Nursing, midwifery, and allied health professions research capacities and cultures: a survey of staff within a university and acute healthcare organisation

This research sought to understand issues associated with research capacity and culture in Nursing, Midwifery and Allied Health Professions (NMAHP) across two organisations (a university and an acute healthcare organisation). A review of evidence has demonstrated that engagement in research by individual clinicians and healthcare organisations improves performance, including health outcomes and processes of care [1]. Data has continued to demonstrate that research-active organisations perform better on outcomes such as reduced patient mortality [2, 3]; increased colorectal cancer survival [4]; improved ratings of organisational performance [3]; and improved patient experience (incorporating observed teamwork, quality of information received and confidence in doctors) [5]. Staff who work in research-active organisations are also more likely to recommend their organisation as a good place to work or to be treated [5]. Evidence for the benefits of a positive research culture therefore continues to grow.

Development of research capacity and culture-has thus become an important strategic priority in the United Kingdom (UK) and elsewhere. There has been a particular focus on professions outside of Medicine, as these represent most of the health and social care workforce. Indeed, the potential positive impacts of doctoral-educated Nurses working in clinical settings has been supported by a recent scoping review [6]. Within the UK, published research strategies for Nurses [7], Midwives [8] and Allied Health Professionals (AHPs) [9] clearly identify ambitions to transform the culture around research and evidence-based practice. In England, this ambition is supported by the National Institute for Health and Care Research and Health Education England, who provide funding to support clinical academic careers at pre-doctoral, doctoral and post-doctoral levels. These schemes are open to NMAHPs and a wide range of other health and social care professions and require active partnerships between universities and health and social care organisations to support awardees [10]. A recent review of these schemes [11] identified that fewer applications were received from AHPs (14% of applications) and Nurses & Midwives (11.5%) than Medics (37%), although the overall rate of success was similar across professions. The only exception to this was for late postdoctoral, senior and chair applications from applicants without a previous National Institute for Health and Care Research award. In this subgroup, professional background was significant, with a 24.5% success rate for AHPs and other health professionals, 16% for Medics, and 9.1% for Dentists, Nurses & Midwives, and non-health professionals. Applications from institutions associated with a medical school were 2.61 times more likely to be successful [11]. So, specific strategies may be required to support NMAHPs to make applications, to support senior applications from Nurses & Midwives, and to support applications from a wider range of institutions.

An innovative example of a strategic partnership aiming to support NMAHP research is the ‘Centre for Care Excellence’, established in 2020 as a jointly funded initiative between Coventry University (subsequently referred to as ‘university’) and University Hospitals Coventry and Warwickshire NHS Trust (subsequently referred to as ‘healthcare organisation’), West Midlands, UK. The aims of the Centre are to integrate research, innovation, practice development and education to make a positive difference to patient experiences and outcomes and to support clinical and academic staff in health service research, delivery, and education. This partnership helps to address the key principles and obligations of those responsible for supporting clinical academics set by the National Institute for Health and Care Research [10]. It addresses areas highlighted by Henshall and colleagues regarding funding, time, infrastructure, leadership, and partnership [12]. The Centre for Care Excellence has appointed five senior NMAHP clinical academics to help achieve those aims. To inform the development of a strategy to meet the needs of staff in both organisations, an online survey was undertaken to identify existing NMAHP research expertise; determine potential barriers and motivators to research; and identify priorities for staff support and development. This research provides unique insight across a university and acute care healthcare organisation.

The Research Capacity and Culture (RCC) Tool [13] has been successfully used in previous healthcare staff evaluations to identify research skills and successes at organisational, team and individual levels; and personal barriers and motivators for research [14‐17]. The present study therefore used the RCC and additional survey questions to address the following aims: 1. To identify the current levels of NMAHP research success and research skills at the team and individual level; 2. To identify the barriers and motivators to NMAHP research; and 3. To identify preferences for support that could be provided by the Centre for Care Excellence.

The protocol was approved by the university Faculty of Health & Life Sciences Ethics Committee (Reference P124919) and ratified by the healthcare organisation’s Research & Development Department (Reference GF0441) in line with the harmonised edition of the ‘Governance Arrangements for Research Ethics Committees’ [18]. All methods were carried out in accordance with the Declaration of Helsinki. An anonymous online questionnaire was developed and administered via Joint Information Systems Committee Online Surveys. Embedded within the questionnaire was full study information, a privacy notice and explicit informed consent. Consent was required before progressing to the main questionnaire. Participants were free to exit the questionnaire at any point by exiting and closing their browser.

NMAHP clinicians, academics and students were recruited via email advertisement containing a brief overview of the project and a link to the online questionnaire. Details were also posted in the healthcare organisation’s staff newsletter. Inclusion criteria were: 1. Current undergraduate, postgraduate or doctorate student or staff member at the university or healthcare organisation; 2. Identifies as one of the NMAHP professional titles regulated by the Health & Care Professions Council or the Nursing & Midwifery Council in the UK; 3. Able to provide informed consent; 4. Able to complete the online questionnaire in English; 5. Aged 18 + years. There were no specific exclusion criteria.

The email was sent to all staff within the School of Nursing, Midwifery and Health at the university. NMAHP curriculum leads at the university were asked to forward details to undergraduate and postgraduate students. The Associate Directors for Nursing, Midwifery, and Allied Health Professionals at the healthcare organisation distributed the email to all staff within their practice areas. Finally, the Research and Development Department at the healthcare organisation distributed the email to everybody on their email contact list. A reminder email was sent out two weeks later. To maximise returns an amendment to ethical approval was secured to allow one further round of emails (and associated two-week reminder).

The questionnaire incorporated the following components of the RCC Tool [13]: ‘team’ success or skill level, ‘individual’ success or skill level, ‘barriers’ and ‘motivators’. The RCC tool was selected as it is well-validated and has been used in other NMAHP studies in the UK and Australia, allowing the results to be directly compared. A modified version of the RCC [19] was used in the present study, which employed a 1–9 scale (plus an ‘unsure’ option) for the success or skill levels (1 = no success/skill and 9 = highest possible success/skill). It was decided to exclude the ‘organisational’ success or skill level of the RCC as the Centre for Care Excellence crosses two organisations (university and healthcare organisation) and the items are identical to the ‘team’ component. The following clarification was added before the ‘team’ questions: “For these questions, please interpret ‘team’ as the group of professionals that you work most closely with in your current role”. The ‘individual’ questions were prefaced with the following clarification: “For these questions, please think about your own personal success or skill levels”. The wording of individual RCC components was as reported by Raschke [19].

Also included were questions about professional background, demographics, professional role, qualifications and the types of support that participants would like to receive from the Centre for Care Excellence (the perceived helpfulness of different types of support, rated from 0 = ‘not at all helpful’ to 4 = ‘extremely helpful’; and the perceived interest in learning more about specific topics, rated from 0 = ‘not at all interested’ to 4 = ‘extremely interested’). These latter questions were developed and refined by the research team based on their professional and research experience. The online questionnaire was piloted by research team members and amended before distribution to participants. The survey opened on 15^th July 2021 and the final submission was on 29^th October 2021.

A total of n = 416 responses were received. Just over half of all respondents (53.6%) were N&M (223/416), AHPs accounted for 32.0% (133/416) and the remainder described a wide range of other roles (60/416, 14.4%) (see Table 1).

Table 2 below illustrates that most respondents stated that they were healthcare organisation employees (300/416, 72.1%), had > 10 years’ experience working in health (277/416, 75.1%), were female (343/416, 82.5%) and were aged ≥ 40 years (267/416, 64.2%). Almost half reported that they had postgraduate qualifications (197/416, 47.4%), with 8.7% having a doctorate (36/416). 30.5% (127/416) identified their primary role as a ‘clinician’, with a very wide range of other roles identified. The response rate was 7.2% (184/2567) for N&M and 7.6% for AHPs (80/1051) employed by the healthcare organisation. The response rate was 25.4% (69/272) for staff employed by the university.

Tables 3, 4, 5, 6 report separate elements of the RCC tool. Table 3 relates to the success or skill level of participants’ teams. N&M respondents rated ‘does planning that is guided by evidence’ and ‘supports a multi-disciplinary approach to research’ as ‘high’, whilst AHPs failed to rate any items as ‘high’. Both groups rated ‘has applied for external funding as ‘low’. Overall, AHPs were more negative than N&M respondents about the skill or success level of their teams. There were statistically significant differences between the ratings of N&M and AHP respondents for 13 of the 19 items and in all cases AHPs rated the items lower. The ‘Other’ group reported higher median values on almost all individual items, with the exception of ‘has incentives & support for mentoring activities’ which was rated the same as N&M.

Table 4 reports data about the individual success/skill levels of respondents, demonstrating consistency across both N&M and AHP respondents, with no statistically significant differences in ratings between groups. The top-rated items related to ‘finding relevant literature’ and ‘critically reviewing the literature’, both being rated as ‘high’ by both groups. Perceived individual success/skill levels were ‘low’ for ‘securing research funding’, ‘submitting an ethics application’, ‘writing for publication in peer-reviewed journals’ and ‘providing advice to less experienced researchers’. The ‘Other’ group reported higher median scores on all items, except for ‘critically reviewing the literature’ where the median value was equal to the other groups.

The major personal barriers to research selected by participants were ‘lack of time for research’ and ‘other work roles take priority’, where a majority of all respondents selected these items (Table 5). There was general consistency between professional groups in the rank order of items, perhaps apart from ‘lack of a coordinated approach to research’ which was ranked 7^th by AHPs (selected by 41.4% of respondents) compared to 14^th by N&M (18.4% of respondents). AHPs also tended to identify more barriers than N&M, with 13 of the 18 items selected by a higher proportion of AHPs than N&M.

Table 6 illustrates the personal motivators to do research. Again, there was a lot of consistency between professions in the items identified, with ‘to develop skills’, ‘increased job satisfaction’ and ‘career advancement’ being the top three items selected overall. The only item that varied substantially in terms of rank was ‘links to universities/clinical services’ which was ranked joint 6^th by AHPs (chosen by 45.1% of respondents) but only ranked 11^th by N&M (27.8% of respondents).

Data presented in Additional file 2 illustrates that, overall, the top three types of support that people would find helpful were ‘mentorship for my team’, ‘mentorship for me’ and ‘in-service training with my team’. However, none of those items featured in the top 3 ranked items for AHPs, suggesting a difference in the support required by the different professional groups. AHPs ranked ‘support with statistical analysis’, ‘support with writing for publications’ and ‘support with grant applications’ as the top 3 ranked items. Finally, Additional file 3 illustrates that the overall top 3 topics of interest were ‘service evaluation’, ‘funding opportunities’ and ‘audit’, although the latter topic was only ranked 10^th by AHPs (N&M ranked this 1^st), again suggesting some differences between professional groups. The table highlights several other differences in ranked priorities between professional groups.

To our knowledge, this is the first NMAHP survey using the RCC tool to explore issues related to research capacity and culture across both university and healthcare settings. We also believe that it is the largest (n = 416) such survey conducted to date. This study has demonstrated the research successes and skills, barriers and motivators, and preferences for support in this staff group. A study by Matus and colleagues [16] (n = 320) used the RCC to explore the research capacity and culture of AHPs within one Australian healthcare organisation. We included a much wider range of health professionals across two separate organisations. A major benefit of using the RCC tool was that we could directly compare our findings with those from previous literature.

It was interesting that AHPs were generally less positive about their teams’ success or skill levels than their N&M colleagues, although the basis for this difference is unclear. It could indicate a genuine difference between groups, but ratings of perceived success or skills could also be moderated by expectations (i.e. if expectations are high but are not met, then success ratings may be lower and vice versa). The relative expectations of different professional groups are currently unknown but could form an interesting focus for future research. In a previous UK study of Nurses and AHPs (n = 224), Luckson and colleagues [15] found no significant differences between groups in their ratings of team success/skill, although ratings were higher in a research-focused hospital (mean 5.28) relative to a non-research-focused hospital (mean 3.61, p < 0.001). Although the AHP ratings in our study were similar to those of Luckson and colleagues [15] (median 4.44 versus mean 5.10 respectively), our N&M ratings were much higher (median 6.67 versus mean 4.51 respectively). This may mean that our N&M sample were particularly positive about their teams.

The most highly rated items at the team level in our study, especially by N&M respondents, were ‘does planning that is guided by evidence’ and ‘supports a multi-disciplinary approach to research’. These latter items were rated more positively by N&M colleagues, perhaps due to historical roles as generators of data for research being led by other health professional groups. Cordrey and colleagues [17] identified ‘does planning that is guided by evidence’ and ‘has leaders that support research’ as the top two items rated as team successes/skills by AHPs (n = 93) in one UK large healthcare organisation, with ‘supports a multi-disciplinary approach to research’ rated third. Matus and colleagues [16] found little distinction between AHPs’ ratings of different team items, although all three of those items were within the large group of 9 items rated most positively in their study.

In the present investigation, there were no significant differences between N&M and AHP groups when rating their individual success or skills. Luckson and colleagues [15] similarly found no statistically significant differences between AHP and Nursing cohorts in the mean individual success/skill scores (mean 4.54 and 4.24 respectively), although those figures were slightly lower than in our study (N&M and AHP both median 5.56). Luckson and colleagues [15] found that scores were significantly higher in a research-focused hospital (mean 4.6) relative to a non-research-focused hospital (mean 3.87, p = 0.003). Ratings for individual success/skill were highest in our study for ‘finding relevant literature’ and ‘critically reviewing the literature’. These two items mirrored the findings for AHP groups in Australia [16] and the UK [17]. Key individual weaknesses identified in the present study for N&M and AHP were ‘securing research funding’, ‘submitting an ethics application’, writing for publication in peer-reviewed journals’ and ‘providing advice to less experienced researchers’. Matus and colleagues [16] identified the same four items as the greatest individual weaknesses in their study. Cordrey and colleagues [17] also identified the same four items in their bottom five, along with ‘writing a research protocol’. This suggests consensus across the available literature in identified individual strengths and weaknesses.

The top two personal barriers to research identified in the present study were ‘lack of time for research’ and ‘other work roles take priority’, both being selected by a majority of respondents in the N&M, AHP and Other groups. These items mirrored the top two barriers identified for Australian and UK AHPs [14, 17]. Pager and colleagues [14] used the RCC tool to explore the motivators and barriers to AHP research capacity in an Australian primary healthcare organisation (n = 85). A majority of AHP respondents in our study also selected ‘lack of suitable backfill’ as a barrier but no other items were selected by a majority of the other two professional groups. Backfill may be a particular issue for AHPs as they are more likely to work Monday-Friday daytime working hours, as opposed to N&M colleagues who are more likely to work shift patterns. This lack of flexibility in AHP working patterns may make it more difficult to identify appropriate backfill. A range of other barriers were identified by a majority of participants in previous research. For example, Pager and colleagues [14] identified ‘desire for work/life balance’ (57%), ‘lack of funds for research’ (55%), ‘lack of skills for research’ (54%) and ‘lack of suitable backfill’ (52%); whilst Cordrey and colleagues [17] identified ‘lack of skills for research’ (63%) and ‘lack of suitable backfill’ (54%). This may suggest that our sample were slightly less pessimistic than those in prior studies.

Three items were identified by most respondents in the present survey as motivators to research: ‘to develop skills’ (78%), ‘increased job satisfaction’ (64%) and ‘career advancement’ (55%). These mirrored the top three items identified by Cordrey and colleagues [17] (87%, 72% and 67% respectively) and the top two of these also matched the findings by Pager and colleagues [14] (‘to develop skills’ 81% and ‘increased job satisfaction’ 68%). Three further items were selected by a majority of respondents in the study by Cordrey and colleagues [17]: ‘problem identified that needs changing’ (55%), ‘to keep the brain stimulated’ (53%) and ‘increased credibility’ (53%). Pager and colleagues [14] found that one further item was identified by a majority: ‘problem identified that needs changing’ (53%). Interestingly, some of the ‘motivators’ in the RCC tool might also be considered as ‘enablers’, that is they could act to help professionals to become research active as well as being a product of research activity. The items potentially meeting both descriptors include ‘Dedicated time for research’, ‘Links to universities/clinical services’, ‘Mentors available to supervise’, ‘Research written into role description’, ‘Research encouraged by managers’, ‘Grant funds’ and ‘Study or research scholarships available’. It is not necessarily easy to determine the precise cause-effect relationships between such factors. However, there seems to be a lot of consistency across the literature in the identified motivators.

Our study identified slight nuances between professional groups in the types of support that were rated as helpful. Although mentorship and in-service training were identified as important when all groups were combined, AHPs identified alternative priorities for support. This may mean that a tailored approach to support may be required for different professional groups.

The analysis of the open-ended questions provided some very useful information that contextualised and supported the quantitative data analysis. In particular, respondents provided some excellent suggestions about what would help staff to become more research active. These were clearly articulated within the cross-cutting themes, and included protecting time for research; integrating research into job roles; individualising skills acquisition; building research partnerships; and ensuring management support.

Overall, the current investigation provides information to guide development of a strategy to enhance NMAHP research capacity and culture. A systematic review of model frameworks for research building research capacity for AHPs [21] identified three themes: ‘supporting clinicians in research’, ‘working together’ and ‘valuing research for excellence’. Their overarching capacity-building framework illustrated an interdependence between items, and the need for an integrated approach to implementation that has clear management and leadership support. Avery and colleagues [22] surveyed NMAHP applicants to doctoral and post-doctoral fellowship schemes offered by the National Institute for Health and Care Research. They found that interactions with colleagues in research positions was a key driver to generating interest in research. Unsurprisingly, respondents were more likely to be research active if they had been awarded a fellowship, an observation that has also been made in medical clinical academic careers [23]. A lack of integration of clinical academic roles across clinical and academic departments and lack of clear career pathways were identified as potential problems. Trusson and colleagues [24] also identified that clear clinical academic career pathways were needed for NMAHPs. Indeed, even the definition of ‘clinical academic’ in non-medical careers may need to be more clearly defined [25]. In the Netherlands, changes in culture, leadership and infrastructure were identified as being required to support clinical academic career pathways in Nursing [26] and effective partnerships between healthcare organisations and universities seem key [27, 28]. All of these issues need to be addressed if NMAHP research capacity and cultureare to be successfully enhanced.

Rich information has been generated to develop strategy to enhance NMAHP research capacity and culture. Much of this strategy could be generic but some nuances may be required to address some specific differences between professional groups, particularly related to perceived team success/skills and priorities for support and development. The key learning points to assist with future strategy development have been summarised in Table 7.