Gender

The gender split of participants (see figure 1) was expected, due to the predominantly ‘female gendered’ occupations being questioned. For example, the majority of nurses (who outnumber AHPs considerably) and midwives, identify as female.17 There were 26 respondents in the study who held these roles.

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Figure 1

How participants described their gender.

Age

Despite the HEE aim of producing future clinical academic leaders early in their career,3 results in figure 2 illustrate that funding is currently being used to support individuals at mid/late career stage. Consequently, there may be potential implications for the career level (progression) and impact NMAHP clinical academics are able to achieve before they reach retirement age. This contrasts to the rhetoric of investing in future leaders, while also suggesting that ‘the potential of high-achieving graduates is underexploited’ (Baltruks, p8)18 as participants were waiting some years post-undergraduate award, to pursue clinical academic ambitions.

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Figure 2

Survey respondents’ age groups.

The current culture within the clinical setting was described as a particular barrier for clinical academic progression by participants in the 20 to 30 year age bracket:

I have come across lots of negativity in pursuing a clinical academic career as a nurse who is only a few years qualified (SR13 nurse/midwife).

They think to be an expert in your field you must’ve been qualified for like fifteen plus years. Well that’s just ridiculous because I know a lot more than some colleagues who’ve been working double the amount of time that I have and that’s just because I like to understand why I'm doing what I'm doing (CS1 nurse/midwife).

This indicates a need for a culture change so that NMAHPs are supported to join the clinical academic career trajectory at an earlier stage, for instance through the apprenticeship model.19 It seems that in some cases, individuals are expected to have a number of years’ experience and a secure clinical role before they are supported to embark on the clinical academic pathway, rather than being able to develop parallel roles like their medical colleagues.

Motivation

In contrast to doctors and dentists, research has not traditionally been a career route for NMAHPs. Participants described being self-motivated to pursue research, rather than follow a predefined path:

I've always, from very early on in my clinical career, had an interest in evidencing the work that I was doing. So I self-motivated really, did service audits and evaluations (CS14 AHP).

Participants overwhelmingly described how their interest in research was driven by improvements to patient care:

Clinical academics are part of the solution. We can innovate and generate the solutions for these age-old problems that we’re seeing, having a robust methodological approach to understanding and exploring the phenomena. But also developing and testing interventions to address these problems (CS9 nurse/midwife).

This illustrates the potential value of investing in clinical academic careers for NMAHPs who can move change from an idea into a tested intervention within their clinical practice.20

Participants often considered leadership of other people in their decision to pursue academic study:

I want to do this for me, but I also want to do it for my daughters to show that women can be in science and can lead in these fields and yes we might have to juggle family things and children, but you can do it (CS7 AHP).

Undertaking doctoral training and following a clinical academic career was also perceived to be about leadership opportunities and potential, as well as building a culture within the NMAHP professions so that many others could follow the path started by the few.

It’s essential for me to have a PhD because we need people to mentor, to supervise. I need to be at that level for the staff coming through, to help them (CS8 nurse/midwife).

Funding

The survey respondents included 35 current PhD students and 10 postdoctoral NMAHP clinical academics. Of these, 11 respondents’ PhDs were funded by the NIHR, 2 of which were the highly competitive and prestigious NIHR Clinical Research Doctoral Fellowship:

With a mortgage, a baby, one on the way it was only an NIHR fellowship… it was that or nothing (CS13 AHP).

I’m the main breadwinner, I earn more than my husband … so that financial part was a big barrier for me. I knew that the best financial support were the NIHR ones, so I took that time to develop that application. It didn’t just affect me, it would affect the whole family (CS7 AHP).

Students who did not manage to get NIHR funding were likely to be offered standard UK Research and Innovation stipends (approximately £14.5K per year).21 This was problematic for participants who had often reached high pay bands by the time they embarked on an academic pathway (eg, the £40K+per year salaries for a senior band 7/8 practitioner).22 It also meant they faced tricky decisions and negotiations about pension and employment rights:

Clearly I think an obstacle is when you get to that high clinical level and you've got mortgages and things, it makes it very difficult to do it on a basic stipend (CS14 AHP).

Some participants had received financial support from their employer which enabled them to make the move into academic study:

My employers said that if I applied for a stipend and was successful they would top me up to my full salary which would allow me to do it essentially full-time (CS14 AHP).

However, this experience was not the norm; rather, NMAHPs were being forced to make sacrifices in order to develop their career portfolio and skills. Nevertheless, 23 respondents (including 11 who had progressed from the NIHR funded Master’s degree in Research Methods) secured PhD funding from alternative sources as indicated in figure 3 below:

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Figure 3

Source of PhD funding (non-NIHR): CLAHRC = Collaboration for Leadership in Applied Health Research and Care; NHS = National Health Service, ESRC = Economic and Social Research Council

These 23 respondents included 11 nurses and 1 midwife which is interesting in terms of the NIHR 10-year report which says that nurses and non-healthcare professionals are less successful and, ‘For ICA, the lower success for nurses is a particular concern’(National Health Service, p11)5 (emphasis added). Our (regional) findings suggest that nurses are successful in securing alternative funding for their PhD studies, therefore NIHR metrics may not be appropriately capturing all NMAHP progression. By restricting progression metrics to purely NIHR funding sources, they are providing a narrative that does not reflect the experiences of clinical academics from these occupations working across the East Midlands region.

Maintaining a clinical role

The NIHR’s guide to the Integrated Clinical Academic (ICA) Programme describes how ‘the individual’s academic and clinical ‘jobs’ are not mutually exclusive but are instead complementary, informing and supporting each other, and definable within a single role’. (NHS Health Education, p6)23 Participants described the benefits of working in their clinical setting:

When I was on the ward I could kind of forget about the PhD but also recognise how it was shaping me as a nurse (CS1 nurse/midwife).

However, working at the same time as doing a PhD was identified as challenging. One participant who had secured a prestigious post before completing her PhD said:

The promotion is massive and the PhD is hugely important. You’ve got to somehow survive with the work and academia all at once and not fall down the rabbit hole and get lost. Yeah that's a big challenge (CS8 nurse/midwife).

Recognising this challenge, the Council of Deans of Health recommend ‘support from the clinical side including agreed study time (Baltruks, p9)18 for clinical academics. However, a recurring theme in the data was that managers are often dealing with operational care delivery challenges and were unwilling, or unable, to release staff to do research:

You have to get your line manager to sign the application form to say they’ll support you and it took a lot of effort to get that signed. They only gave in because my contract was 22½ hours a week. They said ‘what you do in the rest of the time is your own business, but it can’t impact on this, we’re not giving you any time off’. It was ‘what’s this got to do with your job?’ (CS5 nurse/midwife).

A common, potentially problematic issue encountered by the respondents was an apparent lack of recognition of the value of research:

There’s a huge untapped workforce…with the right support and time we could be doing things more effectively and more efficiently, but that isn’t necessarily valued in organisations. We’ve got to see this many patients, (we’re) not using our skills of criticality, reflectivity; we’re not going to innovate and change practice (CS7 AHP).

Despite their achievements during the PhD, many participants expressed anxieties about their future careers, having been made to move aside clinically in order to progress their academic ambitions, rather than being able to develop their academic and clinical skills in tandem. For example a dietician said:

Recently I’ve had to step out of my area of expertise… I’m just doing general, allergies, weight management, which is not my area, but I need to pay the mortgage (CS10 AHP).

This indicates a serious lack of organisational and professional value placed on the knowledge and skills achieved by some clinical academics. As a result, some participants felt there might be no option to stay in their clinical role post-PhD:

I would be keen to stay more NHS-based but constraints with funding and time might end up pushing quite a few of us out into university (CS2 nurse/midwife).

I currently work for an NHS trust, but the lack of support makes me wonder if the only option is to not work clinically, or work bank/agency, which to me is not embracing the value clinical academics can bring to the clinical area (CS13 nurse/midwife).

In contrast to the clear career trajectory for doctors and dentists, ‘early career clinical academics face uncertain career paths and may choose the comparably stable worlds of clinical practice where their skills are in high demand, or a dedicated academic career.’ (Health Education England, p9)3 The main reason being; ‘the scarcity and highly competitive nature of NMAHP postdoctoral research positions (…) and the comparative lack of research funding for healthcare professions other than medicine’ (Health Education England, p9)3 as this participant articulated:

My frustration (is that) the pathway is a pyramid therefore some people will not progress up (CS12 AHP).

The participants who had successfully negotiated this ‘pyramid’ generally did so with the help and support of key individuals within the organisation who were able to champion the cause of aspiring clinical academics at board level. For example:

I have a very supportive divisional head nurse and have been appointed into a trailblazer post; we haven’t got anything similar within the organisation. So there’s real potential to forge out innovative ways in which clinical academics can fulfil that remit of working in clinical practice and undertaking research, but also pave the way for others that want to come up (CS9 nurse/midwife).

Similarly, the chief medical officer argues that ‘developing the next generation of research leaders in clinical research is essential to the UK, (Davies, 502)24 but the data suggest a cliff-edge in the pathway; greater numbers of practitioners are embarking on clinical academic careers, but following PhD, opportunities are scarce. The fortunate have the organisational backing to ‘trailblaze’, but others face a decision to return to their pre-PhD clinical role (and hence not have their academic skills recognised and utilised) or follow a traditional academic research pathway and leave their clinical post behind (thus negating the whole reason for pursuing a clinical academic career).

Individual level

Participants reported benefits such as job satisfaction, increased awareness of research, enhanced skills and sense of achievement. Progression post-master’s level was achieved by 52 respondents, of whom 19 were nurses/midwives. Although this echoes concerns for the relatively low progression rates of nurses/midwives when compared with AHPs,5 6 nurses/midwives were pursuing Master’s level courses at the time of the survey and may have since progressed.

The clinical academic pathway had presented opportunities for career progression. One participant had been ‘talent-spotted’ and offered ‘numerous extra employment and development opportunities’. When asked about any changes to their employment/role/grade since embarking on the clinical academic pathway, almost half (31) of the 63 survey responses described positive changes, although 5 of these reported no change in their pay band. Six had been seconded but risked reverting to their lower pay band when the secondment ended.

Respondents who had gained clinical academic roles described having separate contracts of employment (ie, one each for NHS and academia) with separate employment and pension rights. Nine respondents had been promoted with one becoming a consultant midwife, and another achieving a clinical lectureship (a pivotal post in the NIHR ICA funded clinical academic trajectory).

Patients and their carers

The research undertaken by the participants could potentially make a big difference to patient outcomes and experiences. For example, an AHP had identified an element of practice that could extend and improve the lives of seriously ill children. Another participant had introduced a pre-surgery exercise programme which helped patients to feel involved in the process and was highly rated in a patient satisfaction survey.

These examples illustrate how NMAHPs on a clinical academic pathway are uniquely placed to develop interventions which can be easily implemented with positive results for patient care.

Peers/colleagues

Many participants described their pride at becoming role models, able to support other colleagues into academic study:

I’ve mentored a lot of different kinds of professions to actually realise that it is doable. That’s a really rewarding side to the job to think that you might have helped somebody (to) be a more able clinician, a more able academic which can then impact on the patient (CS7 AHP).

This demonstrates the important role of mentors in encouraging future clinical leaders by providing ‘pastoral support and help(ing) mentees deal with the demands of a clinical academic research career’. (Baltruks, p10)18 It also reveals the value of investing in staff who then give back.

NHS Trust

Recognising that research intensive organisations have better patient outcomes, the Care Quality Commission have introduced research into its quality framework.26 Respondents described numerous benefits for the NHS organisations who supported clinical academic careers. For example:

At the hospital they want this Magnet status.27 The three domains are good clinical outcomes, patient experience and staff experience and part of (that) is having well qualified nurses. They really want to increase the academic underpinnings of nurses and have research leaders…what I’m doing really ticks the boxes of Magnet (CS5 nurse/midwife).

Participants highlighted how supporting clinical academic careers could address current issues with recruitment and retention:

Forty thousand nurses we have a national deficit of, so people can choose where they want to work. They’ll be looking for organisations that are aspirational. So actually offering innovative career pathways that can intellectually challenge, but also have that direct patient care element, is going to be attractive to a lot of people (CS9 nurse/midwife).

These comments resonate with the NIHR’s advice for aspiring clinical academics ‘to base themselves within organisations where the importance of research is well understood and clinical academic careers are appropriately supported.’ (NHS Health Education, p6)23

The data revealed numerous examples of impact resulting from participants’ clinical academic careers, including the potential for substantial savings. For example, one participant’s intervention removes the need for GPs’ referral for physiotherapy, potentially saving ‘multimillion pounds’ across the NHS, and has subsequently been recognised in the NHS long-term plan.28 This illustrates how clinical academics can develop ‘well informed and relevant research’ (NHS England, p5)4 that can quickly be transferred into practice for the benefit of the NHS.

Inter(national)

Participants provided details of multiple academic journal articles and conference presentations enabling worldwide dissemination of their research. In addition, one participant was invited to join an International Working Party developing consensus guidelines for treating children with kidney disease.

In another example, an open-access resource to help professionals to deal with children in mental health crises, specifically those at risk from self-harm, had been ‘disseminated nationally, not just within health, but also in social care and education settings’. This illustrates the wide-ranging impact of clinical academics’ research which can occur more speedily than traditional research.

These reported experiences represent a small snapshot of the benefits of supporting NMAHPs to pursue clinical academic careers and the need to do so, as one participant articulated:

Moving forward we have to look at more sustainable and integrated approaches to embedding clinical academic careers. I’m excited to hear that there’s an apprenticeship framework coming out because for clinical academic careers to be truly embedded within non-medical professional career pathways, it has to be driven by the NHS. Universities get the value of clinical academics and they’re on board, but for it to truly work, we need to have change within the NHS (CS9 nurse/midwife).