2Centre for Nursing and Midwifery Research, Hunter New England Local Health District, Newcastle, NSW 2300 Australia
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2Centre for Nursing and Midwifery Research, Hunter New England Local Health District, Newcastle, NSW 2300 Australia
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2Centre for Nursing and Midwifery Research, Hunter New England Local Health District, Newcastle, NSW 2300 Australia
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1School of Health, University of New England, Armidale, 2351 NSW Australia
2Centre for Nursing and Midwifery Research, Hunter New England Local Health District, Newcastle, NSW 2300 Australia
Vicki Parker, Email: ua.vog.wsn.htlaehenh@rekrap.ikciv.
Contributor Information.
Received 2017 Jan 15; Accepted 2017 Sep 5.
Copyright © The Author[s]. 2017
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License [//creativecommons.org/licenses/by/4.0/], which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author[s] and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver [//creativecommons.org/publicdomain/zero/1.0/] applies to the data made available in this article, unless otherwise stated.
Associated Data
Data Availability StatementThe dataset being analysed / used during the current study is available from the corresponding author on reasonable request.
Abstract
Background
Improving health, patient and system outcomes through a practice-based research agenda requires infrastructural supports, leadership and capacity building approaches, at both the individual and organisational levels. Embedding research as normal nursing and midwifery practice requires a flexible approach that is responsive to the diverse clinical contexts within which care is delivered and the variable research skills and interest of clinicians. This paper reports the study protocol for research being undertaken in a Local Health District [LHD] in New South Wales [NSW] Australia. The study aims to evaluate existing nursing and midwifery research activity, culture, capacity and capability across the LHD. This information, in addition to input from key stakeholders will be used to develop a responsive, productive and sustainable research capacity building framework aimed at enculturating practice-based research activities within and across diverse clinical settings of the LHD.
Methods
A three-phased, sequential mixed-methods action research design underpinned by Normalization Process Theory [NPT].
Participants will be nursing and midwifery clinicians and managers across rural and metropolitan services. A combination of survey, focus group, individual interviews and peer supported action-learning groups will be used to gather data. Quantitative data will be analysed using descriptive statistics, correlation and regression, together with thematic analysis of qualitative data to produce an integrated report.
Discussion
Understanding the current research activity and capacity of nurses and midwives, together with organisational supports and culture is essential to developing a productive and sustainable research environment. However, knowledge alone will not bring about change. This study will move beyond description of barriers to research participation for nurses and midwives and the promulgation of various capacity building frameworks to employ a theory driven action-oriented approach to normalisation of nursing and midwifery research practice. In doing so, our aim is to make possible the utilisation, generation and translation of practice based research that informs improved patient and service delivery outcomes.
Electronic supplementary material
The online version of this article [10.1186/s12912-017-0249-8] contains supplementary material, which is available to authorized users.
Keywords: Action research, Practice-based research, Capacity building, Normalisation process theory [NPT]
Background
Recognition of the dynamic interplay between research and practice is essential to improving the quality of nursing practice. Research yields new evidence that is vital for improving health outcomes for patients and families. Given that nurses and midwives are uniquely placed in relation to health service delivery, patients, their families and carers, these professionals have an important contribution to make in improving patient and health outcomes via practice-based research [1–4]. Nurses’ and midwives’ knowledge and attitudes toward research have been examined extensively over time, as have barriers to nurses and midwives undertaking research [5–8]. However, little attention has been paid to examining the contextual dynamics that impact on the ability to establish a research rich environment and an active and productive clinician research workforce.
Review of the literature highlights the importance of capacity building with appropriate support, at all levels; working with individuals, teams and organisational systems and processes [3]. Further, fostering environments that are conducive to continuous service improvement through research has been shown to be fundamental to embedding research within clinical service delivery [3]. In spite of this extensive work, it remains that few nurses undertake research, and very little truly practice-based research is conducted either by, or in collaboration with clinicians. Notwithstanding the need to establish clinical research career pathways accompanied by formal education, working on the ground in the real world of practice is critical to making research possible and meaningful for nurses and midwives.
This paper outlines a protocol for a study designed to examine and build the research activity, capacity, capability and culture for nurses and midwives and to embed research as a normal legitimised element of clinical practice.
Research capacity has been described as a critical element required to advance nursing and midwifery research and development, and foundational to these professions providing clinical practice excellence [9–11]. Finch [4] defines research capacity as “enhancing the ability within a discipline or professional group to undertake high quality research” [p. 427], and Murphy et al. [12] describes capacity building as the “individual and organisational developments which lead to the greater ability to access, conduct and apply useful research” [p.14]. Condell and Begley’s [13] description of the concept - ‘research capacity building’ provides additional clarity. The authors offer the following, not as a definitive definition, but rather a description of the term as it is applied in the literature and derived from their concept analysis; That is,
“research capacity building implies, a funded, dynamic intervention operationalised through a range of foci and levels to augment the ability to carry out research or achieve objectives in the field of research over the long term, with aspects of social change as an ultimate outcome” [p. 273].
Condell and Begley’s [13] definition has been adopted for the purpose of this study.
Various research capacity building frameworks [RCBF] utilised to enable and support a culture of critical enquiry whilst simultaneously developing individual, team and/or organisational research capacity and capability have been reported in the literature. Descriptive accounts of these approaches range from; providing clinicians with targeted and structured research training and skills development opportunities and initiatives [14, 15], coordinating research activity around the deployment of key individuals, teams and units that are responsible for mentoring and leading clinicians through small local, practice-based research projects [9, 16–18], and whole of service/organisation models that aim to increase research activity and capacity across communities or groups of health care clinicians with a shared goal for driving a collective research agenda, usually within specialist multidisciplinary clinical contexts [12, 19–21].
These descriptive accounts have more recently given way to aggregated interpretations of what has been identified as the essential elements of a productive and sustainable approach to building research capacity within the disciplines of nursing and midwifery [22, 23]. A narrative review undertaken by O’Byrne and Smith [22] of publications from 1999 to 2010 identified three dominant models utilised for research capacity building in nursing and midwifery. The authors described these models as;
“the practice based model where research implementation and evaluation are prioritized; the experiential learning model whereby opportunities to develop research skills are provided through being supported to participate in collaborative research projects; and the facilitative model that integrates the above models to enable a broader approach to co-ordinating research activity, support and education across centres, units and networks in order to target the wider workforce” [p.1367].
Whilst O’Byrne and Smith acknowledge their review was limited by inconsistent definitions of capacity building across studies, together with a lack of evaluation studies with clearly identified outcome measures, it represents a comprehensive presé of activity and focus to date, and has identified a number of critical factors that enable the development of research capacity.
O’Byrne and Smith [22] identify collaboration, mentorship and availability of resources as enablers to research capacity. They also noted corroboration within the literature regarding the requirement for a cohesive plan with strong leadership and investment from managers. These findings support Cooke’s [24] six principles of research capacity building described in her multilevel [individual, team, organisational and supra-organisational] framework for planning and evaluating research capacity building in health care;
developing skills and confidence
developing linkages and partnerships
ensuring the research is close to practice
developing appropriate dissemination
investment in infrastructure
building elements of sustainability and continuity [[24], p.3].
Consistent with Cookes’ principles, Scala et al.’s [23] integrative review identified, “access to infrastructure, leadership support, strategic priorities and relevant interest, educational tactics and leveraging established networks and resources” [p. 428] as key themes associated with successfully engaging clinician nurses in research.
Whilst these critical elements for success have been reported consistently, few studies evaluating capacity building initiatives have been published. Such studies are necessary in order to provide evidence and guidance in the development of models that can be applied and adapted across a range of contexts. This study will examine the dynamic relationship between research and nursing practice in a large health district in New South Wales, Australia. It adopts a participatory action approach to implementation and evaluation of research capacity building in clinical practice.
Methods
Aim
The aim of the study is to identify existing Nursing and Midwifery research activity, capacity, capability and culture within the local health district [LHD] and to embed research as a normal component of nursing practice within clinical practice contexts.
The specific objectives of the study are to:
Understand the current views and attitudes of nurses and midwives in relation to practice-based research.
Identify current research expertise, practice and participation of nurses and midwives.
Understand barriers and enablers of research participation for nurses and midwives.
Gain consensus about what processes, networks and supports are required to normalise nursing and midwifery research practice.
Understand how context influences nursing and midwifery research culture.
Determine the critical success elements of a productive, sustainable and transferable research integration implementation model.
Design
A three-phased, sequential mixed methods action research study design will be utilised. Mixed methods action research takes a participatory, performative focus, integrating quantitative and qualitative methods with an action research methodological approach [25]. Martís’ [26] diagrammatic representation below [Fig. 1] highlights how combining methods in this ways allows for the integration of measurement and understanding to inform collective action.
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Fig. 1
Methodological approaches, methods and aims. Baseline [and simple] model. Figure 1 taken from Martí [26] [with author and publisher permission] originally published in Action Research
Integration of methods will be achieved by taking the evidence derived from quantitative data to participants for reflection and action in focus groups and in action learning sets where it will be used to inform decision making and action to embed research within clinical contexts through cycles of observation, reflection, planning and action. Greenhalgh et al. [27], support the utilisation of Participatory Action Research [PAR] within implementation research, acknowledging the reciprocal interactions between context and program success. This approach will engage nurses and midwives across the LHD working in diverse clinical settings who have varying degrees of research experience, peer and organisational support and accountabilities associated with research.
However, mixed methods action research is not without challenges. Navigation of integration throughout the cycles of the action research process will be particularly challenging, as will including stakeholders as co-researchers and designing workable and accessible methods [25]. Adjunctive utilisation of normalization process theory [NPT] will help mitigate these challenges.
Normalization Process Theory
Normalization Process Theory [NPT], first described by May in 2007 [28] and extended by May, Johnson and Finch in 2015 [29], will be used to guide the implementation and embedding of change into the complex and dynamic ‘real life’ nursing and midwifery practice contexts.
May [28] describes the journey of implementing and embedding interventions into complex environments as “trajectories of contingency”. That is, the processes by which agents negotiate and reconcile the “contending, conflicting and contingent and sometimes turbulent patterns of social action and relations, and their distribution across social time and space” [p. 27]. NPT has four general assumptions;
Innovations become embedded in practice as the result of agents working individually and collectively to enact them; that
Embedding of innovations is accomplished through generative mechanisms that take the form of agentic contributions by individuals and groups in processes of;
Coherence; cognitive participation; collective action; and reflexive monitoring. Mechanisms that are shaped by;
3.
Organising structures and social norms that specify the rules and roles that frame action, and the group processes and interactional conventions through which action is accomplished, and that;
4.
The reproduction of an innovation requires continued investments by agents in ensembles of action that carry forward in time and space. [p. 27]
The theory offers a framework within which to identify and understand the contribution that individual and collective groups of nurses and midwives make [or do not make], within and across dynamic and complex contexts as they negotiate the normative and relational environment in which they work. Work is required to accommodate research activity as an embedded and integrated feature of routine nursing and midwifery practice. Additionally, the complex and interdependent relationship between how nurses and midwives successfully [or unsuccessfully] embed and integrate research into routine practice, and what facilitative or obstructive contingencies operate to influence these outcomes will be illuminated. These findings will be useful in informing RCBFs that are responsive to nurses’ and midwives’ diverse and dynamic needs, but also in providing a robust process and outcome evaluation related to these interventions. Table 1 outlines how NPT will inform action learning sessions in the final phase of the study.
Table 1
Application of normalising process theory
QuestionsDesired outcomeCoherence- What is the nursing and midwifery research capacity?
- How is this evident in our organisation?
- What do we want to achieve and how can we go about it?
- What benefits will accrue in building research capacity amongst nurses and midwives?- Shared goals
- Role identification
- Finding valueCognitive participation- How do we get buy in from stakeholders?
- How do we reconstruct research as legitimate work for N&M in clinical practice environments?
- How do we sustain our efforts?
- How do we garner sponsorship, commitment, and resources from senior and executive level managers?.- Working together
- Reorganisation of work patterns
- Legitimisation – defining actions
- Staying on the caseCollective action- How can we work together to achieve shared goals?
- Taking responsibility and being accountable.
- Who will lead initiatives?- Operational work
- Interaction
- Relational integration
- Skill set workability [Who gets to do what]
- Allocation of resourcesReflexive monitoring- What are we learning?
- How can our learning inform our thinking and actions?- Appraisal
- Redefinition
- Refinement
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A phased approach
The study has three sequential phases outlined in Fig. 2.
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Fig. 2
Study design
Phase one
A LHD wide cross-sectional online survey of all nurses and midwives. Undertaking this initial scoping exercise will be important in providing base-line information about the;
nature of nursing and midwifery research across the LHD
existing research capacity within the disciplines
prevailing nursing and midwifery research culture
perceived barriers confronting nurses and midwives wanting to undertake practice-based research, and
existing enablers within the LHD that support nurses and midwives undertaking practice-based research within the LHD.
Survey development
The survey was developed based on review of existing and modification of previously validated instruments [Additional file 1]. The survey consists of 31 questions related to research activity, capacity, capability and culture, as well as previously identified barriers and enablers to research activity practice and participation in health. The constructs of the survey are detailed in Table 2. The survey also aims to provide demographic information and an overview of current Nursing and Midwifery research activity, individual skills, intentions across the LHD.
Table 2
Survey constructs
DefinitionMeasurement toolIndividual domain Perceived individual research intentionIndividual’s intent to engage with research activities and opportunities in order to inform their practice.Research and Development Culture Index [R & D Culture Index] [33] Perceived individual research capacityIndividual skill level across a variety of research related activities from finding the literature through to dissemination of findings.Research and Development Culture Index [R & D Culture Index] [33]
Research and Capacity Culture Tool [RCC Tool] [8] Perceived research relevanceImportance individual places on research for practice improvement and significance in daily work, relevance to profession and relevance to education.Nursing Research Questionnaire [NRQ] [6] Perceived research valueValue and impact of research in practice and on their profession.Nursing Research Questionnaire [NRQ] [6] Perceived translation of research into practiceExplores whether research is collaborative between clinicians and researchers, is directed by strategic priorities, improves patient and organisational outcomes through sustained practice change and used to evaluate interventions.Organisational domain Perceived organisational supportDegree of organisational support and opportunity for, and application of research in your team or service.Research and Capacity Culture Tool [RCC Tool] [8]
Queensland Health Practitioner Research Capacity Survey. [//www.health.qld.gov.au/hpresearch]. Accessed 29 Nov 2015.