Abstract
It is heartening to see further research being undertaken to understand the perceived tension between professional scope of practice as a nurse and that of a clinical research remit. Why does this topic matter and why is it timely? Well, evidence suggests that unresolved ethical conflicts or challenges in nursing practice (like those described by participants in this study) negatively affect staff retention, job satisfaction, patient care and burnout (Morley 2018). There is a growing body of empirical research describing the role, remit and experience of a clinical research nurse (CRN) (Biswell et al., 2021; Hernon et al., 2020; Zucchelli et al., 2018; Whitehouse and Smith, 2018; Kunhunny and Salmon 2017). The experience of duality has been explored, with implications for professional identity, nurse-patient relationships and research delivery identified (Larkin et al., 2019; Tinkler et al., 2018). Similar dichotomy is described in other nursing roles including academia (Andrew and Robb, 2011).
The reviewed study explored the experience of ten CRNs and their working relationship with other nurses through interview, utilising an interpretative phenomenological analysis approach. It is likely this group reflects the experience of CRNs working in acute hospital settings, but the study may benefit from replication in community and social care settings. We know that CRNs in this setting experience a similar but different caring-research dichotomy, in the context of unmet care needs and support pressures (Biswell et al., 2021). Duality of a research and clinical role, although not a primary outcome at the outset, emerged and is the specific focus in this paper.
This piece of research was undertaken prior to the pandemic and as such it may not reflect the significant impact of the COVID-19 response on the research remit, clinical skills and the pressures to meet care needs of patients on CRNs - a fact acknowledged by the authors. The role of the CRN during the COVID-19 pandemic evolved (Evans 2020; Jones et al., 2020; Iles-Smith 2020) alongside the shifting landscape in which we practice. Research has been highlighted as the exit strategy, as has the central role and expertise of the CRN to drive clinical research in this endeavour (Maxton et al., 2020).
The term duality describes the opposition or balance of two contrasting concepts. A defining feature of clinical research delivery is that it operates at the interface of research and clinical care. A research nurse role by its very essence, then, is clinical. It is a patient-facing role and whether these interactions are for clinical research purposes or standard of care reasons, both are clinical in origin. The balance of duality, as emerged in this study, is in the competing demands of clinical pressures and research delivery requirements and not simply just a clinical versus research remit. The tension is not just due to the requirement to provide clinical care per se, as this should be expected and intertwined within the nursing role (whether required by the study participation or by their standard clinical care). This tension or imbalance seems to sit in the time pressures presented by clinical care that is not associated with research participation itself. In practice, of course, it can be hard to distinguish where the research ends and where the clinical care starts. It may be more subtle than answering a call bell on an inpatient ward or an obvious unmet care need; it may be ordering additional bloods to check a full blood count in a fatigued research participant or referring to smoking cessation services, neither strictly part of the research protocol but essential aspects of patient-centred care and advocacy.
As most CRNs have a clinical aspect to their role, robust induction, clinical supervision, support and training is needed. This is to ensure CRNs are prepared and enabled to effectively and confidently manage such conflicts and challenges to their identity and remit. It was interesting that most participants in this study understood that clinical care was a priority but didn’t strongly identify their own research role as clinical, in and of itself. This is affected by many factors including study type, seniority and experience but perhaps there is work to do within the profession to ensure our clinical specialism and expertise is realised by research nurses themselves. It was surprising that engagement with clinical care outside of the research role was found to be largely driven by reciprocity and not patient-centred care and effectively meeting the patient-care needs. This is perhaps indicative of the pressure that teams are under and the professional dilemma they have with regard to their identity. The inaugural UK and Ireland-based census of research nurses and midwives conducted during 2021 is a good starting place for describing, and subsequently addressing, this professionalism conflict and I eagerly await the results (Mitchell, 2021).