EXPLORING THE RESEARCH CULTURE OF NURSES AND ALLIED HEALTH PROFESSIONALS (AHPS) IN A RESEARCH FOCUSED AND A NON-RESEARCH FOCUSED HEALTHCARE ORGANISATION IN THE UK MANJU LUCKSON PhD 2015 Exploring the research culture of nurses and Allied Health Professionals (AHPs) in a research focused and a non- research focused healthcare organisation in the UK Manju Luckson A thesis submitted in partial fulfilment of the requirements of the Manchester Metropolitan University for the degree of Doctor of Philosophy Department of Nursing Manchester Metropolitan University 2015 ii ACKNOWLEDGEMENT This thesis is the culmination of my journey and my parents’ dream towards obtaining a Ph.D. This effort had been made by the enormous support and guidance of numerous people including my supervisors, family, well-wishers, friends, colleagues and many others. I would like to express my special appreciation and thanks to my supervisor Professor Carol Haigh, who has been a remarkable mentor for me. I would like to thank her for her continuous support and guidance during this thesis and for enabling me to grow as a researcher. I am grateful to her for timely advice, guidance, and brainstorming discussions, especially during the early stages of this thesis. Dr Fiona Duncan, my co-supervisor, has been a tremendous inspiration for me. The words I write here will be insufficient to express my gratitude to her. I would like to thank her for her patience, encouragement and advice given throughout my journey as a PhD student. Both Carol and Fiona have steered me throughout this hard journey. They have motivated and challenged me to put in my best while also understanding my limitations. Besides being great supervisors, they cared for my well-being and always promoted a healthy work-life balance. When I was pregnant twice during the course of my PhD, they permitted me time off from my PhD course, and continued to support me. I would like to thank them for their kindness, compassion and care shown towards me. I would also like to thank Professor Christi Deaton for her initial support and guidance. I cannot express in words nor show how grateful I am to my parents for all they have done for me. My mum, dad and sister, Anju encouraged me so much which kept me on track with this thesis. Their prayers and immense mental support was a real boost to me. iii I would also like to thank to my husband, Luckson Francis Augustine and my children, Livia, Elvia and Ellis. A sincere thanks to my beloved elder daughter, Livia for cheering me up. She kept me going and I did not want to let her down. A thank you too, to my aunties, especially Auntie Rosily, for their support while writing up my PhD. I would especially like to thank all the managers, AHPs, and nurses in City Hospitals and Riverside Hospitals. All of you have been there to support me in the data collection of this thesis. I would like to thank my manager and my colleagues at my work place for all their invaluable support. I had immense support from Libby Holden and Sue Pager from Australia for this study. I express my sincere gratitude to them both. Jo Cooke was also very supportive during this study. Also, a special thanks to Azita Razai, my statistician. In this small document, I have made a genuine effort to acknowledge the many people who have facilitated me to carry out a task of this kind. In fact, there are many more kind hearted people who assisted me in many ways, either directly or indirectly. I sincerely thank all of them. Finally, I dedicate this PhD thesis to my Dad, Chackochen and Mum, Aniamma Pallathu, who taught me the two most important lessons in life; the first lesson is never give up and the second lesson is never forget the first lesson. iv ABSTRACT Exploring the research culture of nurses and Allied Health Professionals (AHPs) in a research focused and a non-research focused healthcare organisation in the UK There is a gap in the knowledge about the research culture of nurses and Allied Health Professionals (AHPs) in the UK, and the influence of a dedicated research strategy and funding. It is important to understand the culture in order to effectively promote evidence- based patient care. The primary aim of this research was to explore the influence of research focused exposure on the research culture of nurses and AHPs in the UK and identify if there was a difference in the research culture between a research focused and non-research focused clinical area (City and Riverside Hospitals). This is a unique and novel study that explored and compared the research culture stance of both AHPs and nurses. A mixed methods design was used in this study. Tools used included the ‘Research Capacity and Culture Tool’ as an online survey, three focus group discussions and 5 semi-structured interviews with senior managers. Focus groups included research naive groups from both hospitals and a research active group from City Hospital. There were 224 responses received from 941 surveys with a 24% response rate. Descriptive statistics of the survey results indicated that there was a difference (p=0.001) in the mean score of the research culture between City Hospital (5.35) and Riverside Hospital (3.90), but not between nurses and AHPs (p= 0.12). Qualitative data findings from the framework analysis were congruent and supported the survey results. The results provided empirical evidence to support a whole level approach in order to improve the research culture. The findings showed that there may not be any difference in the research culture between professional groups. Importantly, new evidence is presented to suggest that there were crucial communication issues which were hampering the research culture and there was a lack of support at the middle v management level which needed to be tackled to improve the research culture of nurses and AHPs. The study highlighted the need to include communication within the Cooke’s Framework if evidence based practice is to influence the quality of patient care. vi TABLE OF CONTENTS 1 CHAPTER 1: INTRODUCTION .................................................. 1 1.1 Study Population ........................................................................................................ 6 1.2 Background ................................................................................................................ 8 1.3 Research culture ....................................................................................................... 11 1.4 Research culture of nurses and AHPs .................................................................... 14 1.5 Context of the study ................................................................................................. 16 1.6 Concept of the study ................................................................................................ 19 1.7 Aims and objectives of the study ............................................................................. 22 1.7.1 Aim ................................................................................................................... 22 1.7.2 Objectives ......................................................................................................... 23 1.8 Methods ..................................................................................................................... 23 1.9 Outline of chapters ................................................................................................... 23 2 CHAPTER 2: STUDY CONTEXT ............................................. 26 2.1 Introduction .............................................................................................................. 26 2.2 Biomedical Research Centre development in UK ................................................ 26 2.3 The vision of City Hospital ...................................................................................... 27 2.4 Multi-professional strategy ..................................................................................... 27 2.5 Research outputs of the organisation ..................................................................... 29 2.5.1 Research funding .............................................................................................. 30 2.5.2 Research active staff ......................................................................................... 31 2.5.3 Publications ...................................................................................................... 32 2.5.4 Fellowships ....................................................................................................... 35 2.5.5 Clinical Impacts ................................................................................................ 35 2.6 Summary of the research output at City hospital ................................................. 36 2.7 Research activity of Riverside Hospital ................................................................. 37 2.8 Conclusion ................................................................................................................ 38 3 CHAPTER 3: LITERATURE REVIEW ..................................... 40 3.1 Introduction .............................................................................................................. 40 3.2 Research Capacity Building .................................................................................... 41 3.3 Tools to measure research culture .......................................................................... 42 3.4 Measuring research culture .................................................................................... 47 3.5 Enablers and barriers of research culture ............................................................. 50 3.5.1 Enablers for an effective research culture: ....................................................... 50 3.5.2 Barriers to an effective research culture ........................................................... 60 vii 3.6 Research environment ............................................................................................. 65 3.7 Collaboration ............................................................................................................ 68 3.8 Difference between nurses and AHPs ..................................................................... 68 3.9 Summary ................................................................................................................... 69 4 CHAPTER 4: METHODOLOGY ............................................... 72 4.1 Introduction .............................................................................................................. 72 4.2 Aims and objectives of the study ............................................................................. 72 4.2.1 Aim ................................................................................................................... 72 4.2.2 Objectives ......................................................................................................... 72 4.3 Background and context to the study areas and participants .............................. 73 4.4 Research approach ................................................................................................... 74 4.5 Research methodology ............................................................................................. 75 4.6 Mixed methodology .................................................................................................. 76 4.6.1 Survey ............................................................................................................... 78 4.6.2 Survey sample .................................................................................................. 79 4.6.3 Focus groups ..................................................................................................... 80 4.6.4 Semi-structured interviews of the senior management team ............................ 81 4.6.5 Framework analysis .......................................................................................... 82 4.6.6 Ethics and governance approval ....................................................................... 83 4.7 Methods and Tools ................................................................................................... 85 4.7.1 Phase 1: Survey and its tool .............................................................................. 85 4.7.2 Survey Method ................................................................................................. 88 4.7.3 Time and period of survey ................................................................................ 90 4.7.4 Confidentiality ................................................................................................. 91 4.8 Phase 2: Focus group ............................................................................................... 91 4.9 Running the Focus Group Sessions ........................................................................ 94 4.10 Phase 3: Semi-structured interviews ...................................................................... 96 4.10.1 Confidentiality ............................................................................................. 97 4.11 Data collection .......................................................................................................... 98 4.11.1 Phase 1 ......................................................................................................... 98 4.11.2 Phase 2 and 3 ............................................................................................... 98 4.12 Validity, Reliability and Generalisability ............................................................... 99 4.12.1 Validity ........................................................................................................ 99 4.12.2 Reliability .................................................................................................. 100 4.13 Data Analysis .......................................................................................................... 103 4.13.1 Phase 1 ....................................................................................................... 103 4.14 Phase two and three: Qualitative data analysis ................................................... 104 4.14.2 Summarising findings ................................................................................ 113 4.15 Advantages and disadvantages of being an insider. ............................................ 113 viii 4.15.1 Depth of information and Knowledge versus objectivity .......................... 114 4.15.2 Honesty versus Bias ................................................................................... 115 4.15.3 Interaction and relationship versus confidentiality and validity ................ 116 4.15.4 Power versus gaining access ...................................................................... 117 4.16 Summary ................................................................................................................. 118 5 CHAPTER 5: SURVEY RESULTS ......................................... 119 5.1 Introduction ............................................................................................................ 119 5.2 Demographic Data of the survey participants ..................................................... 120 5.3 Research Capacities ............................................................................................... 122 5.3.1 Individual research capacities ......................................................................... 122 5.3.2 Divisional/ Ward / Team / Department Level ................................................ 125 5.3.3 Organisational Levels ..................................................................................... 129 5.4 Unsure’ answers in the survey responses ............................................................. 132 5.4.1 Unsure answers. .............................................................................................. 138 5.5 Mean Scores each levels ......................................................................................... 139 5.6 Barriers to a research culture ............................................................................... 142 5.7 Motivations for research........................................................................................ 144 5.8 Current Research Activities .................................................................................. 146 5.9 Difference in research culture between Nurses and AHPs ................................. 146 5.10 Conclusion .............................................................................................................. 147 6 CHAPTER 6: QUALITATIVE DATA RESULTS ..................... 148 6.1 Introduction ............................................................................................................ 148 6.2 Specific themes ....................................................................................................... 150 6.2.1 Lack of skills and knowledge at Individual level ........................................... 151 6.2.2 Lack of Support at Team level ....................................................................... 152 6.2.3 Organisational level: infrastructures and facilities ......................................... 154 6.3 Generic Themes (individual, team and organisational) ...................................... 157 6.3.1 Barriers and enablers of research culture ........................................................ 157 6.3.2 Communication .............................................................................................. 160 6.3.3 Career pathways ............................................................................................. 162 6.3.4 External links and collaboration ..................................................................... 165 6.3.5 Motivators of research culture ........................................................................ 167 6.4 Conclusion .............................................................................................................. 168 7 CHAPTER 7: DISCUSSION AND CONCLUSION ................. 170 7.1 Introduction ............................................................................................................ 170 7.1.1 Aim ................................................................................................................. 170 7.1.2 Objectives ....................................................................................................... 170 ix 7.2 Research culture at different levels ...................................................................... 173 7.2.1 Individual level ............................................................................................... 174 7.2.2 Team level ...................................................................................................... 182 7.2.3 Organisational Level ...................................................................................... 185 7.2.4 Supra-organisational ....................................................................................... 187 7.3 Issues identified from this study ........................................................................... 189 7.3.1 Issue one: Lack of communication and collaboration at three levels ............. 189 7.3.2 Issue 2: Lack of support at team level ............................................................ 192 7.3.3 Issue 3: Lack of knowledge, resources and funding available at individual level 193 7.3.4 Issue 4: Lack of time and increase clinical pressure ....................................... 195 7.3.5 Issue 5: Lack of career pathways .................................................................... 196 7.4 Difference between nurses and AHPs ................................................................... 197 7.5 Strengths of the study ............................................................................................ 198 7.6 Limitations of the study ......................................................................................... 200 7.7 Clinical implications .............................................................................................. 201 7.8 Recommendations .................................................................................................. 202 7.9 Conclusion .............................................................................................................. 203 7.9.1 The key findings of the study ......................................................................... 204 APPENDIX: 1 ORIGINAL RCC TOOL .......................................... 206 APPENDIX 2: MODIFIED RCC TOOL .......................................... 215 REFERENCES .............................................................................. 222 x