Choices and challenges
Part 3. The strategy for research and development in nursing and midwifery
1. Developing infrastructure
In relation to infrastructure, the focus falls on three key areas:
Successive Scottish Executive policy statements on NHSScotland have emphasised the importance of nurses and midwives working in partnership with fellow health care professionals, external agencies, service users and carers in developing and delivering services (see, for instance, Caring for Scotland (SEHD 2001a)). Partnerships are perceived as being key to effectively harnessing the range of skills, experience and abilities available to NHSScotland in the pursuit of excellent care for service users and carers.
The principles of partnership apply equally to the research and development environment. The need to access relevant expertise and utilise resources effectively to maximise benefits for service users and carers demands that all options be explored to ensure appropriate partnership-working opportunities are identified and exploited. Effective partnerships should also help to ensure greater co-ordination in research and development effort, leading to more coherent research and development activity in Scotland.
It is recognised that individual nurses and midwives have been successfully forging research partnerships and alliances with each other and with other professionals, often with limited support and infrastructure to support their efforts. A stronger emphasis on partnership arrangements will increase opportunities for these nurses and midwives and their colleagues to develop their activities further.
Central to the notion of partnerships is the concept of Research Alliances (see Box 4 and Figures 2 and 3). Research Alliances will offer opportunities for peer collaboration and will aim to develop a critical mass of skilled researchers capable of increasing outputs in relation to the Alliance's focused programmes of research. They will create a learning environment in which novice researchers can be nurtured, and will present a portal through which nurses and midwives in a range of settings can contribute to the Alliance's research effort.
Box 4 Research Alliances
For the purposes of this strategy, the term 'Research Alliance' refers to a research community working within a collaborative model to develop focused programmes of research. It is likely to be a 'virtual' body consisting of a variety of organisations (such as HEIs, NRIS and NHS Trusts) and individuals in separate locations throughout Scotland.
Figure 2. Illustrating the 'RESEARCH ALLIANCE MODEL'
Figure 3. Example illustrating a potential 'RESEARCH ALLIANCE'
HEIs and NHSScotland should explore opportunities to develop partnerships based on the Research Alliance model to ensure that the utilisation of existing resources is co-ordinated and that resources are used to maximum potential. Professors and Heads of Departments and NHS Board and Trust Directors of Nursing and Midwifery will have a particular responsibility to provide strong leadership to encourage the creation and development of partnerships.
Funding and funding bodies
Funding of nursing and midwifery research and development activity needs to be managed effectively. The main non-commercial funders of research in the UK are the Health Departments in the four countries, the Research Councils and research charities. The 2001 RAE showed that much nursing and midwifery research was self-funded, with external funding mainly coming from the Health Departments (RAE, 2001). Relatively little arose from other sources, although there were examples of funding being secured from diverse organisations for multidisciplinary projects which had a nursing or midwifery contribution.
Nursing and midwifery receive a disproportionately low allocation of research funding compared to other health care professions (notably, medicine). In addition, while nursing and midwifery pre-registration training programmes funded by SHEFC receive a dedicated research allocation, this is not the case for all those funded through NHSScotland contracts. Funding streams for nursing and midwifery research and development need to be diversified and expanded to ensure that capacity can continue to expand to meet service-users' and carers' needs.
SHEFC, NES, CSO and SEHD should work together to identify funding streams which Research Alliances can use to resource capacity-building strategies.
Building upon the data acquired from the scoping exercise, SEHD and NES will work to identify the potential for research capacity growth and agree future projections, targets and timescales.
Potential funders of research should be encouraged to take a broad view of the range of research projects needed to underpin effective health and health care. For instance, research into health-related quality-of-life issues and the effects of long- and short-term morbidity or disability are important to service users and the public and lend themselves to nursing and midwifery perspectives and investigations. They are relatively under-represented in funded research, however, which consequently presents opportunities for increases in current levels of funding for well-focused studies aiming to improve outcomes for service users and carers.
SEHD, CSO, SHEFC and NES should encourage independent research commissioners (such as voluntary organisations, Research Councils and charities) to base their funding decisions on an extended concept of health and health care research needs.
Developing clinical/academic career pathways
To be in a position to maximise capacity, nursing and midwifery need to develop clinical/academic career pathway models which define leadership roles and map training routes for novice researchers. This is the key platform for the future development of nursing and midwifery research in Scotland.
Traditionally, opportunities for nurses and midwives to secure contracts of employment within the NHS that allowed them to move from clinical to academic positions (and vice versa) have been limited. More opportunities need to be created to allow nurses and midwives to pursue such career options, particularly in remote and rural parts of the country where there may be restricted access to academic settings.
In addition to defining career pathways within nursing and midwifery research, clinical/academic career pathway models can also be developed to demonstrate options for acquiring research training through undertaking research with other health and social care professions (see Box 5).
Box 5 Key elements of a clinical/academic career pathway
A clinical/academic career pathway offers opportunities for:
high-quality research training at different career stages, while allowing the nurse or midwife to maintain involvement in clinical practice
a wide range of training activities that reflect the spectrum of clinical, scientific, social, methodological, managerial and administrative research skills required to meet needs
those who have taken research training to further develop their skills
the creation of sustainable posts which allow experienced researchers to continue developing their research portfolio and collaborations while maintaining involvement in clinical practice.
NHS Boards and Trusts, HEIs, PHIS, NES and the SSPC should work together to develop models of clinical/academic career pathways for NHSScotland, considering the potential benefits of both uni- and multidisciplinary models.
This poses a significant challenge to NHSScotland to demonstrate how it can value and support nurses and midwives undertaking research and development training by enabling them to remain in employment in NHSScotland with options in career development. NHSScotland and HEIs also need to show that they can provide the appropriate infrastructure to ensure that nurses and midwives in clinical/academic roles do not become isolated from colleagues in either practice or academic settings.
HEIs, NHS Boards and Trusts, NES and PHIS should work together to develop innovative approaches to the creation of joint clinical/academic roles which have research activity at their core.
NHS Boards and Trusts should explore means of ensuring continued employment and career progression options within NHSScotland for nurse and midwife researchers.
The Research Governance Framework for Health and Community Care (SEHD, 2001c) sets out the different roles, responsibilities and levels of research involvement of different members of the research team. Box 6 presents a modified version of the framework. Each of the defined levels requires training to enable nurses and midwives to make full contributions to the research effort. The framework shows the route through which future nursing and midwifery research leaders can be developed.
Box 6 Levels of research involvement (modified from SEHD, 2001c)
Principal investigator (lead researcher)
Under the Research Governance Framework for Health and Community Care (SEHD, 2001c), each project must have a named principal investigator who bears overall responsibility for the design and conduct of the study. The principal investigator will usually have completed a recognised research training and will have previous research experience. If inexperienced, an experienced supervisor or investigator should be available. A principal investigator would not normally work full time on any single project (unless a major project is being undertaken), but could be involved in several studies or may combine research with practice, management or teaching.
Research teams usually need a number of investigators to provide the required breadth of knowledge and skills for a study. They could include experienced researchers, inexperienced researchers in learning roles, those who have particular technical skills (such as statisticians) and clinical collaborators. The principal investigator and investigators are named on grant applications and submissions to ethics committees. They develop the research protocol, obtain necessary resources and publish results. They often employ research workers to collect data.
These are experienced individuals with clinical and/or management commitments who are able to facilitate access to service users or staff. They may be involved in research at different levels, but do not necessarily have to be part of the research team.
Individuals employed to carry out the study. Some are skilled researchers who play a major role in study design and data analysis, while others are employed to collect data.
Research students must have academic supervisors and may also have clinical supervisors. These individuals sponsor the study and take responsibility for the proper conduct of the research. Increasingly, steering groups consisting of service, academic and service-user stakeholders also supervise research teams.
Two main obstacles prevent nurses and midwives in service and academic settings from contributing fully to the research and development agenda:
there are too few nurse and midwife researchers with the requisite education and training, and too few nurses and midwives in practice who are research-aware (DoH, 2000)
there is little awareness of existing NHSScotland research networks which facilitate understanding of, and access to, the wider research community.
Workload pressures, lack of protected time, inadequate 'backfill' arrangements and lack of resources in practice settings mean that opportunities for experienced nurses and midwives to undertake research training are restricted (DoH, 2000). Such opportunities are essential, however, in the development of nursing and midwifery research capacity.
While current pre-registration training programmes offer preparation in research awareness and basic methodology, they necessarily focus on developing competencies to ensure that nurses and midwives are adequately prepared for practice. The further development of research awareness, competencies, knowledge and skills requires training at post-registration level, both for newly registered practitioners emerging from training programmes and for nurses and midwives who have been practising in NHSScotland for varying lengths of time.
HEIs and other education providers and NHS Boards and Trusts should provide training programmes designed to enable nurses and midwives to actively participate in research at a variety of levels, ranging from developing research awareness to acting as research collaborators.
CSO, SHEFC, NES, HEIs, NHS Boards and Trusts, SSPC, NRIS and professional organisations/trades unions should work in partnership to enhance the capacity to prepare individuals for future research roles by facilitating doctoral and post-doctoral research opportunities for graduate nurses and midwives.
Supervision is a key consideration for students undertaking research training at post-graduate level. It is important that HEIs facilitate academic staff development to ensure they achieve the appropriate level of knowledge and skills to support the teaching and supervision of students at Masters, doctoral and post-doctoral levels.
HEIs, in collaboration with SHEFC and other funding bodies, should provide opportunities for individuals to acquire the requisite skills, knowledge, competencies and qualifications to support the development and conduct of research projects by post-graduate nursing and midwifery research students.
2. Adopting a focused approach
Although nursing and midwifery are progressing as research disciplines, much of their research is still in the form of small-scale, non-generalisable studies. Nursing and midwifery need to be focused on a clear strategy on how they can best contribute to achieving the national research priorities for NHSScotland and meeting the needs of the people of Scotland. Their current research and development strengths need to be identified to allow Research Alliances to exploit them as the platform for planning programmes of research.
SEHD and SHEFC should undertake a Scotland-wide mapping exercise to identify nursing and midwifery's current research and development strengths to inform the development of programmes in Research Alliances.
It is difficult for researchers to develop a national overview of current strengths in nursing and midwifery research from within the confines of their own environment, regardless of how 'outward looking' and collaborative that environment might be. There is therefore a need for the creation of a national group drawn from a wide constituency to provide a genuinely national perspective.
SEHD should establish a National Group consisting of researchers, health care and public health professionals, managers, policy makers, educators, service users and the public to focus on current strengths in nursing and midwifery research in relation to priorities.
HEIs tend to generate a strong body of knowledge when they can build programmes of research which reflect the particular areas of interest of the institution. In nursing and midwifery departments, these areas are often wide-ranging, spanning, for example, clinical topics, specific research methods, interventions for defined client groups, outcomes-focused research activity, or any combination of these and others.
There is a strong case for nursing and midwifery departments to continue to refine their research portfolios to build on their current expertise and resources, exploiting their strengths to do what they do best, and identifying opportunities for collaborative work within Research Alliances. Developing the body of knowledge and research relevant to the portfolio will strengthen the ability of the HEI sector to influence nursing and midwifery practice and encourage focused post-graduate nursing and midwifery student research.
HEIs should develop research portfolios with defined research programmes which build on the strengths, expertise and resources available to them, and which maximise opportunities for collaboration within Research Alliances.
If post-graduate students match their research interests to the identified research portfolio of individual HEIs, they will be assured of access to the best available supervision and expertise. Support of this kind may be available to students not only from departments of nursing and midwifery, but also from other disciplines within the HEI sector.
HEIs should encourage nursing and midwifery post-graduate research students to be primarily guided in their choice of project by the HEI's research portfolio and programmes.
The further development of research portfolios at HEI and Research Alliance-level raises exciting prospects for bi- or multi-centre collaboration on a UK and/or international basis. Collaborations could focus on research programme design and delivery, offering opportunities for combining resources, widening the scope and scale of research programmes and potentially increasing the influence and standing of nursing and midwifery in Scotland in the international research community.
HEIs, NRIS, PHIS and Research Alliances should consider the potential of bi- or multi-centre collaboration on a UK and/or international basis.
NRIS provides a vital function in demonstrating a model of collaborative, focused research in nursing and midwifery in Scotland and has an ongoing nursing and midwifery research programme developed in collaboration with NHSScotland ( see Box 3).
Subject to approval by CSO following the external peer review process, NRIS should continue to develop its programme of research, ensuring that the programme promotes collaboration with NHSScotland, HEIs, Research Alliances and others.
3. Building an evidence-based culture
Evidence-based practice is integral to the clinical governance agenda in NHSScotland. Studies have shown, however, that there can be a delay of up to 10 years before an intervention based on incontrovertible evidence becomes established practice. This is an issue for all health care professionals, and nursing and midwifery are not alone in facing this challenge.
Efforts to base health and health care on the best available evidence have gained momentum over the last five years. This demands that clear understandings of what constitutes 'evidence' should be formalised, but in practice, much ambiguity in definitions exists. For instance, many assume that evidence can only legitimately be drawn from highly structured research work; if this rule were to be followed, evidence provided from expert judgement and experience would be excluded.
The evidence to support many nursing and midwifery interventions commonly relies on a combination of sources of knowledge. These sources include evidence gleaned from research work, but might also acknowledge the importance of expert opinion, clinical experience and the perspectives of service users and carers. The challenge is how best to combine these different types of evidence to inform clinical decision-making.
Much discussion revolves around the idea of developing an evidence-based 'culture' at NHS Board and Trust level, with little clarity on how that culture can be created. Work carried out by the Foundation of Nursing Studies (FoNS, 2001), however, suggests that the key elements that need to be in place to encourage an evidence-based culture include:
inspirational clinical leadership which empowers and encourages people
organisation-level strategies to encourage evidence-based practice
integration of quality assurance mechanisms such as audit, clinical effectiveness, clinical governance and research and development
development of research-based policies and procedures
development of true multidisciplinary respect, with joint working and research projects
education on evidence-based practice for nurses and midwives
incentives and rewards for nurses and midwives who implement practice based on evidence
easy and equal access to research sources.
It is the responsibility of all in NHSScotland - practitioners, managers, educators and researchers - to contribute to the development of a culture that endorses evidence-based practice.
NHS Boards and Trusts should work to create within their organisations a strong culture that recognises the importance of evidence-based practice. Evidence-based practice should be integral to Board and Trust-level strategies on clinical governance, performance appraisal and staff governance, service delivery and continuing professional development.
Directors of Nursing and Midwifery in NHS Boards and Trusts should ensure their organisations have in place a framework for implementing evidence-based practice in nursing and midwifery.
Directors of Nursing and Midwifery in NHS Boards and Trusts, working with Trust Research and Development Leads, should develop mechanisms to ensure that nurses and midwives in clinical leadership posts (including ward sisters/team leaders, practice development nurses/midwives, clinical nurse specialists, consultant nurses/midwives and public health practitioners) demonstrate a commitment to implementing evidence-based practice.
Individual nurses and midwives are required to 'deliver care based on current evidence, best practice and, where applicable, validated research when it is available' in fulfilment of Clause 6.5 of the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC, 2002). To meet this requirement, they will need access to opportunities to update their knowledge and skills on evidence-based practice through focused educational activity, in accordance with their personal development plans as agreed with managers and supervisors.
Directors of Nursing and Midwifery in NHS Boards and Trusts should ensure their organisation's continuing professional development plan/strategy offers nurses and midwives access to education and training opportunities related to evidence-based practice.
Building an evidence-based culture in nursing and midwifery should begin with students. Developing an evidence-based philosophy among students is likely to lead to a career-long evidence-based focus among the registered nurses and midwives of the future. Pre-registration nursing and midwifery curricula should continue to reflect the importance of evidence-based practice to the delivery of clinically effective, safe and resource-efficient health and health care services.
HEIs, NHS Trusts and the NMC should ensure that the requirement for pre-registration nursing and midwifery curricula to provide students with the necessary competencies to adopt an evidence-based approach to health and health care is met.
4. Promoting dissemination
Dissemination is the vital link between research and development. New knowledge generated from research and which has the potential to improve care delivery needs to be made accessible to the practitioners who can utilise it and the managers who can facilitate change in practice and policy.
A number of studies in the nursing literature, however, have identified barriers to research dissemination and implementation in clinical areas. In many instances, the information generated by research is not disseminating through to the people who would be able to implement it in practice.
French (1999) suggests there may be two main reasons for this:
There is a deficiency in communication: either the necessary research knowledge does not exist; or, it does exist, but not in a format that is acceptable to nurses and midwives.
There is a deficiency in reception: either the research does exist in an acceptable format, but does not reach nurses and midwives; or, the research does exist in an acceptable format, but is not wanted by nurses and midwives.
Publication of research in scholarly peer-reviewed journals is an important dimension of nursing and midwifery research dissemination. Such journals enjoy an international reputation and provide the core material for systematic reviews, which have assumed a vital role in the development of evidence-based practice. Publishing in peer-reviewed journals also provides nursing and midwifery researchers with credit for their academic departments in, for example, RAEs. Nurses and midwives in clinical settings, however, may face difficulties in accessing these journals on a regular basis.
HEIs and Research Alliances have a responsibility to ensure that high quality, peer-reviewed research carried out within institutions is presented for dissemination to the wider nursing and midwifery community. This can be achieved through a variety of portals, which includes scholarly publications (paper and web-based), but also involves conference presentations, in-service education events, summary sheets, discrete summaries for 'popular' nursing and midwifery journals, public and professional meetings, NHS Board and Trust newsletters and the local and national press. Increasingly, electronic means of disseminating research findings and information are being exploited.
HEIs and Research Alliances should develop, publicise and evaluate a dissemination strategy to ensure maximum clinical impact for their research outputs.
Resources to facilitate the interpretation and accessibility of research evidence have grown in the UK in recent years. Initiatives such as the Cochrane Collaboration and the NHS Centre for Reviews and Dissemination aim to review systematically existing research on important clinical or operational questions, collate the findings, and then present them in an accessible way.
Clinical guidelines have been developed as a vehicle to bring evidence directly to those who should be utilising it in their practice. They are systematically developed statements which assist practitioner and service-user decisions about appropriate health and health care for specific clinical circumstances. The Clinical Resource and Audit Group (CRAG) (soon to be subsumed within The NHS Quality Improvement Board in Scotland) established the Scottish Intercollegiate Guidelines Network (SIGN) in 1993 to sponsor and support the development of clinical guidelines for NHSScotland.
Clinical guidelines have been devised for a wide range of topics, but evidence on their implementation shows they are not necessarily successful in changing clinical practice (Grimshaw and Russell, 1993; West et al, 2001). The evidence suggests that where they have worked well, strategies which focus on barriers to and facilitators of implementation have been used (Wye and McClenahan, 2000). One of the strategies utilised in some areas of nursing and midwifery is the provision of key staff to facilitate change management, often referred to as Practice Development Nurses/Midwives (Box 7).
Box 7 Practice development
Practice development is described as:
'...a continuous process of improvement designed to promote increased effectiveness in patient-centred care. It is brought about by enabling health care teams to develop their knowledge and skills and, in doing so, transform the culture and context of care. It is enabled and supported by facilitators who are committed to systematic, rigorous and continuous process of change that will free practitioners to act in new ways that better reflect the perspectives of both service users and service providers'.(Manley, 2000)
The Nursing and Midwifery Practice Development Unit's main priorities are to develop and promote clinical excellence and encourage networking throughout NHSScotland through the sharing of good practice underpinned by evidence. Its work programme should continue to develop to reflect these priorities with the aim of incorporating research evidence where available. Recognising that there is a lack of reliable guidelines and practice guidance focusing on nursing and midwifery practice, NMPDU has published and disseminated 'best practice' statements on topics of clinical importance, with others currently under development.
NMPDU should ensure that the integration of research evidence, where available, is explicit in all the Unit's relevant outputs.
NMPDU will actively link with organisations which currently disseminate research, such as the Foundation of Nursing Studies (FoNS) and professional organisations, forming networks to develop a shared strategic vision that supports the dissemination of evidence generated from research.
The ability to identify gaps in the research evidence is as important as the dissemination of evidence. Through this process, data to inform the development of future research questions can be identified for the research community in Scotland.
NMPDU and appropriate others should inform the research community of potential research questions that arise out of perceived gaps in evidence.
Models of promoting the uptake of evidence-based practice among nurses and midwives have been developed. The FoNS- supported Evidence-based Midwifery Network is a good example (see: http://www.fons.org/networks/ebm/ebmmain.htm ). NMPDU, working in partnership with relevant organisations, can build on initiatives such as this to further utilise networking models and develop new ones to facilitate the dissemination of evidence generated from research to nurses and midwives in NHSScotland. New funding sources will need to be identified to support this activity.
HEIs and NHS Boards and Trusts, in partnership with NMPDU, should utilise existing models for networking and develop new models to support individual nurses and midwives to deliver care that is evidence-based.
Professional organisations, NMPDU, SEHD and FoNS should seek to persuade charities and other funding bodies to support the development of new and existing networks to promote the implementation of evidence-based practice.