Nursing needs good quality research to advance practice and improve patient outcomes (National Institute for Health and Care Research (NIHR), 2020). Unfortunately, nursing has been criticised as relying on practices that are grounded in tradition or past experiences, with limited research-based interventions (Richards et al, 2018; Powers, 2020). Numerous studies have been carried out to identify the barriers and enablers to the conduct of nursing research (Bahadori et al, 2016; Smith et al, 2018; Cleaver, 2020). Many authors believe that nurses' lack of required knowledge, skills and experience, ill-defined career pathways (Smith et al, 2018; Avery et al, 2022) and limited opportunities for participating in research, along with a lack of funding for nurses who wish to pursue careers in research, are all major barriers (Jackson and Kozlowska 2018; Kitson, 2018; NIHR, 2019; Gibson, 2019; Ball and Regan, 2019; Cleaver, 2020). These barriers are compounded by an NHS culture that does not always appreciate nursing research, associated with difficulties in accessing adequate support or mentorship, heavy workloads and a lack of time, with immediate clinical work often being prioritised (Bahadori et al, 2016; Chen et al, 2019; Cowley et al, 2020).
Historically, hospital-based research has been led by doctors (Blake, 2016) with the clinical research nurse (CRN) traditionally supporting research in the NHS, whereas nurse-led research has been based predominantly in universities. In recent years, this division has blurred, with an increasing number of joint academic posts, bespoke roles for nurse researchers in NHS trusts, and more principal investigator (PI) roles for nurses. Key factors that can increase research capacity include transparent role expectations, increasing the value of applied research, organisational commitment and more grant funding opportunities (Lode et al, 2015; Chen et al, 2019).
Terminology in nursing roles in research
Misunderstandings surrounding the terminology and scope of practice within advanced and specialist nurses' roles continue to pervade the profession (Currey et al, 2011; Cooper et al, 2019; Cannaby et al, 2020). There is a broad range of titles attached to dedicated research roles in the NHS; typically, these include CRN, clinical nurse academic and nurse researcher. Table 1 includes key components of nursing roles in research. Other specialist nurse roles, such as nurse consultant, clinical nurse specialist and advanced nurse practitioner, may involve specific research elements linked to the four pillars of practice (clinical practice, leadership and management, education, and research), and expectations within their job descriptions (Health Education England et al, 2017). There is also national variation in titles and roles and inconsistent professional terminology (Faulkner-Gurstein et al, 2019). Many posts have evolved locally, for example, some NHS trusts have introduced ‘research matrons’. The responsibilities associated with the research matron role vary across different trusts, with some matrons managing the delivery team and others developing nursing research.
Table 1. Terminology in nursing roles in research
| Role | Core components of the role |
|---|---|
| Clinical research nurse (CRN) |
|
| Clinical nurse academic |
|
| Nurse researcher |
|
Challenges associated with the role of the clinical research nurse
Despite being one of the fastest-growing nurse specialisms (Royal College of Nursing, 2020), the value of the CRN appears to have been widely overlooked. Several factors contribute to the challenges associated with the role. These include perceptions of the role, hierarchies within research roles, the role itself and the setting in which these roles are positioned (see Box 1 for a typical CRN job summary).
Box 1.Clinical research nurse job summary
To manage set up of studies
| Key components of CRN role (this will vary depending on band and setting) |
|---|
|
Research has suggested that CRNs feel that they are perceived negatively by their peers and the organisation as a whole (Boulton and Beer, 2018; Tinkler et al, 2018). A review of research in nursing and midwifery across the UK and Ireland (Whitehouse and Smith, 2018) identified that the role of the CRN is seen by some as ‘just about recruiting patients’ or data collection. Such misconceptions have led to negative perceptions related to the CRN's role, including subordination to doctors and limited career opportunities (Boulton and Beer, 2018). Workforce shortages also mean that the traditional role held by research nurses has begun to be carried out by personnel from non-nursing, non-clinical backgrounds (Gowie et al, 2020). This may further complicate and undermine the role of the CRN (Boulton and Beer, 2018).
It is the PI or chief investigator (CI) who has ultimate responsibility for clinical research activity, this is often a medical practitioner. However, it is increasingly more commonplace to see nursing, midwifery, and allied health professionals (NMAHPs) within these leadership research roles, although medical colleagues and funders can sometimes be reluctant for CRNs to act as CI or PI for studies (Whitehouse and Smith, 2018).
It has been suggested that the role of the CRN is especially undervalued within the nursing profession itself; this is demonstrated by the limited primary research led by this group and a lack of research to demonstrate the value of the CRN (Whitehouse and Smith, 2018). A systematic literature review on the role of CRNs identified only one primary research article (Cleaver, 2020).
To ensure further development of CRNs' careers and improvements in the image of nursing research, organisations must recognise that this diverse and autonomous role brings nursing-related additional skills and knowledge to research projects that have the potential to impact positively on the quality and safety of patient care (Poston and Buescher, 2010; Dainty and Cooper, 2011; Lode et al, 2015; Tinkler et al, 2018; NIHR, 2020).
Clinical research nurse: career progression
It is important to recognise that not all CRNs will want to become nurse researchers. A UK study of 121 CRNs found that only 10% indicated that they planned to become an independent researcher in the future (Boulton and Beer, 2018). This suggests that research nurses rarely view the role of ‘nurse researcher’ as their career ambition, but many instead plan for career progression within the role of CRN itself. If a clear career structure was available, CRNs might find it easier to pursue a career that involves leading their own research. CRNs possess a unique blend of knowledge and skills (Gibson, 2019) and a high level of competence in the practical aspects of research (Hill, 2018). Given their expertise, CRNs can make a significant contribution to multi-professional research, should be encouraged to collaborate, and be viewed as an active research partner.
The experiences of the authors confirm that it is possible to transition from CRN to nurse researcher. For example, one author (AS), made the transition gradually over several years. While working part-time as a CRN on large multicentred trials, she was also able to secure research funding to improve the wellbeing and conditions of the non-medical workforce. Another (VC), carried out projects independent of her CRN duties to raise the profile of non-medical research and contribute to organisational intelligence. A third (AD), worked as a CRN before undertaking a clinical PhD that was part funded by an NHS trust and a university. All three were provided with unique opportunities that enabled them to build their research career, such as access to research training, and support from experienced PIs and researchers with an established track record. However, they also faced common challenges such as a lack of time, confidence and organisational support. Such challenges mean that very few CRNs will change direction and pursue careers as independent researchers (Lewis et al, 2014; Jones 2015). There is also a limited promotion pathway available in this area of practice and specialism.
Challenges associated with the roles of nurse researcher and clinical nurse academic
The nurse researchers and clinical nurse academic roles focus on the development of evidence relating to nursing and health and social care practice. Although nurses may have overall positive attitudes toward research and research-based practice (Bahadori et al, 2016), the literature suggests that historical perceptions persist, meaning that research produced by nurse researchers and nurse academics is perceived as less valuable by clinical staff, than evidence produced in medically-led clinical trials. This may be due to a lack of alignment with national priorities or the methodologies used, which may deviate from randomised controlled trials (Ford, 2017; Chen et al, 2019). The lack of value attached to nursing research can further compound the impending anxieties and insecurities of early career researchers (Blyth et al, 2018; Gill, 2020).
For nurses pursuing academic roles, specific barriers are consistently described in the literature, including a lack of funding, inadequately protected time, a competitive environment and poor mentorship (Dainty and Cooper, 2011; Gill, 2020). Funders also have high expectations once training has been completed, and clinical nurse academic posts are scarce (Masterson and Robb, 2016). Additionally, in comparison with nurse researchers pursuing full-time careers, often in universities, nurses in clinical academic posts may have a substantive academic contract with a university and a partner NHS body. They may therefore face additional pressures, with the need for professional credibility in both the clinical and academic settings, with research and clinical practice making competing demands on their time and expertise. This may leave some clinical nurse academics feeling isolated and unsupported (Logan et al, 2016).
It may also be worth considering the gendered nature of the academic workforce. Although the Athena Scientific Women's Academic Network (SWAN) Charter has been highly successful in tackling gender inequalities in higher education (Barnard, 2017), gender inequalities continue to impede career progression. Women in academia are awarded less grant funding and achieve fewer high-impact publications, key determinants in progressing research careers. Policies are required to help address these inequalities (Brown et al, 2020). A survey of doctors working in the UK found that female doctors were less likely to pursue a career in research, due to a lack of career flexibility, part-time and flexible working and career advice (Lambert et al, 2015). Changes to undergraduate nursing education over the past two decades are already starting to assist with this challenge by incorporating research modules, increasing research awareness and, ultimately, cultivating a positive research culture within the nursing profession; and for some an interest to continue on this career path.
The importance of developing clinical academic roles in nursing and midwifery has been identified as a priority by the UK government, Health Education England (HEE) and the NIHR. HEE and NIHR offer a variety of doctoral and research training programmes for health professionals who wish to combine research and practice. Nurses are poorly represented in such programmes (Gibson, 2019). In 2019, current NIHR award holders included only 53 nurses and midwives compared to 126 AHPs (Gibson, 2019), which is vastly disproportionate to the number of practitioners on the Nursing and Midwifery Council (NMC) register and the Health and Care Professions Council register. The Medical Research Council (2017) reported that the number of awards to support researchers at the initial post-doctoral career stage has increased across all professions, except for nurses, where they have remained static. More substantial awards aiming to support an independent research career, remain at ‘low levels’ for nurses (NIHR, 2017). The NIHR has recently launched a range of research awards, aimed specifically at NMAHPs to support the development of clinical academic careers (NIHR, 2021a).
Looking to the future
More discourse about recognition of and investment in this complex and highly skilled specialty is needed. This opportunity will not only offer a tangible career pathway for nurses who wish to pursue a career in research but, more importantly, develop a shared understanding of the role and enable priority setting, which can contribute to and expand the credibility of a nurse-driven evidence base within the profession. The chief nursing officer (CNO) strategic plan for research may offer a much-needed framework to support this change (NHS England and NHS Improvement, 2021).
Research career pathways for NMAHPs who wish to develop clinical academic careers are well established. HEE works in close partnership with the NIHR to develop clinical academic careers. The NIHR has also recently launched a new Associate Principal Investigator Scheme, which is open to all health professionals (NIHR, 2021b). The associate PI role may offer an alternative for nurses who do not wish to follow the PhD route. The career pathways for clinical research nurses and nurse researchers employed in full-time roles within the NHS are less clear.
Universities and healthcare providers within the UK are already working together to influence a more positive research culture within nursing, through the nursing education curricula (Willis, 2015). The representative body of the UK university faculties is committed to increasing research placements to help build research capacity and ensure third-year pre-registrants are informed about careers in nursing research (Council of Deans of Health, 2021).
There are many highly trained nurses working across the research spectrum. To further encourage the production of nursing and multi-professional research, and the use of evidence within organisations, it is imperative that NHS trusts offer flexible career pathways for nurses who wish to engage in research and create substantive posts for nurse researchers who can be visible role models (Lopes et al, 2017; de Lange et al, 2019). Such posts will require collaborative relationships between trusts and universities, with joint appointments and the appointment of visiting fellows. This will encourage nurse researchers to participate in academic networks and enable career progression (Avery et al, 2022). Researchers working within organisations are centrally positioned to promote the research agenda, within the context of an ever-changing NHS (Lopes et al, 2017). Research conducted within or alongside clinical practice may be seen as the next generation of research. This will have direct relevance to practice and create more opportunities to produce nurse-led research, as well as promote new career structures and organisational learning.
KEY POINTS
- Nursing roles in research are often misunderstood
- Transparent role expectations can increase research capacity
- Nurses can make a unique contribution to research and patient care
- New roles in NHS settings are required to generate enthusiasm for nursing research
CPD reflective questions
- How can you support evidence-based practice in your clinical area?
- What can your area of work do to increase awareness of nursing roles in research?
- How can you support nursing research in your area of work and more widely?