The research nurses, midwives and allied health professionals (NMAHPS)* we spoke to emphasised the importance of good working relationships with colleagues in direct clinical care roles* (and, in the context of studies in nursing homes, care staff). For some, these relationships were very positive and they felt research was well-integrated into the environment – in recognition that it was ultimately about patient benefit. Other times, situations were less than harmonious and there had been barriers or ‘resistance’ faced – either in relation to research generally, around specific studies, or stemming from negative attitudes about research NMAHPs. Often there had been changes over time; as Ellen said, relationships with ward staff can have “ups and downs”.
The distinction between ‘clinical’ and ‘research’ roles was complicated, and many research NMAHPs emphasised that there were still clinical even though they were not currently in a direct care role. With this in mind but without a clear alternative, we use the term ‘clinical colleagues’ (and sometimes ‘clinical non-research colleagues’) in this section to refer to those employed in direct care roles without a specified research component to their jobs.
When Imogen first started as a research nurse in emergency medicine, there were only a couple of studies running. Research activity and engagement from clinical staff became more established over time.
When Imogen first started as a research nurse in emergency medicine, there were only a couple of studies running. Research activity and engagement from clinical staff became more established over time.
Age at interview: 32
Sex: Female
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When I was first getting into it, because it was, it was moving quite slowly because there wasn’t a huge amount of studies to do, I was interested in it, and I saw the potential for it to be a really, really exciting place to be, as, as time moved on and more studies were coming up and as the team developed. And a lot of it was around sort of engaging the clinical teams in what, what research was and how we could do it, and how it could integrate with, with their sort of everyday roles. So, the job has changed a lot because as we’ve become more established as a team the clinical teams are very well aware of what research is and how it is, it’s used in their everyday practice.
Helen talked about fostering good working relationships with Clinical Nurse Specialists in particular. She felt it was important to convey that research was about ultimately about patient choice and benefit.
Helen talked about fostering good working relationships with Clinical Nurse Specialists in particular. She felt it was important to convey that research was about ultimately about patient choice and benefit.
Age at interview: 53
Sex: Female
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I think we have very good relationships with like the CNS’s [Clinical Nurse Specialists] and the ward staff, I put that down to the, you know, the, the lovely working relationships that my team have because we are always going in, you know, can sometimes be at an inconvenient time. We had a situation a little while ago where some of the CNS’s, there was a few CNS’s and one CNS or a couple of CNS’s would be absolutely fine about us going in to see patients just on the day they’d had, in clinic at the point they’d had their diagnosis and you’d find a little bit of, you know, cherry-picking or gatekeeping and I did a little bit of work around speaking to that, the resisters, I call them resisters, you know, it’s not, it’s not us wanting to put a patient into a study it’s the consultant feels the patient may benefit from going onto that study, may benefit, but also we, we’re experienced nurses and we are experienced and we do know how to approach patients. You know, most of my team have got a lot of experience in the area in which they’re doing the research so yeah, we know that patients might be upset, we know our patients are vulnerable but we know how to handle that. And what we don’t want happening is, you know, three or four years down the line, patients talking and one patient had access to a study, the other patient didn’t have access to the study and that patient, you know, patient perhaps has relapsed so, “Why didn’t I get access to that study?” and, you know, “Because we were told that we couldn’t come and see you because you’d be too upset,” and we can’t be paternalistic, you know, patients have to make those decisions themselves.
Clinical colleagues were often involved in helping research NMAHPs identify potential participants, gain access to patient records, deliver interventions, collect samples, and find appropriate spaces in which to see potential participants. Their attitudes and willingness around these activities could impact on carrying out the study. Good relationships could make studies run smoothly, whilst tense ones could lead to a number of obstacles. Tabitha recalled a study where the clinical midwives mentioned her (as a research midwife) to patients before she saw them, and having a good relationship helped with this: “if they saw the women before me, they’d talk about me and just say, “Oh she’s really nice,” or, you know, “She’s very approachable, would you mind?” And it felt a bit better me going in, if they’d heard that I was going to approach them”. In contrast, some people found that clinical non-research staff acted negatively as gatekeepers by preventing access to potential participants.
Many research NMAHPs acknowledged that research-related activities could (or were perceived to) disrupt or add to already busy clinical workloads for their colleagues. They recognised that this could be a source of tension and often described trying to minimise disruption. Carole described the importance of being “unobtrusive”, and this included fitting around the sometimes unpredictable timings and pace of other clinical activities.
The studies Jisha worked on involved blood samples. She coordinated with ward staff so that research and routine bloods were taken at the same time.
The studies Jisha worked on involved blood samples. She coordinated with ward staff so that research and routine bloods were taken at the same time.
Age at interview: 39
Sex: Female
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We do our research blood. But if they are doing a routine blood, we just combine with that because we don't want to prick the patient twice. So we, we plan our study follow-ups when we recruit them. So if we are recruiting for one patient today, we plan their alternative day sample on maybe Monday, Wednesday, Friday. We prepare all the cards and keep them ready. And we communicate it with the NICU nurse or the ward nurses. And they do daily bloods. So we match-, or with those samples. And we tell them, “Okay, do you mind taking this extra sample?” Or, “If you are not doing that blood or if you want just one blood, leave that with us, we will- when we are pricking the patient, we will collect it for you”. So, that's a- we just communicate to each other and just sort it out.
Carole felt it was important to work around other clinical activities and reduce the impact on her colleagues.
Carole felt it was important to work around other clinical activities and reduce the impact on her colleagues.
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So we try to be unobtrusive. And, and just deal with that lady when and if we can. So we'll make ourselves known and say, “No, you know, we'll wait until you've finished”, or “When's a good time that we can come back after?” Or, “When will this lady-, will you be finished with this lady?” And people are very accommodating. Or in a busy ward, if it's ward rounds and that, you've got to be mindful and just, you know, if you want to access notes and that, you've got to go and politely ask, and say, "Would it be alright, I'm just going to be over there?" Or if you know it's not a right moment, then you don't do it, [background noise] you come back.
You readily know when you've worked on clinical what the scenarios are and what's going on. And then it was like the other day in ultrasound when I was doing a baseline recruitment of a lady, just sat in a quiet corner, when one of the research doctors wanted to take this lady for scan. But he was very nice and said- he shouted out her name, and then she said, “Oh, that's me.” And he looked at the iPad and said, "But are you finished? Is that alright?" And I went, "No, no, no –you go first." And she came into my office after. Because the last thing you want to do is, you know, they see something like a hundred ladies through that ultrasound in a morning, and sometimes it's 67 in an afternoon, so you know how busy it is. So they have their quota of patients that they've got to see. And you know those scans can last 30 minutes, sometimes they'll have to bring them back in. So you've got to be mindful of other people's needs as well as the lady.
Vicky felt it was important to recognise the clinical pressures that her colleagues were under and to feed back study results to them.
Vicky felt it was important to recognise the clinical pressures that her colleagues were under and to feed back study results to them.
Age at interview: 47
Sex: Female
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It's very much about communicating and getting to know the clinical team well. I think that helps a lot. Understanding the sort of clinical pressures they're under. And that's where I think you bring some of your knowledge and expertise from a clinical setting into that as well, so you understand that, you know, they have huge pressures on their time. And their- the part that they role-, play in the research study obviously is only part of what they do the rest of the time. So being able to be quite flexible and adapt, and sort of fit into their needs, and communicating to them what you need and what you can provide to them. But a lot of it is about establishing good relationships. So having continuity. So for example, the children's study, going back to outpatient clinics regularly. So, making sure I had a sort of visible presence there. And that I was available if they had any questions, outside of the sort of direct consultation they were having with parents and the children who were participants as well.
And throughout- again, throughout the lifecycle of the study as well. So they've been involved in hearing the results about the study presented back at a seminar we held. So they had the opportunity to hear the results at an earlier stage, and to feed back what the results might mean to them in practice. Which helped sort of shape how we then presented the studies in publications as well, knowing perhaps what sort of clinicians who would be the end user of the message might feel about our findings.
Some research NMAHPs invested considerable time and effort into overcoming various barriers between clinical and research staff. This included finding ways to embed a positive attitude to research into the setting (such as through staff training and education). Claire described this as “the ‘hidden’ work, which is engaging teams and departments within the hospital, and supporting them to both understand the importance of and engage in offering research studies to their patients”. Sandra recalled conversations in which she had emphasised that research was (or should be) about patient choice and, ultimately, for patient benefit through building evidence.
Many research NMAHPs emphasised that being generally friendly and personable helped build good working relationships with clinical staff. Other examples included minimising disruption when carrying out research activities, doing “favours” and being a visible presence. Sometimes there were also reward systems with prizes in place, and many people talked about making cups of tea or bringing in cake as part of a ‘soft’ process of building relationships. Involvement with research activities was sometimes also offered to clinical staff as part of their Continued Professional Development.
Ellen said that sometimes the clinical staff will not be known to research NMAHPs and she emphasised the importance of “how we ask” for assistance.
Ellen said that sometimes the clinical staff will not be known to research NMAHPs and she emphasised the importance of “how we ask” for assistance.
Age at interview: 50
Sex: Female
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There are, there are sometimes occasions where you have to go to other wards and ask them. And we don't know their staff. Sometimes we start to get to know them as you go there regularly. So I would say that is more about how we ask. Yeah. And how we- we make it as easy for them as possible. So we'll say-, it's an ECG [Electrocardiogram] and a blood test that we need for this, for example. So we'll say, “Do you have an ECG request book? Does someone come round every day and do ECGs? When-?” Most of the wards will have a blood request box, which the doctor will pick up every morning. You know, it’s just, “What's the easiest way?” So that you actually don't have to, as a member of, as a ward nurse, go and take that patient's blood and do an ECG, because we can probably tie it in with when the ward ECGs are getting done anyway [laugh]. Or something like that. So yeah, it is just, it's definitely how you ask. Because some-, I have heard of cases where someone, a research nurse or CTO [Clinical Trials Officer], might go in with a different attitude and sort of say, “This needs doing for the research”, you know what I mean, and then, and then people get resistant.
When Rachel Y led radiography research, she found ways to support her colleagues to have involvement in the studies.
When Rachel Y led radiography research, she found ways to support her colleagues to have involvement in the studies.
Age at interview: 53
Sex: Female
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Therapeutic radiography is, is, you have to work in a team. It’s the way that it’s always been, so you’re actually quite close, you spend a lot of time together, and I didn’t have one colleague, not one, who wasn’t supportive of me doing that role. Bearing in mind, you know, that they, they were basically one person down, being able to treat because I was researching, so there could have been resentment there but there never was. And I think the reason that there wasn’t was right from the outset I was very clear with my manager and she was really supportive of this, that every piece of research I did I would bring at least one of them in on it, so that all of them at some point and there was a period that I can look back at where every single one of them was involved in something, so they had that on their CV’s, and their CPD [Continued Professional Development]. And the other thing that we did was, there were a few projects that actually income generated because we were testing out pieces of kit, and so that we, we, we were paid to do that, and what we did was we put that money into a, into a research pot, for other staff so that when they wanted to go to a conference, an event, they could. And they’d never had that opportunity before. So they were always pretty supportive.
‘Working around’ clinical staff and doing favours for them was seen by some as having reciprocal benefits. Sugrah sometimes stopped to help ward staff when they were very busy and, in turn, they helped to keep study activities going when research staff were not there. For Dawn, ‘helping out’ on the ward was not just about fostering good relationships with staff but also about patient benefit – for example, “reducing the length of time that patients are in” by taking blood pressures or blood samples. She felt that there was usually flexibility in her role to do this extra work, although other times the research needed to be prioritised. A few people described being selective about the tasks they felt comfortable doing and the need for clinical colleagues to understand the limits of this.
Osi was happy to help her clinical colleagues. However, after being caught up in a medical emergency once, she preferred to do “the things that don’t require too much patient care”.
Osi was happy to help her clinical colleagues. However, after being caught up in a medical emergency once, she preferred to do “the things that don’t require too much patient care”.
Age at interview: 27
Sex: Female
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So I learnt quickly to stick to the basic, basic, basic jobs. So there was one day where they are chock-a-blocked and they asked me to help to transfer a lady upstairs. She delivered ages ago, there was just no beds upstairs, "Could you just put her in a wheelchair and just put her upstairs and the midwife's going to hand her over?" So I said, "Okay, I can do that." And ‘cos there was like so many different things going on. So, I was waiting to a consent an [trial] patient, which I think had just delivered and they were kind of just suturing and stuff, so I was just-, just had to bide time with it. So I was like, "Okay." So we put her in the chair and she had a-, she had a vasovagal and she literally-, it was like emergency buzzer, and I was just like-, it was just of all the ladies-, I was just like ‘why’. So after that I was just like I think I should just stick to-, just stick to just doing the stuff, picking up phones. So I pick up phones and I can do some of the equipment that I've-, I helped to introduce, so the fFN machine, I trained them up to do the daily checks. However, if I'm down and they're chock-a-blocked and-, but it hadn’t been done, I don’t mind doing it. I would just say to them, "Well I've done it today ‘cos it wasn’t done, just thought I'd help you guys out," but just little stuff. "Osi, can you get-, can you get that midwife for me?" or just the things that don’t require too much patient care or anything else like that.
Layla found that helping clinical staff sometimes facilitated research. However, it was important to be clear about responsibilities – including to avoid patients feeling obliged to participate in research.
Layla found that helping clinical staff sometimes facilitated research. However, it was important to be clear about responsibilities – including to avoid patients feeling obliged to participate in research.
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So I think it's just if I can help other staff clinically, then that's good for them because it means I'm not adding to their workload. And it's good for me because they're more likely to be receptive to me being there. But it's also- you have to make that distinction-, you have to be quite careful with the women, in terms of making that distinction of although I'm helping out the midwife clinically, I might put the CTG [Cardiotocography machine] on or take bloods, it's- I work there. But at the same time, be really careful to, that, for- I'm not responsible and the clinical midwives know that I'm not responsible for interpreting that CTG or documenting in the notes about what position-. But they, that's still their responsibility and they have to do that. But also for the women, I think it's reassuring to them to know that I'm a midwife but at the same time know that I'm there in the research capacity. And even though I might put that monitor on or, you know, just start them off on that process, they're- you don't want them to feel coerced in any way into then taking part in the research because of it. You don't want them to feel pressured. So they have to know that they- you have to make it very clear to them that, “I'll start this off because-”. And generally, I think they appreciate that by my doing this, it means they're not waiting quite as long either, as if they had to wait for the clinical midwife. But you just- you have to be really careful that you're not making them feel then that they're under an obligation to take part in the study, because you've got those two hats. So, it's- it's just something you have to be very careful of and mindful of.
Whilst favours could mean relatively small and quick tasks, some research NMAHPs had also been asked or expected to do more substantial clinical work. This was a controversial topic regarding staff shortages, particularly in relation to winter pressures and crises. Some research NMAHPs had chosen to make formal arrangements to carry out clinical non-research work. In Imogen’s team, all the research nurses did a monthly supernumerary shift – this helped “maintain the skills” and she “found it was the best way to try and integrate the two teams”.
Some research NMAHPs did favours out of a sense of “guilt” or because they found the adjustment into a research role and the impact on their sense of professional identity challenging. For some, this helped them to retain and demonstrate a shared identity with clinical non-research colleagues at the same time as acknowledging differences in the role. Vicky described relationships with clinical colleagues as being different in research: “understanding that you’re not part of the clinical team directly but obviously you need to work with them very closely”.
Those who had moved from a non-research clinical role to a research role within the same working environment found that their relationships with colleagues could change. Colleagues sometimes said or did things which made research NMAHPs feel like they had become ‘outsiders’. When James moved into a research post, he recalled “people [I used to work with on the wards] saying, “Oh, didn't you used to be a nurse”, and things like that to me”. Familiarity with particular working environments could be helpful though. Dawn found it was a strength that she knew many of the nurses and clinicians already, and how things worked (including where to find medical supplies), at her hospital when she moved into research.
A few people commented that, as the research culture and the working relationships between clinical and research staff improved, some of these strategies were less necessary. Imogen initially spent a lot of time “helping out on the shop floor” which she thinks helped raise the profile of research. With time, she felt that the clinical team gained a good understanding of the value of research and were now very supportive of it. Jisha was also pleased that research was now seen positively in her unit, whereas previously it was primarily deemed to be “extra work”.
As a research midwife ‘champion’, Alison had insight at both local and national levels. She saw it as positive that there seemed to be less need to ‘reward’ clinical staff for supporting research activities in some places.
As a research midwife ‘champion’, Alison had insight at both local and national levels. She saw it as positive that there seemed to be less need to ‘reward’ clinical staff for supporting research activities in some places.
Age at interview: 45
Sex: Female
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So, in the champion role I should say I'm also -, have a national input in that I meet four times a year with all of the champions from the whole country. So, that’s really good to hear about different research midwives' experiences.
And it is very different. And some of the -, you know it's still -, it's still the case that so and so's trying to do a study, but the nurses or midwives there are, you know, don’t want it and you're a pain. So, you can see that on the one side and I definitely see it as a labour ward midwife. The last thing I need is something else to do, but we need to move beyond that. So, there has been a whole period, and I guess we're still in it, of favours and sort of roadshows or championing, or role modelling, how these things don’t have to be an imposition and they can even help you as a clinician; it might even make something simpler. So, there's a lot of baking. When I worked in [trial name], you know the, the team was often bringing cookies or brownies into staff rooms, and just relations, it always comes down to relations – individual, one-on-one relations. So, you find someone who has a bit of an eye; you can see a twinkle in the eye of a certain clinician and you know she's going to be helpful, not obstructive. Latch onto that and go from there and yeh, there's always this element of-, or reward systems or vouchers or draws for having helped identify a recruit to a study. I think I see a little bit less of it, so maybe that’s a good sign that we're actually embedding it, cos it needs to be part and parcel of the clinical pathway, not some bolt-on that’s a favour. It's not a favour, it's how the whole healthcare system works.
Several people highlighted that it was also important to have good relationships with the administrative staff who booked appointments for patients, including for scans. Michael joked that, “in my experience, an Irish accent, a wink and a smile goes a long way”. He found that building relationships works best “if you go up in person, a nice friendly face, I have been known to bring a coffee in the past, a bit of bribery, it works wonders”.
Ellen found that good relationships with the staff who book appointments was important. Making arrangements for the study was often a case of juggling and getting to know where there was flexibility.
Ellen found that good relationships with the staff who book appointments was important. Making arrangements for the study was often a case of juggling and getting to know where there was flexibility.
Age at interview: 50
Sex: Female
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We've built up a relationship with the staff. Mainly the appointment staff [laughs]. Who basically, they're the ones that make the appointments.
And then what we try and do to accommodate the patients for this particular scan-, they have to have an MRI scan, a Doppler scan, of this is neck arteries. An MRI scan, a Doppler scan, a consultant appointment, and see us. So it's trying to get all those four appointments-. Well, we're flexible really. The other three appointments on one day and in really in half a day. Because you don't want one at nine and one at five. So it's deciding which of those three appointments is the least accommodating, [laugh] or least hard to get, and which is the-. So we usually get the MRI first, and then book the consultant, and the Doppler's always very accommodating.
It's just learning about the hospital departments isn't it and what's the easiest way to do it. It's a lot of juggling
Footnotes
*The people interviewed for this website were mostly research NMAHPs (i.e. those employed in a research delivery role). However, we also interviewed some NMAHP researchers (i.e. those leading research as independent researchers). The latter group included people who were undertaking or had completed academic research qualifications, such as PhDs, and many had previously been in (or continued to also be in) research delivery roles. For more information about the distinctions between these roles and the sample of NMAHPs interviewed for this project, please see the Introduction section.
*Many research NMAHPs and NMAHP researchers felt strongly that they continued to be clinical within their research roles. As such, the wording of ‘research’ NMAHPs/staff and ‘clinical’ NMAHPs/staff can be problematic for implying that research is not also clinical activity. Where the wording ‘clinical staff’ is used on the website, we mean for this refer to non-research clinical staff (i.e. those who are not currently employed to carry out research or enrolled to pursue research through an academic qualification).
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