Building research capacity and culture: Exploring nurses' experience of implementing a nurse‐led clinical trial

Abstract Aim To explore the experiences of a nursing team who implemented an international nurse‐led clinical trial in practice and understand the facilitators to their involvement. Background The role and responsibilities of the clinical nurse are advancing to encompass research activity to help inform evidence‐based practice. However, several personal and organisational challenges can inhibit nurses' capacity to implement and undertake research within clinical practice. Methods Three focus groups were conducted with members of a nursing team (N = 18). Thematic analysis was employed, and themes were identified and agreed upon by the research team. Results Five themes were identified: ‘Previous experience of and attitudes to participation in clinical research’, ‘Decision‐making regarding participation in the clinical trial’, ‘Facilitators of participation in the clinical trial’, ‘Challenges of research in nursing practice’ and ‘Future orientation towards research’. Conclusion Through their experiences of implementing a nurse‐led clinical trial within practice, nurses recognized a number of facilitators and challenges to their participation. The perceived relevance of the clinical trial to the nurses' practice, potential to improve patient care and appreciation of the nurse leader's expertise and understanding of their context were key motivators. Reciprocal trust with the nurse leader who was encouraging, motivating, supportive and accessible resulted in the engagement and commitment of the nursing team. Implications for Nursing Management This paper offers a perspective that can inform senior nursing management teams when implementing and conducting evidence‐based research amongst nursing teams and in doing so meet the needs of developing research capacity amongst clinical nurses.

regarding nurses implementing and undertaking research, studies commonly focus on the barriers to their research engagement. Key challenges include personal factors such as lack of knowledge or training, negative attitudes and lack of opportunities (Chien et al., 2013;Lode et al., 2015;Timmins et al., 2012;Vijayalakshmi et al., 2014) and organisational factors include lack of resources, time, funding and support from fellow clinicians (Hagan & Walden, 2017;Lode et al., 2015;Sanjari et al., 2015;Silka et al., 2012). With the expectation for clinical nurses to be research active, there is a need to build research capacity and support nurses in all aspects of the research process (Birkhoff et al., 2020;Cooper et al., 2021;McKee et al., 2017).
Research capacity refers to the ability to conduct nursing research activities in a sustainable manner in a specific context, normally at a group rather than individual level (Chen et al., 2019), while initiatives to support nurses to acquire research skills are necessary.
Several components have been identified as crucial to building research capacity: competence, motivation, infrastructure including material and management support, academic/clinical collaboration and strong leadership (Cooke et al., 2018;Cooper et al., 2021;McKee et al., 2017). The context of an international, multicentre, nurse-led clinical trial was recently used as an opportunity to build research capacity within a cancer nursing team. The aim of this study was to explore the experiences of a nursing team who implemented an international nurse-led clinical trial in order to understand the facilitators to their involvement in the study.

| Study design
This was a qualitative study using Thematic Analysis, a pragmatic approach to qualitative research commonly applied within health care research (Braun & Clarke, 2021). The study was guided by the three key research questions: • What are the experiences of nurses who implemented a nurse-led clinical trial within their practice?
• What motivators exist for nurses to engage in conducting research?
• What are the facilitators and challenges of building research capacity and research culture within a nursing team?

| Context of the clinical trial
The eSMART ® clinical trial tested the advanced symptom management system (ASyMS) intervention which utilizes mobile device technology to enable real-time, 24-h monitoring and management of patients' self-reported chemotherapy-related symptoms within a European multi-centre context (Furlong et al., 2019;Maguire et al., 2021). Patients with cancer used a dedicated mobile device to complete a chemotherapy-related symptom questionnaire daily. For symptoms that required clinical intervention, the algorithm generated 'real time' alerts to the clinical sites via a dedicated clinician handset and alerts were managed by the nursing team ('alert handlers') 24-h a day, 7 days a week. The eSMART trial was conducted in the cancer centre over a four-year period, including a randomized controlled trial that began in July 2016 and was completed in December 2018.
The Lead Cancer Nurse, who was responsible for implementing the study, that is, nurse leader (NL), had worked in a clinical capacity at the cancer centre for over 15 years. The nursing team who participated in the clinical trial comprised 64 nurses from various nursing roles, including staff nurses, nurse managers and clinical nurse specialists, who were based in the oncology dayward and in-patient oncology ward. Staff participation in the clinical trial was on a voluntary basis and was not a requirement within their role. The NL was responsible for staff training, patient recruitment, management of study equipment, data completion, reporting technical/clinical issues and alert handling. The clinical nurses were responsible for handling alerts generated by patients.

| Participants
Purposive sampling was employed to recruit participants (i.e., members of the nursing team involved in the clinical trial) who would provide a comprehensive and well-developed understanding of the phenomenon of interest (Liamputtong & Ezzy, 2005). To be eligible, nurses had to be currently employed at the cancer centre and had to have participated in the implementation and undertaking of the clinical trial at any stage of its duration. The study was advertised by poster and requested nurses to contact the research team if they wished to participate.

| Data collection
Three focus groups (FG) were conducted with a total of 18 participants who met the inclusion criteria once the clinical trial was completed. This data collection method was chosen to draw on the group interaction to generate insights that may not have been possible without the interaction within the group (Barbour & Morgan, 2017).
FG were conducted in a private boardroom within the cancer centre at a time that did not interfere with the participants' working day. FG varied in size as follows: FG1 (n = 4), FG2 (n = 8) and FG3 (n = 6) respectively. Each FG was conducted by two facilitators, who did not have a working relationship with the participants. Two of the facilitators were members of the clinical trial research team within an academic institution, while the third was impartial had no involvement in the clinical trial. A semi-structured topic guide was designed for the FGs. FG duration ranged between 31 and 52 min. A short demographic information form was given to each participant to complete at the end of the FG to capture their educational background and professional experience, as detailed in Table 1.
Field notes were written after each focus group. During data collection, the research team discussed emerging themes to ensure the topic guide reflected the context and was refined if necessary. Data collection was complete when no new themes emerged.

| Data analysis
FG interviews were digitally recorded and transcribed verbatim.
Thematic analysis was used to analyse the data which enabled the research team to identify, interpret and describe in rich detail key elements of participants' accounts and to organise them into meaningful themes systematically and reflexively (Braun & Clarke, 2021). This analysis process included six steps, as defined by the authors: (i) becoming familiar with the data and note taking, (ii) systematically coding the data, (iii) generating initial themes from the coded data, (iv) developing and reviewing themes based, (v) refining, defining and naming themes and (vi) writing the report. One author conducted the initial five steps using Microsoft Word documents and subsequently presented the preliminary themes to the research team. All members of the research team reviewed the proposed themes and read the original data transcripts to validate, refine and agree on the final study themes. To enhance the trustworthiness of the study (Lincoln & Guba, 1985), member checks were undertaken. Participants were sent the final version of the findings and provided feedback for comprehensiveness, with no changes suggested. The research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

| Ethical considerations
Participants received written information about the study and were assured confidentiality and their right to withdraw, without any consequences. Written informed consent was obtained from each participant prior to FG commencement. All personal data was pseudo-anonymized and an identification number was assigned to each participant. The code list was stored in a secure file password-protected Microsoft Word document, which was only available to the research team.

| FINDINGS
Thematic analysis of the FG transcripts identified five major themes, as outlined in Figure 1.
The following findings represent a variety of perspectives of the participants who took part in the clinical trial and their experience of undertaking research. Participant quotations are utilized to illustrate the themes and to highlight the consistency between the data and the research team's findings (Eldh et al., 2020).

| Decision-making regarding participation in the clinical trial
Participants discussed their experience of deciding to take part in the clinical trial when it was presented to them by the NL. A key motivator was how they recognized the research study as an international project being led by nurses, which they believed was unique and engaging and could improve their patient outcomes: 'It's only by doing these audits and research that practice is going to change, to be part of that …' (FG2) Participants commented on their awareness of how the clinical trial was being embedded in their standard patient care practices and though their participation was on a voluntary basis, some felt that it would be beneficial to support the project rather than excluding themselves from it: 'It was going nowhere; we were not getting away without doing it! (Group laughs) … we had a choice obviously but also it was put to us that it was going to be for the long- Participants also recognized the NL's commitment to the clinical trial, unwavering belief in the study and her availability and support which they found inspiring and motivating: 'I remember one of the students ringing her at the weekend and she decided to come over, like she was off that day, and she came in to show her exactly because she was not able to explain it over the phone so you know she was there' (FG3) Second, a key facilitator was the shared accountability and support network they established to undertake the clinical trial: 'You always knew who to go to if you were unsure or whatever, because so many people had decided to participate, there was lots of people to chat around it. There was a good team effort I think'. (FG2) Following official research training on recruitment and data collection for the study provided by the NL and the research team at the initiation of the study, participants described how they also learned from each other regardless of staff role or nursing experience-level: 'I think I probably learned more from the girls who were already doing it' (FG2). Additionally, the NL established a WhatsApp group, including staff involved in the study, to maintain a dialogue and answer any queries: 'the option was there to ask your peers' (FG2). Third, the perceived benefits of undertaking the clinical trial, focusing on their clinical practice, was considered as a motivational facilitator. Participants had a sense of ownership regarding the research as it was nurse-led and regularly referred to the study as 'ours'. Nurses recognized that they were contributing to cancer care practice both on a local and international level which could have future benefits for patient care. Participants also mentioned the benefit of funding received for participating in the trial which was used to invest in their further education or conferences. One participant mentioned how they included this research experience during a promotional job interview. Additionally, some participants commented on how they believed there was excessive responsibility and pressure placed upon the NL in coordinating the research study. One participant underlined how the duties of the NL were 'too much for one person' and others commented that it would have been beneficial if the responsibilities were shared with other designated leaders.

| DISCUSSION
The findings of the current study shed light on the experiences of a nursing team undertaking and integrating a clinical trial within their practice. Echoing previous evidence (Hagan, 2018;Lode et al., 2015;McKee et al., 2017), our study found that prior to their involvement in the clinical trial, the nurses believed undertaking clinical research was not within their remit and they did not expect to be involved (Van While culture and restraints within nursing practice are not conducive to research practice (Birkhoff et al., 2020), context was a critical factor in determining nurses' interest and motivation to implement and undertake the clinical trial. First, nurses recognized how the aim of the nurse-led clinical trial was relevant to their role, whereby it has been found that when research is not relevant to nursing practice it can be a barrier (Hagan & Walden, 2017;McKee et al., 2017). Participants identified how the study aligned with their practice and how it may ultimately improve patient care and identify improved care methods. Second, nurses recognized that the NL understood what it meant to be a cancer nurse, their responsibilities and the nature of the patient profile. Participants were aware of the NL's expertise and understanding of their environment which, in turn, inspired and fostered the belief that they were capable of conducting clinical research within their role. This is outlined in previous literature as imperative to effective leadership (Collins et al., 2020;Ferreira et al., 2020). Consequently, the team further built on their trusting relationship with the NL, previously identified as being important for implementing change (Doody & Doody, 2012;Xu, 2017), and was a key motivator to their involvement in the clinical trial.
Acknowledging Nevertheless, an important facet cited by nurses was that the NL was accessible to them during the trial, echoing Ferreira et al.'s (2020) findings. While the nurses identified how the NL was available to them for training, troubleshooting and informal conversations about the clinical trial, they also valued the innovative training and supports they implemented, echoing Hudson's (2020) findings. Nurses benefited from a WhatsApp group for learning involving the team and educational posters located in the cancer centre, created by the NL.
Similar to findings by Chen et al. (2019) and Ferreira et al. (2020) nurses in this study appreciated being informed of the trial's progress and outcomes by the NL who adopted constructive criticism and positive reinforcement as a communication style in the process. Nurses felt that they were in a safe space where errors (e.g., in recruitment or data collection) if made, were seen as opportunities for learning. The NL's communication approach demonstrated an effective leadership skill identified in previous studies (Doody & Doody, 2012;Hudson, 2020).
As previously mentioned, while nurses were not exposed to the clinical trial study design or the data analysis, their involvement made

| APPLYING TRANSFORMATIONAL LEADERSHIP IN NURSING RESEARCH
The evidence emerging from this study suggests that a leadership style influences followers by building trust, using effective communication skills, encouraging engagement in decision making and empowerment in achieving common goals (Ferreira et al., 2020). More specifically, the style of leadership identified by the nurses is akin to that of transformational leadership (TL) (Collins et al., 2020;Ferreira et al., 2020). The four elements of TL (i.e., ideal influence, inspirational motivation, intellectual stimulation and personal consideration) (Collins et al., 2020;Ferreira et al., 2020;Hudson, 2020;Xu, 2017) were evident in the participants' experience of the research. Transformational leaders can inspire through their innate personality traits and characteristics, such as emotional intelligence (Wang et al., 2018), which cannot be learned. They cultivate relationships based on trust, respect and recognition of individuals' abilities (Hudson, 2020) and foster job satisfaction (Boamah et al., 2018;Wu et al., 2020). TL was effective in empowering nurses in this study to engage in a collective learn-by-doing approach to implement the clinical trial. The nursing team took ownership of the clinical trial and recognized their direct contribution to the evidence-base in line with their increasing sense of empowerment in clinical research activities.
Transformational leaders must have self-confidence and firmly believe in the vision and have courage to achieve their goals (Xu, 2017) which participants observed through the NL's implementation of and unwavering commitment to the clinical trial for its duration. While TL has been previously discussed regarding clinical practice (Collins et al., 2020;Ferreira et al., 2020;Xu, 2017), to the best of the authors' knowledge, this is the first study to explore its role in building research capacity amongst nurses. Our findings contribute to the existing knowledge regarding transformational leaders being change-agents in nursing practice (Boamah et al., 2018) by highlighting their significance in implementing and building research capacity. Figure 2 presents reflections of the NL regarding her experience of co-ordinating the research within clinical practice.

| LIMITATIONS OF THE CURRENT STUDY
A key limitation of this study is the retrospective nature of the data given that it was collected after the clinical trial was completed. A F I G U R E 2 Reflections from the nurse leader longitudinal approach may have garnered in-depth findings regarding how nurses' attitudes to and capacity for research changed over time.

| IMPLICATIONS FOR NURSING MANAGEMENT
TL is an effective model to empower nurses to implement research within clinical practice and to cultivate a research culture. While nurses may be more likely to engage in research if it leads to improved practice or patient care, consideration also must be given to how the research is implemented and the leadership style employed to engage a nursing team. TL has been found to be crucial when inspiring change, innovation and creativity in practice (Collins et al., 2020;Ferreira et al., 2020;Hudson, 2020 (Doody & Doody, 2012) and support the adoption of leadership teams while conducting nursing research.

ACKNOWLEDGMENT
We would like to thank all the nursing staff who participated in the study. No external or intramural funding was received.
No funding was received to conduct the current study. The eSMART project received funding from the European Union's Seventh