Julie

Brief Outline:

Julie is a nurse researcher working in the area of paediatric intensive care. She has been in her current post for 10 years, during which time Julie has undertaken a PhD. Her role has evolved from research delivery to include managerial aspects, independent research and research capacity building.

Background:

Julie is a nurse researcher. She is in a relationship and has children. Her ethnic background is White British.

More about me...

Julie is a nurse researcher working in the area of Paediatric Intensive Care (PIC). Julie’s interest in research started during her undergraduate nurse training. She worked clinically for approximately three years before taking on a part-time audit and research assistant role for research studies on PIC. She returned to clinical nursing full-time but was keen to “get back into” research in the future. She completed a Master’s degree to gain understanding of research governance and methodologies and, on completing this, went to work as a ‘Clinical Research Facilitator’ for Medicines for Children Research Network (MCRN) – a newly-established research network. She enjoyed the studies but the network had also “mopped up a lot of studies that were floundering a little bit”. These included problems with site file management, PI input and research nurse coverage. She missed having a specialty area and felt like “a jack of all trades and master of none”. 

When the opportunity arose, Julie returned “to my own speciality” of Paediatric Intensive Care as a lead research nurse. The move provided her with a promotion, more autonomy and “a fresh slate” to design how research was delivered. Over the 10 years Julie has been in post, she and her colleagues have developed the research team in the unit. Her role has become more managerial but Julie is keen to maintain participation in research activities, particularly qualitative studies. She credits the evolution of her post in part to having supportive managers with an understanding of “where I wanted the job to go and where the unit needed the job to go”, and strong relationships with medical colleagues. Having a research role has affected how Julie feels she is identified by others. She still introduces herself as a nurse to potential participants, but tends to describe herself as a “nurse by background” rather than a “nurse”. “In my heart I’m a nurse, but actually I recognise that that’s not how people would see me”. Julie recently completed her PhD which she worked on part-time over the last eight years. Her official job title recognises her as a ‘Nurse Researcher’ with independent research skills but she feels many people, including nurses, will not know what this means she does on a day-to-day basis. 

Julie describes the structure of research nurse banding and responsibilities in her unit. For example, they employ Band 5 research nurses to provide study support whereas a Band 6 research nurse would more likely be a ‘lead nurse’ for a study. Of the staff that Julie manages, there are currently two clinical nurses working part-time in research as secondments. She believes this is a great arrangement because “they’re staying clinically relevant, they’re still maintaining their skills, but they’re getting a grounding in research”. In terms of her own clinical skills in intensive care nursing, Julie describes herself as “rusty”. She would like to do more clinical work but has had to cut it down over the years.

Julie tries to promote a supportive attitude towards research conduct amongst the nursing workforce, but finds there are tensions. She emphasises that “research is core NHS business” but thinks the pressures in clinical areas can present dilemmas for research nurses, who often feel they are nurses first and research nurses second. For example, Julie felt it was appropriate that the team covered breaks for clinical nurses during the ‘winter pressures’ but was concerned that this was ongoing and was not a long term solution to address staffing shortages. One way that Julie encourages her research team to foster positive relationships with clinical staff is by being a visible presence on the unit every day and timing research visits to fit around ward activities, so that “we’re not adding pressure to staff” at busy times. By liaising with clinical staff, Julie feels that research nurses can become more informed not just about clinical details of the patient but also the wider context (including family dynamics and support structures) which might affect whether and how to approach them about research opportunities. In addition, Julie feels that good relationships between research and clinical nurses can highlight new topics to research and the contribution of research to enhancing patient care. Julie is keen to support both research nurses in her team and clinical nurses to undertake their own research, audits or service improvement projects. Staff can access training and are encouraged to draw on the research expertise of the team to carry out projects and then disseminate the findings: “you’re not just here to deliver this research, actually you’ve got many more skills”.

Julie emphasises that the communication skills of research nurses are crucial – in relation to clinical staff and patients and/or their families. Other skills Julie recommends are an attention to detail and thoroughness. In the context of Paediatric Intensive Care, Julie feels it is important research nurses have the “ability to judge clinical situations” and for this reason favours embedded research staff to deliver research. In terms of her career progression, Julie is looking to pursue clinical-academic pathways in medicine. Her aspiration is to have both a contract within the NHS and the University settings in order to help her succeed in producing well-designed studies which successfully secure funding grants.

Julie talked about the value of health research for patients, the health professionals caring for them, and the overall health care system.

So I mean we’re working, you know, in patient, with patients who unfortunately ten years ago may have died. And so we’re making improvements all the time and research is a, is a core part of that. I mean, I mean it’s been shown, hasn’t it, that if a Trust is research active, even if the patients themselves aren’t in a study, that you get better outcomes. Patients anywhere in that hospital will get better outcomes. This is a research active hospital and paediatric intensive care is a very research active department, and I think it’s about recognising that when you do research, you develop a questioning approach to-, even if that patient, even if patients aren’t in the study, it’s part of that process of ‘can we do this better? What’s working here? What, how, you know, why? How could we do this better? Would this replicate in another patient group?’ And I think it’s also growing your workforce so that people can then write a research proposal, put it in and get funding for it. So I think research is kind of important for patient outcomes, but it’s also important for your staff development, obviously there’s the economic side of it as well, that hopefully there maybe cost improvements, and I mean it’s a sad state of affairs but that is a core driver now, ‘can we do things better and cheaper? Or do we need to do some of the things that we do? Are we doing too many interventions? Could we do less and save money?’ But I think it’s also about the way your-, I mean it could be anything from whether it’s a medication, it could be a device, it could be configuration of the service, and we’re very open to doing different types of studies, we’re not just about randomised control trials and efficacy. For us it’s about patient and family experience, and staff experience as well.

Julie had enjoyed her dissertation as an undergraduate. She took opportunities to become involved in auditing initially and then in research data collection.

So the motivation for research initially, so this is really I guess right back in 2000, 2001, was that I’d actually done research as an undergraduate student, so back in, I graduated in 1997, and my, I did a, I was on the, one of the intakes on a degree programme and it was quite new. And we actually had to carry out an undergraduate research project, and I loved it. I really enjoyed it, partly helped because my big focus of interest at the time was cystic fibrosis, and I did a project involved with children and young people with cystic fibrosis, I worked with the CF team here at the hospital and I really enjoyed it. So I always knew that I had an interest in it and I think that’s one of the things that’s perhaps gone from the undergraduate programme, is that opportunity to be involved in research. 

And then so when there was an opportunity in 2000, 2001 I took on an audit role initially and again, the-, I know obviously audit is very different to research but the principles about the following a process, examining what you do, looking for improvements – I think those principles do cross over, and so actually that kind of led to that interest. And then I got the opportunity to do data collection for a big study, and it really was data collection, but I really enjoyed it because I like-, I think like a lot of research nurses, we like detail, we like a systematic approach, we like to be able to tick things off lists. It’s a very structured approach to things, and that really appealed to me. So then obviously then I had a period of time where I wasn’t doing research, and, but the idea of getting back into that was quite appealing. 

Julie thought that her day-to-day work activity was not what others (including the general public) would recognise as nursing.

It’s always interesting, isn’t it? Like if somebody says to you, “What do you do?” I now say, “I’m a nurse by background,” that’s how I’ve started to address it, because I recognise I don’t function in the typical view of what a nurse does. And partly that makes me a little sad sometimes, ‘cos I think I, I always love, I loved being a nurse and I am a nurse, in my heart I’m a nurse. But actually, that’s not what I do on a day-to-day basis now. And so I normally say, “I’m a nurse by background,” and I then say, “I manage research projects”. ‘Cos it’s quite a hard thing to articulate what a research nurse does. And so I talk about managing research studies, offering patients the chance to take part in them, making sure they all run smoothly, and of course then that all raises, it usually raises the thing of like, “Oh my god, you do research on really ill children.” And it’s amazing the interpretation that people have of what that actually means. But in my own personal identity, I view myself as a, in my heart I’m a nurse but actually I recognise that that’s not how people would see me. So I now sort of say, “Nurse by background, but I’m a, I’m a researcher”.

In the context of paediatric intensive care studies, Julie felt it was helpful to talk to ward staff about patient suitability. Communication within the research team was important too.

So we time our - sort of liaison with the clinicians and the bedside nurses so that it’s post things like ward rounds – we’re not adding pressure to them. So we try and time it well. That we try and discuss with them if a patient is eligible for a study, particularly if, for example, they, there may be a reservation but also as well whether it’s about the dynamics in a family, so things like ‘whose got parental responsibility?’, ‘actually this is a head injury’, ‘is there a sensitivity around it’s a non-accidental injury’, you know, some of those issues that can perhaps make the consent process more, more tricky. 

So I think it’s about liaising with them, not just about the clinical details but also about the family set up and the support structure that’s there. So on a day-to-day basis we try and liaise with the clinical team regularly, but we also make sure that our communication amongst ourselves is good, because the last thing that they want is to be badgered by us as well. And we’ve had this where we’ve got say three or four studies going on and a patient could be eligible for three or four studies, and you may need to prioritise which study. And so we can’t have our team going an asking them, and then someone else coming and asking them, and then someone else coming and asking them, and ‘cos we alienate not only the families but we alienate the staff who are quite protective of the families. 

So we, we make sure that our communication is good amongst ourselves to reduce that.

In Julie’s research team, Band 5 research nurses took consent for observational studies. She thought it was important to consider the family unit when consenting for paediatric intensive care studies.

So obviously a core part of our role is actually taking informed consent for patients to go into a study. As I say, a lot of our studies are defined as low risk observational studies, so we do actually take consent and we use Band 5 nurses and Band 6 nurses to do that. And a core thing of what we teach them is about the fact that you, obviously giving them the information in the form of the participant information sheet but it’s also about you conveying in the language that when you speak to them that this something they can choose to do. And it’s about recognising when a family looks like they’re struggling to make that decision, and I think it’s whether or not they might need you to come and talk to their parents, so grandparents. And okay, we don’t need to take an informed consent from a grandparent but actually if a parent feels that they want you to explain it to other people, then that’s what we would do. So we want to help them, we want to facilitate them making that decision, and if that’s involving speaking to other people, then actually we can do that. 

If it’s, it may be speaking to the child and young person ourselves as well, obviously sadly when they’re on intensive care a lot of our patients are already sedated, so it’s hard to involve them. But we do actually consent for some studies, almost pre-operatively before they come to the unit, so where possible we try and speak to the child or young person as well. So I think it’s about seeing what the family need and trying to meet that. If it’s that they’re concerned and they want to see that you’ve spoken to their cardiac surgeon or their nurse specialist, then we can facilitate that as well. But also recognising that there’s no-, there’s no pressure and it’s absolutely their right to withdraw or, you know, to not even take part in the first place, that they don’t have to take part. And that it will not affect their clinical management otherwise.

Julie ran sessions on various training courses for new staff. She thought this had helped develop a research supportive environment and working relationships.

I also do education for the unit, so every month for example there’s a study day where- so because of the size of our unit, so we have staff from Band 5’s up to a Band 7, on one day a month it’s like their sort of mandatory training update day. And we have a research slot on that every month, and so we give them an update on all the studies that we’re doing, any positive feedback, any areas where we’ve perhaps encountered any challenges, and also we give them the chance to ask us any questions about anything they’ve spotted. It’s also a chance for us to say if we’ve got any secondments, any posts coming up. If there were any conferences coming up and how they go about writing something up.

So we use that as our chance to kind of really engage with people from the unit once a month in a more sort of formal way, and that helps us to promote that research culture but also helps them to ask any questions. ‘Cos I think it’s quite hard on a day-to-day basis, especially when families are there, for staff to turn around and go, “Why are you doing this study?” Like, “Is this really necessary?” But I think the important message that we give the unit is ‘we know that research isn’t for everybody, but what we need them to do is just to support the activity and especially to support families if they’ve made the decision to take part in something’.

Julie encouraged both research and ward staff in her unit to present at conferences and publish. There are various ways she supported this, including reviewing drafts of conference posters.

So for example my day today has been a lot of work preparing work for conference submission, so very, we’re very careful to scrutinise all the work that goes in. So we’re very careful first of all to encourage our nursing and allied health staff on ITU to submit work for conferences, to share what we’re doing. Paediatric intensive care is quite a small community and especially in terms of units that have over ten patients, ten beds. And so actually we all need to learn from each other. And so we have a very strong approach on our unit to support people to put work in for conferences and to also write it up for publication. That side of it needs a bit more work, but the public-, the conference presentations we do really well at. And we have lots of really high-quality work and we make sure that when it’s written up it’s also conducted to a high standard. So a big part of my job is helping people to do that, so I spent four hours yesterday reviewing posters [laughs] but it’s a worthwhile investment because actually staff very quickly pick up those skills and then the next time they come to do a piece of work, actually it’s a lot easier. It’s a much better standard, so it’s takes less investment in the long run.

Julie’s job description was rebadged, from research sister to nurse researcher, since completing her PhD.

It has actually been an evolution of the role, I think that’s because I’ve had very supportive managers who’ve seen the need to grow and develop the role. The job description itself we’ve changed so during that period of time, I should say, for eight years of it, I’ve been doing a PhD part-time as well, so that impacted on it because during that time you’re obviously becoming a chief investigator of your own study. But it’s also, it’s, we re-did, about 18 months ago we re-did the job description to reflect where I wanted the job to go and where, where the unit needed the job to go. And actually now it’s re-badged from being ‘Research Sister’ to ‘Nurse Researcher’, not with any increase in pay and not re-banded in anyway, but just the focus of the job description changed so it’s much more now about moving from that delivery to being an independent researcher, developing the research culture, supporting other staff, education about what research role could involve, you know, what does good research look like, and actually a lot more of an emphasis on public and patient engagement.

Julie felt that communication and team-work were crucial to being a research nurse in intensive care.

But I think the crucial thing is, is the, the research team and their communication skills and their ability to judge clinical situations. And this is one of the reasons I think it’s really helpful that we mostly employ our own intensive care nurses who come into research because they are very good at reading what’s happening clinically and, and then also working with the team. ‘Cos I think that’s another crucial aspect is, is working with the team, to, you optimise the timing, you’re constantly aware of what’s going on with that family that day, that it’s- [clears throat] the numbers may all look okay on this patient but actually that family had just had some terrible news about a sibling of the child, you know, unfortunately the nature of our environment is that it may not just be one child is critically ill, may be two, it may be other members of the family, and so we really need to work with the rest of the team to get the approach right.

Julie described some of the skills and values that are well-suited to research nursing, and also those gained through working in this area which may help with career progression.

So if you’re thinking about moving into a research post I think, well I actually think it’s a really great opportunity for the right kind of person. And I think you-, the way I always say to people is, you know, “Do you feel that one of the things that is frustrating for you in your current job is about the fact that you don’t always have the attention to de-, you are not able to exercise the attention to detail that you would like to? Then this is probably a really good opportunity,” because the absolute key thing for me when I’m looking for people is attention to detail and a thoroughness and if you-, those are core components of it.

I also think as well that you really need to value the communication skills, I think it’s very easy to think that a research job is not- is for people who perhaps struggle more with people and interaction. And I think there’s this sort of view that, you know, we just sit and like numbers and do excel spreadsheets and, and actually for me, it is all about communication. Because you have to be able to liaise and have contact with so many different people and professionals, and you’ve got to be able to articulate very clearly and quickly sometimes, what you’re trying to do. And so for people who struggle with that or-, that’s actually quite difficult. So I think if you are the right kind of person, I think you absolutely should give it a go, I think, I think some of the staff who’ve done research secondments have gone onto do things like advanced nurse practitioner and I think some of those roles-, I mean research or an ability to engage in critical thinking which I view as being part of that, is absolutely a fundamental thing for so many of these advanced posts. Clinical nurse specialists, advanced nurse practitioners, anyone who goes out and to work in the community, who needs autonomy, I think there’s so many things that a background in research nursing could be so useful for.

And so I think-, I appreciate it’s not for everyone, but actually there’s lots of core skills that are so useful.

The research nurses on Julie’s team covered colleagues when there were staff shortages and additional workload pressures on the wards. However, she highlighted that it was “very hard to claw that time back” for research.

But I, you know, at the end of the day you know everything is very, very tight at the moment. I mean an example of this is [knock to mic] during the winter, I think a lot of researchers will tell you that they got called back for, to support clinical care, and that’s, that’s absolutely fine. But we’re through the [gestures quote marks] ‘winter pressures’ now, we’ve got a new pressure which is that we’re being asked to cover breaks still on an ongoing basis and in a more formal way, to actually agree at the beginning of a day when you’re going to cover a break. And I-, it sort of fills me with a bit of ‘ergh’ because I think it’s not that I don’t want to support our clinical colleagues, and absolutely if, if they go down to the unit and things are terrible down there and they need help and no-one’s had a break and there are awful situations going on, of course they need to help. But to start structuring in which breaks you’re going to cover on a day-to-day basis, I just think it’s very hard to claw that time back. And I’ve been in this position before, a few year ago, and, where we were expected to give up to two hours a day for helping the unit. And actually, when you broke it down, it almost worked out, with your own break taken into account, it was, you know, sort of like a quarter to a third of your work-, of your day. So actually, when you added it up over the week we were losing huge amounts of research time to support the unit. And I don’t feel, feel very torn. I think we all feel that clinical responsibility, responsibility for patient safety, patient care, for our colleagues to make sure they’re getting a break, but at the same time we’ve got to make sure that research works. If we don’t answer those research questions, if we don’t recruit to target, if we don’t collect the data, if we don’t make sure everything is done to the book what happens is that study will close, the answer won’t be reached and that study will never get funded again. And I-, it’s a real dilemma and it’s hard to-, and I, you know, hard to make everyone appreciate that picture.