The structure and quality of nurse education in the UK has been scrutinised for many decades, culminating in a significant shift from ward-based learning at certificate level to that at diploma or degree level being delivered in higher education institutions. This professionalisation of nursing in the last decade of the 20th century was influenced by major changes in Department of Health policy, which demanded that a sound evidence base must be applied to nursing practice thereby replicating the model of evidence-based medicine. The requirement for care delivery to be evidence based is built on the premise that a continual research programme to investigate, disseminate and implement findings will enhance decision making in the clinical environment, thereby improving standards of care and patient outcomes. However, for this to be achieved there is an organisational responsibility to drive a positive research culture in order to effectively generate new knowledge and expertise. This paper explores the nursing research culture in the NHS and the strategies employed by the Defence Medical Services for supporting its nurses to generate the high-quality evidence that informs best practice.
- EDUCATION & TRAINING (see Medical Education & Training)
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Historically, student nurse training was delivered in a School of Nursing that was located within a hospital or group of hospitals. The programme typically followed an apprenticeship model comprising ward-based learning of practical skills that had been informed predominantly by tradition.1 ,2 In 1970, the Briggs Committee was established, which served to redefine the structure and quality of nurse education and review the role of the nurse within the NHS. The 1972 report challenged nurses to base the decisions they were making in the clinical setting on the best evidence available at that time.3 Over two decades later, Closs and Cheater4 reported that nursing research was still not highly regarded in the UK and suggested its undertaking had to be valued and rewarded by the NHS before such activity would be fully embraced. They concluded that for research findings to be translated into observable practice the organisation must promote an unequivocally positive research culture with interest and support being clearly evident throughout its entire hierarchical structure. After a further decade, Gill5 reported that evidence of a positive nursing research culture remained woefully lacking when compared with other disciplines. Indeed, much of the literature has continued to report perceived ‘barriers’ to generating the evidence to support best practice.2 ,5–7 Paragraphs 35 and 36 of UK nurses’ code of professional conduct8 stated that the standard of their practice, and advice regarding healthcare products and services, must be evidence based. Despite this, nurses remain relative novices in research when compared with other academic disciplines and influencing change continues to be perceived as a challenge.9
Nursing research culture
Many authors have written about nursing research culture without actually defining the term and therefore there is an assumed understanding of its meaning. For the purpose of this paper a research culture is regarded as a community within a patient care setting that shares the attitudes, beliefs and behaviours to generate new knowledge. In 2006, it was the Government's vision for the NHS to be established as an ‘internationally recognised centre of research excellence’,10 which, within 5 years, would ‘have a thriving research culture’.10 Indeed, it is widely acknowledged that a positive research culture is instrumental in promoting meaningful project outcomes.11 However, concerns remained, which were articulated in the international literature,12 that nurses were not armed with the necessary skill sets to critically evaluate the available evidence to then decide what constituted best practice within their chosen domain. As a result the Advanced Practitioner role was developed; a registered nurse who had gained additional skills to expand their expert knowledge. This Masters level education, together with the implementation of Advanced Practitioners’ decision making and clinical competency in a given specialist field, were aimed at encouraging greater participation in research activity. Concurrently, the Knowledge and Skills Framework (KSF)13 was published incentivising nurses to acquire additional qualifications and exercise new skills that would impact upon the quality of patient care while remunerating them for the added endeavour. These strategies, along with the concepts of modern matrons and nurse consultants, were implemented to advance nursing practice in response to various Department of Health directives.14–16 These strategies alone should have ensured a thriving nursing research culture across the NHS. However, the KSF alluded to nurses maintaining a current understanding of best practice but it lacked a coherent plan as to how this might be achieved. This suggests that the value placed on measuring the improvements in research activity is markedly less than the responsibility to drive it. While there are undoubtedly pockets of excellence in the NHS, nurses blame constraints within their workplace as the contributing factors to their low levels of participation in research. These comprise a lack of skills and confidence to undertake research,1 ,9 ,17 poor collegial support from their managers and doctors18 and a lack of time and allocated resources.19
Following the highly publicised failures in the delivery of care at Mid Staffordshire hospital, the Berwick Report,20 in its title, made ‘a promise to learn and a commitment to act’. Continuous improvement requires a robust support mechanism underpinned by a strategy that has clearly articulated priorities and adequate resources allocated to achieve them. While the sorrow associated with the events at Mid Staffordshire hospital can never be diluted, the report has raised quality improvement ever higher on the healthcare agenda. Creating a positive research culture requires personnel to adapt their mindset and behaviour.21 It is an organisational responsibility to drive a positive research culture in order to effectively generate new knowledge and expertise.22 At all levels of the organisation personnel must feel equally empowered to plan and implement research projects without fear of repercussion.
Nursing research in the DMS
The Defence Medical Services (DMS) identified the importance of nursing research many years ago and sponsored personnel across the three Services to undertake research degrees. This was then galvanised by the establishment of the Academic Department of Military Nursing (ADMN) within the Medical Directorate in 2013, an action made all the more significant as it coincided with major Defence spending cuts. These cuts had demanded a reduction of approximately 17 000 military personnel by 201523 as witnessed in several redundancy tranches in the intervening period. Restructuring is certainly not new to the military and since the closure of military hospitals, announced in the Defence Cost Study 15 (DCS15) report in 1995,24 the majority of military nurses now working in the secondary healthcare setting do so in NHS hospitals at a number of UK locations including Birmingham, Northallerton, Oxford, Portsmouth, Camberley, Epsom and Plymouth. Indeed, many DMS personnel were, and continue to be, recruited from the NHS so Defence nurses working in both sectors have a shared perspective of the research culture within the profession. Other military nurses in smaller numbers are placed at additional locations around the UK if there is a specific training need in preparing them for their operational role. Therefore, the geographically dispersed pockets of research and audit activity undertaken by nurses had not been centrally co-ordinated. As a result, the findings, and subsequent recommendations for change, were rarely recognised beyond a local level, which reduced its impact. The inception of the ADMN provided the platform to capture the wider quality improvement initiatives and ensure they would inform change at the strategic level. Furthermore, the fostering of collegiate ways of working with the NHS host Trusts aims to maximise the benefit to patients being cared for by both sectors.
The ADMN is in its infancy so at the outset it was important to collate the available evidence to inform a coherent strategy that would provide the direction for nursing research to develop in alignment with the future needs of Defence. Barriers to evidence-based practice in nursing are well documented and the scientific literature provided a useful background understanding of the issues likely to need addressing before DMS personnel's appetite for research could be further developed. This was combined with the findings of an earlier internal capability review of the Academic Department of Military Mental Health, which included a survey that was distributed to the Military Mental Health cadre in the UK (D Lamb. A capability review of the Academic Department of Military Mental Health. Unpublished). Respondents comprised both military and civilian nurses, psychiatrists, psychologists and social workers. It concluded that few respondents reported being actively engaged in primary research activity despite significant ongoing audit activity in the clinical environment. They perceived that the predominant barriers to engaging in research were the lack of protected time away from patient care delivery or the prerequisite knowledge, skills and subsequent confidence to undertake such endeavour independently. However, 80% of respondents acknowledged its importance and wished to be more directly involved. Therefore, the appetite to be involved in clinical research among the cadre was positive but there needed to be the appropriate organisational support and allocated resources to motivate meaningful outputs that would directly influence the quality of patient care.
This military context combined with the available scientific literature helped inform the department's strategy to nurture a positive research culture, which comprises several vital components, namely, communication, co-ordination, educational support and collaboration (Figure 1).
Raising awareness of the newly established ADMN across the DMS was the first important step in enabling personnel to understand how they could access available resources in support of projects within their own place of work. This has been achieved by visits to the various military units across the UK, presentations at single and tri-Service annual symposia and by establishing Defence Specialist Advisors (DSAs) as key informants. The DSAs are highly qualified and experienced nurses who are selected for the position at tri-Service appointment boards and are used as the central focus points within each of their cadres to encourage engagement with research activity. The success of this initiative has been measured within the department by the escalating number of requests for advice, project guidance, primary research activity and supervisory sessions for ongoing academic pathways.
During symposia, regular updates are provided of ongoing research projects, the findings and how these have influenced change. Defence nurses then have a raised awareness of change and, of equal importance, an acknowledgement of completed work within certain specialist fields. The latter can prevent duplication of effort and potentially saves endless hours of nugatory work. Furthermore, communication is pivotal in enabling academic links to be forged with fresh vision and the motivation that might progress a project in an entirely new direction, an event that might not otherwise occur.
The ADMN team members were each allocated at least one hospital or military unit, to which large numbers of nurses and allied health professionals were assigned, to act as the point of contact for research activity. This has generated regular (predominantly monthly) Research Advisory Group Meetings as a forum at which ideas for audit and research could be peer reviewed to inspire and support personnel to undertake service evaluation, audit and research. This has been particularly successful, and is demonstrated by the increasing numbers of attendees, audit and research projects being undertaken and the increasing number of papers being published in peer-reviewed journals. It has provided many nurses with the confidence to challenge observed practice and to be more reflective about their own. All audit and research activity is done with the collaborative support of the host Trust and the military command structure.
Military primary healthcare provision, in the UK and overseas, is geographically widely dispersed as are the mental healthcare facilities. A multidisciplinary Regional Research Network is currently being created to capture these disciplines to provide them with the structure by which key stakeholders would similarly meet to focus the prioritisation and development of their projects. These forums will be supported (either physically or virtually) by military nursing academics as a means of ‘peer review’ to ensure that ongoing project development is relevant to the Medical Director's strategic direction, a process that also eradicates the duplication of effort. Peer review has been shown to benefit collaboration in both time and quality of outputs25 and will be the focus for educational sessions. The aim is to better prepare personnel to undertake their own projects by developing their knowledge and confidence as it is a model proved to be successful in the secondary healthcare sector as previously described.
Hesselbein26 stated that ‘culture does not change because we desire it. Culture changes when the organisation is transformed’. To enable a positive nursing research culture there must be a noticeable transformation at both the organisational (macro) and the individual (micro) level.27 Support in both of these areas must be available to more easily facilitate change and accelerate its implementation.
In acknowledging that nurses perceive available time as a significant barrier to their engagement with research activity, there is a responsibility for resources to be built into their practice to validate it as a ‘legitimate nursing activity’.28 This has been recognised by the DMS by the introduction of additional tri-Service research posts and international travelling scholarships that introduce personnel to a wealth of opportunity that will further their academic and career development. An initiative to replicate the practice of Medical Officers and include research into a nurse's job plan is also being considered, which will endorse the legitimacy of research activity and enhance the cultural change at the macrolevel, which is a necessity for microlevel adaption of mindset and subsequent behaviour.21 Nurses must accept that research is an essential component of providing quality care, otherwise time set aside for research activity after handover and between shifts will quickly be consumed by the increasing demands of patient care. It must not be permitted to be an ‘either or’ decision as the two are inextricably linked. Effort should be shared at both levels to dispel this time barrier.27
Personnel's perceived lack of research skills has also been recognised by the organisation of Military Nursing Research study days that take place on a quarterly basis. These are targeted at Defence nurses on current academic pathways (sponsored either by the Ministry of Defence (MoD) or personally by the individual) or those who have an interest in undertaking audit and research within their own place of work. Furthermore, the ADMN team members also support students on the Defence studies programme at Birmingham City University by delivering lectures introducing them to research methods and provide an open-door policy for those wishing to discuss their particular projects individually. The primary aim of educational support is to defuse the myth that research is too complicated. This then generates inclusivity by dispelling the perceived barriers and enables nurses to understand the language and the process required to achieve organisational support and funding for a particular project. They are given the confidence to understand that the skills nurses inherently use every day when assessing the clinical status of their patients mirror those required to undertake a simple audit. Indeed, nurses constantly assess and evaluate the outcomes of their practice (standards) based on the care they delivered the day before and how that has impacted upon the patient's condition over time. They respond to visual cues and adapt their care accordingly, which is an iterative reflective process that replicates the audit cycle used to constantly improve care quality and the patient's experience. It is envisaged that this simple analogy will make the undertaking of an audit seem less intimidating if personnel can personalise the concept and ultimately take ownership of it.
A positive research culture requires personnel to have the necessary skill sets and committed collegial relationships19 and, in these austere times, innovative ways of working. The latter has been instrumental in ensuring a recent project to investigate the efficacy of patient diaries is achieved. Building capacity within one individual's job plan to independently undertake the project would not have been possible so a collaborative approach has been adopted. A team of personnel from different Units have been recruited to share the workload with support from their respective Chains of Command and guidance from the ADMN. The project aims to develop junior personnel in the undertaking of research from the formulation of a question, through the methodological considerations and the ethical approval process to data collection, analysis and report writing. They will gain further professional development when writing publications for peer-reviewed journals and presenting the project at various conferences. Personnel are also reminded that there are often funding opportunities available within charity organisations so fostering collaborations with those that align with a particular area of interest is an innovative way of achieving wider support for potential research projects.
The Medical Director's vision is for the Medical Directorate to be an internationally renowned organisation that leads military medical innovation in research, education and clinical practice and develops concepts that encompass health promotion, prevention of injury and illness and care from insult to rehabilitation in all healthcare environments. The collaborative research with national and international academic institutions that is being undertaken by the department ensures that ADMN is meeting the Medical Director's vision.
There has been significant investment at the macrolevel of the DMS to enhance the military nursing research culture, demonstrated by the establishment of the ADMN and the creation of new posts during austere times and the availability of international travelling scholarships. The nursing component is an integral part of the Medical Director's vision for the future of military medical innovation in research so it remains for the microlevel to perpetuate the transformation in research culture. Mitigations to the perceived barriers to undertaking and using nursing research have been incorporated into the ADMN strategic planning that will continue to nurture a positive culture within the organisation.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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