Duality of practice in clinical research nursing

Sampling

Most proponents of IPA endorse the recruitment of a homogenous sample to ensure that the research findings are meaningful (Brocki and Wearden, 2006; Pringle et al., 2011; Smith et al., 2009; Smith, 2011). This was achieved by ensuring that all participants were active CRNs (that is, CRNs that were actively involved in recruitment and delivery of clinical research projects/clinical trials). As some CRNs work independently with one principal investigator and others work with a number of investigators, some degree of heterogeneity was included. Indeed, Pringle et al. (2011) suggested that the effectiveness of IPA might be compromised if the sample is too specific or unique. Subsequently, limited heterogeneity also broadened the scope of the research, whilst reflecting some of the breadth of the settings and experiences that CRNs have, both nationally and internationally. Though IPA does not seek to be comparative or representative, commonalities can be useful to a wider audience (Smith et al., 2009).

Using a purposive sampling approach, participants were sought who were most likely to answer the research questions (Robson and McCartan, 2016; Smith et al., 2009). Purposive sampling assisted in ensuring that the participants had the experience that was required to answer the research question and also allowed selection of nurses who work independently and others who work in a team (Bryman, 2008). Following this process, 10 CRNs were recruited. Of the 10 participants, eight were female and two male, seven worked in research teams with other research nurses, whilst three worked more independently. All were either National Health Service band 6 (senior staff nurse level) or seven nurses (charge nurse level), or University equivalents. Three of the 10 participants worked in the same unit. All worked in large teaching hospitals. The study was given ethical approval by Queen Margaret University. In accordance with this, written informed consent was obtained from all participants in advance of their interview and participants were allocated a number following a non-chronological system to maintain anonymity.

Data collection

Brocki and Wearden (2006) and Smith et al. (2009) suggest that a number of data collection methods can be used in IPA, including focus groups, observational notes and diaries. However, the most frequently used method is semi structured interviews. These were utilised in this study as they allowed for the participants to explore their experiences, whilst providing a framework for discussion (Hanson et al., 2011).

In IPA the semi-structured approach is often incorporated into an overall interview schedule (detailing questions) that allows the participant to answer key open questions, but also be invited to be more analytical (Brocki and Wearden, 2006; Smith et al., 2009). This approach was used to provide a flexible structure for the interviews. Following review of the literature the questions used are detailed in Table 1. The interviews were conducted throughout 2018.

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Table 1.

Questions used in the interviews.

• What is it like to be ‘you’ in this job?

• Can you describe your experiences of facilitating research in a clinical setting?

• What are your experiences of interactions with clinical nurses?

• What do you think about these experiences?

Following the questions detailed in Table 1, participants in the wider study were not specifically asked about dual/clinical aspects of their role. Subsequently, if this was explored in the interviews, it was at the participant’s own instigation and was not directly prompted by any of the questions posed by the interviewer. Interview data were recorded on an electronic recording device and were transcribed by the researcher. Any pauses, emphases, laughs or other changes in tone were noted to assist in linguistic analysis (Finlay, 1999).

Findings

Of the 10 participants, nine discussed that they undertake clinical duties in their CRN role, though the rationale for this varied between participants. The findings from these participants appeared to indicate that dual clinical and clinical research roles either had a positive, neutral or negative impact on their experience. These will be explored in this section under the three headings of positive, neutral and negative perspectives.

As a context for this exploration, all of the CRNs expressed an understanding that, despite a universal appreciation of the importance of research, they clearly understood their professional responsibility for patients, the primary importance of clinical care and the need for it to be prioritised in a demanding environment. They also indicated that they understood the pressures that clinical staff face. This also reflected a patient-centred approach. Three examples of this are as follows:

P1 ‘I’ve always said. Your clinical care comes first. Research is second. The staff know that. I have said that. I can do what I need to do later’.

Positive perspectives

Six of the participants highlighted how assisting with clinical care could have positive outcomes in terms of supporting patient care and building positive relationships with the clinical nursing team.

The general context for a dual role appeared to be related to the CRNs, wish to help with clinical care and, importantly for some, to be seen to help. For most, this also had an element of quid pro quo, or by way of explicitly or implicitly building up feelings of goodwill with the clinical nurses. In this light, Participants 5 and 8 very much viewed clinical and clinical research work as forming a symbiotic relationship.

P5 ‘We are here to support you with the research patient, but they are also clinical patients. Helping and supporting. This is important, so that the clinical team feel supported by the research team and vice versa because we work together, especially in clinical research so that we have a good relationship’.

Participants 6 and 7 also indicated that when they undertook clinical duties, it was often directly related to responsibilities that they had for the research studies that were being undertaken. In this way, Participant 6 explained that there could be multiple benefits in these actions.

P6 ‘But equally, you can be helpful, when you can. Say for example, you are taking off a set of bloods from someone, you ask if you can do any bloods for them, at the same time. Not only helpful for the patient, but it might also sweeten the deal, for clinical colleagues’.

Whilst Participant 7 articulated a desire to be helpful to clinical staff.

P7 ‘Another thing that I do is make myself useful. If blood needs taken, if a cannula needs to go in, if someone needs taken to the toilet, then, um, I’m there. I can do it, that’s not a problem’.

Participant 3 expressed that helping is sometimes initiated because the CRNs are part of the larger team. However, they also indicated that an additional effect could be to help to build positive relationships with the clinical nurses.

P3 ‘Sometimes you do think, it would be really good for me to go and do something for this patient because it would help the nurse out and ingratiate me, but that’s not the driving factor, because often you are just doing it as part of that. We very much try to see that we are all part of the same team’

Participant 3 also indicated that by undertaking some clinical duties, it may help to strengthen the feeling that CRNs are part of the team.

P3 ‘They know that we will, you know, and if the unit is busy, like it is at the moment, we are quite happy to go in and help by, you know, toileting patients or giving treatments, or to make up antibiotics, or whatever. We recognise that we are all working together in the department. So, we will do that, because we are part of the team’.

Whilst Participant 2 also noted that this approach was particularly useful in terms of building positive relationships.

P2 ‘It is really important, in that situation. If you can do something that the clinical team could do…that is to everyone’s advantage [pause] it really helps with relationship building, for obvious reasons. That frees them up to do something else’.

These examples demonstrate some of the ways in which a CRN can utilise a clinical component of their role to contribute to patient care and confirm how this can be mutually beneficial for clinical nurses and the CRN colleagues.

Neutral perspectives

In addition to positive thoughts on the dual role, some of the participants also offered more neutral perspectives on this.

Participant 5 noted that they were happy to help out with clinical care, but they were cognisant of the potential impact that this might have on their time to devote to research duties.

P5 ‘One day they [the clinical nurses] were asking for help and I was there, they would ask me to help. This is very useful. Anything you can do to help the clinical team, because they are very busy…We do not want to add to the clinical staff workload, but at the same time you want to do research’.

Furthermore, Participant 9 noted that conducting clinical duties may have been related to their own feelings of guilt.

P9 ‘Well, I think I had worked there long enough that I could survey the department and knew how bad it was and if it did look like clinically it was becoming unsafe, I would go to speak to my line mangers and say “I think I really DO need to go and help”. Emm, just probably for my own guilt’.

But Participant 9 also expressed that this was not something that could be assured of. This was because they were aware that clinical care was not their primary responsibility and by helping out their ability to undertake clinical research responsibilities could be compromised.

P9 ‘I didn’t want to get into the habit of that, because I was being paid to do another job, so you had to be quite strong and say “No” unless it was close to being [a significant event]’.

Following on from the awareness of how busy the unit was, Participants 4 and 6 indicated that undertaking clinical duties could be related to this.

P4 ‘Sometimes we also try to help out. You know if ward is really horrendous we will ask if we can help out, but we don’t…it is something that we have spoken about and I think people would be willing to go and do. We do act as a pair of eyes if the nurse needs to nip off for something’.

Unlike the positive experiences explored in the previous section, these examples demonstrate that CRNs, considerations for undertaking clinical duties might be more nuanced. They also indicate how dual aspects of the CRN role might be connected with feelings of guilt, whilst also highlighting that some CRNs are aware that undertaking clinical duties could impinge on their research workload.

Negative perspectives

Lastly, some of the participants indicated that assisting with clinical care might be associated with more negative consequences.

Participant 9 indicated that a dual role could have more negative outcomes as some clinical nurses seemed to express that helping with clinical care should be a priority, as it was perceived that there were no time pressures associated with their clinical research workload.

P9 ‘Most people were supportive and curious, but there are a few characters that, especially if they don’t understand the role of a research nurse, or have no idea what you do, or what you are doing and didn’t really have any interest, then they would be thinking “You should be helping us, because you can do your job whenever”, that was quite difficult’

Interestingly, a perception that CRNs did not undertake clinical care could be conflated with not being a nurse anymore or an opinion that it was not ‘real’ nursing. An example of this was discussed by Participant 10.

P10 ‘However, outside of work, when I talked to other nurses and physios, there was a definite attitude that I was turning my back on the profession. That I was somehow too posh to wash…, about being elitist…there was this feeling that I was turning my back on being a nurse and, yeah, what was wrong with just helping people, being a nurse, washing a patient, being in a ward’.

Additionally, Participant 6 appeared to equate helping out directly to more recognisable ‘nursing’ duties. Thereby, potentially, indicating that the CRN role could not be described as such. This was a recurring theme in some of the discussions, with the concept of the CRN role sometimes not being perceived as a ‘real’ nursing role.

P6 ‘I think particularly because they don’t just see us walking about with the age old thing about walking around with a clipboard, not really doing anything, so we will do nursing things’.

This was particularly acute for Participant 10 as they had not worked clinically prior to becoming a research nurse. As a consequence of this, they themselves questioned whether they were a ‘real’ nurse.

P10 ‘I am kind of OK with it, because I have never been a ‘real’ nurse…Most of my friends who are research nurses, had a time when they were clinical and they have that duality of experience, so I didn’t go from one to another, like I have always been in research any time I have been nursing. So, as I said earlier, at the beginning of my career I was acutely aware of my lack of clinical skills’.

Though, after Participant 10 had considered this, they concluded ‘of course I am a real nurse’.

The examples described above detail more negative perspectives; be it either in terms of a perception that the work of the CRN, or that the CRN role itself, was undervalued. These perceptions were also expressed by some of the CRNs themselves.

The excerpts from the interviews serve to demonstrate some of the experiences that CRNs have had relating to a dual role. They have ranged for the positive, to more neutral (or considered) to perceptions that were more negative in nature.