Florence Nightingale's legacy for clinical academics: A framework analysis of a clinical professorial network and a model for clinical academia

Background: Clinical academic nursing roles are rare, and clinical academic leadership positions even more scarce. Amongst the United Kingdom (UK) academia, only 3% of nurses who are employed within universities are clinically active. Furthermore, access to research fellowships and research grant funding for nurses in clinical or academic practice is also limited. The work of Florence Nightingale, the original role model for clinical academic nursing, is discussed in terms of how this has shaped and influenced that of clinical academic nurse leaders in modern UK healthcare settings. We analysed case studies with a view to providing exemplars and informing a new model by which to visualise a trajectory of clinical academic careers. Methods: A Framework analysis of seven exemplar cases was conducted for a net work of Clinical Academic Nursing Professors ( n = 7), using a structured template. Independent analysis highlighted shared features of the roles: (a) model of clinical academic practice, (b) infrastructure for the post, (c) capacity- building initiatives, (d) strategic influence, (e) wider influence, (f) local and national implementation initia -tives, (g) research area and focus and (h) impact and contribution. Findings: All seven of the professors of nursing involved in this discourse were based in both universities and healthcare organisations in an equal split. All had national and international profiles in their specialist clinical areas and were implementing innova tion in their clinical and teaching settings through boundary spanning. We outline a model for career trajectories in clinical academia, and how leadership is crucial.

that of clinical academic nurse leaders in modern UK healthcare settings. We analysed case studies with a view to providing exemplars and informing a new model by which to visualise a trajectory of clinical academic careers.
Methods: A Framework analysis of seven exemplar cases was conducted for a network of Clinical Academic Nursing Professors (n = 7), using a structured template. Findings: All seven of the professors of nursing involved in this discourse were based in both universities and healthcare organisations in an equal split. All had national and international profiles in their specialist clinical areas and were implementing innovation in their clinical and teaching settings through boundary spanning. We outline a model for career trajectories in clinical academia, and how leadership is crucial.

| Florence Nightingale-the original clinical academic nurse
Florence Nightingale can be viewed as the original, and most-well known, clinical academic for nursing. She applied the best evidence and clinical practice of her time to improve patient outcomes through increasing patients' access to fresh air, nutrition and sanitation (Nightingale, 1859). She further campaigned for major hospital reform using data and statistics. The bi-centenary of her birth in 2020 and global Year of the Nurse being celebrated in 2020/2021 (World Health Organisation, 2020) is a timely opportunity to publicise her work and to re-examine her teaching in relation to modern healthcare and how it might inform modern clinical practice. A framework analysis, using Ritchie and Spencer's principles (Ritchie & Spencer, 1994), is presented with the aim of developing the themes in clinical academic practice adopted by the seven members in this network. We propose a model for clinical academic nursing practice and discuss its potential application to the nursing profession.
Currently, clinical academics across all professions focus on conducting, appraising and implementing research in clinical settings, exactly as Nightingale's trailblazing work exemplified.
Having witnessed the appalling conditions in which wounded soldiers in the Crimean War were treated, Nightingale worked with William Farr and John Sutherland of the Sanitary Commission to learn how to use statistics to predict mortality (National Archives, 2014), convey complex information and ultimately to change nursing practice. She developed visual representations to help communicate complex information, one of which became known as the polar area or 'rose' diagram, and remains in use today. Her extraordinary ability to communicate data led to her being the first woman admitted to the Royal Statistical Society. However, it is her application of those data to her clinical practice in the field hospitals that is of greater significance and allowed her to demonstrate that most deaths in the Crimean War were not from battle injuries but from infection.
Nightingale transformed clinical hygiene practices across field hospitals in the Crimea resulting in a decrease in deaths by an astounding 99% from 1855-1856 (National Archives, 2014). She influenced government healthcare policy through lobbying, as exemplified by her successful campaign for hospitals to be mandated to collect routine statistics. This allowed comparison across regions and countries, assisting progress in epidemiological research in healthcare worldwide. She believed that the role of nurses was key to implementing improvements in healthcare, and to this end, she established the Florence Nightingale School of Nursing in London, and in 1859 published a guide to clinical practice, 'Notes on Nursing' (Nightingale, 1859).

| Clinical academia in nursing
The central belief held by Nightingale, which is shared by modern clinical academics, was that research and evidence are the foundations of clinical practice and enquiry. We recognise that this leadership might be on varied levels, and that it might range from junior researchers and junior clinical practitioners who are leading on a project, to professors leading a programme of research in clinical practice. That all nurses should understand, implement and initiate research is regarded as fundamental, as is the need for them to be trained to do so (Nursing & Midwifery Council, 2018). The time taken for research findings to become embedded in clinical practice has been estimated as averaging Conclusion: The model outlined emphasises the different stages of clinical academic roles in nursing. Nursing as a discipline needs to embrace the value of these roles, which have great potential to raise the standards of healthcare and the status of the profession.

K E Y W O R D S
Clinical academic, Florence Nightingale, framework analysis, Nursing research, professorial, senior leadership What does this paper contribute to the wider global community?
• For clinical academic pathways in nursing to flourish, there needs to be strong leadership, institutional and personal commitment. We outline a model where clinical academic leaders can be considered as spearheaders, who support clinicians in research, from toe dippers to waders and trackers.
• Florence Nightingale remains an important model for research-active clinical nurses who wish to innovate in their practice through research.
• Clinical academic leaders have impact beyond their own sphere of clinical expertise to pave the way for others and create a milieu for clinically applied research innovations. 17 years (Curtis et al., 2017;Davis et al., 2003;Morris et al., 2011).
Clinical academics in nursing seek to address this by their contributions to developing a nursing workforce adept at applying and leading research directly relevant to clinical practice. In Australia, clinical chairs are not uncommon and these seek to act as a bridge between academic institutions and clinical practice (Wallis & Chaboyer, 2012), with a drive for clinical academia evidenced since the 1990 s (Darbyshire, 2010;Davidson et al., 2006). However, as in China, the Nordic coun- In contrast to discrete educational or research initiatives with a specific goal and endpoint, clinical academics strive to continuously improve practice and address the evidence base. This is facilitated by enabling academics to remain active in clinical practice, as is more common in medical professions throughout the world.
There have been significant challenges in developing a clinical academic nursing workforce globally (Carter et al., 2020;Emami et al., 2017;Kelly et al., 2018), with most research in this area describing partnership models, in which academics or educators work on projects in clinical practice, or with clinical practitioners working on a finite project rather than a clinical academic pathway. An example was the Global Health Service Partnership in Africa (Stuart-Shor et al., 2017), where educators work with nurses in clinical practice across the United States and Kenya to share knowledge. However, historically, nurses who developed as academics have been employed by universities (Baltruks & Callaghan, 2018;Baltruks et al., 2020), with few remaining in a clinical environment, thereby limiting the potential for rapid dissemination or implementation of research into clinical practice.

| Clinical academia innovations
Since it was established in 2006, the NIHR has supported an increase in numbers of clinical academics in nursing. However, less than ten Moreover, the impetus in nursing is for direct patient care, placing it at a higher value and priority than non-patient-oriented activities.
This misplaced, or even biased, value is also evident in the mini- Therefore, involvement in research is something that nurses should do because it improves service delivery and patient outcomes. Boaz et al., (2015) suggested that when clinicians and healthcare organisations engage in research, there is the likelihood of improvement in the organisational healthcare performance, even when that has not been the primary aim of the research. There is also evidence that research-active UK NHS Trusts have improved outcomes, including satisfaction and lower risk-adjusted mortality for acute admissions (Jonker & Fisher, 2018;Ozdemir et al., 2016). This means that having a larger clinical academic workforce is highly likely to improve patient outcomes above and beyond the actual research aims of specific projects.

| Articulating the added value of senior clinical academic leadership in healthcare and higher education
Senior-level joint appointments between healthcare and higher education organisations have been demonstrated to enhance the research culture, yielding significant benefits not only to the hosting organisations by ensuring rapid knowledge transfer and implementation, but also to individual clinicians (Jinks & Green, 2004).
Moreover, joint appointments, particularly at professorial level, have been considered a way to enhance clinically based research developments (Jinks & Green, 2004;Westwood et al., 2018). In the  (Darbyshire, 2010). Yet, they have been regarded by some as a success, particularly as bridge-builders (Lumby, 1996;Wallis & Chaboyer, 2012). Senior leadership is also a significant factor in the success of such appointments, as they are more able to implement change and lead others in research, growing an active research environment in which using best evidence in clinical practice becomes the norm. Furthermore, they can act as a bridge between higher education and healthcare institutions, which can be viewed as a boundary spanning role (Williams, 2002).
'Boundary spanning' is the concept of reaching across organisational structures to build relationships, interconnections and interdependencies. It can be done at an individual level, to develop and manage interactions, and at an organisational level, by setting up policies and structures that facilitate and define the relationships between individuals and their respective organisations (Williams, 2002). Boundary spanning is the activity by which individuals within an organisation bridge to another organisation, functioning in both clinical and academic worlds with credibility and transferrable skills.
Boundary spanners act as information brokers, as ambassadors or diplomats and as conduits for resources, information and influence.
The challenge in Nursing and Midwifery in the UK is that only 3% of academic posts have joint clinical academic contracts, which requires both worlds to be inhabited simultaneously (Baltruks et al., 2020). According to the University Hospitals Association's (formerly

| SAMPLE , S E T TING AND ME THODS
Models of practice in clinical academia vary significantly across the UK. With the aim of exploring this further and to demonstrate the variation in practice, a network of clinical professors (n = 7) representing three of the nations in the UK (Northern Ireland, Scotland and England [there was no Welsh representative in post]) individually collated role case study descriptions, using a comprehensive written template developed through consensus within the group, to capture textual data about each of their roles, including ways of working, practice, leadership and policy impact. The authors analysed this for initial themes, using a framework analysis approach. However, given the subject was about individual roles and to provide independence, a framework analysis of the models was independently conducted by an experienced researcher (initials to be supplied) to draw these data into themes (Table 1). The initial framework analysis propositions were informed by both the literature and experiential knowledge. The independent researcher and two of the network (initials to be supplied) reviewed the themes together to verify themes identified independently, and to provide member-checking of the textual data.

| Framework analysis of case studies
Framework analysis is a qualitative method ideally suited for applied policy and related research (Ritchie & Spencer, 1994). It is an approach suited to research that has specific questions, a limited time frame, a pre-designed sample and a priori issues (e.g. organisational and integration issues) that need to be addressed. Although Framework analysis may generate theories, the prime concern is to describe and interpret what is happening in a particular setting.
Framework analysis allows either collection of all the data and then subsequent analysis, or concurrent analysis and collection. In the analysis stage, the gathered data are sifted, charted and sorted in accordance with key issues and themes. This involves a five-step process: 1. familiarisation; 2. identifying a thematic framework; 3.
indexing; 4. charting; and 5. mapping and interpretation (Ritchie & Spencer, 1994). The researcher becomes familiar with the data, noting key ideas and recurrent themes, and identifying a thematic framework with emerging themes or issues. These concepts and themes then form the basis of a thematic framework to filter and classify the data. Subsequent indexing and charting involve identifying and moving sections of data that correspond to the emerging TA B L E 1 Framework analysis of 7 FNF Professorial roles

| Findings from framework analysis
Exploration To advance nursing science and practice, nurse-led programmes of research need to be fostered to maintain academic and clinical credibility within the broader clinical and health science arena.
Having embedded, clinically active researchers in healthcare organisations, who lead research programmes, are important for rolemodelling and driving effective nursing care. This in turn improves care processes and patient/client outcomes. The case study data emphasise how these roles impact on patient outcomes beyond the research outputs of specific studies. Moreover, as the analysis in Table 1 summarises, these posts facilitate rapid knowledge transfer into clinical guidelines and practice at both local and national levels (see Appendix S1. for the full Framework analysis).

| Proposal for a clinical academic model
This case study framework analysis has outlined themes and commonalities in these senior posts at clinical nursing professorial level.
As the data attests, the theme of capacity building was a promi- Florence Nightingale was a unique trailblazer and able to drive significant change, in modern healthcare systems, it is recognised that this activity needs to take place in an environment and culture that is receptive to, and promotes, research to inform clinical practice.

| LI M ITATI O N S
We aimed to identify how leadership roles contribute to the clinical academic landscape, and limitations include the small sample; however, this was a whole sample of these clinical academic nurses in unique roles. Including independent analysis provided some rigour to analysis and helped demonstrate trustworthiness of the data, but we recognise the limitations around an auto-analysis. We aimed to outline how these kinds of unique professorial positions can also be used to develop clinical academics of the future, using a network exemplar (all of which had a 50% clinical component). However, we recognise that more alternative and independent sources from other clinical professorial working models may have complemented or provided opposing models to our descriptions of these positions and employment models.
Honouring Florence Nightingale's legacy, we need clinical academic nurses working across the spectrum of research activity, from toe dippers to spearheaders, and working on synthesis and evalua- Having clear examples of how clinical academia can work successfully contributes to exemplar pathways for others to work from.
Nurses need to raise the profile of clinical academia more broadly in order for the role clinical academics have as boundary spanners between higher education and clinical practice, and to make research accessible to all, ultimately improving patient care by being the interface between robust evidence and care.

CO N FLI C T O F I NTE R E S T
We have no conflicts of interest to declare, and this was an unfunded study.

AUTH O R CO NTR I B UTI O N S
NP conceived of the paper, with contributions from all the authors.
All authors, NP, BJ, CD, CM, FM and MB, contributed to data collection and writing of the report. NP, BJ and MB contributed to the literature search and study design, LW conducted independent analysis, and NP and BJ also contributed to data analysis. All authors read and approved the final article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.