The advanced nursing role was first seen in the UK in the mid-1990s (Gray, 2016). In the early years of the advanced nursing role, the UK Central Council for Nursing, Midwifery and Health Visiting (predecessor to the Nursing and Midwifery Council (NMC)) did not set standards to avoid restricting the development and innovation of an emerging area of nursing practice (Gray, 2016). This led to a lack of clarity in relation to the scope of practice, training, qualifications and the skills required to undertake the role safely and effectively. Advanced nursing titles emerged in an unplanned way for similar roles being established by individual organisations in response to local need due to the absence of agreement from a regulatory body (Gray, 2016).
In the UK, palliative care nurses work at an advanced level and frequently hold the title of clinical nurse specialist (CNS). In general, the CNS has a more in-depth knowledge of a specific field of nursing care (Cooper et al, 2019). Much has been written on advanced nursing roles including their title, effectiveness and role preparation (Duffield et al, 2021). Several organisations developed frameworks to help clarify the scope of the advanced nursing role and its educational requirements to stakeholders including the Department of Health (Department of Health, 2010), Royal College of Nursing (RCN, 2018), International Council of Nursing (International Council of Nurses, 2019), and Health Education England (HEE, 2017). All the frameworks included an element of research as a key area of the CNS role.
There is limited evidence into the research role of the community CNS working in a palliative role. The Advanced Professional Framework developed by the HEE is set out under four pillars: clinical practice, leadership and management, education, and research (HEE, 2017). Although originally designed for the NHS, it was anticipated that the framework would be used by health organisations across England.
Method
Aim
This study aimed to explore what influences CNSs practising in a community palliative setting to engage with research activities.
Objectives
This research had the following objectives:
- Explore CNSs' participation in research activity
- Explore how CNSs developed their research skills
- Explore the past research experience of CNSs
- Explore CNSs' perceptions of their organisations regarding CNSs and research.
Study design
The research used a qualitative approach. As the researcher was a nurse who was also working in a specialist palliative care environment, a phenomenological approach described by Heidegger (Chesterton and Jack, 2021) was used.
Data collection
Data were collected using semi-structured interviews which lasted about 40 minutes in a private space at the participants' place of work. A semi-structured interview schedule guided the novice researcher to cover all areas of the individual lived experience (Cooligan, 2014) but did not seek to explore the reasons why these experiences happened (Guerrero-Castaneda et al, 2017). The interview questions reflected the advanced clinical practice research pillar of the Advanced Practice Framework (HEE, 2017); they explored engagement in the research activities in the HEE research pillar, namely, clinical audit, applying current research to clinical practice, developing policies or processes to reflect current research, identifying evidence gaps, conducting research and sharing research projects.
Sample
The researcher approached hospices and community palliative care organisations within a 50-mile radius. In total, three organisations agreed to facilitate interviews with their CNS team; however, nurses from only two organisations agreed to be interviewed. Using a gatekeeper in each organisation, a total of eight nurses were interviewed.
Data analysis
The researcher transcribed each interview, rechecking each them to ensure accuracy. The interview transcripts were read and re-read to develop the coding and address the research objectives. The data was then coded to develop the thematic analysis in a circular method. This rechecking allowed larger themes to emerge and smaller themes were let go (Baun and Clarke, 2013).
Ethical considerations
The study had the approval of the ethics committee from the local university (Ethics reference number: FHSRECSS000116). This included approval of the consent arrangements for participants, anonymising of data, recording and deleting of interviews and storage arrangements on transcribed interviews on a password protected device.
Findings
A total of eight participants were interviewed from two charitable specialist care organisations. All participants were female and Caucasian. They had been working in their present roles for 1–13 years. Atleast five participants had previously worked for other organisations in a similar role.
Overall, five major themes emerged from the data analysis: research negativity and enthusiasm, clinical focus, audits, organisational support and keeping up to date.
Research negativity and enthusiasm
Atleast five of the participants either had ambivalent or negative views around research. Previous nurse education had an effect upon the participants' long-term views of research:
‘I did Project 2000…research was talked about all through my training, I had a tutor, that I just didn't click with or connect with, who was the research teacher…it knocked my confidence, so I can't do that….I never failed at any of them, apart from that one research module, and it was all a disaster really’.
(Participant 4)
This negative experience during university diploma education lead to a dread of the research module when completing a degree later:
‘When I did my degree that was the one, the research module, I would have to do. I just dreaded it. It was ok, I did also have a colleague, who was really into research. She sort of explained it, on my level. I still found it very hard, but I got through it.’
(Participant 4)
A participant completed the other modules in her degree, but did not see any benefit in undertaking a larger final project focused on a topic relevant to her area of practice:
‘I didn't do a dissertation, no. I was wisely told not to bother doing a dissertation, so I didn't’.
(Participant 7)
In contrast, three participants viewed the research component of their degree as a positive experience. They were keen to remain engaged with research and hoped to complete further research activity.
‘So, I did my dissertation on families' and patients' perspectives on advance care planning…I felt it was very much about from the health care professionals’ point of view, but actually, has anyone asked patients what they want? What is important to them? Because there is much less written on that…
So, I found it really interesting, because I had never read it, but one of the terms I use at work now is ‘in the moment decision making’ …My dissertation was on that.’
(Participant 6)
‘The area that I used to work in was a new field of expertise in young adult palliative care. The piece of research that I wrote from, as part of my dissertation, was looking at the basic problems that young adults had, and what were their basic needs were in palliative care. It was trying to set a basis for a new field.’
(Participant 8)
‘So, when I did my degree…I was a district nurse at the time. So, I looked at carers in care homes, you know because there is such a massive turnover of staff and their knowledge base in diabetes care…it's quite surprising their actual knowledge was quite minimal, so from there the idea was everyone put in some teaching strategies, but that was in another life, but it was still relevant.’
(Participant 5)
All three participants enthused about the new knowledge gained from their dissertation and the sense of achievement in completing this component of their degrees. They also had a desire to be more involved in further research, either as part of academic study or when time allowed.
Clinical focus
A total of five participants had no real interest in any research activity, preferring to focus on their clinical activity:
‘Brutal honesty, no. I find research quite dry…I am really sorry…Because I am ‘a hands-on doing person’ rather than a ‘reading literature type person’. I don't think anyone in my team is into research.’
(Participant 3)
‘Research is a little bit of a subject that hasn't been of great interest to me. I think you either do or you don't, don't you? So, I will be honest it's nothing, it's not where I would like to be going.’
(Participant 2)
‘I have sort of in my career, I have always wanted to remain very clinical and that is why I am not any more senior than I am and…that's my choice, really. I have always hoped that other people would do the policies and procedures and I don't mind.’
(Participant 4)
Audits
Audits are one of the areas of research in which CNSs are most likely to be involved. At least seven of the participants had been involved in some aspect of an audit, such as through collecting data or attending the audit meeting, while one participant had been involved in the whole audit cycle. The participants viewed this as a way to improve patient care or demonstrate the quality of their services. For example:
‘From the actions of other audits that we put out, we saw improvements, we were pleased with that…In terms of audits, I am probably a little bit more, because it's clinical, anything that I can see is clinical, that will improve clinical because I am always keen to improve clinical services.’
(Participant 5)
‘I have set up clinical audits. I did one here looking into syringe drivers…to check the time scales of us requesting the syringe driver and them being set them up…to see if we could make a difference…A syringe driver audit identified a problem with supply, the need for more syringe drivers and (nurse) re-training because they don't get used very often by staff on the wards, so you lose your skills, so they don't feel confident and safe at the end of the day’.
(Participant 3 referring to a hospital syringe driver audit)
‘Collecting data to see if we needed to increase staff numbers at the weekend in the hospital and that went on for 4 months. I did lead that. I forgot about that. But I am sure it wasn't very good.’
(Participant 4)
‘I have completed audit for how syringe drivers were used in the community…I haven't had anything to do with analysing the results, just filling in a questionnaire, and submitting it. That is as much as I have ever done’.
(Participant 6)
‘We were making some changes to the rota system when I was a district nurse, when we were introducing a late shift we did some audit then about patient need, and whether it warranted a late shift. That was quite a big piece of work which completely informed the fact that we did need one.’
(Participant 1).
Organisational support
Participants were asked about their managers' expectations of their research responsibilities, their involvement in audits, policy writing or research.
‘It's not something she says, ‘This is something that I want you to do.’ It's left, if it is something we are interested in.’
(Participant 2)
‘No. I wouldn't like them to!’
(Participant 4)
Research activity was not an expectation, even for the participants who had used these skills in previous roles. For example:
‘I don't know if you remember when NHS Direct first came about. I was on the panel to help write the Patient Group Directives. We all went to Hampshire, and we had to find the research too. I forgot about this too. It was to back up (what) the algorithms’.
(Participant 4)
Some three participants had worked on audits that improved patient care with one of these audits being published. They had no expectation from their current manager in continuing the use of these skills in their role. The only exception was the participant who also managed a team – her manager expected her to write policies, standard operating procedures and conduct audits:
‘Yes. The audit for death, that was quite a recent thing.’
(Participant 5)
Some three participants thought that time was allocated for research activity. But they viewed their time as a precious resource and expected their focus to be clinical care rather than additional research activity. For example:
‘The job, like any job, is all encompassing, all exhausting. Our days are much longer than they should be; they start earlier, they finish later, we never get a lunch break. So, we don't want to take anything else on. Certainly you don't want to go home and read a load of…you want to watch TV.’
(Participant 7)
‘It's not because I have found any of the topics that don't really stimulate me, it's more that, if I am honest, it is probably time. Time is probably the thing that stops me.’
(Participant 5)
‘As I say, I haven't hardly had time to catch my breath, to look up.’
(Participant 8)
Keeping up to date
At least three participants mentioned working in an organisation with a dedicated research team, where they had the opportunity to help with research recruitment and listen to research outcomes, but they were not actively involved in the research process. For example:
‘I think we are lucky here to be honest…we have such a proactive research department here. I would probably sit back.’
(Participant 5)
‘So, there was a study done here on mindfulness and analgesia and the relationship between the two and I was kind of part of that group, but I wasn't involved in the actual study itself.’
(Participant 1)
‘We have a research Professor here who keeps us up to date, and sends us emails of people coming to speak, what she is involved in and how we can help.’
(Participant 2)
The participants talked about how they kept up-to-date with the latest practice without being actively involved in research. Talking to others was key to achieving this. For example:
‘Although maybe I am not chasing the research, but it comes and hits me in the face annually because I am using an updated book. It chases me really’.
(Participant 1)
‘I mean, we constantly chat within the team. Oh, can I run something by you? I have this issue, what would you do?… We would use things like the British National Formulary and the Palliative Care Formulary and/or from experience of colleagues who would say, ‘Well, actually I have tried that for that and that was really useful.’
(Participant 3)
‘But because I have worked in another area, and I have a mobile phone number for a consultant at another hospice. I will sometimes use them.’
(Participant 6)
Accessibility of information was also important. A nurse achieved this using social media:
‘On a Facebook forum and someone had published their preliminary bit for their PhD, and he was looking at, would people with frailty benefit from palliative care services at end of life. You know there is lots of evidence that people have got similar symptom burdens than to people with cancer and it is not being recognised.’
(Participant 8)
‘(Information) needs to be accessible to us, as we are running around like headless chickens doing the best we can for our patients. It's a resource that give us confidence and gives our patients the best care. But that information needs to get to us and be as accessible to us.’
(Participant 8)
Discussion
While this study only collected data from eight palliative care CNSs based in two hospices, it revealed a potential gap between the Advanced Clinical Practice Framework (HEE, 2017) and the current palliative care CNS role. In this study, some participants enthused about their research education and viewed it a part of their specialist role. However, for most participants, research was part of their academic education but it was not viewed as central to their clinical role with their initial experience of research education, casting a long shadow into their future practice and the value placed upon evidence. A practitioner's belief in the value of evidence-based practice (EBP) has been found to be associated with their ability to implement EBP in practice (Melnyk, 2018). Therefore, nurse educators need to link the development of research skills to real life situations to assist a CNS transfer their knowledge of research gained during an academic award into their clinical practice (Singleton 2017). Melnyk et al (2018) have suggested that nurses in an academic role may themselves not have used research within their clinical practice and only apply research to their teaching of personal study. Further academic nurses may have no experience of using research to embed EBP into a clinical setting so that students can end up with a muddled view of the relationship between research, EBP and quality improvement (Melnyk et al, 2018). This view is demonstrated by students who view a research appraisal tool as a means to demonstrate research skills in order to pass an academic assignment, rather than considering it relevant to solving problems in clinical practice (Hewitt-Taylor et al, 2012). Although there is limited evidence into the pedagogical design of a course to most effectively embed EBP, King et al (2022) have suggested that the key features of an effective educational programme include experiential learning with collaborative groups and the inclusion of mentoring as effective teaching strategies.
The ability to apply research findings to influence clinical practice is a skill for all nurses and is a key component of the future nurse standards (NMC, 2018). A CNS working at a specialist level needs additional skills to those expected in a Band 5 preceptorship post. Nurses with Masters Level education or above have a more positive attitude and higher level of competence in EBP, although a short intensive course in EBP has also been shown to increase competence in this area of advanced practice (Melnyk et al, 2018).
Advanced clinical practitioner education was set at Level 7, that is, a taught postgraduate Masters qualification with associated descriptors of knowledge, understanding and application of knowledge (Quality Assurance Agency for Higher Education, 2014). The apprenticeship framework for advanced clinical practitioners set out by Skills for Health (2018) brought together all four pillars of expected competencies (HEE, 2017) to enable the integration of the knowledge, skills and behaviours across the expected advanced clinical practitioner standards.
A criticism of many previous education programmes was their focus on the clinical skills element of the advanced role. This included those clinical skills which were traditionally carried out by medical staff to the neglect of other key areas of the role, including the ability to use research to influence and improve clinical practice (Gray, 2016). The final Masters Level apprentice assessment is a presentation of practice, a report outlining a change that the nurse has made in practice which is followed by a presentation to a panel which assesses if the knowledge, skills and behaviours of a potential advanced practitioner are achieved (Skills for Health, 2018). This assessment aims to provide nurses with the opportunity to demonstrate their use of research skills, to identify an area for improvement and how the evidence has influenced an improvement in practice. This approach provides an opportunity to demonstrate the proficiencies of research, leadership, education and clinical practice skills to embed a change to clinical practice (Skills for Health, 2018). Through the synoptic assessment, the nurse can demonstrate that they can find and utilise research effectively in the context of each of the other pillars of research, education, leadership as well as clinical practice (Leiber, 2019). Melnyk et al (2018) have described a ‘so what’ approach for nurses undertaking research so that the final Masters Level assessment can be an effective way for a CNS to translate their research skills into clinical practice (Melnyk, 2018).
The study participants appeared to hold a traditional view of EBP – using the best evidence and the values of individual patients to plan care was an essential part of their CNS role. However, a belief in EBP is not necessarily enough as, nurses do not always have the confidence and skills to interpret and critique research and combine this with innovation to embed changes in clinical practice (Singleton, 2017). In addition to research skills, nurses also need leadership skills to share EBP and influence practice changes within a wider team. Yet, the study participants reported that they stayed in a role to ‘stay clinical’, thereby implying that the research skills are the domain of more senior nurses (McNett et al, 2021). While there is generally a consensus on the clinical part of the CNS role, all other areas of practice outside the patient facing domain are lacking in clarity (Serra-Barril et al, 2022); this is despite a clear consensus across multiple frameworks for advanced practice.
Saunders and Vehvilainen-Julkenen (2017) have noted that nurses with less than 5 years' experience tend to believe that their personal clinical practice is evidence based, especially when compared to nurses with over 20 years' experience. This is of particular significance in a CNS palliative care role where nurses can have many years of experience (Hospice UK, 2021).
An Irish study on palliative care nurses supported the view of the CNS as a solely clinically focused role with only advanced practitioners needing additional skills in leadership, facilitating education, updating guidelines and undertaking research (Begley et al, 2013). However, this view of the CNS role does not reflect professional guidance, with research having been a key component even in the infancy of CNS roles in the 1990s and was in the guidance laid down by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting.
The expectation to share EBP ideas with others is integral to the HEE (2017) research pillar, but interestingly, no minimum expectation was expressed by any of the participants. Saunders and Vehvilainen-Julkenen (2017) found that nurses believed 58% of their clinical practice should be evidence based. This suggests that there is a disconnect with EBP being a low priority for the CNS role, although they are simultaneously viewed as the best source of EBP information for others in the nursing team (Saunders and Vehvilainen-Julkenen, 2017).
Clinical audit is the area of research practice in which most of the study participants had had experience, and echoes the expectation that evaluation of both their own practice and that of their colleagues is key to meeting national standards with improvements to services, when necessary (HEE, 2017). The participants seemed to hold the view that audit fitted with their clinically focused identity, with its direct link to patient care and its potential contribution to improving clinical care, rather than a more straightforward research role (Saunders and Vehvilainen-Julkenen, 2017). The framework of clinical audit also provides nurses with an effective tool for use when discussing making collaborative changes in practice with other professionals, especially when changes are required in the activity of allied professionals (Hut-Mossel, 2021).
It could be argued that clinical audit is not a specialist skill. The future nurse standards (NMC, 2018) expect all registrants to participate in all stages of the audit cycle and use the findings to bring about continuous improvement. This is a view shared by Melnyk et al (2018), who proposed that research activity can be divided into two distinct proficiency stages: 13 key areas for all registered nurses, with 11 additional competencies for advanced practice. Clinical audit fits into the former list of capabilities for all registered nurses (Melnyk et al, 2018). It was noteworthy that, while most of the participants could recall participation in previous audits, none described ongoing engagement with current audits.
The participants described their managers as ‘passive and invisible’ in the research ‘pillar’ of their CNS role. Managers need to have an expectation that during preparation for the CNS role all nurses should reach a level of competence in EBP to demonstrate the value that they place on it as an integral part of the CNS role (Melnyk et al, 2018). The managers may well need further education themselves to effectively role-model and demonstrate leadership in relation to EBP skills (Lunden et al, 2021). Nurses also need education to develop their underpinning knowledge to effectively lead on EBP projects in clinical practice. This is especially true if managers do not have skills in this area and do not view research capabilities as a priority when selecting education modules for the development of nurses in their team (Kerr and Rainey, 2021).
In addition to supporting nurse education, organisations need to develop EBP mentors to implement and sustain EBP effectively in clinical practice. If managers do not routinely value EBP skills in their team, a CNS will not experience role-modelling of behaviour in this area of practice in the same way they do for the clinical part of their role (Singleton 2017; Melnyk et al, 2018).
Lack of protected time was identified as a key barrier in this small study. Lack of time does not allow nurses to engage with external evidence which relates to their clinical role; this has been noted as an ongoing issue in a current stretched healthcare workforce (Kerr and Rainey, 2021). The barriers that CNSs face in an organisation include lack of time, lack of support by mentors and a pre-existing culture which leave nurses with a conflicted view of how an organisation values EBP (Kerr and Rainey, 2021). Research activities are constrained by a lack of time and space in a busy work environment (Serra-Barril et al, 2022).
Viewing EBP as a valid use of working time should be a priority which needs promoting by the senior team in an organisation if it is to be both accepted and also an expected use of working hours (Eaton et al, 2015). For this to happen, EBP needs to be a whole organisational objective.
The lack of EBP mentors also needs tackling at an organisational level. Hospices could develop a partnership relationship with their local universities to provide an effective EBP mentors. This could be an effective way to develop these skills routinely across their whole organisation (Melnyk, 2018).
Embedding EBP cannot be left to individual nurses who believe it is a key part of their role. Rather, it requires a whole system approach with organisational support, an open culture to identify areas for improvement and effective teamwork across disciplines. A whole system culture of EBP will avoid improvements being introduced within the silos of individual teams rather than across the whole organisation (Melnyk et al, 2018). This approach requires managers at both a middle and executive level who support EBP.
In an ever-changing healthcare environment, constant updating is required. Nurses are most likely to base their clinical decision-making on their existing knowledge and information from colleagues and protocols, than primary research (Lunden et al, 2021). Alternatively, internal policies can provide the means by which a CNS can update their knowledge (Malik et al, 2015). Using colleagues and guidelines can be described as ‘third party research’ – that is, using evidence that has already been interpreted by others (Stokke et al, 2014). This will often involve several sources of research applied to a particular area. While guidelines and advice of colleagues may be a source of sound evidence upon which to base care, it is also important that sources of evidence can be questioned by practitioners who have sufficient research skills. This should help identify research bias or incorrect interpretations of study findings.
Limitations
Only eight participants from two organisations contributed to the study despite many services being invited to contribute to the study within a 50-mile radius. The extent to which the eight participants reflect the wider CNS palliative care population is unknown.
Conclusion
The palliative care CNSs in this study did not describe their roles as having a research contribution as set out in the HEE (2017) framework. This could potentially reflect the resource pressures in their services but it may also reflect the view that a CNS role is predominately clinical, with little regard for the other aspects expected of advanced level practitioners. This may have implications not only for EBP in palliative care but also for other nurses, such as district nurses, who seek the expertise of their local CNSs when they are delivering palliative and end-of-life care.
Key points
- Evidence-based practice (EBP) the embedding of research into clinical practice is a key component of the CNS role, however, this area is poorly understood by individual nurses and organisations
- Clinical nurse specialists (CNSs) recognise the value of EBP to patient care but view their clinical role as a higher priority
- To effectively carry out the research part of their CNS role, nurses need EBP role models, a Masters level education and allocated time
- Managers and organisations have a key role in supporting their specialist nurses to develop and embed these skills.
CPD reflective questions
- Think about your skills; how did you develop these evidence-based practice (EBP) skills?
- In your area of practice what are the enablers and barriers to the research part of your role?
- When you reflect on your role how does it reflect the research pillar of advanced practice? Do you notice any gaps in either knowledge or skills to use in your clinical role?
- Who have been your EBP role models? What skills and attitudes did you learn from them? Who in the MDT would view you as a role model in this area?