International evolution of clinical leadership and consultant roles
The earliest clinical leadership roles were shaped by and linked to graduate education programmes for nurses. The first advanced practice role emerged in the United States during the 1950s in the form of Clinical Nurse Specialist (CNS) when Peplau developed a graduate programme to prepare advanced practitioners in psychiatric nursing at Rutgers University (Ropka & Fay 1984). Likewise in Canada, the emergence of postgraduate nursing education during the 1970s led to recognition of the CNS role (Pauly et al. 2004). In 1980, the American Nurses’ Association officially recognized that a nurse specialist was prepared at the graduate level and considered an expert clinician (Wyers et al. 1985). In the UK, an advanced practice/Clinical Nurse Consultant role was created by Manley during the 1990s to facilitate the development of nurses and nursing with the aim of providing improved patient services (Manley 1997). The role of nurse consultant was officially introduced in 1999 (National Health Service Executive 1999). These roles are forerunners of many advanced practice roles, and have, in part, led to our argument for the Clinical Nurse Research Consultant role for nurses and people in the 21st century.
Over the last 20 years in Australia, roles have emerged in various forms and at different times depending on the governing body in each state or territory. In the state of Victoria, Clinical Nurse Consultants emerged in the late 1980s in specific domains of stomal therapy, infection control and diabetes education only. At the same time, in another state, New South Wales, Clinical Nurse Consultant roles were developed to retain experienced nurses in many areas of clinical practice by providing a career pathway that recognized advanced clinical nursing skills (Vaughan et al. 2005). As a consequence of the differing genesis of Clinical Nurse Consultant roles, salary scales, reporting lines, job descriptions and educational prerequisites differ between positions and organizations.
Clinical nurse research consultants will provide clinical, research and education leadership
The core roles of a Clinical Nurse Research Consultant (CNRC) would be: to direct organizational change in clinical units, champion the use of evidence-based practice among nurses, provide clinical expertise including direct patient care, lead research programmes and act as a consultant between nurses, educators, academics and administrators. Nomenclature and terminology in advanced and specialist nursing roles continue to plague the profession; however, this new role should have a title that is recognized nationally and internationally and is linked to a national, preferably global, standard in terms of scope of practice. The title should reflect the clinical, research, teaching and leadership components of the role and ideally situate the role in both clinical and academic career structures. As the purpose of this article is to discuss the workings of this proposed role rather than the finer points of the title, the role will be referred to as CNRC for the purposes of the following discussion.
The UK Clinical Research Collaboration (UKCRC) Subcommittee for Nurses in Clinical Research proposed that clinical/academic careers may be achieved by balancing clinical nurse, researcher and educator roles [UKCRC Subcommittee for Nurses in Clinical Research (Workforce) 2007]. The CNRC role proposed is the next step in advancing nursing as a discipline and a way for the profession to drive its own future through research and practice change. The UKCRC also suggest that further development of a clinical/academic career including a research component could be realized by the additional development of nurses in existing roles, specifically Nurse Educators and nurses in senior roles such as Clinical Nurse Consultants [UKCRC Subcommittee for Nurses in Clinical Research (Workforce) 2007]. More recently, clinical academic careers have been proposed to facilitate research and clinical practice (O’Neill 2010), but these have not been operationalized. Although it is early, this could prove an exciting opportunity for nurses with research and clinical expertise at the highest level to have an impact on practice and patient outcomes, although the role and responsibilities may not fully match with our proposed CNRC role.
A completely new role operating in a clinical practice, research and educational framework in both operational and consultative roles need not be drawn up to satisfy the CNRC for clinical research leadership. Kring (2008), for example, argued that because the scope of practice of CNSs in the United States of America (USA) closely meets the competencies required for the knowledge transfer of evidence-based practice, CNSs are ideal for playing a leading role in driving the uptake of evidence in healthcare settings. In the USA and Australia, Nurse Practitioners may also take up a CNRC role, but in doing so, their primary responsibilities would change dramatically from direct service (patient care) delivery to those proposed in this article. Thus, we are not arguing strongly for NPs to change roles. The equivalent Australian advanced nursing role of the CNS in the USA is the Clinical Nurse Consultant (CNC) (Jannings & Armitage 2001). Although the individualized nature of the CNC role means that specific practices can vary considerably between individual CNCs (Vaughan et al. 2005), their practice operates in clinical service and consultancy, clinical leadership, research, education, clinical services planning and management domains (NSW Department of Health 2000). Hence, CNCs are ideal to take up a CNRC leadership role. Indeed, the CNC role is distinct from other Australian advanced nursing roles because research generation and setting educational priorities are already core responsibilities (Conway & Elwin 2007), although these are rarely met. To be effective as genuine clinical research leaders as proposed in the CNRC role, the scope of practice among Australian CNCs would need to be expanded to incorporate a higher level of research and educational responsibilities and standardized nationally. Surveys conducted in New South Wales indicate that research activities are not prominent features of CNCs’ daily nursing activities (Dawson & Benson 1997, O’Baugh et al. 2007). Indeed, research activity was low even among CNCs with experience in a specialty field and a postgraduate nursing qualification. Although CNCs at grades 2 and 3 (scale of 1–5) are expected to carry out independent research projects and be principal researchers in large studies (NSW Department of Health 2000), O’Baugh et al. (2007) found that very few CNCs were fulfilling these responsibilities. The majority of CNCs are still unable to fulfil these research responsibilities because they do not have the education preparation or skills for leading research, nor organizational expectations or infrastructure/support to do so.
Nurse Educators are also well positioned to evolve into CNRCs. Due to their teaching responsibilities, Nurse Educators often have higher levels of research awareness and utilization than Nurse Managers or clinical nurses. Milner et al. (2005) indicated that educators’ knowledge positions them well to facilitate evidence-based nursing practice with clinicians. Given that clinical Nurse Educators already function in knowledge brokering roles between staff nurses and administrators, and between researchers and clinicians, Milner et al. (2005) also suggested that ‘reconfiguring the clinical Nurse Educator role and providing education and support to enhance their research knowledge and skill may be important strategies for the pursuit of an evidence base for nursing practice in organisations’ (p. 912).
For CNCs or Nurse Educators to fulfil the role expectations of our proposed CNRC role, research training is essential. That is, the CNRC must be doctorally prepared. Although many senior nurses in Australia hold Master’s degrees, the majority of Master of Nursing programmes in Australia and elsewhere internationally are coursework with the option of a minor thesis. An Honours degree is considered an important step for research training and has to be encouraged among undergraduate students (House of Representatives: Standing Committee on Industry, Science and Innovation 2008). However, a Doctor of Philosophy (PhD) remains the gold standard for preparing members of every discipline to undertake and lead independent rigorous research. Without a PhD, a CNRC would never secure competitive research funding or receive respect from colleagues as a credible researcher. Thus, doctoral preparation is vital.
A PhD prepared CNRC will assist in overcoming some major barriers that has an impact on a nurse’s capacity to engage in research and translate findings into clinical practice. At present, many Australian CNCs or educators have insufficient research training to conduct independent research because appointments have been based on clinical skills and experience rather than educational preparation (Appel et al. 1996). Similarly, in the UK, a critical mass of clinical nurses who are qualified and experienced to lead research projects is lacking and the opportunities for research training are limited [UKCRC Subcommittee for Nurses in Clinical Research (Workforce) 2007]. The cost of doctoral studies can prohibit nurses undertaking such high level study. In Australia, there are no study fees for a PhD, but the individual usually sacrifices a part or all of their income for up to 5 years. With the global shortage of qualified nurses and employment of non-qualified staff in health agencies, governments must support nurses to gain PhDs, so that nursing care is appropriate, structured, delegated and measured.
As the CNRC will need to role model, mentor and supervise research to improve patient outcomes unique to each health agency, a PhD is essential. Doctorally prepared nurses possess advanced conceptual and decision-making skills critical to informing and evaluating practice improvements in complex practice environments. A study of PhD prepared nurses working in clinical roles as CNSs and NPs in the USA found that these nurses could provide nursing leadership but had limited capacity to bridge the research/practice gap because they were not in research positions unlike the CNRC we are proposing (McNett 2006). Rather, these nurses were employed to deliver patient care as a priority of their CNS or NP role (McNett 2006). Only nurses with clinically based PhD studies will be suitably prepared for the CNRC role. In a study of Australian nurses with PhDs, only 4 of 19 respondents worked in clinical areas (Wilkes & Mohan 2008). Despite the obvious potential opportunity for improving practice and patient outcomes, one respondent stated that her PhD was not clinically based, and so she remained ill-prepared to impact patient care (Wilkes & Mohan 2008). Fortunately, few nurses in Australia now complete non-clinical doctoral studies.
Many current employment models do not support clinical nurses to engage in research, and there are few clear pathways for nurses to be in senior roles to integrate research and clinical practice [UKCRC Subcommittee for Nurses in Clinical Research (Workforce) 2007, Wilkes & Mohan 2008]. Indeed, many nurse leaders in Australian health agencies do not value nurses with higher research degrees in the clinical environment (Wilkes & Mohan 2008). This situation is in stark contrast with medicine, where doctors with academic appointments hold clinical leadership roles to mentor their less experienced colleagues. Such teaching and mentoring occur daily on clinical rounds; a model that we suggest CNRCs mimic to improve nursing practice and patient outcomes.
The CNRC role will initially be open for Nurse Educators and CNCs to apply for; however, this career path is not exclusive. Clinical Nurse Specialists may also aspire to undertake the role. While gaining clinical expertise and teaching opportunities clinically, the CNS could commence doctoral studies. This proposed clinical research career path is open to all registered nurses interested in leading nursing research. Indeed, our experience and observations over the last decade in Australia suggest that many nurses undertaking or possessing a PhD followed this exact trajectory. Currently, many nurses undertaking research in healthcare agencies report statistically significant barriers such as working alone; limited education, mentoring and training opportunities; poor organizational support; and disconnection from academic departments of nursing, particularly when the research is driven or supervised by other health professionals [UKCRC Subcommittee for Nurses in Clinical Research (Workforce) 2007]. A lack of a research career structure combined with the notion that a PhD is the expected qualification for independent research skills highlights the need for a new career pathway for senior clinical nurse experts with PhDs. The aim of the new career pathway and CNRC role proposed in this article was to progress research leadership and capacity building in nursing, and to accelerate implementation of research evidence into clinical practice, thereby improving patient care. We also argue that the CNRC role is the perfect preparation for Chairs of Clinical Nursing. Indeed, clinical in this context means place of work, research programme focus and practice skill of the individual appointee. In Australia, few Professors of Nursing provide direct patient care or work with clinicians at the bedside to improve practice and patient outcomes. The USA model of joint appointments seems to offer more opportunity for Chairs and Professors of Nursing to engage in clinical practice.
Benefits of the CNRC
The CNRC role would make significant contributions to nursing through active development of research agendas in healthcare settings. One of the key facilitators of evidence-based practice and implementing research evidence into practice is an affiliation with a university or academic centre (Olade 2004). Conceptualizing the CNRC role as a specialist research leadership role for PhD-prepared nurses has four major benefits. First, CNRCs will have appropriate research training (PhD) to fulfil higher research functions envisaged by the CNC nurses award (NSW Department of Health 2000) including initiation of original research projects and leading large scale, competitively funded, multi-site research. Second, it would legitimize the requirement for CNRCs to allocate adequate time for conducting research activities. Third, the close engagement that CNRCs would have with clinical practice would ensure that research would be relevant and responsive to specific local issues. Finally, strategies to improve clinical practice and optimize clinical decision-making would be ecologically valid and supported by organizational systems. The benefits of embedding research and evidence-based practice in clinical care are many and include improved health outcomes for people, increased staff satisfaction, improved staff retention, optimal use of healthcare resources and reduced hospital admissions (Refshauge 2008).
To maximize research effectiveness, the CNRC must hold a joint appointment between a healthcare facility and a university in a partnership framework. Effective and strategic partnerships are needed to create sustainable education programmes to address long-term challenges of preparing a skilled and adequate nursing workforce (O’Neil & Krauel 2004). Research and evidence-based practice should be the cornerstone of nursing education and, to provide research leadership, CNRCs must be employed and work across the hospital/university interface. A joint appointment model would allow the CNRC to bridge perceived and real gaps between nursing academia and healthcare agencies, and conduct rigorous research relevant to both partners. In this model, CNRCs would be accountable for delivering research that fits with strategic National and local directions such as National Health Priority Areas, organizational directions and service plans and clinical needs. This model allows for the CNRC to provide clinical, education and research leadership to emerging clinical issues such as management of pandemic illnesses (e.g. H1N1, SARS) or changing health demographics (ageing, obesity and mental health problems). The CNRC could also synthesize evidence for nursing practices to inform equipment purchases to reduce wastage and improve practice and patient outcomes. Furthermore, the impact of research implementation on key outcomes could be systematically and readily evaluated.
A key aim of the CNRC role is deeper investment in clinical research by creating a partnership supported by a joint appointment model that allows both the industry and academic sectors to have ownership of, and a vested interest in, successful research programmes. However, the skills required for this go far beyond those of research. The role of intermediaries in bridging the gap between research and clinical practice is well documented (Milner et al. 2005). Critically, the CNRC will need to possess high level interpersonal and negotiation skills to act as a successful intermediary between clinical practice and academe. A joint appointment would facilitate navigation between two very different organizational structures, and bring the university and healthcare sector closer in common understandings and purposes. The CNRC role and appointment in this framework would also place high value on clinical nursing skills and integration of research in practice; invaluable messages to students of nursing and clinicians alike.
Informal education and leadership is vital to the successful integration of research findings into practice (Thompson et al. 2001, Pravikoff et al. 2005, Rolfe et al. 2008). The CNRC would improve uptake of evidence-based practice by formal and informal education. Developing CNCs and Nurse Educators to undertake the CNRC role means that these nurses would be starting with expert clinical skills; expertize in formal education of others; and potentially an understanding of the relationships between clinical decision-making, evidence-based practice and clinical care. As a PhD-prepared researcher, CNRCs would be highly competent in engaging in independent research, and bring research skills to the bedside to further enhance their own understandings of current clinical practice and decision-making. The presence of a CNRC in the clinical arena as a highly visible clinical leader means that CNRCs would be effective informal educators and change agents in domains beyond research. This is particularly required in Western nursing; other priorities may well be more critical in Eastern nursing.
One of the most important elements of successful practice change is the change agent. The CNRC would be in the pivotal position of being a respected clinical leader with a unique and multifaceted skill set. Therefore, the CNRC will be well positioned to act as a champion for organizational and cultural change. Local opinion leaders can promote evidence-based practice and reduce non-compliance with desired practice, particularly in the hospital setting (Doumit et al. 2009). Individuals perceived by their colleagues as likeable, credible, trustworthy and ‘educationally influential’ have the power to influence behavioural change in others (Doumit et al. 2009). Opinion leaders enable other clinicians by assisting them to identify the evidence underpinning best practice and facilitate behavioural change by empowering clinicians to use best available evidence in practice (Doumit et al. 2009). Furthermore, opinion leaders have been shown to be more effective in promoting evidence-based practice than traditional methods such as audit and feedback or lectures (Doumit et al. 2009).
Role modelling evidence-based practice is especially important for inexperienced nurses to implement evidence-based practice (Ferguson & Day 2007). The high visibility of CNRC means they could act as trusted clinical leaders who role model practice changes and empower nurses to engage in evidence-based practice. Actively engaging nurses in research will positively influence nurses’ research utilization. Nurses who read at least one journal regularly or who attend research courses had significantly higher levels of research utilization (Rogers 2000). The CNRC is a key position to foster further research education via research groups or journal clubs, thus creating the next generation of evidence-based practice champions. Furthermore, positioning the CNRC in a clinical area daily could exploit nursing’s oral/aural culture to ensure that evidence-based practice and research enthusiasm is the norm. As a leader in clinical practice, research and education, the CNRC will advance nursing by taking proactive rather than reactive stance towards improving clinical practice through research. Nursing leadership at this level enables nursing to be anticipative and be responsive to 21st century problems with a 21st century solution.