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Why nursing research matters

To coincide with the RCN international nursing research conference in Edinburgh we take a look at the state of nursing research. It has come a long way in a short time, but a key challenge is ensuring the aim is firmly on studies that benefit frontline practice.

Hundreds of nurses from around the world are heading to Edinburgh this week to take part in one of the biggest events devoted to research – the RCN’s international nursing research conference. Over three days on April 6-8, delegates from academic and clinical backgrounds will share their findings on an extraordinarily broad range of issues.

The topics include working with service users and carers, multidisciplinary teamwork, the politics and ethics of research, dealing with the media, workforce issues, managing poor performance, mental health, palliative care, leadership and, inevitably, funding.

The breadth and depth of these presentations reflect the diversity of modern nursing and how far nursing research has come in a relatively short space of time. And there are many reasons to be optimistic about nursing research today.

Internationally, there are probably more nurses doing research than ever before, with more multidisciplinary working and more nurses acting as research leaders. The volume of published research around nursing has grown significantly.

In the UK, the fact that nursing is now a graduate entry profession means many nurses have master’s degrees or PhDs. In the past dozen years the number of chairs or professors of nursing has doubled from 132 to 260, while those holding joint clinical academic posts have tripled over the same period.

All this is set against a backdrop of healthcare policies that stress the importance of evidence-based practice, an expansion of the sources for research funding and an education regime that equips nurses to be critical thinkers when delivering care.

But it is not all good news. Although nursing professorships are increasing, for example, it is happening from a very low base.

They are still dwarfed by medical professors who number more than 1,300 – despite the fact the nursing workforce is almost three times the size. There are also a disproportionately high number of male professors (27%) and a disproportionately low number of black and minority ethnic (BME) nurses (5%) in the top jobs.

At the same time, nursing’s public reputation has taken a few knocks in recent years thanks to events such as the Mid Staffordshire NHS Foundation Trust scandal. The Francis inquiry made it clear that whatever theories are held about good, evidence-based nursing care, it was not translating into practice on many wards.

For Pam Smith, professorial fellow in nursing studies at the University of Edinburgh, who will be giving a keynote speech on the emotional labour of nursing at this week’s conference, the problems uncovered at Mid Staffs fit into a wider pattern of poor performance, where health staff fall back on ‘routinisation’ as a defence against anxiety and excessive pressures.

‘There tends to be a disempowerment of workers in these extreme regimes,’ she says. ‘They don’t have any mechanisms to resolve issues so they seek protection in sticking to the routine.’

She fears a service driven by targets and finance risks scapegoating nursing. The belt-tightening also threatens research and development, which has been an easy target when health bodies face substantial cuts. Yet nurse research could offer a way forward on some of these issues, she suggests.

King’s College London nursing professor Ruth Harris agrees. ‘Nurse training in the UK has now been university-based for more than 20 years and that has had an enormous influence on the profession, she says.

‘The university environment is all about evidence-based practice and academic rigour – it encourages you to question care. You’re also dealing with colleagues in other faculties and disciplines. It has given nursing and nursing research greater self-confidence.’

Methodology

At the same time this expertise needs to be relentlessly focused on the interface between nurses, service users and their families. ‘Ultimately everything is about that and we need to keep our eye on the ball at all times,’ says Professor Harris.

Then there is the question of methodology. An inevitable tension exists between the biomedical model of research, which tends to have higher academic status, and more qualitative, interpersonal studies.

Swansea University emeritus nursing professor Gary Rolfe recalls facing this conundrum when as a nurse teacher he moved into the university environment in the early 1990s. ‘I began to realise there were two agendas, he says. ‘The university focus was on publishing in academic journals and getting research grants from prestigious awarding bodies, but that had no real relevance to nursing practice.

Funding

Funding is a perennial challenge for all healthcare researchers. The sources of funding are as great as they have ever been. But the competition for those funds is greater as well – and many of them now require multidisciplinary approaches.

Nurses must be thick-skinned about the bidding process, which often ends in rejection, says King’s College London nursing professor Ruth Harris. ‘There may be a temptation to just curl up and leave it. But success comes from rewriting and changing a failed bid in response to the comments.

‘You have to understand that one can only fund so many applications that come in. You have to keep on trying. As we get a critical mass of nurses there will be more support.’

‘I was torn. A lot of my research was small scale action research, working locally. Suddenly that wasn’t valued any more, so what was I to do? I could carry on meeting the university agenda that guaranteed promotion, or I could stick with the nursing agenda, working with practitioners that would largely go unrecognised.’

Professor Rolfe was able to find a middle way that satisfied both his own needs and those of his employers. But he feels the dilemma remains. He thinks universities are encouraging too much research of the wrong kind that doesn’t impact on practice. Too often the emphasis is on ‘brick making’ rather than ‘building’, he says.

‘We are getting buried by an avalanche of bricks or research papers. Researchers are producing tons of random, unconnected data, most of which is never read. We need to value other ways of doing research.

‘It seems that nursing is being presented as a technical discipline, where you produce generalisable, rigorous evidence and apply it to practice. But that’s only one way of looking at nursing.’

Therapeutic encounter

In his view, nursing is a therapeutic encounter between individuals. ‘We need to help nurses understand the people they work with.’

He believes the failings at Mid Staffs resulted more from a lack of imagination than under-staffing. ‘Nurses walked by patients because they didn’t see them as human beings, they didn’t imagine themselves in that position. So patients became an obstacle to getting the job done.

‘My argument is that to care for someone we need first to care about them – so we need more studies that help us understand our patients as people. Rather than generalisable data, we need research that engages at an individual level.’

Professor Rolfe would like to see more small scale studies and collaborative inquiries. ‘We need more individual research which would be generalisable not in its findings, but in the methods.’ Nursing research can also be guilty of silo thinking, failing to make connections with similar work being undertaken in related fields, says Michael Traynor, professor of nursing policy at the Centre for Critical Research in Nursing and Midwifery, London, and chair of the conference scientific committee.

Researchers are producing tons of random, unconnected data, most of which is never read

He feels many researchers aren’t aware of the body of knowledge they are contributing to. Nurses often present findings at conferences as though they are completely fresh when in fact they are variations on well-established themes.

This is partly the result of the way much research is now funded, he believes. ‘Apart from the big grants, a lot of the funding we get comes from funders who want answers to particular workforce issues. So the researcher produces the report and that’s the end of it.

‘But another explanation is a lack of vision. A lot of people only ever do research from the perspective of nursing, so maybe they have never really inhabited or got to feel at home in another discipline like sociology or psychology.’

Despite the challenges and setbacks, researchers remain optimistic about the future. ‘The good news is that the best nurse researchers have got better and are integrating into big research projects that attract big grants,’ says Professor Traynor. ‘They are high quality and more multidisciplinary.

‘And it may be that we still have a relatively small number of nurses who are involved in doing research, but my impression is that most nurses are now research-minded. That is an important step change.’

Research into practice

The Joanna Briggs Institute in Adelaide, South Australia is an independent research and development centre dedicated to providing the best available evidence to inform clinical decision making at the point of care.

Established 20 years ago with the specific aim of implementing nursing research (it was named after the first matron of Royal Adelaide Hospital), it now covers a wide range of health-related issues. Around the world, it works with 78 collaborative centres in 31 different countries.

A big factor in the institute’s success is its ability to synthesise the best internationally available evidence and provide this information in formats that are appropriate and relevant to the health system that is taking it on. Its database includes 399 systematic reviews, 834 recommended practices and more than 2,700 evidence summaries.

The growth of action research and the increase in clinical nurse researchers also reflects a greater determination to ensure findings are implemented (see above).

One of the keys will be linking up not only with clinical and academic colleagues but also with service users and their families. ‘That’s when we start building patterns and getting evidence into practice,’ Professor Harris says.

‘We have to find the opportunities and make the most of them. But we also have to value what we do. When we value what we do, then other people will value it as well.

‘We have a vast range of skills in research and we are using those skills in evaluating complexity and understanding patient experience. But we have to be confident and enthusiastic – we must keep persevering’.

See also reflections, page 26

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