An action research approach for developing research and innovation in nursing and midwifery practice: Building research capacity in one NHS foundation trust
Introduction
In 2001, the National Health Service (NHS) in the United Kingdom set out a 10 year process of reform in order to provide more effective healthcare with a commitment to improving the quality of its services (Department of Health, 2001a, Department of Health, 2001b). This has been reinforced through subsequent policy and legislation (Department of Health, 2004, Darzi, 2008). One initiative is the establishment of NHS Foundation Trusts, which are independent, not for profit businesses with accountability to local communities; created to decentralise public services. However, they represent a profound change in the history of the NHS and the way in which services are managed and provided. The Department of Health (2009) anticipates that NHS Foundation Trusts will play a key role in initiating and sustaining progress within the NHS. This is supported by an independent review undertaken by the Healthcare commission which claimed that NHS Foundation Trusts were making good progress in developing innovative approaches to care delivery.
Currently, there are 121 NHS foundation Trusts in operation across England which represents half of all eligible Trusts, with an aim of delivering an all Foundation Trust model for the NHS. Supporting policy documents suggest that the government expects behavioural and cultural changes within Foundation Trusts, particularly around innovation and service redesign. However, how this might be managed remains unclear.
In a British NHS context, research capacity building (RCB) has been linked with the policy debate for some time, and has been a central theme within strategy and policy literature (McCance et al., 2007). Significantly, it is embedded in the recently published NHS Constitution (2009) which confirms the commitment of the NHS to the promotion and conduct of research through setting out formal legislative requirements for NHS service providers to promote and increase research activity. The Operating Framework for the NHS in England 2009/2010 (Department of Health, 2008) has also made it clear that RCB must be central to the NHS in order to improve the quality of care. The link between the need for research capacity building initiatives in order to improve quality is also a global priority. McCance et al. (2007) suggest that building nursing capacity is recognised as a significant challenge worldwide and identifies that research and development should be harnessed as vehicles for quality improvement. However, Edwards et al. (2009) point out the lack of international research capacity-building opportunities, particularly in lower and middle-income countries, and suggest that the lack of international research capacity building initiatives for nurses is symptomatic of a wider failure to systematically strengthen research capacity in the international nursing community.
Research capacity building is defined by the DH as ‘a process of individual and institutional development which leads to higher levels of skills and greater ability to perform useful research’ (Trostle, 1992). Finch (2003) defined research capacity building as enhancing the ability within a professional group to undertake high-quality research. However, as McCance et al. (2007) point out, it can be defined in much broader terms to include research-related activities or in terms of being informed and critical consumers of research. Condell and Begley (2007) highlight such ambiguities within literature attempting to define this term and suggest that this is because there are a variety of contexts and ways in which the terms, ‘capacity building’ and ‘research capacity’ are utilised by research policy-makers, funders and researchers themselves. However, Segrott et al.'s (2006) systematic review identified that there is a subtle but important distinction between developing research and developing research capacity. They suggest that the former focuses directly on the production of research, by increasing the quantity of research projects, and that research capacity is about producing the ability of individuals to undertake research activity through creating the necessary infrastructure to facilitate this process. However, as McCance et al. (2007) point out, while progress has been made with rising investment in nursing and midwifery research development, building capacity and infrastructure remain important challenges.
Cooke (2005) defines infrastructure as structures and processes that are set up to enable the smooth and effective running of research projects, and identifies several elements which could contribute to an effective infrastructure; providing project management skills; appropriate supervision with academic and management support; and protected time and replacement costs as well as funding to support projects. However, the majority of these suggestions are anecdotal and not based upon empirical evidence. Segrott et al. (2006) suggest more specific elements to an effective infrastructure for research capacity building, including a research manager to provide strategic direction and support for individuals in managing projects; the creation of a pool of research leaders; research activity formally included in job descriptions and a financial commitment to invest in research capability (Research skills training) and capacity (funding research projects). Internationally, within the literature the strategies for RCB appear to be centred on either developing research-centred facilities or providing training and development opportunities. In Australia, Happell (2008) outlines how Nursing Clinical Development Units (NCDU), which originated in the United Kingdom in the 1980s have helped to reduce the gap between research and practice, promoted practice innovation and fostered collaboration between academic institutions and clinical practice. Similarly, in the UK, The Department of Health recognises the need for interdependence between Strategic Health Authorities, higher education institutions and clinical services in developing a workforce which has the ability to utilise and conduct research. In the United States of America (USA) Jenerette et al. (2008) describe how nursing partnership centres have enhanced staff competencies in the design and conduct of research and strengthened the research environment. Similarly, Conrad (2008) outlines how the establishment of Regional Training Centres have developed more research capacity in nurses in Canada and maximised research opportunities in response to local need. However, some authors have documented challenges to implementing such initiatives citing the main barriers as lack of resources, staff resistance and lack of management support (Happell, 2008). Many authors have outlined the use of training schemes as effective strategies in building research capability in staff. In the USA, Selig et al. (2009) described how the use of an evidence-based practice fellowship programme has changed the nursing culture in one institution from reliance on ritualistic practice to one embedded in a firm evidence-base. Similarly, Ried et al. (2007) outlined a grant funding scheme in Australia, which provided research bursaries, writing grants and research fellowships to a group of primary health care nurses, resulting in a growth in their capacity and confidence in undertaking research activity. However, an evaluation of this intervention (Ried et al., 2007) identified that more than half of the participants cited lack of time, limited financial support and lack of access to experts as significant barriers to future research activity, suggesting that RCB interventions need to have elements of sustainability embedded within the framework.
The importance of research capacity building within UK NHS Foundation Trusts and throughout the international nursing community highlights the need for empirical work investigating strategies for the implementation and evaluation of RCB activities within these organisations. However, Segrott et al.'s (2006) review concluded that there are very few contributions to the literature that provide specific examples of the situated process of capacity development to enable the ability to harness specific insights from capacity building in one institution to inform the development of strategies within other institutions.
The aim of this study was to develop an infrastructure for research capacity-building (RCB) in one UK NHS foundation Trust.
Section snippets
Methods
This study employed an action research methodology in order to develop an infrastructure for research capacity building within one UK NHS Foundation Trust. Action research is a qualitative research approach that lends itself to studying research participants in their natural settings with the purpose of informing community change. As an iterative enquiry process it balances problem solving actions implemented in a collaborative context in order to understand the underlying cause to enable
Research activity was not embedded in the culture of the organisation (Table 1)
In a discussion with the staff of all grades there was a general recognition that research was regarded as a specialised activity and in some instances it was seen as the domain of the medical staff. There was no real expectation among participants that nurses or midwives would lead research. Generally, those interviewed were not aware of any frameworks to support innovation within the Trust and when questioned about how they would approach developing an innovative idea into a project could
The planning stage
In action research, the planning stage consists of an overall plan of how to reach the objective of the project. Coghlan and Casey (2001) emphasise the importance of collaboration in planning action. In light of this a series of briefing and action planning sessions were held during May to July 2008. This allowed the researchers to share the findings of the pre-step exercise and involve key individuals in the Trust to collaborate in developing an Action plan.
The identification of the key
Discussion of the pre-step and infrastructure development stages
One of the main findings from these two phases of the study was that research activity did not appear to be embedded in the culture of the organisation (Table 1) contradicting the current health policy which anticipates behavioural and cultural changes within Foundation Trusts, particularly around innovation and service redesign (Department of Health, 2008, Department of Health, 2009). Perhaps this is unsurprising, as McCance et al. (2007) argue, this might reflect the reality of the practice
Conclusion
This paper has reported the findings from the pre-step of an action research study and outlined how this was used to create an infrastructure to support research capacity building within one NHS Foundation Trust Hospital in the United Kingdom.
The study identified perceived barriers to RCB activity in nurses and midwives who were involved in the project and developed and implemented a framework of structures and processes to overcome those barriers identified (Table 3). The structures and
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