Nurse researchers: creating a force for change

Why do we do it x way? What would happen if we did y way instead? How about if we did both x and y ways? With the pool of nurses who have pursued or are pursuing postgraduate study ever growing, more and more nurses are carrying out research in diverse topics using a broad spectrum of research methodologies for their master’s and PhD degrees. Some of these nurses won’t want to stop there and will go on to pursue research as a career, which prompts further questions like: Why do research? How do you get to do research? And what types of research are a ‘force for change’?

Why do it?

Ask researcher Jane Koziol-McLain why she pursued a research career and she says she’s always had a questioning mind, from her early says nursing at an emergency department in Chicago.

She was curious when each time a new registrar was rotated to her ED they brought with them their own variation on ED practice.

“I wondered, why is it there are these different ways of doing things? Don’t we know which way is better?” says Koziol-McLain, whose questioning mind eventually led her to Auckland and her current position as professor of nursing at AUT.

Likewise, Dr Kathy Nelson, acting head of Victoria University’s Graduate School of Nursing, says she had a questioning mind and recalls wanting to know why mental health clients appeared to have insight into their illness the second time they were admitted but not at their first. That was back in the late 1970s when nurse researchers were few and far between and she was unable to find a supervisor for her curiosity-driven research. But curious she remained and she sought jobs that brought her research experience until she made it up the research ladder to become a researcher herself.

Dr Andrew Jull of The University of Auckland remembers emerging from his first foray into university studies without a degree, but with a strong desire to do research and to be of service. He eventually combined the two with nursing; first as an early ‘adopter’ of the Cochrane approach of using evidence to ensure best practice and then by becoming a researcher himself to help fill the gaps in evidence about what is best practice and what makes a difference to patients.

Honouring the special insight that nursing provides into illness and health is another driver for nurse researchers, believes Massey University’s professor of nursing Jenny Carryer.

“If think about a lot of the PhDs that have been done – there’s a desire to actually [honour and reflect] an alternative or more people-centred way of how people experience health and illness. And how they experience health service delivery.”

Koziol-McLain would agree, saying nurses have so much to offer research based on the knowledge they gain from working alongside clients. “It really is quite a privilege to be with people and support them in gaining health during those difficult times… Along with that privilege really does come a responsibility to do the best that we can.”

In the case of Koziol-McLain – whose major research focus for more than two decades has been family violence – this sense of responsibility saw her volunteering at women’s refuges so she could gain a wider perspective on domestic violence than the limited view she got as an ED nurse.

How do you do it? Getting the skills and finding the time

The question to follow ‘why’ nurses pursue research is ‘how do they do it?’ Perseverance and tenacity seem to be important qualities, as even now – when there are dedicated postgraduate paths for nurses and funding for course costs is more widely available – it is no easy task to pursue a research career.

“When I think back to my own time doing a PhD – actually working full-time with small children – it was a mad time of life. You’d never do it twice,” says Carryer.

Many nurses still come to postgraduate study later in life so nursing PhD students can often be juggling children, mortgages and demanding senior nursing roles. And the very few full-time PhD scholarships available to clinical nurses are highly contestable and may not be viable if the nurse is the family’s principal breadwinner. So part-time study is often the only option – stretching a PhD from the usual three years into six.

“But it is interesting how many nurses actually soldier through that process,” says Carryer.

Gaining the research skills that studying for a master’s and a PhD will provide is an essential step for nurses who want to pursue a full-time research career and ultimately lead their own research teams.

Established researchers say that potentially all nurses can play a role in research projects making a difference to clients, be it simply helping recruit participants or right through to being lead investigators for million-dollar-plus research projects. Nurses also work in research teams as clinical research nurses carrying out a variety of clinical and research roles and others work as research managers coordinating and managing research trials.

“Nurses have incredible skills and knowledge and the respect of clients and an understanding of clients and communities,” says Koziol-McLain. “So nurses, I think, are very well positioned to make an important contribution to research.”

Nurses interested in becoming more actively involved in research can just start small by volunteering for improvement projects or putting their hands up to assist in local research (see ‘Tips’).

Finding a mentor at work or in the local nursing school can also help nurses get a foot in the door by joining a research project and building skills, experience and gradually building that all-important research track record.
Koziol-McLain says being a principal investigator for a small nurse-led research project as an ED nurse, prior to even starting her master’s degree, was an important stepping stone to her next job and more research opportunities. “When I was interviewed for the job they were impressed that we had started the study, conducted it safely, finished it and reported on it.”

Gaining a PhD is also not always essential – as associate professor of nursing Andrew Jull points out – to winning major research grants if you build the right research team around you and gain a reputation in your research niche.

After completing his master’s degree – a systematic review of evidence on an aspect of venous leg ulcer (VLU) care – he identified a gap in nursing research as “very few folk” doing quantitative research had a nursing background and he was keen to fund and run his own quantitative research.

Jull says there was a perception that it was necessary to have a PhD first, but he wasn’t convinced as he knew that very few of his medical colleagues had PhDs and they still won funding. “So I thought, ‘Why can’t I do that?’
“And it seemed to me that the key to getting funding was having the right kind of team – so if you had skills gaps then you had the team around you to support those skills gaps.”

This philosophy helped him eventually win a Health Research Council grant for a multi-centre research trial that also helped build a network of nurse research collaborators around the country with whom he continues to work nearly 15 years later. “It is the people working at the study centres who really make me look good. They do all the hard work when it comes to turning trials into reality.” This research also ultimately led to his PhD.

How do you fund it? Getting the funding to answer your research question

Getting the funding to release your time and meet the costs of a research project is rarely simple.

For nurses who join academia, the Performance-Based Research Fund (PBRF), which divvies up a substantial pool of government funding to universities and participating polytechnics based on the research performance of individual academic staff, has led to increased pressures and rewards for doing research, says Carryer. (Nursing, which is still regarded as an emerging research field, compared with established academic disciplines like medicine, has not fared well in the initial PBRF rounds, coming in at 41 out of 42 disciplines in 2012, but it was noted that nursing scholars had improved their average score “markedly” since the first bruising results in 2003.)

Carryer says while it is hard enough for nursing academics with high teaching loads to find the time and money to do research, it is “very, very difficult” for nurses to do so in clinical practice.

“So the bulk of the research being done by nurses in practice is being done by people engaged in a master’s or doctoral programme.” That hasn’t prevented nurses from completing prizewinning PhD research ‘on the job’, including Waikato neonatal nurse practitioner Dr Debbie Harris’s “Sugar Babies Study” and Auckland intensive care nurse and senior research fellow Dr Rachael Parke, who last year was the first nurse to receive The University of Auckland’s Vice Chancellor’s Award for best doctoral thesis of 2015 for her work investigating the effect of nasal high flow oxygen in patients following cardiac surgery. And some district health boards have created nurse-focused research positions – like that of Dr Sandy Richardson, who is based at Christchurch Hospital as the country’s only emergency nurse researcher, as well as being a senior lecturer for the University of Otago’s Centre for Postgraduate Nursing.

Dr Beverley Burrell, a senior lecturer and researcher at Otago’s Centre for Postgraduate Nursing, believes that the more young or early career nurses who obtain PhDs, the more likely nursing as a profession and discipline will succeed in building long-term research collaborations and teams and in winning those elusive major research grants.

Nurses are not alone in their frustration around winning funding grants to support research. With limited funding pools available for health research – for example, of the 321 research funding applications to the Health Research Council last year just 33 were successful – rejection is more common than not.

It is also a case of nothing ventured, nothing gained, and Kathy Nelson for one believes nurses don’t apply often enough for funding to explore nursing research questions. She says most people applying to the HRC have to apply a couple of times and sometimes three to win funding for a project.

Jull well knows this and says funding his current aspirin trial (see related article) was a matter of perseverance. The team first applied for an HRC grant back in 2010 and got to the second round before being declined; the second application didn’t even make it to the second round. The third time they just applied for pilot funding and were still declined and then finally on the fourth attempt – after a related small trial had been published – they gained enough traction to be awarded a grant.

Burrell says it never hurts to apply for research grants. “Don’t be put off as you learn a lot from applying, even if it’s a rejection, as you learn how to shape-up applications and become more successful. And you do have to keep applying for money in different sources.”

Knowing the research priorities of funders is also important and Burrell says new researchers applying for major research grants need to be mindful of what funders are seeking.

What research should you choose?

So what type of research can create a ‘force for change’? What sort of research are funders looking for? And how much should nurse research be influenced by such funding drivers?

Answering these questions could probably generate several research projects alone as research philosophy is a field in its own right.

But the pragmatic answer to the middle question is that on the whole funders, like the HRC, generally favour research that can be translated into evidence-based practice. “Funders definitely favour studies that can show effectiveness and research that just doesn’t sit on a shelf but is rolled out and utilised,” says Burrell.

So funders largely, but not exclusively, favour quantitative over qualitative research. As in the international hierarchy of evidence-based practice, it is the randomised controlled trial (RCT) that sits at the top. Which, as Jull noted earlier, is an area that nursing research was traditionally not strong in; but with the nursing sector fostering of collaborative research teams – sometimes interdisciplinary and increasingly international – this is changing and nurse-led RCT trials are becoming more common (see examples next page).

On the other hand, the research form that nursing has been strong in for longer, qualitative research has gained more legitimacy over time. “When I did my PhD in 1997 qualitative work was considered relatively radical,” recalls Carryer. “That is no longer the case at all. And major funding bodies now consider qualitative research quite realistically.”

She acknowledges, though, it is still a challenge to get research funding for the “highly experiential, lived-experience type” of qualitative research, which she says many nurses still tend to gravitate towards. “Because at the end of the day that’s what fascinates nurses – it’s what informs what we do.”

Which brings us back to the opening question – what type of research can create a ‘force for change’?

Burrell thinks a primary driver of nurse research should be what is good for patients. “I think we’ve had an introspective view in the past of looking at the profession a lot. I don’t think you can neglect that, but really our business is about better patient outcomes and improving healthcare delivery for the population – that is our main purpose, isn’t it?”

Koziol-McLain says another driver is nursing’s sense of justice and concern about health inequalities that makes nursing research often focus on improving systems to promote wellbeing and health. Carryer agrees there’s a critical need to do research that may influence policy, though she adds that policy is too often “insufficiently and infrequently” informed by research.

Her own experience of policymakers’ readiness to be informed by a major quantitative research project she led (published in 2011 with the late Professor Donna Diers of Yale University) was mixed. The research team looked at the impact of registered nurse staff levels on nurse-sensitive patient outcomes following the 1990s health reforms and, after analysing 12 million discharges from New Zealand hospitals, showed that there is a clear relationship between declining RN staff levels and rising nurse-sensitive negative indicators. “I didn’t have a sense really that that work was taken particularly seriously,” says Carryer. “Even though it was based on huge numbers and had quite significant findings.”

What the nurse researchers all agree on is that there is no ‘one-size-fits-all’ research approach that can answer the many research questions that could make a difference to the health outcomes and experiences of the populations that nurses serve.

Koziol-McLain believes the research method should be driven by the practice issue or health challenge the researcher wants to tackle and then by establishing the best way to address those issues in a way that will be heard by the target audience and help create change.

“It is also important to have the ears of the policy-makers and sometimes that’s the nurses you work with, sometimes the interdisciplinary team and sometimes the Government.”

She says that means sometimes the best method is a randomised controlled trial and other times it may be qualitative research that tells stories – as stories can be very powerful in engaging people. Burrell agrees that RCTs have their place but there are other important research questions that need qualitative work; for example, interviews that ‘drill down’ and elicit people’s pattern of thinking that influences and motivates their health behaviour.

Others add that sometimes a mix of quantitative and qualitative research is the answer and that there should always be room for pure, serendipitous research and for research that gives voice to philosophical and ethical debates. “We can’t neglect any of them,” says Burrell.

Because questioning minds are a force for change in whichever direction their curiosity may take them.