Providing more opportunities for the health and care workforce to participate in research, quality improvement projects and service evaluations (critical enquiry activities) increases employee retention and improves patient safety (Boaz et al, 2015).
The NHS long term plan recognises the importance of increasing research capacity and capability within the NHS and advocates for study and innovation initiatives to improve future outcomes (NHS England, 2019). Several national strategies (NHS, 2021; NHS England, 2022; 2023) have created a step change in nursing, midwifery and allied health profession research in England; however, to take strategies and transform them into reality in clinical practice, all stakeholders – such as organisations (involving boards and management), practitioners and professional bodies – need to think differently about how to make this happen.
Scoping the capacity and capability of nursing, midwifery and allied health professionals to design, deliver and lead embedded critical enquiry activities in one East of England NHS trust showed that such opportunities for these staff were limited (Whitehouse et al, 2022a). This scoping work also identified fewer opportunities, both clinical and non-clinical, for health and care staff outside medicine and dentistry.
To provide exposure to the realities of combining clinical demands and academic development, the James Paget University Hospitals Research, Evaluation and Quality Improvement (REQuIre) scholarship was launched in May 2022. This followed the establishment of the nursing, midwifery and allied health professions embedded researcher model (Whitehouse et al, 2022b).
The scholarship programme aimed to provide support and infrastructure for novice researchers with all levels of health and care experience and from any background in health and social care.
Its purpose was twofold: to boost people's confidence in critical enquiry activities; and to develop capacity and capability to devise and lead robust projects that have a direct impact on their area(s) of work and staff and/or patients.
This article presents the development of the inaugural scholarship programme with the outcomes of a concurrent live evaluation of the first cohort.
Method
Programme design
Funding
An application was submitted to the James Paget University Hospitals innovation fund to support workforce backfill so scholars could have protected time to carry out their research, consumables (for scholar projects and dissemination of work) and sustainable considerations (eg carbon offsetting). This was awarded in November 2021.
Stakeholder engagement activities and scholarship design and structure
The initial programme design was developed between December 2021 and January 2022 by the scholarship facilitation team. It was tested with staff and two patient groups. Table 1 provides some background on the facilitation team and the patient and public groups involved.
| Job title | Background |
|---|---|
| Senior nurse for nursing, midwifery and allied health profession research | Registered nurse, UK. Fourteen years’ research and evaluation experience, including delivery and design. Developed the concept and led the development of the nursing, midwifery and allied health profession research and evaluation service |
| Research and evaluation associate | Registered nurse in India and the UK. Education background with growing expertise in evaluation methodologies. On a clinical academic pathway |
| Research grants adviser | Registered paramedic. Fifteen years’ experience in the ambulance service and research delivery activity. Supported the development and submission of multiple grants |
| Head of quality improvement | Registered pharmacy technician. Ten years’ experience of quality improvement leadership and methodologies |
| Professor of practice development | Registered nurse, experienced in research, evaluation and practice development |
| Hospital patient forum | A group based in the hospital that includes patients and carers |
| Big C patient group | A group based in Norwich of people who typically have received or supported someone who has received cancer treatment locally |
*Scholars also identified their own relevant patient and public involvement groups (whether local or national) depending on their work area and group availability
Components deemed essential by staff and patients are shown in Figure 1. Scholars were involved in the co-design approach by requesting specific topics at two time points to shape the focus and delivery of sessions (Table 2).
| Module | Title (morning) | Active learning sets (afternoon) |
|---|---|---|
| 1 | Introduction to the scholarship team, critical enquiry, active learning, sustainable healthcare and projects | Considering your project Round tables ×4: stakeholder engagement, sustainable healthcare, how to formulate a project plan/aim, scholars networking table |
| 2 | Bite-size quality improvement, research and service evaluation Logic models and project planning*Scholars able to request 2-hour session of their choice for module 3 | Formulating and confirming your project Reflecting on stakeholder engagement activities since module 1 |
| 3 | Ethical considerations and governance *Scholars’ choice: consent for interviews/surveys, designing questions and focus groups | Getting ready to collect dataProject templates; capturing the project as a brief protocolSubmitting governance documentation |
| 4 | Leadership, change and political awareness | Considering your position as a leader and navigating your political savvy |
| 5 | Integrated learning across organisations and wider horizons*Scholars able to request two-hour session of their choice for module 6 | Cross-organisational knowledge, networking |
| 6 | Scholar wellbeing*Scholars’ choice: writing an abstract and designing your poster | Making concise your abstract and poster contentConsidering and formulating your data into usable information |
| 7 | Career opportunities and the research landscape | Project focus and research delivery in clinical practice |
| 8 | Inspiration and opportunitiesEmbedding research | Project focus and preparing for the showcase |
| 9 | Public showcase event |
*Each module started with a reconnecting activity and time for active learning and ended with descriptors of independent learning suggestions (mandatory and suggested)
The final structure and module content considered comments from all groups (Table 2).
Evaluation design
Realist evaluation is an approach to assessing organisational interventions (Nielsen and Miraglia, 2017). Middle range theories are crucial programme theories that outline how intervention mechanisms work within a context to bring about certain outcomes (Roodbari et al, 2021).
A realist conceptual framework for analysing the process of building research, evaluation and quality improvement (QI) capacity and capability through the scholarship programme was developed. This enabled the faciliation team to formulate the middle range theory in the context of the scholarship:
‘When [the] health and social care workforce are given the opportunity to have a combination of protected time, one-to-one mentorship, facilitated learning sessions and self-directed learning, they are likely to develop increased capacity, confidence and capability to undertake critical enquiry, grow their leadership skills, and undertake robust projects which have an impact in their area of work.’
Figure 2 presents the formulation of our middle range theory.
Consent
Scholars were invited to participate in the evaluation via email and received a participant information leaflet which detailed how all data collected through the study would be used. Scholars were under no obligation to take part and understood they were able to withdraw at any time. All scholars invited (n=9) provided formal written consent.
Data collection
Data were collected at multiple time points (Table 3) from the scholars (n=9). They were collected through snap surveys immediately at the end of each mandatory monthly session. Interviews were completed after scholars had completed the programme.
| Data collection method | Detail | Time point | Analysis |
|---|---|---|---|
| Scholar pre-learning survey | Sent via email. A brief survey reflecting current capacity, capability and confidence of scholars | Before starting the scholarship | Descriptive |
| Scholar post-module snapshot | Qualitative questions
|
Directly following attendance at each module | DescriptiveSnap survey data was reviewed by HH and MS initially, then reviewed again ahead of this publication by CLW |
| Scholar interviews/stories; semi-structured, face-to-face interviews | The participant interview guide is provided as supplementary material and is available on request | During and after the scholarship | Qualitative data were analysed using thematic analysis (Braun and Clarke, 2006). Interviews were transcribed and thematic analysis conducted by HH and CLW independently then compared and refined |
| Scholar post-learning survey | Sent via email. A brief survey reflecting scholars’ views of their own capacity, capability and confidence. | Within 2 weeks followin completion of the scholarship | Descriptive |
| Posters, attendance sheets, module facilitator observations | Scholar posters were made available online | All time points |
A secondary project exploring the sustainable (green healthcare) impacts of developing an educational programme was completed in parallel and is available alongside this publication as a twin paper (Whitehouse et al, 2024).
Ethical considerations
A favourable opinion from the Faculty of Medicine and Health Sciences Research Ethics Subcommittee at the University of East Anglia (ID ETH2122-1661) was given. This work was undertaken as a service evaluation so did not require Health Research Authority research ethics approval. Local approval and governance processes were followed for the evaluation through the hospital research support and governance group.
Results
Advertising the scholarship programme and organising the drop-in sessions raised the profile of the scholarship and other educational research programmes and funding opportunities.
Twenty members of staff attended the drop-in sessions. Of these, 60% (n=12) formally applied to the scholarship programme and 75% (n=9/12) of those were awarded places.
The 25% (n=3/12) who were unsuccessful were supported by the hospital nursing, midwifery and allied health professionals research and evaluation team or QI team to apply for other funding streams such as the Health Foundation Q Community or the Burdett Trust.
These three staff were given informal mentorship for their projects. Four (20%) employees did not need the scholarship programme but were ready for more research-focused programmes; they were advised and supported to apply for the National Institute for Health Research/Health Education England Clinical Academic Careers East of England pre-master's internship programme. All these applications were successful.
The remaining 20% (n=4/20) of staff attending the drop-in sessions were managers who were keen to support staff in their areas should anyone decide to apply.
Scholars
Scholars were aged 25–55 years, 89% female, 89% White British and 11% British Asian. Roles included registered nurse, occupational therapist, armed forces advocate, support worker, charity-based liaison worker and quality manager.
Table 4 sets out the scholars’ projects and achievements reached within the year following scholarship completion.
| Project | Achievements |
|---|---|
| Mobile attention deficit hyperactivity disorder (ADHD) clinics – sustainable healthcare driven | Mobile ADHD clinics continue successfully. Small-scale projects are being undertaken by all members of the scholar's teams Shortlisted for a British Journal of Nursing award |
| Capturing the procurement process impact to make recommendations that benefit patients and staff | Shortlisted for Health Foundation Q Community bid Continuation of the work into the next phase – implementation of the process in the clinical environment Awarded a British Lymphology Society award |
| Mental health support for paediatric staff supporting an increase in patients with mental health conditions | Developed an educational resource for staff in the service in collaboration with the mental health team |
| Understanding levers for change to support the development of an inflammatory arthritis self-management pathway | Awarded an Applied Research Collaboration implementation fellowship to continue the workPresented at a British Society of Rheumatology conference |
| Development of a service that supports forces veterans and ensures the trust is compliant with the Armed Forces Covenant | Trust awarded Veterans Aware statusAwarded gold in the Ministry of Defence employer recognition schemePost made permanent having previously been fixed term |
| Evaluation of current support for families and staff experiencing miscarriage and baby loss #MaxsLegacy | Royal College of Nursing National Support Worker AwardFirst formal bereavement support worker post createdAftercare service establishedChief midwifery officer for England clinical excellence award achievedPublication in the British Journal of Midwifery (Whitehouse et al, 2023) |
| Waiting well – supporting patients waiting for hip or knee replacements to wait well and be ready for surgery | Appointed the first social prescriber in the regionSupport for patients based on feedback and co-design implemented into the waiting-well pathway |
| Evaluation of the East Anglian Air Ambulance aftercare service patient peer support group | Co-designed and created a nationally available YouTube video with patientsNominated for an air ambulance awards (decided later in 2024)Publication in draft |
| Evaluating the serious incident tactical group and the patient safety incident response framework | Led system-wide quality strategy implementationPromotion to senior position |
All scholars completed National Institute for Health Research Good Clinical Practice training as part of independent learning which ensured formal research readiness
Figure 3 shows survey statements and responses made before and after the scholarship, which demonstrate growth in scholars’ capacity, capability and confidence. All participants anticipated the programme would give them skills and resources to undertake a QI or evaluation project, and all agreed or strongly agreed with the reflective question statement on this after the scholarship.
Themes
Scholars identified confidence as the biggest barrier or enabler to the conduct of critical enquiry activities within their areas of work. As confidence rose over the programme, scholars’ personal and professional abilities also grew. Thematic analysis was therefore conducted while holding influences upon confidence with enablers and barriers in mind.
Six overarching themes arose from analysis of the interviews and snap survey data. These were: value; expertise; attitudes; meaningful responsive support; brain space; and skills and knowledge acquisition. Each theme included sub-themes. The themes and sub-themes are shown in Figure 4.
Middle range theory demonstrated through qualitative interviews
Value of mentorship
Mentorship was linked to scholar confidence because it provided reassurance, and supported critical considerations and reflections about oneself as well as project work:
‘So my mentor is amazing. She was really open at the beginning and said “I'm not going to be able to help you with the Harvard system, but I can open your mind to different ways of doing things”… she just makes you feel like you can do anything.’
Scholar 6
Protected time
The experience of protected time generated feelings of privilege and guilt. It challenged scholars’ confidence, while both testing and enhancing their prioritisation skills:
‘Protected time has been difficult to do and I think everyone will tell you that's just because of where we're at in the system. But I've had the confidence to prioritise my time much more. I feel it's helped me to be able to say, ‘Actually, no, I'm in charge of my priorities today and this is what I need to do now’… doing it for the scholarships probably helped me feel more confident in doing it in other parts of my work as well.’
Scholar 5
‘Just guilt – the pressure comes from me though and that is a problem. I'm making the problem because I put the pressure on myself.’
Scholar 9
Facilitated learning
Facilitated sessions that focused on embedding theoretical underpinning knowledge supported learning when combined with practical application to scholars’ own projects:
‘It literally came off the cuff of her political awareness and leadership presentation – I went to a meeting and directly spoke about challenges in care delivery. It's not just about challenging politics and higher levels– it's about being able to raise issues without any comeback and to be open and honest. I was able to be brave enough to speak up. I hadn't done that before.’
Scholar 6
‘Yes, the session was very good, you know, especially the Data Protection Act. I know about data protection in India but here everything is new. It made me think before I take the decision whether I am right because I need to know the basic things.’
Scholar 1
‘Even basic IT skills, like in Microsoft Forms – I had never ever done one of those and now I can help others.’
Scholar 4
Community support network
The community feel of the group was valued by scholars and generated elements of trust, value and vision, shared belonging and shared learning:
‘Finding a group of colleagues I wouldn't necessarily have come across in my day-to-day working life – finding that we have similarities in some of our challenges, values and what we want to achieve even though we're working in different bits of the system and at different levels to achieve them.’
Scholar 8
Discussion
The results of this evaluation demonstrated a positive outcome against our original programme theory.
A particular emphasis was placed by scholars on the confidence component as the key to impactful projects and self-development. Results demonstrated that growth in confidence was achieved through challenging their comfort zone (leadership of a project), mentorship and guidance (personal growth) and comfort zone familiarity (being embedded within their area of expertise). This is important because it presents the software of values, attitudes and perceptions as equally important to them as the hardware of methods, guidelines and specific skills (Boaz et al, 2016).
Bringing together scholars with different backgrounds but shared values that facilitated bonding led to increased psychological safety; being part of a network with shared interests and values provides social capital (Putnam, 2002). The scholars saw social capital as valuable to their learning and development, with its direct impact as an enabler or indeed a barrier. While much evidence in the literature discusses why social capital is important, there is less evidence as to how it can be generated (Putnam, 2002; Vannebo and Ljunggren, 2021). The authors suggest the scholarship programme with its intentional links across organisational boundaries is an example of how create social capital can be created to benefit capacity in critical enquiry activities.
Independent learning days were reported as difficult when scholars knew their teams were short-staffed or affected by sickness absence. However, they did not feel pressure from managers to be at the bedside. Upon reflection, scholars identified that they continued to be supported by their managers as per the contractual agreement drawn up in advance of the scholarship. Guilt as a concept appeared to stem from within themselves and an inherent desire to support their teams, or concern they were viewed by others as being ‘on a jolly’. However, when refining their views further, scholars noted generally that no colleagues had expressed this view to them, but the thought that they might think that way was disabling. The feeling of ‘not being a real professional [eg nurse]’ was a hindrance (Henshall et al, 2021; Hansen et al, 2022).
It can be seen from scholars’ projects that thinking time allowed ideas to be developed, challenged, further refined and trialled. It was also contagious, with scholars’ colleagues engaging in practice and developing their own projects as a direct result. The outputs from scholars presented in Table 4 and through their posters combined with the ripple effect of teams continuing or building new projects, and valuing and making space for project work demonstrated true success from embedding critical enquiry scholarship in the practice environment.
Limitations
Building and delivering the programme required high levels of resources and reflection concurrently to ensure scholars had the correct amount of support at the right time, and ensuring this was challenging. Future cohorts should receive one-to-one time every month from a member of the facilitation team to discuss their project's progress, alongside support from their
The first half of the inaugural programme was delivered during a time of Covid restrictions, and this prevented some scholars from undertaking stakeholder engagement activities as much as they would have liked. This was a unique situation, however, and scholars used the options that were available to them at the time effectively.
Recommendations
Future programmes could increase the number of scholars to identify the optimum number to produce the best experience, quality and safety for those involved. Measures should be included to consider the impact on scholars and the programme facilitation team as well as resource and value. Cohorts should continue to include mixed professional groups across multiple organisations. The long-term impact of the programme in terms of confidence, culture in the workplace, career satisfaction and continued or additional project work should be measured.
Conclusion
The unique combination of theory and practice embedded in a real-world context led to positive outcomes for staff, patients, carers and the facilitation team as real-life changes were made in clinical environments. Capacity, capability and confidence increased for each scholar and their organisation. Guilt was identified as the major barrier and originated mostly from the scholars themselves. Social capital was identified as an enabler because of its impact upon scholar confidence. Future cohorts should test the optimum number of scholars to ensure safety, quality and experience.
KEY POINTS
- Opportunities for nurses, midwives and allied health professionals to design, deliver and lead critical enquiry activities are often limited
- A scholarship programme focusing on developing people and projects concurrently contributes to research readiness and increased confidence in the workforce
- The embedded nature of this programme, with projects being based within scholars’ areas of work, is key to success
- Networking across organisations can generate social capital, which can boost collaboration across workplace boundaries
CPD reflective questions
- What projects can you think of that could affect patients or staff in your clinical area of work?
- What does psychological safety look like in your team or department?
- How might undertaking projects in your area of work impact morale, recruitment and retention?