Clinical academic research internships: What works for nurses and the wider nursing, midwifery and allied health professional workforce

Nurse-led research and innovation is key to improving health experiences and out comes and reducing health inequalities. Clinical academic training programmes for nurses to develop research and innovation skills alongside continued development of their clinical practice are becoming increasingly established at national, regional and local levels. Though widely supported, geographical variation in the range and scope of opportunities available remains. It is imperative that clinical academic op portunities for nurses continue to grow to ensure equity of access and opportunity so that the potential of nurse-led clinical academic research to improve quality of care, health experience and health outcomes can be realised. In this paper, we describe and report on clinical academic internship opportunities available to nurses to share in -ternationally, a range of innovative programmes currently in operation across the UK. Examples of some of the tangible benefits for patients, professional development, clinical teams and NHS organisations resulting from these clinical academic intern ships are illustrated. Information from local evaluations of internship programmes was


| BACKGROUND AND INTRODUCTION
The term clinical academic is used to describe a healthcare professional who combines research and clinical practice (Baltruks & Callaghan, 2018). There are two main types of clinical academics in the UK: clinically active academics who primarily work in Universities and clinically active health researchers who primarily work in health and social care organisations. Both types undertake research that is grounded in clinical practice to address clinically important questions and improve health experiences and outcomes. Research has found that when individuals and healthcare organisations engage in research, patients have better outcomes (Downing et al., 2017), mortality rates are lower (Bennett et al., 2012;Ozdemir et al., 2015), and organisational healthcare performance is improved . The positive impact of research for patients and health professionals is one of its five core workstreams. However, as relative newcomers to clinical academic opportunities and careers, nurses, midwives and allied health professionals presently lag behind other disciplines. Collectively, nurses, midwives and allied health professionals (NMAHPs) make up more than two-thirds of the healthcare workforce (The Nuffield Trust, 2019), yet they constitute 1%, <1% and 4% of trainees in the National Institute of Health Research (NIHR) research training infrastructure, respectively (NIHR, 2017). Although clinical academic opportunities for NMAHPs to develop research and innovation skills alongside their clinical practice have become increasingly established at national, regional and local levels over the last decade, there is clearly a long way to go, and none more so, than for the nursing profession.
Whilst focused on nurses, this paper is positioned in the wider
The UK is well served with research and innovation infrastructure and numerous opportunities exist at national levels to support aspiring clinical academic researchers and career pathways. UK-wide, across the four nations, there are a range of research training fellowship programmes for NMAHPs (Table 1)

INTERNSHIP OPPORTUNITIES
Clinical academic internships are important because they provide opportunities for those new to research to gain research knowledge, experience and skills often by undertaking smaller scale, clinically relevant research projects whilst supported by experienced researchers. Although there are regional clinical academic research internships on offer, there is much disparity in type and availability of opportunities at this level. This variation is a result of differences in regional research capacity and capability building funding streams and research infrastructure. For example, regional clinical academic internship programmes have been supported by Health Education England (HEE), (an organisation responsible for health workforce education, training and development) and NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), and since 2019, Applied Research Collaborations (ARC) (organisations to address regional health and care issues) in some, but not all regions.
Even when these programmes exist regionally, nurses may have less opportunity to access them because clinical areas do not have established links with the Universities that host them. A case study demonstrating the importance of designated research capacity and capability funding streams and systems at regional level can be seen in Box 1.

INTERNSHIP OPPORTUNITIES
More recently, individual NHS Trusts have developed their own unique clinical academic internship programmes in response to local need and availability of resources to support them. As with regional programmes, local opportunities vary. Examples of some of the

PROGRAMME EVALUATION
Evaluation of the clinical academic internships has taken the form of programme evaluation questionnaires, interviews, internship reports, meetings and/or group discussions with interns and their BOX 1 Regional research capacity and capability building case study Funded by HEE and NIHR, the North West regional clinical academic internship programmes were first introduced in 2014 (Miller et al., 2020). Hosted by the University of Central Lancashire, these master's degree level accredited programmes supported 42 healthcare professionals, representing 5 NHS Hospital Trusts enabling practitioners to experience a research role whilst optimising their clinical expertise. Building on these programmes, the capacity building theme for NIHR Collaboration for Leadership in Applied Health Research and Care North West Coast (CLAHRC NWC) supported clinical academic internships from February 2015 to September 2019 (Khan et al., 2020). During this period, 67 interns from health and social care organisations and local authorities from across the North West Coast region were supported to complete projects important to their employing organisations, patients, service users and carers. Regional internship programmes have additional benefits of being able to draw on and share learning across a wider range of research partners, public advisors and health and social care organisations, thus allowing them to address regional health priorities.

FIGURE 1 Examples of local clinical academic internship programme case studies
Key: *0.2wte = 7.5 hours, the equivalent of one day per week and 0.4wte = 15 hours, equivalent to two days per week. **NIHR CLAHRC/ARC NWC (NaƟonal InsƟtute of Health Research CollaboraƟon for Leadership in Applied Health Research and Care / Applied Research CollaboraƟon, North West Coast).

Goals
To increase research and innovation capacity and capability of nursing staff.
To increase confidence of nurses to challenge practice, ask questions and to use and implement research in practice. To provide local, clinical academic opportunities to support those wishing to develop a clinical academic career. To attract and retain high-quality staff. To enable aspiring clinical academics to develop skills and attributes to support applications for competitive research training fellowships.

Model
Protected time for a given period to undertake clinical academic internship research work.

Eligibility
Early career Nurses, (Midwives and AHPs), though commonly also open to mid and senior career staff in recognition of usual clinical career trajectories. Some programmes are also open to non-registered health practitioners based on need and interest.

Activity types
To develop research skills by working with senior clinicians and experienced researchers, undertaking research training and/or undertaking local, small-scale, evidence-based clinical research projects with clear potential benefit for patients and/or clinical teams.

Programme
Bespoke, personalised training and activities based on individual's and organisation's needs and goals.

Funding
Protected clinical academic research time is funded.

BOX 3 Professional development case study: from research newcomer to nurse clinical doctoral research fellow
A Band 6 clinical nurse based within acute medicine at Western Sussex Hospitals NHS Foundation Trust joined the Clinical Improvement Scholarship programme with no previous experience or knowledge of research and clinical academic roles. Following completion of her first degree in Nursing, she had been working full time in clinical practice for several years demonstrating a real passion for improving care for patients and supporting staff mental health and well-being. Her main reasons for applying to the scholarship were related to growing frustration with her ability to feel she was making a difference which had also led to her considering leaving her nursing role. During the scholarship programme, whilst also developing her masters level research experience, she was able to successfully achieve two improvement projects, one introducing a new pain scoring system for patients with dementia and the other developing a manager's toolkit for supporting staff mental health and well-being. In the last 2 years, she has successfully helped roll this out across the whole organisation with the backing of our Chief Executive, won the Trust annual award for innovation in practice, written an article for publication and been accepted to present at an International Nursing conference. In May 2020, following a successful application, she began a new clinical academic role as Nurse/Clinical Doctoral Research Fellow where she will be researching holistic care of frail elderly patients in the acute care environment as part of her everyday practice over the next 4-5 years.

BOX 4 Benefits for patients, clinical teams and NHS Organisation case study: from research newcomer to nationally recognised dementia champion
A Band 4 Health Care Assistant working in the Emergency Department at Lancashire Teaching Hospitals NHS Foundation Trust recognised that dementia care was at a high standard but could be enhanced for patients in the later stages of dementia. She undertook a clinical academic internship to explore the experiences of staff working in hyper-acute/acute settings in communicating with patients who have dementia. She then developed and implemented an adaptation to patient identification wristbands for patients with dementia with the aim of enhancing person-centred care and ensuring that health professionals across a range of settings including emergency departments, imaging and wards were discretely alerted when checking patient details, enabling staff to then utilise their dementia training. In recognition of her innovation and drive to improve care for patients with dementia, she won the 'Caring Category' Quality Award in recognition of the adaptation to patient wristbands for patients with dementia in the Emergency Department and is now recognised as a Dementia Champion. The idea has been implemented in a range of hospital and community settings, improving the communication with and care of patients with dementia. The project has been presented at national conferences and clinical meetings and used as a case study example by the Royal College of Nursing to celebrate nursing practice and by NHS England as a case study of good practice. clinical academic mentors, academic supervisors, clinical leads and public advisors (Bell & Colleran, 2019;Miller et al., 2020;Olive, 2019a

INTERNSHIPS: WHAT WORKS FOR NURSES AND THE WIDER NMAHP WORKFORCE?
The benefits of clinical academic internships for patients, interns, clinical teams and NHS organisations are clear. However, for nurses, especially early career nurses on the front-line of 24/7 health service delivery, securing their participation in clinical academic opportunities may initially be difficult. Nursing shortages (The Health

BOX 5 Embedding research culture across the organisation case study: from research newcomer to NHS Trust research champion
A Band 7 clinical nurse specialist working in the spinal cord injury centre at the Royal National Orthopaedic Hospital NHS Trust was passionate about improving the care experiences and outcomes of her patients but lacked confidence in her ability to undertake research. She held a first degree but had no experience of research or improvement work and had never written any papers for publication. During the internship period, she received coaching from an experienced researcher and attended monthly support meetings and regular training sessions. She went on to conduct a service evaluation, which was published in the British Journal of Nursing, presented her work at two international conferences and was shortlisted for an improvement fellowship. Three years later, she is undertaking a Masters in Research, writes a regular blog for the Nursing Times and is a research champion for the Trust, supporting other nurses to develop research confidence.
Foundation, 2019) and clinical workload demands due to high bed occupancy rates averaging at more than 90% (Ewbank et al., 2020) add to this nurse-specific challenge.

| Recruitment and retention
Connecting

| Funding
Financial pressures across the NHS mean that local clinical academic internships are often run on limited budgets sourced from a variety of funding pots. Replacement funding for interns to be released from practice is essential. Even with replacement funding, release is not always possible as periods of peak practice demand meant that nurse and midwives' pre-arranged clinical academic research days were sometimes rescheduled (Bell & Colleran, 2019;Olive, 2019b

| Clinical academic support
Even within a small cohort, clinical academic interns will be pursuing Capacity for supervisors to be flexible and responsive to changing support needs is important. In addition to regular, formal progress monitoring and support mechanisms, informal opportunities, such as lunch or coffee break catch-ups, enable peer-to-peer clinical academic support networks to develop across the institution.

| Research culture
Senior clinical leaders that understand the benefits of clinical academic research were key for clinical academic opportunities to become established and grow. Clinical areas that had a strong patient experience-centred and quality improvement culture were keen to nominate and support colleagues applying for and undertaking clini-

Clinical team
The clinical academic internship project is important for the clinical team and endorsed by team leader(s). The clinical academic internship project contributes to the clinical team's strategic goals. Clinical team engaged from beginning and agree project focus. Clinical leads involved in internship selection and recruitment.
Timeframe and resource Being mindful of importance of demonstrable benefits in a reasonable timeframe for often stretched teams.

Internships
Interns working together on the same or related projects can enhance momentum and project results.
Clinical academic support Early identification of a core clinical academic support team and corresponding training and development for intern. A core clinical academic support team to provide rounded support and advice consisting of clinical lead(s), postdoctoral (or equivalent), experienced subject and/or methodological researcher(s) and public and patient advisor. Responsiveness to integrate additional expert members in the clinical academic support team as needed. Regular, at least monthly, formal and informal progress monitoring and support to help keep intern on track and prevent isolation.

Flexibility
Built-in programme flexibility, for example, drop-in and intern-led sessions in addition to anticipated and planned training sessions so learning activities are relevant and timely.

Sustainability
Draw on and make the most of existing research infrastructure and research and innovation networks. A developing community of research active NMAHPs with the skills and impetus to buddy and support or mentor others.  (Bell & Colleran, 2019;Bench et al., 2019). Findings from a focus group study (Bench et al., 2019) found that nurses may feel more comfortable with the idea of improvement projects and see these as more relevant to their role and to their local setting. Clinical academic internship quality improvement projects tend to focus first on developing a project idea and then on exploring the right methodology for it. Whilst these internships often fulfil the criteria of an improvement rather than a research project, they nonetheless increase interns' understanding of the differences, and simultaneously, their confidence and competence in both research and improvement methodologies (Bell & Colleran, 2019;Bench et al., 2019;Miller et al., 2020).  The UK has excellent research infrastructure that supports national pre-doctoral, doctoral and post-doctoral research training fellowships and regional and local clinical academic internship opportunities are increasing. However, geographical variation means that access for some may be limited. It is imperative that clinical academic opportunities for nurses continue to grow to ensure equity of access and opportunity so that the potential of nurse-led clinical academic research to improve quality of care, health experiences and health outcomes can be realised.