Enablers and barriers to progressing a clinical academic career in nursing, midwifery and allied health professions: A cross-sectional survey

Aims and Objectives: This study aimed to understand the routes by which nurses, midwives and allied health professionals (NMAHPs)


| BACKG ROU N D
Building sustainable capacity for the generation of research is critical, not only for developing research excellence but to improve health outcomes (Hanney et al., 2013). Whilst integrated clinical and research career pathways exist for doctors, in many countries comparable opportunities have been ill-defined for nurses, midwives and allied health professionals (NMAHPs) (Smith et al., 2018;Van Oostveen et al., 2017). Often those interested in becoming involved in research do not know where to begin. As a consequence, these professions are not at the same stage of research capacity development as medicine, yet they form the vast majority of the clinical workforce which provides care to patients (Carrick-Sen et al., 2016).
In response to these concerns in England, the Clinical Academic  • This is the first survey using a national sample to consider career progression, experiences and views of individuals pursuing a clinical academic career. It builds and extends on evidence from different countries on the facilitators and barriers to pursuit of a clinical academic career that are common to the health professions.
• Whilst there are some unique aspects to the NIHR fellowship programme, there appear to be some common obstacles to pursuing a clinical academic career path and solutions to these merit serious consideration globally.
• Improved career pathways, greater flexibility and reward mechanisms and a culture that values academically trained health-care professionals appear to be common components for successful development of research capacity and capability in these groups.
[BHF]: What we fund, 2020) as well as funders like the Medical the Netherlands and Australia, are recognising the importance of developing an infrastructure to achieve growth in research capacity in these professions and identified the need for formalised research training pathways at junior levels (Carrick-Sen et al., 2019;Kim, 2009;Smith et al., 2018;Van Oostveen et al., 2017 (Trusson et al., 2019) there is still a concern that embedding a research-based culture is a major challenge in healthcare (Brown et al., 2015). In 2015, in England, the Shape of Caring Review (known as the Willis Report) was published highlighting the specific need to generate a research culture in nursing and provide the architecture to make change necessary (HEE, 2015b). The Willis Report emphasised the importance of clinical academic roles in nursing and the need to continue to expand and develop them. It suggested significant architecture to make the changes necessary, including sustained national and local coordination.
Some of the challenges in relation to this pathway, like lack of clear entry points, no clear model of career progression and insufficient post-doctoral posts, continue to be reinforced as critical issues (Baltruks & Callaghan, 2018;Trusson et al., 2019). These closely mirror previous analysis of factors hypothesised as critical to establishing a robust and sustainable clinical academic career pathway for nurses, midwifery and the allied health professions (Latter et al., 2009;Westwood et al., 2018). Alongside the ongoing debate around the concerns and issues raised by this career path, there remains an appetite in the UK, Europe and in many parts of the world to explore formalised training pathways underpinned by infrastructure and funding.

| Aim
The aim of the study was to provide an overview of the career pro- It was pre-tested by five past applicants during the adaptation and development stage and amendments were made following feedback. The final questionnaire contained 7 sections, the first section related to 'initial interest and experience in research' and included questions such as 'which of the following first sparked your interest in research'? and 'how did you gain your first research experience'?
The second section asked about pursuing a higher degree and included questions about the main motivation for pursuing a higher degree and the funding. The other sections focussed on career since applying for a fellowship; current position; reflections on career to date; careers advice, support and guidance and demographics. Not all participants were presented with every question; survey questions were tailored to the participant and in some cases, the question pathway depended on responses to earlier questions. The iSurvey tool enabled routing to be built into the questionnaire, so for example, questions specific to doctoral respondents were only directed to those who indicated they had applied for a doctoral fellowship. This minimised the complexity of the survey for participants.
The responses were downloaded into an excel database. The first author (MA) conducted the data analysis. Only the data from those who reached the end of the survey and clicked the 'save and finish' tab were included in the analysis. The analysis of the data was descriptive, with findings reported as frequencies and percentages.
Open-text answers were analysed using thematic analysis using an EXCEL database; data were coded and main themes were developed. There was no imputation of missing values within the data and missing data were included as a category within the data for each question. Some of the responses relate to all respondents and others exclude participants 'still undertaking fellowship/funded programme of study'.
The study was reviewed and approved by the University of Southampton, School of Health Sciences Research Ethics Committee.
A full account of the methods used in this study are available in the report (Richardson et al., 2019). The STROBE checklist was used in the reporting of the study (see File S3).

| RE SULTS
The email invitations were successfully delivered (did not bounce) to 904 past applicants and 231 went on to complete the online questionnaire (clicked 'save and finish'); a 25.6% response rate. A further 85 invitations were sent to awarded applicants to 7 additional funders, with a similar response rate, but the findings from those respondents are not reported here. Overall, 162 participants (70.1%) had complete data, 55 participants (23.8%) had 1 piece of missing data and 14 participants (6.1%) had more than one piece of missing data. When considering each question, the mean missing data per question was 1.8% (range: 0-31.3%). There was no imputation of missing values within the data.
The findings presented in this paper focus first on the demographics and early career of respondents; those who completed the survey were, in the main, in the initial phase of their research career and showed some variation between the different professional groups around early research experiences. Secondly, key enablers and barriers to career progression from the survey responses have been summarised and these relate mainly to funding opportunities and availability of positions as well as the importance of local senior academics and mentors in providing advice and support.

| Demographics
A total of 134 doctoral and 96 post-doctoral applicants participated (one participants' fellowship level was unknown); there were more females in both cohorts. Doctoral applicants tended to be younger with nearly 80% under 50 years. Around two-thirds were allied health professionals, health-care scientists or pharmacists and the majority of respondents were white British (71%), with a broad range of ethnic groups represented (Table 1).
Overall, there were less awarded than rejected respondents in both the doctoral (awarded: 46.3%) and post-doctoral cohorts (awarded: 49%). The term 'awarded doctoral applicants' referred to doctoral applicants who indicated in the survey that they had completed a PhD and indicated this was since 2010 or were still undertaking their PhD and that their PhD was funded by NIHR and/or HEE. The term 'awarded post-doctoral applicants' referred to those who indicated that their most recent application was successful. The term 'rejected doctoral applicants' referred to those that have not been 'awarded' based on the above definition and the term 'rejected post-doctoral applicant' referred to those who indicated that their most recent application was not successful. Just under half of respondents (n = 109, 47%) indicated they were pursuing a clinical academic career (CAC).
Most respondents were early in their research career. Overall, just over a third of doctoral (38.8%, n = 52) and just under a third of post-doctoral (29.2%, n = 28) respondents were still undertaking a fellowship/funded programme of study via any funder and just over three quarters had made only one career transition (N = 115, 76.2%) following their fellowship application. The majority indicated they were research-active in their current role (70% of the doctoral applicants and 93% of post-doctoral applicants).

| Overview of career choices
All respondents were asked about their early career choices. Interest Overall, nearly half (47.6%) had their first research experience during their BSc undergraduate project; however, this was less often the case for nurses/midwives/health visitors (n = 27, 37.5%) than other NMAHPs (n = 80, 51.6%) (Figure 1). Some respondents (n = 15, 6.5%) had their first research experience whilst working as clinical research staff; this was more common for nurses/midwives/health visitors (n = 12, 16.7%). The table shows the demographics of respondents to the survey where data on fellowship level was available (n = 230). For one participant the information on fellowship type was missing. The percentages shown are calculated from the total number of respondents within each cohort. The professions of the respondents were: allied health professionals (n = 120), nurse, midwife, health visitor (n = 72), healthcare or clinical scientist (n = 20), pharmacist (n = 9), prefer not to say or missing (n = 4), dual role (n = 2), clinical psychologist (n = 2), public health specialist (n = 2).

| Enablers
With regard to doctoral respondents (n = 82) (excluding those still undertaking), those awarded a fellowship were more likely to be research-active in their current role than rejected applicants (79.2% and 65.5%, respectively). Most post-doctoral respondents, whether they had been awarded a fellowship or not, were research-active (awarded: 95.2%, rejected: 90.9%).

Career path (awarded only)
When considering the career path of awarded respondents (

| Barriers
Participants reported a range of difficulties encountered whilst pursuing a research-related career. Of 228 (99%) pursuing this career path, just over 70% indicated it was difficult or very difficult (Figure 3).

Challenges on completion of higher degree
When asked to indicate how much of a challenge a list of factors were on completion of their higher degree (scale of one to five)

F I G U R E 1 A figure to show responses to survey questions asking about 1a
. what sparked their interest in research and 1b. how they gained their first research experience. The questions were asked to all 231 respondents; with missing data for 1 respondent for Figure 1a.
The data are shown as percentages.
(n = 145), just over 40% found securing a research-related post that reflected their chosen area of focus 'a lot' (score five) of a challenge.
Just over a quarter (28.3%, 27.6%, 26.9%) found securing a post at an appropriate clinical level, one that reflected the knowledge and skills acquired during the training fellowship or a position where they could sustain some research activity 'a lot' (score 5) of a challenge.

Across career transitions
Of the awarded respondents, 45 had transitioned to one or more roles following their fellowship and of these, just under 85% (n = 38) had experienced some sort of barrier. Overall, the most commonly indicated barriers related to research roles; availability of positions (33.3%), funding (26.7%) and maintaining research activity (26.7%).
Nearly half of 24 awarded doctoral respondents who had moved to their first role indicated that 'inadequate support from employing institution' was a barrier (Table 2).

Financial impact of pursuing a CAC
Of those pursuing a CAC (n = 109), just under 60% (n = 65) indicated they had been effected financially and this was most commonly due to 'slower progression through the salary bands' (n = 37) or lower current salary as a result of pursuing this career path (n = 30).

F I G U R E 2
A graph to show the factors that would make it easier to pursue an integrated clinical academic career. In total, 109 participants who had indicated they were following this career path were asked; data were missing in 5 participants. The data are shown as percentages.

F I G U R E 3
A graph to show the ease or difficulty of pursuing a clinical (n = 200, missing data for 1 respondent), research (n = 228, missing data for 2 respondents) and integrated clinical academic career path (n = 109, missing data for 5 respondents). The data includes responses only for those who indicated that they were following these career paths and are shown as a percentage of those pursuing each career path.

| Advice, support and guidance
Since becoming interested in a research-related career, nearly all respondents had received some kind of advice, support and guidance (96%). The three most commonly accessed sources were from senior clinical academics (56%), a mentor or fellowship award holder (52% and 49%, respectively). The least frequently accessed sources were University careers advice, other formal careers advice and research training programme director ( Figure 4).
Overall, just over a quarter (27.3%) were fairly or very dissatisfied with the advice, support and guidance they had received. More of the awarded cohort found advice, support and guidance important in their decision to take the career path they had compared with their rejected counterparts.

In England, introduction of a national Integrated Clinical Academic
Programme has provided a route into a clinical academic career (Health Education England, 2015a) and is enabling a new generation of nurses, midwives and allied health professionals to follow an academic career. With over 225 funded since the scheme was launched, the programme has clearly increased the number of individuals pursuing this career option. The NIHR scheme is the largest of a number of funding opportunities for NMAHPS and sits alongside other condition-specific schemes offered by charities across England (BHF: What we fund, 2020; CRUK: Our funding schemes, 2020).
This survey was designed to capture, and is the first analysis of, the routes by which applicants to NIHR schemes first become interested Maintaining research activity 6 (25.0) 6 (28. students are not 'purposefully nurtured to become…researchers…' (UKCRC, 2007). This difference could also be attributed to the lon- Although often described as difficult, desire for a research career path appeared strong and, in the most part, resolute, even amongst rejected respondents. However, absence of a well-defined postgraduate education and training pathway, unlike in medicine, impacts on both desirability and viability of pursuing a CAC. There remains uncertainty around role definitions and expectations, with some early career researchers describing it as an unknown role, highlighting the importance of finding your identity within an organisation to fully thrive (Cowley et al., 2020). Greater recognition that this is a legitimate and valued career pathway would accelerate the contribution of this group to the development and evaluation of innovations in health-care (Cowley et al., 2020). Although all will not be suited or able to continue along such a pathway, the absence of a clearly artic- findings from our survey indicate that there is scope to improve access to, and provision of, support and guidance as less than half were satisfied with advice and support received.
As far as we know, this is the first national survey to consider clinical academic career progression in NMAHPs. Interestingly, research with doctors and dentists (Lopes et al., 2017;MRC, 2015;Ranieri et al., 2016), despite this group having a well-characterised career path, has revealed similar findings in terms of barriers and enablers to career progression. Amongst doctors and dentists, experience and skills gained through training and research, securing funding and mentoring were all considered to be important enablers for career development (MRC, 2015). There is also a lack of clarity amongst doctors and dentists regarding aspirations and routes to progression as a clinical academic (MRC, 2015). When considering specifically impact of an Academic Clinical Fellowship (ACF) scheme (Clough et al., 2017), similar benefits and challenges were also highlighted, particularly balancing clinical and academic activities. However, doctors and dentists have a longer history and more established route into clinical academic roles. NMAHPs might learn from some of these experiences. A survey of senior UK doctors found that female doctors felt more disincentivised to pursue a clinical academic career compared to their male counterparts due to lack of career flexibility and the desire for more part-time posts, flexible working and career guidance (Lambert et al., 2015). Although other factors were highlighted as the main issue in our survey, it is important to consider factors such as these and ensure flexibility in routes and roles when further developing clinical academic routes in the NMAHPS.

| CON CLUS ION
The introduction of the NIHR fellowship scheme has proved popular and successfully developed a cadre of non-medical clinical academics. However, as is the case in many countries developing similar career routes, the lack of a formal career structure for those with research training in clinical practice leaves many having to find their own way, often with little support from employers, and frequently with nowhere to go but their previous jobs. These schemes are therefore at risk of not realising the potential benefits of clinical academic careers both for developing research excellence and improving patient outcomes. This study underlines the importance of overcoming barriers like perceptions of value of research in, and about, practice and lack of infrastructure directed at supporting development and implementation of roles. There is an argument that sustainable change might only be brought about if clinical academic pathways for NMAHPs are supported through national and regional and organisational policies helping to ensure a consistent approach which extends to the entire career pathway.

| RELE VAN CE TO CLINI C AL PR AC TI CE
A facilitative culture and supporting infrastructure to enable nurses, midwives and the allied healthcare professions establish and sustain a clinical academic career will ensure they are better used for the benefit of the public and patients, the organisations they work for, and the health-care system. Investment in a clinically active academic research workforce underpins these professions' contribution to transformational changes in patient care, strengthen leadership and increase the visibility and impact of research.

ACK N OWLED G EM ENTS
We would like to thank the survey respondents. to conduct the survey as part of her fellowship programme.

CO NTR I B UTI O N S
Conceived the idea: AR; designed the study: AR, GW and MA; designed the survey, collected and analysed the data: MA and AR; drafted the manuscript: AR and MA; critically reviewed the manuscript: GW. All authors read and approved the final manuscript.

DATA S H A R I N G S TAT E M E N T
Data are available on reasonable request.