Registered nurses with a PhD : an asset in clinical care

Background: Shortcomings in providing health care may cause otherwise preventable patient harm and suffering, while also increasing the cost of healthcare delivery. Approximately one-third of all patients do not receive scientifically based care and about one-quarter receive care that is either unnecessary or associated with risk of injury. Nursing is the professional domain of the registered nurse (RN), including both scientific knowledge and patient-related clinical practice. There is now scientific evidence that the educational level of RNs (bachelor’s degree or higher), as well as professional skills, has a positive effect on patient outcome. Educational level (master’s degree or higher) also has a positive impact on the application of research findings in the clinical setting. Furthermore, a relationship between clinical research and improved quality of care has been established. The late twentieth century higher education reform saw nursing education in Sweden transition from a vocational education to an academic education. An important motive for this transition to a more academic emphasis in nursing education was to ensure quality of patient care for the future. To date, since the first RN thesis in 1978, there are about 1700 RNs with a PhD degree (RN/PhDs) in Sweden. Despite the steady increase in this number, few RN/PhDs are involved in clinical care. There is still limited knowledge concerning the role and function of RN/PhDs working in clinical care and the value their services can potentially bring to health care.

Aims: The overall aim of this thesis was to investigate whether and how RN/PhDs working at university hospitals contribute to improvement of care. Four sub-studies were undertaken to meet the following specific objectives. Study I) to explore published articles concerning clinical contributions from RN/PhDs regarding their impact on quality and improvement of nursing care; Study II) to investigate what RNs with a PhD working in clinical practice experience in terms of their role, function and work context; Study III) to explore what factors have a bearing on the ability of RNs and physicians to combine clinical work with research after earning a PhD; Study IV) to investigate how managers perceive and apply the skills and expertise of RNs with a PhD as a resource in clinical practice.

Methods: Different methods were applied. Study I is based on a systematic literature review. Study II is based on data from individual interviews that were analyzed using inductive, qualitative content analysis. Study III involved the analysis of data from individual interviews using conventional content analysis. Study IV incorporated data from individual telephone interviews and subjected them to thematic analysis.

Results: The main areas of responsibility for RN/PhDs involved in clinical care relate to improvement of clinical care and implementation of research findings. In this context, the leadership role of the RN/PhD was considered to be essential. In order to contribute with their skills to support development of evidence-based practice (EBP) and the furthering of skills among colleagues, support from managers was essential to establish a conducive setting for the RN/PhDs. One problem in this regard is that managers are not always aware of what skills RN/PhDs are able to contribute. Maintaining a strong association with the academic world was perceived to be important. The opportunity to combine the clinical and academic aspects of nursing was considered essential in order for RN/PhDs to influence and improve care, yet few such combined positions are currently available. The opportunities for RN/PhDs to conduct research after earning their PhD are limited; one important reason is the challenge faced by inexperienced researchers in obtaining research funding. In addition, the infrastructure to help support research among RN/PhDs working in clinical care is limited.

Conclusions: An informed approach among managers is key to safeguard the skills and expertise of RN/PhDs so as to promote good quality nursing care and EBP; RN/PhDs with a clear job description can serve as a potent force to facilitate EBP, improve the transfer of scientific knowledge into clinical practice, point out relevant research questions that address challenges emerging from clinical practice, and conduct clinical research, provide clinical training and competence development among colleagues; An increase in the number of combined academic/clinical employment opportunities for RN/PhDs can help bridge theory and practice, for the benefit of patients, nurses, students and managers.

List of scientific papers

I. Orton, M. L., Nelson Follin, N., Dannapfel, P., Wengström, Y. (2021). Roles and functions in clinical care for registered nurses with a PhD – A systematic literature review. Scandinavian journal of caring sciences.
https://doi.org/10.1111/scs.12979

II. Orton, M.L., Andersson, A., Wallin, L., Forsman, H., & Eldh, A.C. (2019). Nursing management matters for registered nurses with a PhD working in clinical practice. Journal of Nursing Management. 2019 Jul;27(5):955-962.
https://doi.org/10.1111/jonm.12750

III. Orton, M. L., Nilsen, P., Nelson Follin, N., Dannapfel, P. (2020). Is it possible for registered nurses and physicians to combine research and clinical work to facilitate evidence-based practice? Worldviews on Evidence Based Nursing. 2021 Feb;18(1):15-22.
https://doi.org/10.1111/wvn.12481

IV. Orton, M. L., Wengström, Y., Smeds Alenius, L., Andersson, Å., Nelson Follin, N., Dannapfel, P. (2021). How registered nurses with PhDs are currently used in clinical care: managerial views. [Submitted]