Received date: 9 March 2006 Accepted date: 5 May 2006
Quality research is one antecedent to quality improvement in clinical care. The commitment of nurses within primary care to the success of externally funded research studies is often crucial, but the nature of their input may not be formally acknowledged.We received a request to provide a certificate for a nurse who had taken responsibility for delivering a research study intervention, regarding smoking cessation, to patients in her practice. To address this requestwe sought to develop a certificate that would reflect national policy and be acceptable to nurses,nursing leads/managers and researchers. We considered how the certificate might be used to encourage interest in research, to support the provision of quality clinical care, and to enhance the professional development of nurses. To achieve this we attempted to link the research activities undertaken to indicators identified within the NHS Knowledge and Skills Framework. The article describes how the certificate was developed and agreed. Its derivation is supportive to both clinical and research governance.Importantly, the article also raises the question of how the professional nursing community and their managers might want to develop the approach in order to inform the development of career paths inservice that include and support research activities as integral to the delivery of high quality care.
careers, nurses, professional development, research
Appropriate and successful recruitment of patients is fundamental to high-quality research in primary care. This involves general practice and community staff responding to the requirements of a research study with commitment and attention to detail, and is dependent on a degree of goodwill. Such quality research is one antecedent to quality improvement in practice.
Informal discussions about the progress of research projects within our academic unit often highlight how progress has been facilitated through the interest, commitment and skills of individual members of the practice team. These individuals, often nurses, make an invaluable contribution to research, but their input is rarely formally acknowledged. Their contribution ranges from identifying patients for a particular study, to explaining the nature of the research study, to delivering care in accordance with a study protocol, and to recording relevant information and data. There is, necessarily, a very strong relationship between the processes with which they engage on behalf of the research study, and best practice in terms of patient care, disease management and record keeping.
The importance of this issue was reinforced for us recently when one practice asked whether our academic unit might provide a certificate of acknowledgement for nurses who were helping to deliver the study intervention (to improve smoking cessation) in one of our research projects. This request seemed entirely reasonable and provided an opportunity to consider how involvement in research is integral to the contribution that nurses make to quality clinical care.
Developing a certificate to respond to this one request would not have been difficult. However, we were concerned to review the potential of this suggestion. We were aware that the interests of various groups would be involved if a certificate of acknowledgement for participation in a research study became common practice. Key groups identified were: the professional nursing community, service/research and development (R&D) managers in primary care, and the academic research community.
We sought to determine the value of a certificate to the interests of these groups by reviewing the ‘fit’ of such a developmentwith current national policies (for nursing and research), and by seeking comment from those directly involved.
Fit with national policy
Key policy documents relating to nursing emphasise the link between quality research and quality care. Research is seen to underpin excellence in clinical care.[3,4] In addition it is acknowledged that nurses play a crucial role in improving the quality of services offered through developments to practice grounded in research evidence.
Within national R&D policy there has been an ongoing concern to strengthen the capacity of those working in primary care to engage in research to improve patient care.[1,5] The importance of ensuring that clinical trials and other research studies can effectively recruit a patient base is seen as paramount.6 In addition, there is increasing concern that the link between research and improved care for patients should be explicit, as well as the potential impact on the quality of service delivery.
The policy documents relating to nursing also highlight the importance of recognising R&D activity within the professional development of nurses.[3,4] It is recommended that R&D activity should be seen as legitimate, and that engagement in R&D activity should be acknowledged and rewarded. Further, it is suggested that opportunities to develop skills in R&D should be encouraged, and that effort should be committed to developing viable career pathways that involve a research element.
Clearly it is helpful to link these recommendations with the documentation available in support of the Department of Health’s ‘Agenda for Change’ initiative. This initiative included the definition of a skills escalator for health professionals. The escalator provides a reference point for considering the competencies that underpin skill development in support of clinical care (although currently, ‘Agenda for Change’ does not necessarily apply to all healthcare professionals in primary care). This skills escalator identifies key competencies that can be applied at different levels. In the working draft, R&D was identified as a separate dimension within which the levels of engagement were clearly listed (from ‘assist with research and development’ at level 1 to ‘establish, implement and improve strategies for research and development’ at level 4). Within the final version of the NHS Knowledge and Skills Framework (KSF), R&D is no longer treated as a separate dimension.8 Instead R&D skills are shown as integral to core competencies in the provision of quality care. This is discussed in more detail below.
Fit with stakeholder perspectives
Informal approaches were made to various nursing leads, nurses, service R&D leads and researchers with whom the academic unit was in contact. Contact was also made with representatives from the Royal College of Nursing. The response to the suggestion of a certificate was positive. Perceived benefits mentioned are listed in Box 1. The only cautionary comment was made by those involved in research governance activities. They perceived that in time it would be appropriate to move towards an accreditation/quality assurance process rather than just an acknowledgement of involvement in research.
Researchers were positive provided that the certificates were easy to produce and complete. They welcomed an opportunity to formally acknowledge the help and commitment they had received from healthcare professionals within general practice and community teams.
Researchers were also keen that the certificate should be sufficiently flexible to be used with other members of healthcare teams beyond nurses (e.g. data managers, healthcare assistants, phlebotomists or receptionists) who were also key to the success of the study and to the quality of the services provided. Researchers noted that, in general practices, nursing and administrative staff are not always involved in the decision to undertake research. They believed that some personal positive outcome was particularly important for staff who were shouldering some of the workload of the research activity, but who had not specifically volunteered for this role.
Increasingly, researchers return to practice and community teams with whom they have already worked to offer the opportunity to participate in a new research project. The sense of goodwill established through the conduct and outcomes from the earlier project may well have a significant bearing on the willingness of the healthcare team to participate in the second project. A certificate might make a contribution to building and maintaining a positive relationship between researchers and the nurses and other members of practice and community teams with whom they work.
While researchers were positive about using a certificate it was acknowledged that there may be some logistical problems. For example, some studies involve a large number of general practices and the research team may not have a detailed understanding of the contribution of individual team members. However, it was felt that this knowledge could be provided by practice managers or other lead contacts who wished to obtain certificates for their team members.
The certificate was designed to reflect the requirements identified via the review of the underlying policies and the requirements of those who would be affected by its implementation (see Appendix 1 – the certificate).
It was considered important to include the perceived impact on patient care. This reflects the professional priorities of practice teams (i.e. the central importance of patients and their wellbeing) and the increasing recognition within national R&D policy that the links between research and the positive impact on services should be made more explicit.
A final section for completion by the nurses involved was included. This links the certificate to the processes of learning and reflection that nurses are required to complete as they develop their professional development portfolios. Experience from local studies suggests that nurses (and other health professionals) welcome the opportunity to review and improve the care they offer to patients as they engage on a research project.
The relationship to recent Department of Health initiatives defining a common framework for professional competencies is clearly important. However, as mentioned above, the final version of the NHS KSF does not include R&D as a separate dimension. The index to the NHS KSF indicates that R&D interests are incorporated within the two dimensions of: ‘Development and innovation’ and ‘Information collection and analysis’. The former is primarily concerned with the identification, appraisal, adoption and evaluation of new service developments. Progression through this dimension moves from the appraisal of concepts, methods and practices developed by others (level 1) to piloting and testing new developments (levels 2 and 3), and to initiating new developments (level 4). Nurses may well be contributing to these processes within a research study. Reinforcing awareness of the link between innovation and research is helpful since it should encourage approaches to service development that are evidenced based and appropriately evaluated.
The dimension relating to ‘Information collection and analysis’ specifically focuses on the skills of gathering, analysing and interpreting data. This has direct relevance to the tasks a nurse may be undertaking when helping to support a research study. Indicators defined for the various levels all link closely with good practice in the collection and management of data, whether for the purpose of routine service or for research.
However, these two dimensions do not cover the important and highly responsible role that nurses may play in recruiting patients to studies, and in delivering the study intervention according to a protocol. (Protocols involving clinical care will usually be developed with reference to current evidence and national guidelines and thus reflect best practice as it is currently understood). These activities relate to the important NHSKSF dimensions of ‘quality’ and of ‘interventions and treatments’ in support of health and wellbeing. Examples of the relevant indicators within these dimensions are shown in Table 1.
It was not appropriate to use the exact wording from the indicators in the NHS KSF within the certificate, because these were not sufficiently tailored to the research process and their use was unlikely to make sense in this context to either researchers or nurses. Instead we have used headings within the certificate to flag up the sections of the NHS KSF to which the listed activities are most likely to apply. This may help to legitimise research activity and to position research as a highly regulated activity closely supportive to the clinical governance agenda.
The certificate should enhance awareness of the opportunity to develop skills and experience in R&D while also highlighting how research activities link to the provision of high-quality care. It should also help to show that R&D skills are acknowledged and valued. The clarity of any career progression in R&D is not as clear in the final version of the NHS KSF as in the working draft. However, it is possible to see how a nurse might progress towards greater levels of competence in R&Dactivities. The nurse might, for example, begin by collecting data (level 1), and progress to delivering the intervention to the patient (level 2). Subsequently, the nurse might work with a research project team to identify the best way to incorporate clinical guidelines, that apply to a specific research area in practice (level 3). Particularly in this latter case the nurse would be working with the research team to apply and develop best practice.
This article has concentrated on the role of nurses and the development of a certificate in support of externally funded research studies. It is increasingly the case that nurses are taking responsibility for initiating and leading research studies and there is concern to support these committed researchers and the academic departments with whom they relate.[9,10] Appropriately acknowledged engagement in the projects of experienced researchers may help nurses to gain valuable research skills at an early stage in their career. Some of these nurses may progress to taking a leading role in research projects. Use of the certificate, and awareness of the principles on which it is based may help them to use the KSF constructively to track and promote their increasing seniority and responsibility. This is consistent with current initiatives and policy recommendations to develop career paths for nurses that include an acknowledged research component.[9,12]
Although our first task is to promote and evaluate the use of the fairly simple certificate suggested, a subsequent task may be to consider how pathways into higher levels of competence in research might be reflected in the certificate and, where appropriate, supported by local training linked to the provision of quality health care. This might provide a means to make pathways into research from a service role more visible and acceptable.
As researchers in close touch with service providers, we have been able to develop the certificate and explain its derivation and intended used. However, we would welcome further discussion from within the primary care community about how this approach might be usefully developed and applied both as a tool to support professional development of nurses and as a tool to support the link between research and the provision of quality care.
.................. XXXXX Project Research Team ..................
would like to acknowledge the help of:
.................. Name of individual .................. from .................. Name of practice/community team .................. in the research project
.................. Project title, Year ..................
The study aimed to: .................. impact on NHS/patient care ..................
Contribution to study
Your own reflection on your contribution