Starting a career in research nursing during a global pandemic

In March 2020, the World Health Organization declared the novel coronavirus (COVID-19) outbreak a global pandemic, which limited research activities and career advancement for those working in this area (Iles-Smith et al, 2020; Castro-Sánchez et al, 2021). Castro-Sánchez et al (2021) suggested that a lack of clinical research beyond acute care environments may have hampered learning opportunities, particularly for nurse-led research, until collaboration to identify some of the operational barriers and facilitators to their transition that they experienced, and offers strategies that counter these challenges, as described by Braun and Clarke (2019) and Whitehouse et al (2022).

Table 1 provides a timeline of their journey from January 2020 to January 2023.

‘Green as grass, keen as mustard’: a mixture of enthusiasm and inexperience

The research nurses, KR and AJ, were recruited to a National Institute for Health and Care Research trial taking place within the nurses' NHS Trust (see Box 1). This aimed to explore the novel management of the symptoms of patients with irritable bowel syndrome. Both nurses were new to clinical research; this section discusses their lack of research experience and their motivation for a career change.

Box 1.Study hypothesisThe study hypothesis presumes that many people with irritable bowel syndrome-(IBS-) like symptoms have organic underlying diagnoses that are missed if National Institute for Health and Care Excellence (NICE) criteria for the diagnosis and treatment of IBS are followed.Patients who presented to primary care surgeries with IBS-like symptoms, including diarrhoea, were allocated to one of two ‘arms’ – this was to provide a comparison of outcomes from management following NICE guidance with more detailed, but largely non-invasive, investigations that aimed to identify currently missed organic disorders.This was a National Institute for Health and Care Research (NIHR) study funded by Research for Patient Benefit; International Standard Randomised Control Trial number: 87945798 (2020)

AJ had worked in critical care for 4 years since qualifying as a nurse and felt that the time had come for a change and decided to pursue a career in research nursing. In contrast, KR had an extensive background beyond her 6 years in the acute sector, as a nurse and midwife, with almost 20 years in health visiting. She was keen to retain autonomy yet broaden her skill set by exploring a new specialty. Their respective new roles presented the opportunity to pioneer a nurse-led approach to the research, devised and overseen by an experienced consultant gastroenterologist and honorary professor in gastroenterology, with bespoke training and assessment.

Inevitably, the COVID-19 pandemic disrupted the scheduled induction to the organisation, tailored educational programme and orientation to the field of research, which delayed the launch of the trial and incurred operational consequences. With the urgent need for and prioritisation of COVID-19-related research, other health research became a casualty of the pandemic (Singh et al, 2020; Iles-Smith et al, 2020), with new studies suspended, including postponement of the study that KR and AJ were employed to lead and manage. The halting of studies reduced the visibility of research while clinical redeployment impacted capacity (Castro-Sánchez et al, 2021). In addition, resources were redirected to deliver patient care to address chronic nurse understaffing, constituting a sector-wide issue that resulted in depleted research expertise during a critical time as nurses were redeployed to the front line. Ultimately, both KR and AJ were allocated to a community hospital; this was a period of reacclimatisation for KR – to be back in uniform, working exhausting 12-hour shifts in a ward environment where the culture and practices had significantly changed from her previous experiences on wards in the 1990s, such as computerised drug rounds and use of National Early Warning Scores (Royal College of Physicians, 2017). However, she extended her sphere of competence with the clinical upskilling and refresher training provided on syringe drivers, urinary catheterisation and frailty assessments. Castro-Sánchez et al (2021) identified the emotional toll of bedside nursing during the pandemic and the fear of contracting or spreading the virus to others, which resonated with both nurses.

As the duration of their redeployment was unknown, both nurses wondered if or when their research nursing career would start, balancing their feelings of having a duty of care to their current work, while establishing a new expression of themselves as ‘research nurses’ (Goffman, 1959). Although unplanned, redeployment provided them with an opportunity to foster a professional relationship with one another during a time of uncertainty, with a shared lived experience of the transition from clinical practice to research. KR and AJ were aware of their enthusiasm for, and inexperience in, research and the uphill trajectory they faced.

KR and AJ also experienced heightened feelings of insecurity because they had both relinquished permanent positions to take up fixed-term contracts. Singh et al (2020) highlighted the uncertainty and stressors for staff on fixed-term contracts, especially during the height of the pandemic, which occurred due to research restrictions and career instability. Although it was a consolation to be employed by a large NHS organisation, the implications for retaining and valuing professionals and the precarity of short-term contracts merits attention beyond this article (including the need to develop career development frameworks for early career researchers and clinical academic careers).

‘Spires and steeples’: overcoming challenges

The nurses' experience of learning how to navigate research processes during COVID-19 can be portrayed using the ‘spires and steeples’ simile, evocative of the Lincolnshire landscape.

After 2 months of delivering clinical care, KR and AJ were released back to the research team and embarked upon intense specialist preparation for their new roles, albeit remotely, using Microsoft Teams and other hybrid platforms. The nurses shadowed their research nurse colleagues by listening in on phone calls or observing virtual consultations. At times, although their presence was overt, and with patient consent, they felt that they were eavesdropping on sensitive clinical conversations, and were imposing on patients' privacy. KR also wondered whether their presence might have subtly influenced discussions with patients pertaining to their continence and gastric symptoms, adding to their embarrassment. The participants' choice of being seen or switching the camera off was respected. Despite the challenges that arose from virtual consultations, such as technological competency and connectivity issues (Fowler, 2023), study participants anecdotally reported that the virtual consultations were more beneficial than in-person interviews, facilitating flexibility of venue and time. In particular, the option to stay at home in a familiar environment with access to private toilet facilities, avoiding travel and long waiting-times, also reduced anxiety. Such sentiments were corroborated by an Oxleas NHS Foundation Trust survey (2020), in which the convenience of remote appointments was viewed positively overall for follow-up that did not require physical examination. However, appropriateness was dependent on the nature and style of the appointment, with a preference for video rather than telephone appointments expressed.

The lack of face-to-face interactions prevented the nurses from meeting the multidisciplinary research team in person for several months. As a consequence of the pandemic restrictions, research recruitment practices were adapted, with amendments required to permit the use of electronic consent forms and virtual consultations, as discussed by Iles-Smith et al (2020). Notable changes were a shift from paper-based documents to uploading data to a computer database, thereby adhering to infection prevention measures, along with the use of a QR code to link to recruitment resources. Although undertaking research during a pandemic caused some problems, the learning experience still held value because research staff were forced to adapt, be pragmatic and find new ways to work.

The nurses initially felt daunted by working closely with the chief investigator, with whom they had weekly meetings. However, they overcame these feelings and came to recognise the privilege of discussing progress and being able to tailor their input. KR and AJ developed resilience and regained confidence as they transitioned from being formerly expert practitioners to becoming novices again, and honing skills and embedding assimilated knowledge to emerge once more as competent beings (Benner, 1982). The experience was akin to that outlined by Lainson et al (2019), who recounted the frustrations of moving between the ‘practitioner’ and ‘researcher’ social identities and the need for reassurance, highlighting issues such as the potential discomfort generated by the immersion into a new culture, the use of unfamiliar terminology, and power imbalances in the research relationship. Consequently, making suggestions and sharing information to prompt discussion enhances a sense of value and nurse participation in multidisciplinary decision-making (Wallace et al, 2019).

During their research training, KR and AJ received an assessment of competency via an examination, which was combined with role play. This added to a sense of being under scrutiny for the nurses, particularly when they were being filmed or recorded for quality assurance. This led to feelings of performance anxiety but helped to develop confidence in the long term. Additional competencies were developed such as the use of digital systems (SystmOne), databases (EDGE) and the acquisition of practical skills such as venepuncture through simulation, shadowing and supervised practice in the phlebotomy clinic. Presenting cases and applying analytical reflection allowed the research nurses to adopt a consistent approach to patients. They developed integrity that echoed that of the ‘narrative practitioner’ (Lainson et al, 2019), whereby the ‘story’ is told.

Importantly, the nurses also attended a teaching session on motivational interviewing (Rollnick and Miller, 1991) to develop knowledge and ensure competency when establishing participants' willingness to change health behaviours.

Together KR and AJ overcame many hurdles, ‘found their feet’ and traversed the ‘muddy swamps’ (Finlay, 2002). Finlay (2002) likened researchers to explorers with a ‘map’ to self-discovery. Their mutual journey from being ‘study buddies’ to ‘critical friends’ facilitated an honest rapport with one another and they were able to share thoughts, ideas and the division of labour, thereby capitalising on their respective strengths. They integrated with their research colleagues under the nurturing leadership of their line manager. With the guidance of the professor, the nurses became practitioner-researchers, encouraged to present their work locally within the Trust and externally to university students, staff and at conferences.

‘Down the rabbit hole’: taking the plunge into a new field of work

The study required the research nurses to be involved in producing resources, which involved the design and creation of case report forms, patient information sheets, packs, tools and even a logo. Neither had appreciated the amount of audit, logistics or marketing skills required for ‘promoting’ the study to sites for recruitment. Communicating and encouraging others to take part in research has previously been described as a ‘sales pitch’ (Fletcher et al, 2012). Such activity, whereby a research study is presented as a care option offered to potential participants, was initially disconcerting for both nurses. This added to a sense of unease as both KR and AJ are inclined to be introverted, self-effacing and quiet. These personality traits made this aspect of research more challenging; however, as the nurses honed their skills, they developed a greater appreciation of how the opportunity to contribute to a trial is underpinned by informed choice and that providing information to potential participants is part of this. Moreover, it has increased both their confidence and competence in public speaking and presenting. This is the art of being a patient advocate: balancing enthusiasm for the study with ensuring that prospective patients are free to make their own decision on whether or not to take part. The nurses always attempted to maintain a sincere, credible, and unbiased approach, recognised as a ‘caring recruitment dichotomy’ (Tinkler et al, 2018; McCabe et al, 2019; Hernon et al, 2020).

The nurses were also required to use social media and other communication channels to raise awareness of the study, amid restricted footfall following the COVID-19 lockdowns. To overcome barriers that lockdowns imposed they liaised with statutory, pharmacological, charitable and corporate organisations, and sought guidance from Patient and Public Involvement steering group members.

A particular problem was the need to adapt the breath test (Box 2) process, as outlined in the study protocol, for those participants randomised to the nurse-led arm of the trial. This incurred a change from supervised collection of breath samples because this was considered an ‘aerosol-generating procedure’ that could not be supervised due to COVID-19. Consequently, an instructional video clip was created for participants to complement the explanatory leaflet for successful home sampling. This demonstrated how to perform the procedure. The delivery and return of breath kits also necessitated a change in organisation because of postal issues, requiring the use of other methods, such as collecting the samples in person, which took time. Overall, such actions showed the nurses' flexibility and accountability, which echo innovations in data and sample collection described by Iles-Smith et al (2020).

Box 2.The glucose breath testThe glucose breath test was a first-line intervention advocated to identify whether an underlying condition − small bowel bacterial overgrowth − was present in patients with irritable bowel syndrome. It is caused by gas-producing bacteria, which can be treated with antibiotics

Lainson et al (2019) discussed the notion of ‘hurdles’ in the research terrain. Obstacles encountered by the nurses consisted of the unavailability of treatment options and equipment and administrative anomalies, which incurred frustrating delays. A launch event for the research study was not possible due to the COVID-19 restrictions. The nurses appreciated the disparities in agendas and priorities between the study team and the frontline clinicians who put forward patients for the trial, which were compounded by the pandemic. They offered sensitive and tailored support by balancing enthusiasm with the drive to meet targets.

It was pertinent to identify the ‘gatekeepers’ or research-minded practitioners, to establish with whom it was best to liaise, when and how to avert friction, optimise appropriate referrals and to avoid frustrating staff or overwhelming recruitment sites. The nurses recognised the importance of networking and building a rapport with primary care staff to deliver effective research. Similarly, Lech et al (2021) discussed the significance of GP involvement in research. Likewise, recognition that issues arise for individuals who do not enrol or who withdraw or disengage from the trial, serve to emphasise that obtaining consent is an ongoing process rather than a one-off event, as individual circumstances may change. It was important to have empathy for research participants and to acknowledge an honest, holistic partnership with them, rather than merely seeing them as conduits for data collection (Finlay, 2002; Lainson et al, 2019). It is also ethical to explore participant expectations and motivations and to establish whether it is the right time in a patient's journey to take part in a research study.

Recruitment for the study used a convenience sampling approach, whereby the most readily available participants were selected (Polit and Beck, 2021). Participants were recruited when they presented to their primary care health professional with the relevant symptoms. It was the responsibility of the practitioner to inform the patient about the study and seek permission to pass their details to the research team. According to Lech et al (2021), recruitment of GPs and their patients is a challenge in the conduct of research in primary care, due to lack of time and administrative burden. These issues were amplified during the pandemic as GP practices were required to prioritise the COVID-19 and influenza vaccination programmes (Privor-Dumm et al, 2021). On occasion, potential participants contacted the research team directly after seeing study adverts or hearing about it through word of mouth. However, such inquiries then required clinical endorsement to proceed, as the nurses could only access the patient's care record after completing the consent process. Consequently, the research nurses relied on participant and practitioner commitment, and applying effective communication skills in their interactions with primary care staff.

Fletcher et al (2012) identified various primary care research barriers, including poor communication or misunderstanding about research methods, a sense of feeling overwhelmed and having concerns about patient harm or problems that could occur. This highlights that good quality communication, study education and integration between the research team and clinicians in the delivery of effective research are imperatives. Connelly and Peltzer (2016) suggested that using GP services as the intermediary source for recruitment can be a demographic or structural barrier to ensuring a representative sample. Although GP sites that declined to participate were a source of frustration for the research nurses, KR and AJ endeavoured to be inclusive and empathetic in their approaches to recruitment within the rural community practices that agreed to participate.

Despite disappointment when potential participants were not eligible, declined to take part or withdrew from the trial, the nurses demonstrated resilience, learning that it was not a personal rejection. Furthermore, the nurses developed an awareness of unconscious pressures to ‘justify’ progress to the chief investigator at their weekly meetings. For both nurses, this was congruent with a fear of failure, a wish to avoid conflict, to impress, and to achieve recognition, approval and validation, which could be both unsettling and motivational.

From the outset, the nurses and participants were constantly reacclimatising to the language used in research and gastroenterology. For the nurses, one example of this was the use of the word ‘power’ when assessing trial viability; in the case of trial participants this was the use of the word ‘motion’ with reference to bowel movements, which some did not understand and one participant misunderstood it to mean ‘emotion’. Visual tools, such as charts depicting stool form and units of alcohol, were used with participants to clarify, normalise and overcome inhibition, along with contemporary references to contextual issues, such as the case of Dame Deborah James, the ‘Bowel Babe’. The use of these aids demonstrated nuanced judgements and reflexivity in the research process, as described by Nadin and Cassell (2006) and Olmos-Vega et al (2023).

Periodically, the nurses struggled to maintain momentum but observed an upturn in the number and suitability of referrals converted into recruits, following refresher sessions with sites and clinicians (Table 1). The eligibility criteria and protocol that framed the study used open-ended, rigorous questioning techniques so that patients' true lived experiences were recorded, which enriched the data. Connelly and Peltzer (2016) and Varpio et al (2021) described this need for skilful inquiry to deepen quality and clarify understanding, thereby enriching the data beyond superficial reporting. Despite their respective future career uncertainty, the nurses relished their dynamic roles in the research.

Conclusion

Beginning careers as research nurses during a global pandemic was a challenge. However, the journey facilitated additional learning and development, both professionally and personally. KR and AJ are proud of the work they have done, particularly the new skills, resilience and flexibility they gained, as well as to have been involved in such an important study.

Some participants stated that the study had improved their quality of life as the result of the care and treatment provided, as well as the support from the nurses. As the end of the study approached, the nurses considered the next step in their careers with both desiring to remain in clinical research. The pandemic further highlighted the importance of research as the basis of evidence-based practice, which is a vital part of health care.

KEY POINTS

• Taking on new careers as research nurses is challenging, and especially so during a global pandemic, when all aspects of health care were subject to change
• The use of fixed-term contracts in research and role insecurity merits further exploration
• The relevance of marketing skills in 21st century nursing is worthy of review. These may be skills that need teaching in nurse education
• The personal characteristics required of research nurses include adaptability, integrity and resilience, to enable them to develop ownership and a ‘solution-focused’ approach to the research being undertaken

CPD reflective questions

• Reflect on your own experience of nursing during the pandemic. What adjustments did you and your organisation make?
• Weigh up the benefits and challenges of seeking a fixed-term contract
• Describe your current level of involvement with research. Are there opportunities to get further involved?
• Discuss your work governance structure with a colleague and how this interfaces with other organisations. How might you access alternative services to recruit participants for research?