Thinking bigger about research
Research in nursing has developed rapidly over the last 40 years. It is now beginning to be seen as a legitimate and integral aspect of routine activity in clinical as well as academic settings. But there is still a long way to go before nursing research is properly recognized and supported, and its full potential is realized. Nurses and nursing can, at times, be rather introspective and a good deal of time seems to be spent on ‘navel-gazing’. The language of theory often dominates discussions about research in nursing and while much time and effort has been invested (but, I would argue, with limited success) in staking out its unique knowledge base and distinctive methods, much less has been spent on productive action. Of course, there should be critical thinking in the formulation of research questions, but there also should be more creativity and sophistication in the design and conduct of research studies, which are often dealing with highly complex issues. However, despite claims to the contrary, I would suggest that research in nursing is no more complex than in many other fields, and many of the issues faced, and the methods used, are similar.
Rather depressingly, much research activity in nursing is still typified by small-scale projects, conducted in a single ward by a lone individual who, however well intentioned and motivated, may have limited (or no) experience, time, funding or support. Many of these studies are so limited in their scope and application that they are bound to fail to answer the questions that they were designed to address. In fact, they make little or no impact on our knowledge base. This raises issues not only about the wisdom, ethics and practicalities of conducting research of this kind, but also about the use of public money and scarce valuable resources. Most research is funded, directly and indirectly, from public money and nurses have a duty to spend this wisely and to be clear about what is efficacious, effective, efficient and economic in the practice of nursing research.
What is required is a ‘paradigm shift’ in research in nursing so that we move away from small-scale, single-setting, individually-led research projects to large-scale, multicentre, team-led, thematic programmes of research, preferably on an international scale, but certainly at least national. This will help develop depth in the knowledge base, focus attention on real priorities for research, build a strong scientific community, and build up a strong research infrastructure. Programmes of research, unlike individual projects, have the capacity to serve as the locus for the development of a research-intensive environment that, in turn, provides a strong environment for research training and facilitation. Establishing programmes of research is not an unrealistic goal if there is sufficient will, commitment, and investment. It has been acknowledged in the UK now that there is a strong case for additional investment to develop a number of designated centres of expertise (Department of Health 2000) and it seems logical, if these are developed, that research programmes be located in (or associated with) these national centres, and linked relevantly and appropriately with their core themes.
There is no doubt that the development of programmatic research will require a concerted effort from a host of key players. Such an initiative is likely to succeed only if the planned programme is developed as a collaborative enterprise; is aligned to an important issue of concern to contemporary healthcare; has an adequate funding base and infrastructure; and has the necessary expert input from appropriate disciplines. Nurses do not operate in isolation and, in an era of multi- and inter-disciplinary/agency collaboration, it is only sensible to recognize the value of eclectic research teams. Although high quality primary research is being done by nurses in areas of national priority – such as cancer, heart disease and mental health – comparatively little of this work is being done across multiple centres, using a range of expertise, and developing systematically over many years into coherent national or international research programmes. This deficiency is due to limited funding opportunities (Rafferty et al. 2003), but this is not the sole reason. Lack of expertise, infrastructure support, career opportunities and confidence are important factors too.
Much research in nursing is concerned, quite rightly, with clinical issues and yet relatively few nurses are trained in clinical research. Apart from notable exceptions, predominantly in the United States, few nurses have been trained in laboratory research. This is not to say that all nurse researchers should be laboratory scientists, but it would be nice to have some! Currently, the balance is very much in favour of nurses who have undergone research training in the context of social sciences and humanities, and this is evident in the current knowledge base and the research focus of nursing.
Interestingly, in my own field – that of cardiovascular nursing – there are nurses conducting physiological, pharmacological and biochemical research. They are often trained to doctoral level in nursing and then serve an apprenticeship, including doctoral and postdoctoral training, in biology, for example, before returning to the nursing field. Nurse researchers of this genre work closely with researchers from other fields, including medicine, as well as with nurses in practice, education and management. In some cases, their research has attracted funding from national bodies for substantial amounts of money and periods of time. It is with this kind of support that researchers are able to develop a coherent and systematic programme of research over time. Staff of high calibre can be attracted and retained; pre-, peri-, and postdoctoral training can be provided, and career trajectories can be developed, including those with a joint clinical and academic remit. This also enhances the reputation and credibility of these researchers amongst their clinical and academic colleagues, not only within nursing but also with others outside our own field. Research that is undertaken in this kind of strong infrastructure can be highly influential and it has the potential to inform and shape health policy.
Again, using the example of the field of cardiovascular nursing, the growing influence and impact of strong nursing research can be seen to be making a significant contribution, particularly in North America and Australia. Interestingly, in the United States, Canada and Australia – but not yet in the United Kingdom – chairs in cardiovascular nursing have been established. These have been endowed by philanthropic individuals and charitable bodies, with some funded by central government. A recently established nursing chair at the University of South Australia is particularly innovative in that it is funded by the National Heart Foundation of Australia in a joint venture with a pharmaceutical company. This indicates vision and creativity, and reflects the important role that charities and industry play in funding, supporting and promoting research that is at the level of ongoing, programmatic activity. It is clear that medical research depends on the successful collaboration between the clinically-aware laboratory scientist and the laboratory-aware clinician. I would suggest that nursing research should emulate aspects of this. If nurses are to function and be valued as equal partners in the clinical research team it is only right that they acquire the necessary knowledge and skills.
I believe that much of the reluctance or inertia in taking this leap to programmatic research nursing is linked to a lack of vision, strategy, focus, energy, and confidence. As with any other activity, research requires leadership. The aim is to cultivate and nurture nurses in the research enterprise. Research leadership should support innovation; provide direction, purpose and motivation; and build confidence and expertise. It is essential that we develop and sustain an active and vital research culture where imaginative and critical thinking is the norm, and productive and useful output is the taken-for-granted expectation. Research is a human activity and invariably a team effort. The ideal is to be able to assemble a team of individuals who are sufficiently different to complement each other and contribute to different facets of the design and conduct of the research. The hallmark of a good research team is that it has an ethos of openness, creativity, flexibility, mutual respect, healthy skepticism, and a willingness to question the status quo or accepted conventions (Thompson 1998). There must be a shared vision, but diversity in terms of research concepts, theories, and methods must also be valued highly. Working as a member of a research team, however, can also be perceived as threatening, challenging cherished assumptions and beliefs; and there can be difficult issues to manage, such as clashes of personality, vested interests and some degree of rivalry. Researchers can indeed be ruthless people!
But we need more ruthless ambition in nursing research and nurses need to get much more politically astute in the research enterprise. We need to lobby policy-makers more actively, engage more with other key players, and seek to actively influence the health-related research agenda. Nurses need to work at building collaborative partnerships across government agencies, research councils, charities, and commerce and industry. Thus, a clear strategy is required for all of these activities, together with continuing effort on building of research capacity, supervision and mentorship, and the attraction and retention of research-productive staff. We all have to recognize that such strategies are long-term and require investment, commitment, and evaluation, and all of our strategies need to be flexible, responsive, and proactive in order to be relevant in a rapidly changing world.
Nurse researchers need to start thinking big, and thinking in new ways about research. Pragmatism and integrity are essential. Perhaps, most of all, nurse researchers need to become willing to take more risks.