Choices and challenges
Part 1. Setting the context
The intention to develop a strategy for research and development in nursing and midwifery in Scotland was indicated in Caring for Scotland (SEHD, 2001a) , the national strategy for nursing and midwifery.
Caring for Scotland stressed the importance of research and development to nursing and midwifery practice and the delivery of clinically effective, evidence-based, high-quality services. It set out the aims and objectives of the strategy for research and development, which are to address issues of skills, capacity, funding and resources, support, dissemination, partnerships and clinical/academic career pathways in research and development.
A Taskforce was assembled to deliver on these aspirations, consisting of representatives from NHSScotland, the higher education sector, Chief Scientist Office (CSO), NHS Education for Scotland (NES), the Nursing and Midwifery Practice Development Unit (NMPDU), the Nursing Research Initiative for Scotland (NRIS) and professional organisations ( Appendix 1). The strategy presented in this document is the outcome of their efforts.
Research is defined as:
'Original investigation undertaken in order to gain knowledge and understanding.' (RAE, 2001)
'The rigorous and systematic enquiry, conducted on a scale using methods commensurate with the issue to be investigated and designed to lead to generalisable contributions to knowledge.' (DoH, 1993)
Development is defined as:
'The planned, systematic process of implementation of change.' (DoH, 1993)
Evidence-based practice is defined as:
'...an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide the option that suits the patient best'. (Gray, 1997)
It is enacted when:
'...decisions that affect the care of patients are taken with due weight accorded to all valid relevant information'. (Hicks, 1997)
Context of research and development within NHSScotland
NHSScotland is driven by the issues that are central to the Scottish Executive's plans for a healthy, caring Scotland - social inclusion, social justice, equitable access to services, involving service users and the public in the design and delivery of services, delivering clinical effectiveness through evidence-based practice, and developing a culture of lifelong learning.
The Health Plan for NHSScotland, Our National Health: a plan for action, a plan for change (SEHD, 2000), defined the importance of evidence-based practice and research in the development of quality services by stating:
One of the keys to improving health is to find good evidence about what works. Research and evaluation are vital elements of a responsive, effective, learning health service(SEHD, 2000) .
The Health Plan goes on to describe how the new performance management framework for NHSScotland focuses on assessing health improvement, clinical outcomes and standards of service through the evaluation of evidence-based clinical and service standards.
Evidence-based practice supported by high quality research is the foundation of clinical governance. Clinical governance was introduced to the service through Designed to Care (SODoH, 1998a) , and provides a framework for the improvement of health and health care services through the development and maintenance of high standards. It requires a commitment from all in NHSScotland to work with service users and the public to develop clinically effective care based on sound evidence.
The involvement of service users and the public is vital in developing high quality, responsive and effective health and health care services. The Health Plan expressed NHSScotland's commitment to increasing service-user and public involvement by stating:
A patient-centred NHS must not just be a slogan: it must become a way of life. We want to work with the NHS to ensure that a patient focus is embedded in the culture(SEHD, 2000).
A service-user/public focus must not only drive the planning, delivery and monitoring of services in NHSScotland (SEHD, 2001b); it must also drive the design and conduct of research and development activity. NHS Boards will develop local strategic frameworks for involving service users and the public at every level by March 2003. The CSO is currently developing the capacity of around 25 members of the public to be fully involved in its work, with the support of the Involving People Team in the Scottish Executive.
While the context of research and development in NHSScotland is clearly important, nursing and midwifery research is conducted within an international setting. The activity of nursing and midwifery research in other parts of the world is influential to, and is influenced by, what happens in Scotland.
A review of international models of research carried out as part of the process of developing this strategy suggested that many countries are focusing on the same issues as Scotland. Building research infrastructure and capacity are commonly identified as areas for urgent attention in individual nations' nursing and midwifery research agendas. The experience of nurse and midwife researchers in other parts of the world is a powerful mechanism for helping those in Scotland to define their strengths and identify areas for improvement (see Box 1).
Box 1 The Workgroup of European Nurse Researchers (WENR)
WENR was established in 1978 with the dual aims of:
WENR's position on advancing nurse research in Europe sets out what they wish to achieve, including building on the Council of Europe Nursing Research report to influence European health policy and promote the value of nursing research for the people of Europe ( WENR, 2001) .
Research and development drivers within NHSScotland
Research and development are recognised as key underpinning elements in delivering quality services in NHSScotland. MEL(1998)75, which offered guidance on implementing clinical governance in NHS Trusts, stated that a Trust in which clinical governance was working effectively would demonstrate:
A variety of policies and mechanisms have been developed to support this activity throughout the service. The Research Strategy for The NHS in Scotland (SODoH, 1998b) was published in 1998, and is currently being revised. The strategy sets out the main clinical focus for research activity and identifies the priority the Scottish Executive places on tackling issues related to inequalities and the causes of ill-health.
The strategy has been followed by the Research Governance Framework for Health and Community Care (SEHD, 2001c). This crucial document defines standards for good research practice and stresses the importance of partnerships in developing research activity. It describes the roles and responsibilities of the main individuals and organisations involved in initiating, conducting, evaluating, funding and disseminating research.
The Research Governance Framework emphasises the importance of the ethical dimension of research. The development of new procedures to co-ordinate the work of research ethics committees is being led by the Department of Health in close co-operation with CSO. The Royal College of Nursing has also produced guidance on research ethics for nurses and midwives (RCN, 1998).
Research in NHSScotland is funded from a diverse range of sources. The Research and Development Support Fund has been established to meet the costs to NHSScotland of hosting externally funded, non-commercial research conducted within it, and to allow NHSScotland to disseminate relevant research. The support fund is managed and monitored by CSO, with allocations dependent on the volume and quality of research within an organisation.
Funding for research in Scotland is also provided by bodies from other parts of the UK and abroad. This reflects a strong willingness among researchers in Scotland to work with colleagues from outwith the country, and a desire to ensure that research carried out within Scotland is of sufficiently high quality to have an impact on health and health care services in other parts of the world.
Nursing and midwifery research
Nurses and midwives form the largest group of staff in the health service and, as Caring for Scotland (SEHD, 2001a) states, are the most visible and recognisable symbols of NHSScotland. They embody the values people most cherish and play a major role in determining the quality of care experienced by service users and carers.
Nursing and midwifery are diverse and eclectic professions which demand a wide and robust knowledge and evidence base. It is important that the practice of nurses and midwives should be based on research and, in common with all other health professions, that the research from which the evidence base for practice is derived should accord with key fundamental principles. To reflect the potential of research to improve care and outcomes, research activity should:
reflect the needs of the people of Scotland
aim to maximise benefits for service users and their carers
comply with agreed ethical standards
be based on strong design, approval, conduct and dissemination processes that are appropriate to the subject of the study and which comply with accepted international standards of research excellence.
Nursing and midwifery are relatively new academic disciplines, however, and their influence on the wider health and health care research agenda has not yet matched the significance of their clinical influence. The report of the Taskforce on Research in Nursing, Midwifery and Health Visiting in England (DoH, 1993), for instance, found that nursing research was underdeveloped, fragmented, lacked a clear strategy and vision and was isolated from the wider body of research in the health arena.
Substantial progress has been made in nursing and midwifery research since the publication of the Taskforce report. The research awareness of nurses and midwives in clinical settings is developing, and a defined clinical/academic career pathway in research is beginning to emerge. There have been advances in the quality of research produced within academic institutions as measured in successive Research Assessment Exercises (RAEs), both in uni- and multidisciplinary research activities ( see Appendix 2). Overall, RAE ratings are still low, but this is understandable given the relative newness of nursing and midwifery research compared to almost all other academic disciplines.
In Scotland, nursing and midwifery research has become established within academic institutions, with some departments building focused research portfolios. A key aim of this strategy is to encourage research and development activity in all nursing and midwifery departments, albeit to varying degrees. Nurses' and midwives' relative inexperience in research, however, may act as a disincentive to potential funders, and applications for funding from nurse and midwife researchers have tended to be inconsistent in quality. Nurses and midwives are nevertheless becoming more skilled in making bids for funds from CSO and other funding bodies, and some are now involved in multidisciplinary research and development work.
Despite these evident advances, few would question that nursing and midwifery have yet to fully establish themselves as research-focused, evidence-based professions. A strategy to set out means of developing research awareness, promoting research activity and utilisation and forging clinical/academic career pathways in research is urgently needed to develop the largely untapped potential of nursing and midwifery research to improve services for service users and carers.
Support opportunities for nursing and midwifery research and development within NHSScotland
Nursing and midwifery require strong systems and structures to support and nurture research and development activity and to maximise their contribution to research and development within NHSScotland. A number of organisations fulfil key functions in supporting and facilitating research and development across the service in Scotland (Figure 1). These organisations offer opportunities for nurses and midwives to access networks, advice and support for their research and development activity, and include those listed below.
Figure 1. Support opportunities for nursing and midwifery research and development within NHSScotland
Chief Scientist Office (CSO)
CSO commissions, funds, encourages and supports research and advises the Scottish Executive Health Department (SEHD) on how research contributes to improvements in health and health care. Among its main functions are:
funding investigator-led research projects
sponsoring research training initiatives
defining research priorities
developing a research strategy for NHSScotland
promoting dissemination and implementation of research findings
encouraging strong research ethics appraisal and research governance
supporting a number of research units across Scotland, including NRIS
encouraging multidisciplinary, collaborative research.
CSO funds research and development support within NHSScotland to allow research funded by various bodies and CSO-approved programmes to utilise NHS personnel and facilities. It also funds the management of research in NHS Trusts to enable them to provide Research and Development Offices (Box 2), which offer a vast array of facilities and resources.
Box 2 NHS Research and Development Offices
Most Research and Development Offices in NHSScotland were set up to manage the Research and Development Support Fund, which came into effect in April 1998. With this funding system came a requirement for NHS Trusts to maintain accurate and up-to-date records of all research and development activity within their organisation.
Research and Development Offices manage the process of research project registration, financial and peer review, and final management approval. A large part of their work therefore involves information co-ordination and management and dissemination of information in an appropriate form to the CSO, the National Research Register 1 and the research community.
They provide help and advice to researchers on a wide range of topics, including:
training opportunities for NHSScotland staff
access to experts in various research areas, including librarian contacts, statistical advice and grant sources.
Research and Development Offices also manage commercial research and development issues, play a key role in the effective implementation of the Research Governance Framework for Health and Community Care (SEHD, 2001c) and monitor standards of research activity within their organisations.
1 The National Research Register is a UK-wide research database in which all publicly funded research is recorded.
Nursing Research Initiative for Scotland (NRIS)
NRIS was established in 1994 to provide a focus within Scotland for direct patient care research. It has Scotland-wide scope, with staff based at Glasgow Caledonian University and Stirling University. While nursing is a central theme within the unit's programme (Box 3), it has a multidisciplinary research remit and its work encompasses all care settings. Funding of this unit is subject to periodic external peer review by a panel which reports to CSO.
Box 3 NRIS research activity
The research activity in NRIS has been restructured to reflect four research themes:
Practitioner judgement and decision-making This programme carries out research into how nurses and midwives make judgements and decisions about areas of clinical practice. It reflects key issues in policy and existing research in the field of judgement and decision-making. The programme explores the quality of the judgements and decisions that practitioners make, the impact these decisions have on patient care, and ways in which decision-making practice can be improved.
Practitioner interventions The Practitioner Interventions Programme aims to provide rigorous research evidence relating to the effectiveness of fundamental interventions carried out by nurses, allied health professionals (AHPs) and midwives. To achieve this rigour, the programme consists predominantly of multi-centre randomised controlled trials and systematic reviews of the literature. The programme focuses on interventions that impact on the symptoms and side-effects experienced by patients with cancer and urogenital problems.
Patient-centred outcomes Conventional measurements of clinical outcome do not fully evaluate the impact of much of the work of health care professionals on care received by patients. Patient-centred approaches to outcome measurement can identify and quantify the changing nature of patient need, inform practice and provide a means to evaluate the day-to-day care provided by health care professionals, in partnership with patients.
Stroke In recognition of its impact in Scotland, NRIS established a programme of research into stroke in 2001. The research conducted within the programme reflects the longitudinal nature of post-stroke care, the multidisciplinary nature of that care and relevant social and geographical exclusion issues.
Nursing and Midwifery Practice Development Unit (NMPDU)*
NMPDU was established to develop and promote clinical excellence and encourage networking and the sharing of good practice throughout NHSScotland. The overall aim is to ensure that practice and role development is taken forward across Scotland consistently and cohesively. NMPDU has also created a number of 'best practice' statements, based on best evidence, to drive clinical practice.
Clinical Standards Board for Scotland (CSBS)*
The remit of the CSBS is to develop and run a national system of quality assurance of clinical services with the aim of promoting public confidence in NHSScotland. It fulfils its function in partnership with health care professionals and the general public, defining standards for clinical services, assessing performance against the standards throughout NHSScotland, and publishing the results of its assessments.
*Our National Health: a plan for action, a plan for change (SEHD, 2000) signalled the need to integrate and co-ordinate the workof organisations and initiatives aimed at improving the quality of health and health care provided in Scotland. In January 2003, a new special health board - the NHS Quality Improvement Board in Scotland - will be established, bringing together the Clinical Standards Board for Scotland (CSBS), the Nursing and Midwifery Practice Development Unit (NMPDU), the Scottish Health Advisory Service (SHAS), the Clinical Research and Audit Group (CRAG) and the Health Technology Board for Scotland (HTBS).
NHS Education for Scotland (NES)
NES was established as a Special Health Board on 1 April 2002. Its aim is to contribute to the highest quality of health and health care in NHSScotland by promoting best practice in the education and lifelong learning of all its staff. The new body builds on the work of the National Board for Nursing, Midwifery and Health Visiting for Scotland (NBS), the Postqualification Education Board for Health Service Pharmacists (PQEB) and the Scottish Council for Postgraduate Medical and Dental Education (SCPMDE) in extending its activities to cover all staff groups.
Scottish School of Primary Care (SSPC)
The SSPC arose as a result of Shaping the Future: a Primary Care Research and Development Strategy for Scotland (SEHD, 1999) as the national organisation promoting research and increasing capacity for research in primary care across Scotland. It is funded by the SEHD, CSO and the Scottish Higher Education Funding Council (SHEFC), and is part of NES. The School provides high-quality research evidence to inform decisions made by service users, practitioners, managers and policy makers, and develops research capacity and capability within Scotland through increasing the accessibility of education and training in primary care research.
Public Health Institute of Scotland (PHIS)
PHIS is a national organisation created as a result of The Review of the Public Health Function in Scotland (Scottish Executive, 1999). Its purpose is to increase co-ordination and leadership for public health in Scotland by maximising the impact of the combined efforts of the many national, regional and local organisations working to improve health. Its work programme includes strengthening the public health information base, assembling and disseminating the public health evidence base and supporting the development of public health skills. From 2003, PHIS will be amalgamated with the Health Education Board for Scotland (HEBS) to further strengthen the health improvement function in Scotland.
Scottish Higher Education Funding Council (SHEFC)
The main strand of the Scottish Executive's support for research in higher education institutions (HEIs) is administered principally by SHEFC. The council supports research capacity by distributing funding to HEIs selectively according to the quality of research in each institution as measured by the RAE. SHEFC funding for research activity also underpins and encourages investment in research projects from other potential funders such as Research Councils, the European Union, research charities and private funding bodies.
Organisations such as the Royal College of Nursing (RCN), Royal College of Midwives (RCM) and the Community Practitioners' and Health Visitors' Association (CPHVA) have been instrumental in promoting the evidence-based agenda in health and health care. They have established networks, societies, policies and strategies to support nursing and midwifery research activity. The RCN, for instance, has progressed a programme of work to raise the profile of nursing research among medical research charities and has developed research and development partnerships.