at the first day, gave me an idea for a project that I wanted to do. . ..I work in radiotherapy. And people that have treatment have skin reactions as a side effect. . .in the literature, it’s described as, your skin can go red, which is not the case in dark skinned people. . ..If I was never in that room, I don’t know if I would have thought of that [P7]

It’s given me a lot of thought into where I need to do to improve and what I need to do to become a leader in research and innovation. And just in general where I need to work on as a clinician. Because a clinical academic role is one that bridges the gap between both clinicians and academics. So, knowing where your niche is. . ..and actually saying I’ve learnt this through the course and going forwards this is something we could think about and potentially get into [P1]

The leadership element of the programme was reported to be enlightening. This part of the programme was felt to have helped participants to reflect on aspects of their personal and professional self that had not been apparent to them before. It is possible that this had been a personal barrier to building their clinical academic career previously. In the example below, the participant is reflecting on how the leadership development opportunity enhanced their communications skills.

I’ve learned things about myself that I didn’t know, like I interrupt people. . .So, this is something I am working on. . .now I have realised that if I listen the person sometimes picks up the topic that I want [P6]

Participants commented on what they had learned during the leadership days and the wider impact of this. As well as having a greater understanding of communication, participants noted that they had begun to focus more on building relationships.

There was a lot of emphasis in what type of leader you are and what type of people you are working with and how you can improve relationships. . ..but definitely the most important thing is getting people to listen to you and actually do what you want [P7]

Participants appeared to be beginning to transform their thinking which, as a consequence, boosted confidence. This was facilitated through access to the connections and networks of clinicians and academics within the delivery team.

Level 3: Behaviour

Impact on clinical practice

Participants described how what they had learned on the programme was unexpected and helped in their clinical practice.

It was quite eye opening, and it allowed me to pick up some of those skills that I think has quite helped me in clinical practice generally and yeah I enjoyed it [P1]

I’ve tried to implement just little bits of knowledge that I have learned over the past few months. . .things that I didn’t really know before [P7]

I’ve had three students from January to now and I have given them my knowledge that I’ve learned [P5]

Clearly, participants recognised the value of skills they were developing from the programme in terms of having a wider impact, that is, teaching others within the clinical learning environment and getting them to engage with knowledge (and skills) gained from the programme.

There was some reflection on the difficulties of obtaining opportunities to develop leadership skills and the balance of clinical, academic and leadership skills within clinical healthcare practice that is often overlooked on a day-to-day basis. The nature of clinical work was also discussed in terms of the constraints on time and getting time away from practice to undertake research and leadership training. In this sense, it was less about getting on a particular course, but instead recognising that it might be too much to take on additional study while continuing to work clinically.

There are certain reasons why people don’t go into leadership roles. . .they just have too much commitment. . .but having that senior support around has taught me the ability to talk to get time protected, away from having that one hour to run off and try and get it during lunch so as not to disrupt clinical time too much [P1]

As participants’ thinking transformed, the way they viewed clinical leadership was questioned in terms of ‘what defines leadership?’ and ‘how leadership translates into practice?’. Leadership was considered by some as abstract, fluid and constructed out of the need for hierarchy in healthcare teams. Despite these questions and considerations about leadership, there was evidence that the programme has raised awareness of leadership in action. This shift in thinking about leadership had begun to be influential in the way participants had started to approach leadership in their clinical practice.

I’m more willing to take on certain things, I'm more willing to be conscious of my own abilities when I’m supervising someone or when I’m talking to someone who I’m supporting someone. . . I think what the cause has done is it’s allowed me to be more comfortable in voicing out that actually I might know a little bit about this [P4]

I’ve always known what I’m talking about, but still wasn’t confident in talking about it. Now I’ve got affirmation that yes, you know what you are talking about, so you can talk confidently [P6]

Early on there was a lot of emphasis on networking and how to approach people and share ideas. And that’s allowed me to. . .network in probably a better way that I would have without it. . .So, I think that’s really good research and leadership wise. . .And the skills I have implemented afterward. . .I think just knowing what type of leader you are and being able to use that is a strength [P7]

There was a substantive shift in participants’ confidence to see themselves as clinical leaders and this enabled them to feel they had a legitimate leadership voice and were beginning to develop a sense of identity as leader. As individuals progress through their clinical academic career, knowing themselves as a leader and bringing along others by sharing knowledge will be important in establishing this as a viable career option for NMAHPs.

Level 4: Results

The notable outcomes reported here were the positive and significant effects on perceived competence regarding participants’ ability to continue with their research and pursue a clinical academic career with a focus on bridging the gap between clinical and academic work. As a result of the support participants received on the programme, many were thinking about moving forward with career aspirations and goals they had before entering the programme but had felt they lacked the confidence to progress these.

It’s allowed me to think about the trajectory of my career as well as my abilities and my aspirations [P1]

The people that I’ve met on the group and the support going forward is valued [P7]

The above quote illustrates that the delivery team were instrumental in supporting participants and how bringing together a group of EM individuals was anticipated to be useful in the future.

Since completion of the programme, one participant has gone on to be successful in gaining a NIHR/HEE ICA PCAF, and one participant has been successful in gaining a funded PhD opportunity with a local university. Both of these participants remain in clinical practice alongside their research training to continue to develop their clinical and leadership skills within an NHS setting. All participants are now connected with research teams in their field of expertise and have mentors and development plans to support their clinical academic aspirations going forward.

Discussion

The aim of this study was to assess the impact of the ‘Ethnic Minority Step into Clinical Academic Careers Programme’ and the range of benefits from the type of training described here is broad and varied. In addition, the KP-model (Kirkpatrick, 1994) provides a guide for assessing the extent to which the training programme has been effective, while also offering a way to consider how such programmes might be modified in the future to increase their effectiveness.

The need for leaders to promote and actively demonstrate an organisational culture whereby ethnically diverse individuals are purposefully supported has recently become a major goal of healthcare policy (Messenger and Pollard, 2022). The evaluation of the programme and the participants’ reaction (level 1 of the KP-Model) suggests this approach has been successful in building confidence, motivating and inspiring those from EM backgrounds to realise their career goals and aspirations in research.

Powell et al. (2022) reported that racism exists, across all stages of the research process, in health-related research in the United Kingdom. In order to address this, it is important to support individuals from EM backgrounds, who work clinically, to undertake research activities. There is strong evidence that engaging healthcare professionals in research significantly improves the overall healthcare performance of an organisation (Boaz et al., 2015), but when an individual is treated by someone of the same race and ethnic background health outcomes are improved (Stuart and Nielsen, 2011). This is because signs and symptoms of declining health may be more easily recognised, for example, changes in skin colour, etc. Patients may also feel more comfortable to communicate health-related symptoms to someone from the same culture (Jongen et al., 2018).

Research conducted by Adhikari et al. (2023) highlights the significance of developing leadership skills in those from EM backgrounds to ensure healthcare systems are representative of the populations they serve. While Westwood et al. (2018), expressed the importance of developing NMAHP leaders to drive research into practice. The learning (level 2) and behaviour (level 3) from this programme is evidence that participants agreed with the importance of developing leadership skills and a sense of self alongside developing the skills required to conduct research. Moreover, it also demonstrates the potential of the programme to be successful in increasing diversity in the clinical academic workforce in the future.

Initial interest in the programme highlights that NMAHPs from diverse backgrounds across the health and social care system in the East Midlands and beyond are of significant interest to those wishing to pursue clinical academic and research careers. Due to the complexity of evaluating long-term and wider impact, the associated costs and limited methods, it is difficult to prove a direct relationship between leadership development and/or research training activities in relation to the fourth level (i.e. result) of the KP-model (1959, 1994). However, this evaluation has shown that the programme was able to support all its participants to become involved in research or enter research-training programmes, to get them started on their clinical academic pathway. Going forward, establishing (and funding) programmes such as this will be pivotal to ensure that a 21st century NHS is delivered and meets the needs of a pluralistic society.

Strengths and limitations

This study has several strengths and limitations. The programme delivery team has a considerable amount of knowledge and experience pertaining to the structure and functionality of the NHS, which is highly beneficial in helping participants to navigate this complex and dynamic environment. However, the lack of ethnic diversity with the delivery team may have been an additional barrier to participants who might have considered applying to the programme. At this stage, it is also difficult to ascertain the cause and effect of the training in relation to the wider impacts such as patient care and outcomes. Further work will be needed going forward to understand how programmes such as ‘Step Into’ might affect the broader context of the NHS. Moreover, the data were limited as only three participants returned to undertake a follow-up interview, which was more at length than the initial interview; therefore, we had less data from some of the participants. This made it difficult to include a wide range of excerpts from some of the participants.

The evaluation presented here has been undertaken on a small number of participants (n = 8) in one geographic location. It is therefore difficult to comment on the transferability of the findings to a wider and/or larger sample. However, outcomes reported by participants reflect the success of the programme and indicate that the type of support described can be useful for encouraging more individuals from EM backgrounds to consider a clinical academic career in the future. This demonstrates the potential of this initiative to be replicated on a wider scale, both nationally and internationally to offer much needed opportunities, mentorship and tailored support for NMAHP healthcare professionals from EM backgrounds.

Conclusion

When organisations work together towards realising equitable support, through targeted mentoring and leadership development training, it can build confidence, inspire and motivate individuals from EM backgrounds to realise their career aspirations and goals. It is important to continue to support individuals from EM backgrounds so that clinical and research roles are reflective of, and can effectively meet the needs of, a complex and diverse general population.

Key points for policy, practice and/or research

• Organisations must work purposefully and collaboratively to realise equitable support for individuals from ethnic minority backgrounds.

• Programmes should include targeted mentoring and leadership development training for those from EM backgrounds.

• Failure to support people from EM backgrounds to become clinical academics will result in a continuation of limited diversity among senior leaders of clinical research.

• This early programme evaluation indicates that a combination of information about research, clinical academic career pathways and leadership development is successful in building confidence and inspiring those from EM backgrounds to realise their career goals and aspirations in research.

Biography

Louise Bramley has a wealth of clinical, research and leadership experience in acute care and currently combines research and practice within a large NHS Trust.

Carmel Bond is a Mental Health Nurse and Academic. Her research has focussed on compassion in healthcare, and she is passionate about various topics related to wellbeing.

Gemma Stacey is a Mental Health Nurse, Academic and Charity Executive. Her research and practice has focussed on creating psychologically safe learning environments for staff and students

Ellie Dring is a Clinical Academic and NIHR Senior Nursing Leader. She combines research and practice with a clinical role focussing on evidence-based practice and skin integrity.

Alison Cowley is a Clinical Academic Physiotherapist who has worked in a number of clinical, operational, transformational and research roles within the NHS.

Vicky Booth is a Clinical-Academic Neurological Physiotherapist and NIHR/HEE ICA Clinical Lecturer (2020/23). She supports clinical-academic and research careers in the AHP workforce and practices clinically within neurological rehabilitation.

Helen Janiszewski is Clinical Academic Consultant Midwife combining research and practice at a large NHS Trust. Her research specialises in women with IBD.

Joanne Cooper has extensive experience in strategic leadership for nursing research. She is passionate about establishing a roadmap for embedding research as core business, including clinical academic roles and equality of opportunity.