Nurse Edurohon Todq ( 199 I, 11, 17% 17R 0 Longman Group UK 1.d 1991

Nurse Education Tomorrow Conference 1990

The what and how of teaching research

Elisabeth H Clark and Jennifer Sleep

Within the last decade nurse educators have been required to introduce research into the curriculum of every pre- and post-registration programme. This has lead to a debate concerning what practitioners need to know about research and about the best way to teach the research component of any educational programme. Two main approaches may be identified: facilitating research awareness and learning research by ‘doing’. Both approaches raise a number of logistical and ethical problems. Certain of’ these problems are compounded by the large numbers of’ nurses who may be required to undertake a research project as a course component. Moreover, the absence of research evidence about the most effective means of educating nurses to become discerning consumers of research leaves the teacher without a sound framework to guide educational practice.

In the light of recent educational reforms, this paper considers the unprecedented opportunities for nurse and midwife teachers to explore the role of research in the curriculum and in teaching.

There is currently considerable variation in the way in which research is introduced into the

curriculum and taught in nurse education pro-

grammes in the UK. Two main approaches can

broadly be identified: facilitating an awareness

of research with the aim of increasing the use of

research findings in practice. and learning about

research by ‘doing’. These differing perspectives

have been highlighted in an ongoing debate in

the nursing press. Armitage and Rees (1988a)

suggest that completing project work (which

encompasses the conduct of research) can pro-

vide ‘one of the most creative and satisfying

Elisabeth H Clark BA PhD Director, Distance Learning Centre, South Bank Polytechnic, London, Jennifer Sleep RN RM MTD BA Research Coordinator, Berkshire College of Nursing and Midwifery, Royal Berkshire Hospital, Craven Road, Reading RGl 5AN (Requests for offprints to JS) Manuscript accepted 1 September 1990

forms of learning’. Skidmore (1988) supports

this view in correspondence published in Nur-

sing Times. He argues, ‘. from my experience

the best way to learn about research is to do it:

While there is a place for awareness/appreciation

within the research learning process there is no

substitute for hands-on experience’. Meanwhile,

the RCN’s Adviser on Research in Nursing

suggests, ‘There is no question but that the

nursing profession must base its care as far as

possible on well-researched and documented

evidence’. But he then goes on to question how

the time needed to teach nursing students the

‘complex skills required to undertake research in

a safe and responsible manner’ can be found,

and also raises the issue of the supervision of

research projects (Denton 1989).

Whilst it is unlikely that a consensus on the

most effective approach will be achieved

amongst educators, it is important for individual

172

NURSE EDUCATION TODAY 173

teachers and institutions responsible for nurse other hand, may be problematic given the range education programmes to develop a specific of research traditions and data gathering tech- strategy in relation to the teaching of research. niques employed by nurse researchers and the In this paper we shall begin to explore some of breadth of issues relevant to nursing and mid- the main issues related to each of these approa- wifery. This poses a real challenge to all those ches, focusing on pre- and post-registration involved in revising current programmes and education up to and including first degree level. planning new courses.

THE PLACE OF RESEARCH IN NURSING

Recent educational reforms offer nurse teachers an unprecedented opportunity to strengthen the role of research within the curriculum. Both pre- and post-registration education frame- works issued by the National Boards contain a specific research component. For instance. the guidelines and criteria for course development produced by the English National Board in relation to Project 2000 recommend that the curriculum should reflect ‘the integration of theory and practice underpinned by relevant research’ (ENB 1989). This same document further advocates that students should be able to ‘identify the nature of knowledge which informs practice, basing all nursing practice on relevant, available research findings’. Perhaps for the first time, then, we are witnessing very real attempts to create the ‘research-based profession’ initially called for in the Report of the Committee on Nursing (DHSS 1972).

On an individual level, the discerning critical thinker, ‘the knowledgeable doer’, envisaged as the product of Project 2000 courses endorses the vision of nursing as a practice profession which uses research to inform its knowledge base. In our attempts to create this kind of practitioner, important decisions have to be made as to which of the two approaches identified above will be the most effective. Traditional models of teaching research taken from other disciplines such as psychology, sociology and medicine proliferate in academic institutions and may be inappropriate to a practice profession such as nursing. It would certainly appear that nursing and midwifery are pioneering the way in terms of advocating an awareness of research as an appropriate goal. Learning by doing, on the

Given the differing nature of the two approa- ches it is necessary to be absofutely clear about the overall aim of any research component. Clearly research is not being studied for its own sake but as a means of increasing knowledge and understanding of particular fields of study and of improving practice. Once an overall aim is agreed and specified, genera1 learning outcomes and specific learning outcomes can more easily be identified. The Table outlines a possible aim and specific competencies (or general learning outcomes) for each approach.

But which approach is appropriate and when? Sometimes there is no choice. For instance, the objectives of the English National Board Course No. 870 (Welsh National Board Course No. 6): An Introduction to the Understanding and Application of Research make it quite clear that the focus should be on awareness. Even so, some students still seem to apply for the course in the hope that it will prepare them to undertake research. And, even if the student is clear about the emphasis, his/her manager may have other expectations. For other courses which include a research component, it may be simply a matter of individual teacher or institutional preference that determines which of the two stategies is selected, or perhaps it may be the academic level the course is designed to achieve (for example, levels 1, 2 or 3 wi:hin the Credit Accumulation and Transfer Scheme of the Council for National Academic Awards).

Undertaking research is not a normal part of the work of the majority of nurses, although some may be involved in the research of others. Every nurse is, however, expected to use research to improve professional practice and one of the current priorities within the profes- sion is to narrow the research/practice divide (Ketefian 1975). One way of achieving this is to ensure that every nurse, midwife and health visitor is given the opportunity to become a

174 NURSE EDUCATION TODAY

confident and skilled consumer of research and is encouraged to recognise its potential to influ- ence and improve health care. It is important, therefore, to capture nurses’ interest as well as to expose them to the principles of research. Can this consumer role best be learned by requiring students to undertake a study? It would seem that many of the competencies associated with learning by doing, outlined in the Table, do not

directly address this goal. We, therefore, pose

the question: is it necessary and/or desirable for

every student to undertake a small piece of

original research? Indeed, do such projects con-

tribute to the body of knowledge within nursing? If such a strategy is deemed desirable, however, then we must clearly protect potential subjects within the health care system by exploring alter- native means of gaining hands-on experience of research.

Table

Research Awareness Aim: To improve standards of care and enhance the professional status of nurses, midwives and health visitors

Competencies

Practitioners need to be able to:

* identify the main sources of knowledge underpinning professional practice

* seek and identify relevant information sources including those drawn from other disciplines

* provide a sound rationale for clinical decisions and actions through a process of critical and reflective thinking

* understand the research process in order to evaluate research

* use research in practice * protect the rights of patients/clients and colleagues

in the conduct of health care research

Aim: To conduct research and contribute to the body of nursing knowledge

Competencies

Practitioners need to be able to:

* identify researchable questions * identify appropriate supervision and mentorship * conduct a literature search and review * select a design appropriate to the research question * develop a research proposal * collect, analyse and interpret data * write a research report and disseminate findings

CONSTRAINTS

Both strategies raise a number of important

issues which may militate against the successful achievement of learning outcomes. Firstly, it is common to find negative attitudes and ignor- ance about research within the profession and an assumption that research is a luxury for an academic elite (McFarlane 1984). This separa- tism is further compounded by the tension which exists between ‘doing’ nursing, on the one

hand, and reflective practice, on the other. In effect, research can provide a valuable window or mirror for practice, offering insight into the ‘what’ and ‘how’ of nursing. A key factor which can influence the receptivity of nurses to

research utilisation is the climate prevailing in both service and management spheres. This was borne out in a recent study by Champion and Leach (1989) which reported that a major influ- ence in the utilisation of research was the support nurses received from their leaders and administrators which was not necessarily forth-

coming. This view is endorsed by Funk et al (1989) who suggest that innovation in practice is not valued by either clinicians or their employers. It is, therefore, unrealistic for edu- cation programmes to aim to change attitudes and to introduce research-based practices into

the workplace unless the climate is receptive to change (compare the introduction of the nurs- ing process in the late 1970s and 1980s).

Secondly, when teaching research in pre- and post-registration courses there is often an issue of time constraints in timetables which are already overburdened, coupled with frequently unrealistic expectations about the amount of

time needed to prepare students to achieve learning outcomes. For instance, in order to be able to evaluate a research report in an informed way, students need to be familiar with different research traditions and a range of methods of data collection and analysis. In the authors’ experience, developing the necessary skills and confidence in these areas requires a considerable investment of time: whether through self-direc- ted study based on resources such as the modules of the Research Awareness Programme pro- duced by the South Bank Polytechnic or through

NURSEEDUCATIONTODA~ 175

a taught/mixed mode approach such as the 40 days allocated to the ENB Course 870. Students also require access to information sources, including a well stocked library, the services of a qualified librarian and the provision of photo- copying facilities (Wakeham 1990).

There are also time implications for the preparation of tutors to teach research with enthusiasm and confidence. A recent survey undertaken in Northern Ireland found that 43% of the education staff (n = 88 and a response rate of 80%) had received no research training and a further 26% had only attended individual study days (The National Board for Nursing, Mid- wifery and Health Visiting for Northern Ireland 1990).

Thirdly, there is a danger of students being exposed to ‘replicative teaching’, that is to say, to several introductory ‘doses’ of research because the overall strategy for research education has been poorly developed. It is obviously important that colleagues agree about issues such as the way in which research is incorporated into the curri- culum of a particular course. Research concepts may be introduced early into the nursing curri- culum and then integrated throughout all the course components; alternatively, a separate research element may be taught, preferably towards the beginning of a course. The Northern Ireland survey reported that the majority (73%) of tutors/senior tutors who responded considered that research teaching should be integrated throughout the curricu- lum, whilst the remaining 27% thought that it should be taught as a separate entity. Whilst the former model may be highly desirable, it does require all those teaching on a particular course to have a very clear idea about how their contri- bution fits in with that of the rest of the teaching team. Its effectiveness is also dependent on every teacher both having an adequate understanding of research and feeling comfortable with, and knowledgeable about, research findings in their own practice area/discipline. In addition, this model raises the question of how and when students are first introduced to the fundamental principles of research. Once this has been achieved, a process approach, where as much emphasis is placed on the way in which particular

knowledge has been generated as on content, would enable students to be made constantly aware of current research issues.

Fourthly, whilst recognising that nursing and medical problems exist interdependently there is a real need to focus on issues which fall within the nursing/midwifery sphere of influence. Students may, therefore, need help in developing a clearer concept of nursing and in identifying nursing/midwifery as opposed to medical issues. Janken et al (1988) noted that ‘nurses Iacked experience in discriminating nursing from medical problems, at times submit- ting medical diagnosis and treatments commonly seen [in clinical practice] . . as “nursing problems” ‘.

The factors highlighted above are common to both approaches. However, the teaching of research by doing raises further considerations. Competent supervision is an obvious prerequi- site (Armitage & Rees 1988b). How can the profession develop the necessary expertise to meet this need given that personal experience of conducting research must surely be a prior requirement before individuals can fulfil this role confidently and competently? Needless to say, it is important that any learning experience in relation to research should be positive, other- wise there is a real danger that students will become disenchanted and sceptical. Good super- vision will also ensure that the research that is conducted is well-designed and appropriately executed, thus protecting all those who partici- pate in the study. Given the range of courses which may include a research project it is neces- sary to be mindful of the potential over-expo- sure to research of clients and those working within the health care system. This could be further exacerbated if individual projects are undertaken. The issue, in turn, has implications for the ethical approval necessary prior to the conduct of any study involving patients/clients or their relatives; such permission should also be sought when staff are to be the focus of the investigation (Renfrew 1989). The volume of projects that might be generated could create difficulties for the functioning of the District/ Hospital Ethics Committees. If supplementary Nursing Ethics Committees are established to

176 NURSE EDUCATION TODA1

accommodate an increased volume of proposals, it is important that they should he affiliated to

the main committee and equally rigorous in their

deliberations.

The breadth of researchable issues requires

the utilisation of a wide range of methodological

approaches. This poses a further challenge to

those preparing students to undertake research

projects ~ is it feasible to provide a sound

grounding in experimental, survey and ethno-

graphic research in the time available? If not,

there may be a real risk that students’ choice of

subject may be influenced by their choice of a

method which they regard to be the simplest.

Alternatively, teachers may confine their

preparation to one method (usually, in practice,

the survey approach) with the associated prob-

lem that students may then assume that it is the

most appropriate method for nursing research.

Time constraints can also create problems when

it comes to data analysis. It is quite wrong to

suppose that all that is needed is to consult a

statistician. In order to ask the right questions

and understand the answers, nurses must at least

understand the basic structure and logic of

statistics. To introduce the most basic descriptive

and inferential statistical techniques requires a

considerable number of teaching hours.

There appears to be a widespread assumption

that a research study undertaken in the context

of a degree programme should be original. This

may result in unrealistic and unnecessary

pressure on students to search for an issue which

has not previously been investigated. In a disci-

pline such as nursing, this belies the rich

potential offered by replication studies which

can yield valuable insights into the usefulness or

otherwise of previously published, small-scale

studies (Ryland 1989). Moreover, meta-analysis

provides a useful means by which the findings

from such studies may be synthesised to provide

valuable insight into specific nursing/midwifery

questions (Lee 1988).

AN ALTERNATIVE APPROACH

Learning by ‘doing’ need not. however, involve

the conduct of studies by individual students.

Several of the potential difficulties outlined

above may be overcome by encouraging a group

approach. Some of the strengths and weaknesses

of a class project are identified by Molyneux

(1984) and Goodall (1986), whilst Akinsanya

( 1988) describes a number of interesting group

projects, the findings of which were subsequen-

tly published, thereby adding to the body of

nursing knowledge. Group exercises intro-

ducing specific data collection techniques can

also be undertaken in a classroom setting using

peers to supply the data (see Wattley & Muller

1984). This experiential approach offers an

alternative means of learning about research

through the undertaking of structured activities

designed to introduce a range of data gathering

techniques. For example, the difficulty of ensur-

ing inter-rater reliability can be illustrated by

devising a coding system for recording observed

behaviour patterns. This can be applied in a

group activity using a video recording as the

focus for identifying interactions. Such an

approach offers the added advantage of ena-

bling students to explore, at first hand, some of

the practical problems faced by researchers: this

can help nurses to gain insight into the research

process that will enable them to read published

research more realistically and sensitivelv than

might otherwise be possible using a purely

theoretical approach. It should. however, be

emphasised that practical exposure of this kind

to selected aspects of the research process is

primarily intended to illustrate methodological

issues facing researchers, with the aim of helping

nurses to understand and evaluate published

research better, rather than as a systematic

preparation for becoming a researcher.

Whilst doing research obviously involves the

collection and analysis of data, it need not

involve the generation of new data. McArt and

McDougal (1985) suggest that secondary anal-

ysis can also provide an alternative and valid

mode of enquiry. This involves the re-analysis of

data which have already been collected and

analysed as a means of developing research skills

without the need for original data to be collected.

Examples of readily available sources include

census data, unit returns to DHAs and Quality

Assurance assessments. Indeed, Robinson

NURSE EDUCATION TODAY 177

(1988) argues that ‘in nursing we are sur- rounded by data - patients’ records, minutes of meetings, equipment lists duty rotas - the list is potentially enormous - all of which could form the basis of some exciting and useful project work’. Finally, Overfield and Duffy ( 1984) describe the practice of ‘learning by proposing to do’ whereby the teaching is directed towards teaching students how to do research, but with this process only being taken throllgh to the proposal preparation stage. The proposed research is not actually carried out, thus avoiding all the potential problems related to research conduct. Such a strategy, however, seems to offer few advantages as it neither achieves the goal of generating new knowledge nor of using research as a means of improving practice. It is for these reasons that Mander (3988) urges caution in employing this approach.

Whichever approach is adopted, it is impor- tant that every teaching institution creates a culture that supports and nurtures nurses in the development of nursing research (Polk 1989). Nurses and midwives need to experience every- day discussions of research issues, see staff involved in the conduct of studies and encounter changes in practice that have been introduced as a result of research. In short, health care prac- titioners need to be socialised to think about research and see that those who are teaching them value its contribution and are committed to its development (Munro 1985).

RECOMMENDATIONS

The issues highlighted in this paper are not only being currently debated in the UK but also in the USA. Given their importance for every edu- cationalist involved in teaching nurses, midwives and health visitors there is considerable scope for a national forum to provide a focus for the debate, dissemination and exchange of ideas. This might encompass tried and tested teaching strategies, specific resources, and ideas for inno- vative methods of assessment. Since there are alternative strategies for teaching research it is very important for each curriculum develop- ment eroun to be auite clear about the overall

goal(s) and the specific learning outcomes of research component of any course. Moreover, the chosen framework would need to be sup- ported and defended in any validation process. If nurse teachers are unclear about the most appropriate approach there is a real danger that traditional models of teaching research will be imposed by colleagues working in institutions of higher education with whom links are being forged.

Finally, the dearth of substantive research concerning differing teaching strategies needs to be addressed. Whilst every course teacher is expected to evaluate formally their programme content both in terms of student satisfaction and the achievement of specific learning outcomes, there is an urgent need for independent research to determine which method(s) best achieve specific goals and learning outcomes. Such studies should include an evaluation ofthe needs of teachers, their preparation to fulfil their role and the attitudes of nurse students towards research both before and after under- taking the research component of a course.

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