Departamento de saúde 2000 para uma estratégia de pesquisa e desenvolvimento de enfermagem

Bolsas, subsídios e bolsas de estudo: uma estratégia para desenvolver a capacidade de pesquisa em cuidados de saúde primários.

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Fundo.

Os médicos de clínica geral e outros profissionais de cuidados de saúde primários são frequentemente o primeiro ponto de contato para pacientes que necessitam de cuidados de saúde. Identificar, compreender e vincular a evidência atual às melhores práticas pode ser um desafio e requer, pelo menos, uma compreensão básica dos princípios e metodologias da pesquisa. No entanto, nem todos os profissionais de cuidados de saúde primários são treinados em pesquisa ou têm experiência de pesquisa. Com o objetivo de aprimorar as habilidades de pesquisa e desenvolver uma cultura de pesquisa em cuidados de saúde primários, os departamentos universitários de prática geral e saúde rural foram apoiados desde 2000 pelo governo australiano financiado pela "Estratégia de Avaliação e Desenvolvimento de Pesquisa em Saúde Primária de Saúde" (PHCRED).

Um pequeno esquema de financiamento de subsídios para apoiar os profissionais de cuidados de saúde primários foi implementado através do programa PHCRED na Flinders University, no sul da Austrália, entre 2002 e 2005. O esquema incorporou mentores acadêmicos e três tipos de apoio financeiro: bolsas de estudo, subsídios de redação e bolsas de pesquisa. Este artigo descreve os resultados do regime de financiamento e contribui para o debate em torno da eficácia dos esquemas de financiamento como forma de construir capacidade de pesquisa.

Os beneficiários de financiamento que completaram suas pesquisas foram convidados a participar de uma entrevista telefônica semi-estruturada de 40 minutos. Foi solicitado feedback sobre a aquisição de habilidades de pesquisa, resultados de publicação, desenvolvimento de capacidade de pesquisa, confiança e interesse em pesquisa e percepção de pesquisa. Os dados também foram coletados sobre dados demográficos, tópicos de pesquisa e tempo necessário para concluir as atividades planejadas.

O esquema de financiamento apoiou 24 bolsas de estudo, 11 subsídios de redação e três bolsistas de pesquisa. Quase metade (47%) de todos os beneficiários de subsídios eram profissionais de saúde aliados, seguidos por médicos de clínica geral (21%). A maioria (70%) eram pesquisadores novatos e de início da carreira.

Oitenta e nove por cento dos beneficiários da subvenção foram entrevistados. A capacidade, a confiança e o nível de habilidades de pesquisa em dez áreas principais foram geralmente considerados como tendo melhorado como resultado do prêmio. Mais da metade (53%) apresentaram suas pesquisas e 32% publicaram ou enviaram um artigo em uma revista revisada por pares.

Conclusão.

Um pequeno esquema de apoio e mentoria através de um Departamento Universitário pode efetivamente aprimorar as habilidades de pesquisa, a confiança, a produção e o interesse na pesquisa de profissionais da saúde primária.

Fundo.

A investigação e a investigação em matéria de alfabetização desempenham um papel cada vez mais importante na garantia e no reforço da prestação de cuidados de saúde baseados em evidências. Historicamente, os profissionais de saúde primários não foram adequadamente treinados em metodologia de pesquisa, um déficit que foi reconhecido internacionalmente [1-4].

Em 2000, o governo australiano abordou a necessidade de construir capacidade de pesquisa no setor de cuidados de saúde primários ao fornecer um financiamento de 50 milhões de AUD ao longo de um período de seis anos para a Estratégia nacional de Avaliação e Desenvolvimento de Pesquisa em Saúde Primária (PHCRED) e # x02018; Fase Um "[5]. Os programas regionais PHCRED nos Departamentos Universitários de Prática Geral e Saúde Rural formaram uma parte desta Estratégia [5]. O programa PHCRED na Flinders University, na Austrália do Sul, desenvolveu uma variedade de atividades de capacitação de pesquisa sob a égide de uma rede de pesquisa do Sul da Austrália recentemente formada para cuidados de saúde primários chamada 'SARNet' [6,7].

Neste artigo, relatamos os resultados e a avaliação do esquema de financiamento da subvenção da rede de pesquisa que apoiou uma coorte multidisciplinar de 38 profissionais de saúde primários e pesquisadores de carreira inicial entre 2002 e 2005. O financiamento foi premiado de várias maneiras: como bolsa de pesquisa (US $ 5.000) para desenvolver e realizar um pequeno estudo de pesquisa, como um subsídio de escrita (US $ 500) para incentivar a divulgação de resultados de pesquisas em revistas com pontuação ou como posto de pesquisa (0.2 e # x02018; 0.5 FTE ao longo de 1 ano) para apoiar o desenvolvimento de habilidades de pesquisa em um ambiente acadêmico. Cada pesquisador foi orientado por um membro da equipe principal da PHCRED de quatro universitários a tempo parcial e teve acesso a atividades da rede SARNet, incluindo oficinas de treinamento, material didático baseado na web, um fórum de discussão online e outros eventos de rede.

Existe uma escassez de estudos empíricos que avaliam sistematicamente programas de capacitação, que podem fornecer informações valiosas sobre impacto, eficiência e eficácia e ajudar a planejar futuras iniciativas [3]. Nosso estudo aborda essa lacuna e fornece um exemplo de uma estratégia bem-sucedida para a construção de capacidade de pesquisa em cuidados de saúde primários.

Com o objetivo de desenvolver experiência em pesquisa, habilidades e confiança dos profissionais de saúde primários, o programa Flinder PHCRED lançou o regime de bolsas de estudo e bolsas de estudo em 2002. Os pedidos de pedidos foram anunciados anualmente através do site da rede de pesquisa 'SARNet' [8] e Lista de membros da rede [7]. Profissionais em prática geral, saúde aliada e outras áreas de cuidados de saúde primários foram elegíveis para solicitar financiamento PHCRED. Além dos subscritores de bolsas e bolsas de estudo, o programa PHCRED apoiou um pequeno número de pesquisadores. Os bolsistas da pesquisa foram incluídos na avaliação do esquema de financiamento da PHCRED, pois eles tiveram acesso à mesma equipe de tutoria e recursos de rede que os outros destinatários de financiamento.

Os pesquisadores receberam um mentor designado, que forneceu continuidade de conhecimentos, assessoria e suporte em todas as etapas do projeto de pesquisa, incluindo, quando necessário, o desenvolvimento de um plano de pesquisa, apresentação de aplicativos de ética, aconselhamento sobre coleta e análise de dados e elaboração de um relatório de estudo ou artigo para publicação revisada por pares. Reuniões regulares entre mentor e mentee foram organizadas ao longo do projeto, ocorrendo cara a cara, através de teleconferências, ou através de correspondência por e-mail. Ocasionalmente, orientação em áreas específicas, como estatísticas e questões de consumo, foi procurada por especialistas externos. O Mentoring adotou princípios de aprendizagem para adultos: dar apoio quando e quando necessário, no nível profissional apropriado e ser orientado por propósito. O tempo de orientação variou de acordo com o nível de experiência dos pesquisadores e a natureza do projeto de pesquisa.

Todos os financiadores deveriam apresentar seu trabalho em um evento adequado (por exemplo, conferência) e escrever um relatório final abrangente. Inicialmente, os subsídios foram concedidos por um período de um ano. Em alguns casos, os prazos de um ano revelaram-se insuficientes e precisavam ser estendidos para atingir os objetivos do projeto.

Para avaliar o esquema de financiamento, 38 financiadores da PHCRED que completaram seus projetos até o início de 2006 foram convidados a participar de uma entrevista telefônica semi-estruturada de 40 minutos realizada por um entrevistador externo e independente. Foi solicitado feedback sobre a aquisição de habilidades de pesquisa, resultados de publicação, o impacto na confiança e o interesse em buscar pesquisas no futuro em relação ao projeto financiado pelo PHCRED. As respostas foram registradas textualmente, e os participantes verificaram as transcrições quanto à exatidão. Analisamos dados quantitativos usando o programa estatístico SPSS 13.0 e empregamos uma abordagem fenomenológica para codificar os dados qualitativos de acordo com os temas. A aprovação da ética foi obtida pelo Comitê de Ética em Pesquisa Social e Comportamental da Universidade Flinders.

Embora os dados sobre dados demográficos básicos, profissão, tópicos de pesquisa e resultados estejam disponíveis para todos os financiadores (n = 38), outros achados são baseados no feedback dos participantes em nosso estudo de avaliação (n = 34). Os subsídios apoiados, mas também as equipes de pesquisa, por exemplo, uma organização de consumidores de sete membros e grupos de estudantes de enfermagem de 20 membros foram beneficiários de bolsas únicas. Para avaliar o impacto das bolsas nessas equipes de pesquisa, pedimos a um membro senal representativo do grupo para dar feedback em nome de sua equipe.

Demografia e atividades de pesquisa.

Trinta e quatro (89%) bolsistas participaram da avaliação; 21 dos 24 bolsistas (88%), 10 dos 11 bolsistas (91%) e 3 dos 3 pesquisadores. A maioria dos destinatários do financiamento Flinders PHCRED morava na região metropolitana de Adelaide (73,5%), era do sexo feminino (74%) e entre os 35 e os 54 anos (79%). Quase 20% dos beneficiários da concessão estavam baseados no sul da Austrália rural e Victoria, na região do Grande Triângulo Verde (GGT) [9]. Os programas PHCRED da Universidade Flinders em Adelaide (SA) e da Universidade de Triangulação Verde da Grande Guerra Verde em Warrnambool (VIC) colaboraram nas atividades relacionadas à SARNet e adotaram o regime de bolsas de estudo e de escritura Flriders PHCRED em 2004. Todos os bolsistas e bolsistas de escritura incluídos Neste estudo foram orientados pelo mesmo núcleo da equipe de quatro universitários de PHCRED. As reuniões foram realizadas cara a cara ou por e-mail e telefone, dependendo de horários, localização e status do projeto.

A maioria dos donos eram profissionais de saúde aliados (47%). Um número menor foi médico geral (GPs) (21%), pessoal da Divisão de Prática Geral (16%) e profissionais de enfermagem, estudantes de cuidados médicos e primários e uma organização de consumidores (Figura 1). ). A maioria dos donos individuais possuía pelo menos uma qualificação de pós-graduação, incluindo Diploma de Pós-Graduação (n = 5), mestrado (n = 11) e doutorado (n = 5). Quatro detentores de bolsa possuíam uma Bolsa do Royal Australian College of General Practice (FRACGP). Os tópicos de pesquisa incluíram a prática geral (42%), assuntos de saúde aliados, incluindo temas de nutrição e saúde mental (34%), promoção da saúde, pesquisa de enfermagem e saúde indígena (Figura 1).

As bolsas apoiaram uma grande variedade de projetos de estudo, incluindo um ensaio clínico controlado randomizado, revisões de literatura, revisões sistemáticas, estudo de caso retrospectivo, aplicações de bolsas, pesquisas em grupos focais, inquéritos de questionários e entrevistas, pesquisa de ação participativa, avaliação de programas de promoção da saúde, intercâmbio e disseminação de informações relevantes para cuidados de saúde através de pôsteres de estudantes, um site ou um manual de consumidores. A maioria dos subsídios de redação (64%) cumpriu seu objetivo principal, apoiando pesquisadores de carreira inicial na preparação de um manuscrito para publicação revisada por pares. Todos os três bolsistas de pesquisa financiados pela PHCRED usaram seu tempo protegido para planejar, conduzir e analisar um pequeno estudo de pesquisa. Dois colegas prepararam pelo menos um manuscrito para publicação, e um colega decidiu continuar sua pesquisa como aluno de doutorado. Figura & # x200B; A Figura 2 2 fornece uma visão geral das conquistas dos destinatários da concessão Flinder PHCRED. Alguns exemplos de projetos de pesquisa realizados são apresentados na Tabela # x200B; Tabela 1 1.

Experiência de pesquisa.

Avaliamos o impacto do regime de financiamento de subvenções no desenvolvimento de competências utilizando uma ferramenta visual com dez áreas principais de competências de investigação, a "aranha de pesquisa" [7, 10]. Uma cópia da aranha da pesquisa estava disponível para os titulares de concessões durante a entrevista por telefone. Os titulares dos subsídios foram convidados a avaliar o nível de habilidade percebido de 1 = 'sem experiência' para 5 = 'muito experiente' antes e após a atividade de pesquisa. Figura & # x200B; A Figura 3a resume os níveis médios de habilidade de pesquisa nos dois momentos de todos os receptores de financiamento da PHCRED que participam da avaliação (n = 34). Os níveis de habilidades de pesquisa aumentaram em 9 de cada 10 áreas de habilidades, incluindo a escrita para publicação e uso de métodos de pesquisa quantitativos e qualitativos.

As Figuras 3b e # x02018; d representam o desenvolvimento de habilidades de pesquisa por categoria de financiamento de subvenção (bolsa de estudos, bolsa de escrita, pesquisador). O maior impacto em todas as categorias foi alcançado nas atividades de redação acadêmica, em particular na "pesquisa editorial", indicada por um aumento de 1,5% do aumento de 5 pontos nos três grupos. A pontuação mediana após a atividade de concessão foi 3 e # x000b1; 1.1 para os destinatários das bolsas de bolsa e de redação e 4 e # x000b1; 1.1 para os bolsistas da pesquisa. As atividades de concessão tiveram pouco impacto nos níveis de experiência percebida na pesquisa de literatura de bolsistas (escore mediano = 4 e # x000b1; 0,8), habilidades críticas de avaliação de titulares de bolsas de escrita (pontuação mediana = 3 e # x000b1; 0,7) e sobre habilidades para analisando e interpretando os resultados dos pesquisadores (pontuação média = 4 e # x000b1; 0,6).

Para avaliar o nível de experiência de pesquisa anterior dos financiadores, pedimos aos participantes que decidam qual das quatro categorias de pesquisa que eles consideraram pertenceram. As quatro categorias de pesquisa fizeram parte do modelo de construção de capacidade Flinders PHCRED, anteriormente descrito por Farmer & # x00026; Weston [6]. As quatro categorias são: não participantes (com pouca ou nenhuma experiência anterior em pesquisa); participantes (experiência como parte de uma equipe de pesquisa); gerentes / formadores (tanto de pesquisa líder, seja em treinamento formal para fazê-lo); e acadêmicos (com, ou levando para um doutorado). Cerca de um terço de todos os donos (29,4%) se classificaram como pesquisadores novatos (não participantes) antes do financiado e 40% sentiram que pertenciam à "categoria participante". No final da atividade financiada, 35% dos beneficiários da concessão se consideraram ter movido para uma categoria superior de experiência de pesquisa, em particular os "não participantes", dos quais 60% sentiram que passaram de "não participante" para 'participante' (Tabela # x200B; (Tabela 2 2).

Capacidade, confiança e interesse na pesquisa.

Os destinatários dos subsídios foram convidados a avaliar o impacto da atividade apoiada sobre sua capacidade e confiança para participar ou iniciar um projeto de pesquisa, sua confiança para buscar apoio colegiado para colaboração de pesquisa e seu interesse geral em fazer pesquisas futuras. O impacto foi medido em uma escala de 5 pontos, com uma pontuação de 1 refletindo "sem impacto", e uma pontuação de 5 refletindo "impacto substancial". Figura & # x200B; A Figura 4 4 resume o impacto médio da atividade de pesquisa apoiada sobre a capacidade, confiança e interesse dos participantes para cada grupo de beneficiários de subsídios. As pontuações de impacto foram diretamente correlacionadas com o tipo de financiamento, com classificação de concessão de escrita mais baixa e pesquisa de outros cargos com classificação mais alta em capacidade e problemas de confiança. No geral, o impacto das atividades de concessão na "capacidade de participar da pesquisa" foi classificado com a pontuação mediana de 3 e # x000b1; 1,1 para a escrita dos financiadores, 4 e # x000b1; 0,9 para bolsistas e uma mediana de 5 e # x000b1; 2,3 para pesquisadores. Um pouco esperado, as bolsas de escrita tiveram pouco impacto na capacidade de construção (mediana = 2 e # x000b1; 0,9) e confiança (mediana = 2,5 e # x000b1; 1,2) para "iniciar um projeto de pesquisa". Todos os beneficiários da subvenção indicaram que o regime de financiamento teve um alto impacto no "interesse em prosseguir a pesquisa no futuro" (mediana = 4 e # x000b1; 1.5).

Disseminação dos achados da pesquisa.

Quase dois terços (62%) dos beneficiários da subvenção relataram disseminar os achados da pesquisa na conclusão da atividade de concessão. Cerca de metade (53%) apresentaram suas descobertas em uma ou mais conferências, incluindo conferências a nível estadual, nacional ou internacional e um terço dos donos da bolsa deu um seminário a uma audiência local. Quatro trabalhos foram publicados no momento da entrevista (4 destinatários de subsídios) e outros sete destinatários de subsídios apresentaram um artigo para publicação em uma revista revisada por pares. Outras formas de divulgação incluíram exibições de cartazes locais, artigos em boletins nacionais e links para relatórios completos em sites. Mais de 70% dos entrevistados estavam satisfeitos por ter cumprido os objetivos da atividade financiada.

Aspectos de apoio no esquema de financiamento da PHCRED.

Para avaliar o apoio recebido pelos beneficiários do esquema de financiamento Flinders PHCRED para capacitação, os participantes foram convidados a avaliar a importância dos seguintes seis aspectos: financiamento, acesso a um mentor PHCRED atribuído, orientação externa ou supervisão, equipe PHCRED ( excluindo o mentor), acesso a recursos de pesquisa baseados na Web da SARNet e oportunidades de networking. A importância foi avaliada em uma escala de 5 pontos com uma pontuação de 1 indicando que esse aspecto era "muito pouco importante" para 5 indicando que era "muito importante". Tabela # x200B; O Quadro 3 3 fornece uma visão geral das classificações dos entrevistados sobre quais aspectos do suporte foram considerados "importantes" ou "muito importantes". O recebimento de financiamento para o projeto de pesquisa desempenhou um papel importante para a maioria dos donos (85%), enquanto dois terços indicaram que a equipe de suporte acadêmico (mentor e equipe PHCRED) foi crucial para realizar sua pesquisa. Além disso, 47% comentaram que a flexibilidade e o suporte de seu local de trabalho eram essenciais para atingir o objetivo de seu projeto.

Prazo para a conclusão das atividades de concessão.

Devido aos ciclos de financiamento de um ano pré-determinados pelo órgão nacional de financiamento, o Departamento de Saúde e Envelhecimento do Governo Australiano, todas as concessões Flinder PHCRED foram inicialmente premiadas por um período máximo de um ano. No entanto, durante o período de financiamento 2002 & # x02018; 05, tornou-se evidente que alguns destinatários da bolsa de estudos e de escrita exigiam mais de um ano para concluir e publicar o projeto (Figura xBB, Figura 5). O tempo extra era necessário para a coleta, análise e publicação de dados, e as atividades do projeto às vezes eram diferidas devido a outros compromissos de trabalho (comunicação pessoal). Uma vez que os fundos premiados eram de montante fixo, a equipe de tutoria apoiou cerca de metade da bolsa de estudos e do autor da bolsa, além do prazo de um ano. Em geral, a maioria dos detentores de bolsas (84%) e do autor da redação (82%) completaram seus projetos em dois anos (Figura xBBB (Figura 5). Um pequeno número de projetos de bolsas de estudos e bolsas de estudo (n = 6) levaram até 29 meses para serem concluídos (Figura # x200B; (Figura 5 5).

Percepção de pesquisa, barreiras e capacitadores.

A equipe da PHCRED estava interessada em qualquer mudança experimentada pelos beneficiários da concessão na percepção de pesquisa como resultado da atividade suportada. A análise de dados qualitativos revelou que 21% relataram que encontraram pesquisas agora menos intimidantes, 12% comentaram que obtiveram uma melhor compreensão dos processos de pesquisa, 8% observaram que a experiência os ajudou a refletir criticamente sobre a pesquisa publicada e 6% acolheram o maior conscientização sobre fontes de financiamento para pesquisas e processos de pedidos de subvenção. As seguintes cotações refletem a mudança dos participantes na percepção da pesquisa:

& # x02022; "O esquema ajudou a desmistificar a pesquisa".

& # x02022; "O esquema tornou a pesquisa acessível".

& # x02022; "Estou agora ciente do que está envolvido na pesquisa".

& # x02022; "A pesquisa é um processo de aprendizagem".

& # x02022; "A pesquisa é mais complicada do que eu pensava. Existem tantas maneiras diferentes de abordar um projeto e leva tempo para descobrir exatamente o que você quer fazer e escolher o processo certo para obter um resultado".

& # x02022; "A pesquisa é importante para conduzir a mudança, porque coleta a evidência para impulsionar a mudança".

& # x02022; "Aprendi através do processo de revisão crítica que, apenas porque algo é publicado, não é necessariamente uma boa pesquisa".

& # x02022; "Agora aprecio o valor das discussões com os colegas ao solicitar o financiamento".

Quando questionados sobre barreiras e facilitadores para a futura participação na pesquisa, mais da metade (59%) dos participantes identificaram o "tempo" como uma barreira significativa, 38% estavam cientes de "restrições financeiras" e 12% reconheceram que "o apoio limitado pelo local de trabalho "poderia prejudicar a pesquisa. Outras barreiras à pesquisa mencionada foram "acesso a especialistas, p. estatísticos e "suporte por escrito, p. pedido de concessão ". As citações seguintes refletem as opiniões sobre os obstáculos à pesquisa expressos pelos destinatários da concessão:

& # x02022; "Sempre há outras prioridades".

& # x02022; "É mais fácil obter financiamento para o trabalho clínico. Os médicos obtêm o carregamento clínico e outros profissionais de saúde não, isso é uma desigualdade".

& # x02022; "Passar para as atividades de pesquisa significa uma perda de renda".

& # x02022; "A pesquisa não é um negócio central".

Os facilitadores comuns para futuras atividades de pesquisa de beneficiários de bolsas foram identificados como colaboração em equipes de pesquisa, formando parcerias (29%), acesso a mentores acadêmicos (27%) e habilidades de pesquisa adquirida (24%). Um bolsista ficou particularmente impressionado com os benefícios do conceito de orientação para pesquisadores de carreira inicial e iniciou um programa de orientação para estudantes em sua Disciplina Universitária (Escola de Enfermagem e Obstetrícia).

Interesse nas atividades futuras de pesquisa.

O interesse em prosseguir as futuras atividades de pesquisa expressadas pelos beneficiários das bolsas foi muito encorajador. Quase todos os participantes (94%) manifestaram interesse em pesquisar, 91% sentiram-se encorajados a publicar pesquisas, 88% estavam entusiasmados para se candidatarem a financiamentos de pesquisa e 76% queriam participar de mais treinamento de pesquisa Quase dois terços estavam considerando realizando estudos de pós-graduação (Tabela # x200B; (Tabela 4). 4). Cerca de um terço (31%) dos donos se viram como se tornando "pesquisadores clínicos" em cinco anos e 29% disseram que trabalhariam para obter uma posição acadêmica.

Pesquisadores de carreira precoce recomendam o esquema de financiamento.

Quase todos os financiadores Flinders PHCRED (94%) concordaram que recomendariam uma iniciativa de capacitação, como bolsas de estudo e bolsas de escrita, para outros pesquisadores novatos. Eles sentiram que a combinação de tutoria e algum apoio financeiro poderia "começar" uma carreira na pesquisa, fornecendo tempo protegido e consultoria especializada em um ambiente de apoio. Os seguintes comentários foram feitos pelos participantes da pesquisa:

& # x02022; "O esquema de financiamento oferece uma ótima oportunidade para obter os seus" pés "molhados".

& # x02022; "A combinação de recursos e suporte é fantástica para pesquisadores novatos".

& # x02022; "Isso ajuda você a alcançar os objetivos que você definiu".

& # x02022; "O esquema é uma ótima maneira de permitir que as pessoas sejam divulgadas para fazer pesquisas".

& # x02022; "Isso dá um começo inicial com uma rede de segurança por tempo e suporte".

& # x02022; "Há poucas outras oportunidades desse tipo, então a iniciativa é incrivelmente importante".

Discussão.

Nosso estudo fornece evidências de que um pequeno esquema de apoio e mentoria pode ser um meio eficaz para desenvolver a capacidade de pesquisa dos profissionais da saúde primária.

O pequeno regime de financiamento de subvenções formou uma estratégia do modelo Flinder PHCRED para capacitação de profissionais de cuidados de saúde primários [6]. O modelo incorpora princípios fundamentais de um ambiente de pesquisa de apoio em atividades de capacitação. O tempo protegido, a orientação, o acesso a conhecimentos académicos, treinamento, infra-estrutura através de uma rede de pesquisa, oportunidades de apresentação e comentários sobre manuscritos para publicação revisada por pares são componentes importantes do quadro de capacitação [11-14]. O feedback e os resultados da coorte de beneficiários de subsídios apresentados aqui revelaram que o esquema de financiamento e orientação contribuiu para um aumento geral das habilidades básicas de pesquisa (Figura 3) e teve um impacto positivo na autopercepção de capacidade, confiança e interesse no envolvimento da pesquisa em curso na maioria dos destinatários da concessão (Figura # x200B; (Figura 4, Tabela 4, Tabela 2).

Embora o suporte consistisse em instrumentos (dinheiro, tempo, instalações universitárias) e componentes específicos do mentor (conselho, direção, engajamento, feedback) [14], os resultados também dependiam das características individuais do destinatário, por exemplo, motivação, compromisso e nível de experiência de pesquisa anterior. Portanto, a eficácia deste programa precisa ser vista à luz dessas características individuais. Uma vez que a maioria dos candidatos à subvenção eram pesquisadores novatos ou de carreira inicial (70%, Tabela # x200B; Tabela 2) 2) o número total de publicações revisadas por pares no final do regime de subvenção não pode ser necessariamente considerado como um indicador objetivo da eficácia do programa. Em vez disso, outros indicadores, como o aumento da confiança, as habilidades metodológicas e a adoção de hábitos acadêmicos em um ambiente de apoio, anteriormente identificados como facilitadores importantes para a construção de capacidade e interesse da pesquisa [12,13,15], foram incluídos na avaliação de eficácia. Além disso, descobrimos que o prazo de um ano para a redação de bolsas e bolsas não era suficiente para completar o projeto. O desenvolvimento de habilidades de pesquisa e a capacidade de completar um projeto são muito dependentes do indivíduo e do projeto que está sendo realizado. Outras questões, como a carga de trabalho existente e os compromissos de tempo, também precisam ser consideradas. A flexibilidade no financiamento dos arranjos de pesquisa é, portanto, importante para acomodar o leque de habilidades e circunstâncias dos profissionais da saúde primária.

Embora, como esperado, nem todos os destinatários da subvenção pudessem publicar suas descobertas no final do período de financiamento, a taxa de publicação final, incluindo os envios para periódicos revisados ​​por pares em nosso estudo (32%, 11 dos 34 em excesso). um período de três anos) é comparável ao número de publicação alcançado por um programa de bolsas de cuidados primários no Reino Unido (31%, 6 de 19 em um período de 5 anos) [16]. Os artigos aceitos para publicação incluíram, por exemplo, uma revisão sistemática sobre o gerenciamento não-farmacológico da fadiga e um artigo sobre a aceitação da amamentação em público.

É importante ressaltar que, embora a publicação dos resultados da pesquisa seja altamente relevante, também é claro que as habilidades de escrita e o conhecimento do processo de publicação, por exemplo, como lidar com os comentários dos revisores, precisam de tempo e experiência para se desenvolver.

Os subsídios de redação (500 AUD cada) fornecidos através do esquema de financiamento Flinders PHCRED podem ser uma estratégia para facilitar o desenvolvimento guiado de habilidades acadêmicas de escrita (veja também [14]). Eles forneceram tanto um link entre o escritor novato e um mentor mais experiente, e um incentivo financeiro para reservar o tempo para escrever. O processo de escrita também pode ser facilitado com grupos de escrita suportados pelos pares [17], que também foram estabelecidos através do programa Flinder PHCRED [18] e acessados ​​pelos pesquisadores.

Além do apoio de especialistas e colegas, os resultados das atividades de concessão também dependiam de motivação e compromisso individuais. Os destinatários da subvenção foram regularmente contactados pelo gerente do programa e / ou mentor, eo progresso foi avaliado seis meses. Os fundos atribuídos foram alocados em duas parcelas, sendo uma parte paga no início da atividade de subsídio e o restante no recebimento de um relatório final abrangente. O contato freqüente entre o centro do programa na universidade e a bolsa de estudos e os destinatários de bolsas de escrita fora do campus eram muitas vezes essenciais para a progressão bem-sucedida e a conclusão dos projetos. A maioria dos contatos foi feita por e-mail e telefone, disponível para todos os destinatários do financiamento, sugerindo pouca diferença em relação ao apoio entre profissionais locais e rurais. O tempo necessário e os esforços feitos para fornecer motivação e apoio contínuos a uma coorte de donos não devem ser subestimados e precisam ser considerados para a sustentabilidade a longo prazo e a continuidade dos programas de capacitação semelhantes ao programa pequeno de apoio e mentoria da Flinders PHCRED.

Além disso, a disponibilidade de um fornecimento adequado de mentores acadêmicos para o desenvolvimento contínuo de projetos promissores e para apoiar profissionais orientados para a pesquisa é crucial. Mentoring tem consistentemente um alto nível de importância em treinamento e desenvolvimento de pesquisa [19-21]. Ao mesmo tempo, é claramente uma demanda significativa no tempo, como nossa experiência indica. Por exemplo, um mentor do esquema de subsídio Flinders PHCRED trabalhou um equivalente a 0,1 FTE (ou 3 x 52018; 5 horas por semana) para apoiar regularmente uma coorte de três beneficiários de bolsas que eram pesquisadores novatos e três beneficiários de bolsas de escrita com antecedentes de pesquisa limitados . Com base em nossa experiência, o tempo necessário para orientar um pesquisador novato pode ser estimado em aproximadamente uma hora por semana por relacionamento mentor-pesquisador. Assim, ao abordar questões de tempo e disponibilidade de mentores, é essencial que a orientação seja vista como um componente chave para o desenvolvimento das habilidades de pesquisa e proporcionou um alto nível de prioridade entre os pesquisadores estabelecidos. Possíveis soluções estão incorporando um esquema de mentor nos planos estratégicos das instituições governamentais ou o estabelecimento de um programa de mentor externo.

O programa Flinder PHCRED funcionou com um orçamento de 230.000 AUD por ano, que financiou em média oito bolsas (total de 40.000 AUD), quatro subsídios de redação (total de 2.000 AUD) e um pesquisador (30.000 AUD) por ano e incluiu salários para um pequeno equipe de quatro acadêmicos experientes (nível BD, totalizando cerca de 1,9 FTE) e um assistente de administração (0,1 FTE). A equipe principal forneceu a infra-estrutura do programa, incluindo o desenvolvimento do esquema de financiamento e sua avaliação, desenvolvimento e entrega de treinamento, material educacional, site e boletins informativos.

Outros resultados tangíveis do regime de subvenção incluíram indivíduos e grupos que conseguiram tirar proveito de suas novas habilidades, confiança e conhecimento sobre os processos de pesquisa, formando colaborações de pesquisa e construindo redes de suporte locais. Pelo menos, nove dos destinatários da bolsa Flreders PHCRED (de 24) e os três pesquisadores implementaram os resultados da pesquisa no local de trabalho e / ou estão atualmente realizando mais treinamento de pesquisa de pós-graduação. Dois exemplos demonstram claramente o impacto das bolsas de bolsa e bolsas de estudo a este respeito. Em primeiro lugar, um projeto que promove a alimentação saudável e a atividade física em um ambiente de ensino secundário resultou na implementação de arranjos de cantinas alternativas para fornecer alternativas alimentares saudáveis ​​para crianças, bem como o desenvolvimento de um currículo de educação física. Um segundo exemplo foi a avaliação de um programa de jardim de infância que apoia o desenvolvimento de crianças pré-escolares. Além da publicação em periódicos revisados ​​por pares, a divulgação dos resultados aos formuladores de políticas locais e nacionais foi realizada e os pedidos foram recebidos para explorar a implementação do programa interestatal. Outros resultados incluem o envolvimento em mais treinamento de pesquisa de pós-graduação como resultado do crescente interesse em pesquisa devido à atividade de concessão, com cinco dos 38 praticantes em nossa coorte progredindo para uma candidatura de maior grau no momento da entrevista.

Como os cuidados de saúde primários são multidisciplinares, os profissionais de qualquer disciplina eram elegíveis para bolsas financiadas por PHCRED, subsídios de redação e bolsas de pesquisa. Strikingly, the majority of applicants supported by Flinders PHCRED between 2002 and 2005 were allied health professionals, nurses and other non-medical health care professionals, implying a high demand and welcomed research opportunity by non-medical disciplines. On the other hand, the eight general practitioners supported by our program conducted projects of generally less elaborate nature and progress was slower compared to the group of non-medical applicants (details not shown). The disparity between general practice research and other disciplines health has been reported by others [22], suggesting that engagement of general practitioners in research might require an approach different to the scheme applied by the Flinders PHCRED model. Change management approaches, such as described by Langley et al. [23] and practice-based research networks [24-26], have been suggested as alternative ways to engage general practitioners in research [4].

Most Flinders PHCRED bursaries and all fellowships resulted in increased skills and knowledge of the recipient in all aspects of a research cycle, from formulating a research question to dissemination of research findings, on a topic relevant to their own practice. In comparison, change management approaches and practice-based networks often concentrate on practitioner's involvement in selected aspects of the research process, e. g. data collection, on a topic of broad general interest [24]. Many general practitioners under pressure of work may feel unable to embrace opportunities to be more involved in research and the solution to developing a research culture amongst general practitioners may require a longer term approach. A comprehensive and practical program to ensure that GP registrars and medical students are trained in aspects of research may be required so that the next generation of general practitioners are better placed to undertake research or to implement research findings.

This article includes views of funding recipients of the bursary, writing grant and fellowship schemes. We acknowledge that the findings of only three research fellows cannot necessarily be generalised. Nevertheless, inclusion of the fellows in our evaluation of the PHCRED funding scheme provided valuable insights into the potential of a structured fellowship program to form part of a career pathway in research for primary health care practitioners. The Australian Government Department of Health and Ageing has responded to this need through providing ongoing funding for a 'Researcher Development Placement (RDP) Program' ‘ 60,000 AUD for each University Department of General Practice or Rural Health ‘ in Phase Two (2006 to 2009) of the PHCRED Strategy [5].

This paper indicates that a small grant funding scheme can have clear and tangible outcomes in the form of publications, increased skills in undertaking research and developing collaborations and increased confidence. Our study adds to the body of knowledge about the role and effectiveness of such schemes in developing strategies for building research capacity amongst primary health care practitioners.

Conclusão.

A small grant and mentoring scheme situated within a supportive research capacity building environment can provide important pathways to generate research skills, confidence and research aware attitudes amongst practising primary health care professionals with limited research experience. In our study the scheme also stimulated further research involvement and encouraged publication and implementation of findings into practice.

List of abbreviations.

AUD ‘ Dólar australiano.

FTE ‘ Full Time Equivalent.

GGT ‘ Greater Green Triangle region (SA, VIC)

GP ‘ General Practitioner.

PHC ‘ Primary Health Care.

PHCRED ‘ Primary Health Care Research Evaluation & Development program.

PhD ‘ Doctor of Philosophy, Higher Degree in Health Sciences.

RF ‘ Research Fellow.

SA ‘ South Australia.

SARNet ‘ South Australian Research Network for primary health care.

WG ‘ Writing Grant.

Competing interests.

The author(s) declare that they have no competing interests.

Authors' contributions.

All authors (KR, EAF, KMW) conceptualised the study. KR conducted data analysis and prepared the manuscript with contributions by KMW and EAF. All authors approved the final version.

Pre-publication history.

The pre-publication history for this paper can be accessed here:

Agradecimentos.

We would like to thank all funding holders who participated in this study, as well as our external interviewer Susan Rochester. The PHCRED program is funded under the Researcher Capacity Building Initiative by the Australian Government Department of Health and Ageing.

Models, Strategies, and Tools: Theory in Implementing Evidence-Based Findings into Health Care Practice.

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.

Most attempts to implement evidence-based practices in clinical settings are either only partially successful, or unsuccessful, in the attempt. 1 ‘ 6 Our objective in this paper is to describe ways to use theory to provide a foundation for designing and planning strategies for intervention and selecting tools with a better than random probability of success in implementing evidence-based findings into practice. We focus on theories appropriate to change processes in clinical settings, typically complex organizations with multiple functioning parts.

We believe that explicitly outlining and understanding some form of theory that explains the reason for why an intervention may work to induce planned change is a critical step in planning interventions to change provider or patient behavior, particularly in order to promote evidence-based care. We also believe that the information presented in this paper is relevant and important both for researchers and for people involved in quality improvement activities in health care organizations. In quality improvement, there may be a reluctance to examine theoretical bases for planning implementation activities and efforts, possibly in part because of a perceived need to differentiate between the nature of quality improvement activities and the nature of research, and in part because a focus on theory may not appear relevant, when the imperative is to act quickly. This has been described as the Nike™ school of implementation: Just do it.

A prominent recent example is the administrative data feedback for effective cardiac treatment (AFFECT) study report of a negative trial of administrative data feedback in attempting to improve hospital performance on key indicators of cardiac care. 7 The principles guiding the design of the study were empirical, applying insights and findings from prior studies. No explicit theories of individual or organizational behavior change were applied in planning the design and conducting the study. While several limitations were acknowledged by the authors, the authors did not address the “why” of the unsuccessful trial beyond pointing to elements that could have been improved. In his accompanying editorial, Peterson 8 points to additional features that could have been incorporated into this trial that may have enhanced the probability of success. Implicit in his discussion are theoretical perspectives, such as those underlying the use of opinion leaders to influence key stakeholders within the target organizations in the study, or the concept of intensity or dose of intervention. Underlying the concept of sufficient dose is the mechanism of action: until there is a clear understanding of the mechanism of action by which an intervention is likely to succeed, it is difficult to grapple with issues of dose or intensity. We posit that in interventions to induce planned change in health care, theory provides clues to the mechanism(s) by which the intervention is successful. Without explicit attention to theory, many key aspects of the intervention may be ignored.

Another recently published article describes the difficulties in applying evidence from a systematic review of audit and feedback interventions to decision making about how best to use audit and feedback in future intervention efforts. 9 The authors describe their inability to glean information on key aspects of conducting audit and feedback from the published literature. As a result, little can be learned from prior efforts other than success or failure in specific attempts.

Even when theory is used to frame a study, it may then be largely ignored in the development of strategies, interventions, and selection of tools. A counter example to this approach is the PRocess modelling in ImpleMEntation research (PRIME) study, a collaborative effort among researchers in Canada and the UK, which is embarking on a multiyear, multiphase proposal to construct and test instruments to measure and operationalize concepts from a carefully selected set of behavior change theories, then test the relationship between the concepts as theorized and the amount of change observed in the specific areas under study. 10 This study has particular promise for exploring the value of a number of widely known and applied theories of behavior change at the individual and dyadic levels. As yet, the links from the theoretical concepts or constructs to intervention planning have not been developed, but this is planned in the next phase of the project, once the measurement development and validation processes are completed.

One problem with having little or no theoretical basis for intervention planning is that strategies adopted for implementation, and tools selected as mechanisms to induce behavior change, are neither tightly linked to strategy nor to any underlying theory. As a result, there is little reason to believe a priori that the actions, which constitute the intervention, would succeed in inducing behavior change. We propose an approach that can be applied using any theoretical framework that specifies reasons for behavior change at the individual level, or at levels above the individual, to be applied as part of an implementation planning process. As part of this approach, we specify questions to be addressed as models are considered, strategies selected, and tools created, adopted, and/or adapted for use in the implementation process. We refer the reader to another paper in this issue to guide the process of selecting interventions, which should follow a thorough diagnosis or needs assessment as part of the planning process (Kochevar et al., under review, this issue).

In addition to the general issue of motivating intervention choices by a strong theoretical basis for action, the interaction between individual and organization is not always addressed in planning interventions. We believe that this interaction, particularly in complex organizations such as those in health care, is critical to selecting appropriate theory to predict both individual behavior change, and change in an organizational context. Use of theory may be most helpful when the targeted action takes place in an organization with multiple actors, multiple layers, and complex factors affecting decision-making processes, which characterizes almost any health care organization. There are many diverse theories that describe processes contributing to organizational change. 11 ‘ 19 However, theories of organizational change rarely apply to planned activities of change, particularly when the change operates at levels within the organization, and do not necessarily affect the organization as a whole.

A POTENTIAL ROLE FOR THEORY IN CONSTRUCTING MODELS.

In Figure 1 , we show a schematic approach to using theory systematically in the process of moving to intervention and evaluation.

Many proposals for implementation research projects or studies use models or frameworks to guide their implementation planning. However, many of the models used are not based on theory, or are based only loosely on underlying theory from which they are derived. While they might have been more closely linked to theory when they were initially proposed, these models have often been restated and reinterpreted, and the original tight linkage with theory is lost. This process is analogous to repeatedly copying copies of originals; over time, the original signal is attenuated, and the meaning can be lost.

A fully developed theory, in the context of behavior change, addresses the question: why do people or organizational entities behave as they do? Given the way they behave, what would motivate them to change behavior? Expanding this to include organizational issues, theory should provide hypotheses and guidance to action at both the individual and higher levels of the organization: the subunit or microsystem, or the unit level (e. g., clinic or nursing unit), or still higher levels. For example, theories guiding social marketing could be linked with those taking an ecologic view of competition for scarce resources within that organization, and a model marketing information for competitive advantage could be developed for use as part of a strategy of introducing planned change. Theory informs the models that provide the under girding or infrastructure, much like the frame of a house.

THE ROLE OF MODELS IN CHOOSING STRATEGY.

In most health services research studies, heuristic models are used primarily to demonstrate the variables to be included in measurement and in analysis. The boxes in the models are used as categories to demonstrate types of variables. Little attention is paid, often, to the meaning of arrows, and to placement of the boxes. In implementation research, both the boxes and what is contained in them, and the arrows indicating theorized functional relationships, are important. If, for example, a set of patient factors (age, gender, marital status, health status), and a set of provider factors (age, gender, years of practice, type of provider) have been identified as theoretically important, the functional relationship between them needs to be specified. For example, using a modified principal-agent theory which predicts that when providers are similar to patients in age, gender, socio-economic status, and race/ethnicity, they are more likely to listen to their patients and act according to the patients' expressed wishes, an implementation researcher may decide on a strategy to promote empathy between provider and patient.

The strategy may still be high level, linked to theory. It provides overall direction for further planning. It may include more than 1 intervention, and should also include contingency plans for addressing barriers and maximizing use of facilitators, as these emerge through the process of implementing the intervention and carrying out the planned strategy. Assessment and enumeration of probable barriers and facilitators should be precursors to strategy selection or be concurrent as part of strategy planning. Development of strategy, and strategic planning for implementing an intervention, are often not included in the process of planning to initiate behavior change. Many of the lessons learned through the QuERI projects to date (Hagedorn et al., under review, this issue) demonstrate the importance of engaging in a systematic, strategic planning process before initiating an intervention or set of interventions. If the theory underlying the planned change includes both individual-level theory and change at some level above that of the individual, an assessment of organizational readiness to change and existing organizational culture and climate may be appropriate as part of strategic planning.

THE ROLE OF STRATEGY IN SELECTING INTERVENTIONS.

Once a guiding strategy is selected based on the underlying theory or theories guiding the study, mapping the strategy to interventions is essential. Here the literature on interventions in promoting evidence-based practice implementation is helpful. There is a broad catalogue of interventions, with some information about what appears to be more or less effective. 3 , 20 ‘ 28.

However, it is possible that lack of effectiveness could be because of several factors, including those we address in this paper. Lack of tight linkage to theory, as well as lack of tight linkage to problem diagnosis (Kochevar et al., under review, this issue) can decrease the likelihood of successful implementation. In addition, issues related to organizational factors that may not have been appropriately addressed can also make implementation unsuccessful. Because a fair amount of implementation research has either ignored, or only partially dealt with, organizational issues, it is difficult to assess how effective strategies might be if these concerns were addressed.

The choice of intervention, which is the focus of most implementation studies, should be dependent primarily on the selected theory: why do people behave as observed in this setting, and what intervention could effect desirable change?

CHOOSING TOOLS.

Tailoring an intervention to a specific context requires development of tools that are usually very specific to the intervention, to the content of the desired change, and frequently to the context in which the intervention will take place. There are many examples of tools available from prior studies. One difficulty is that these tools are often highly specific to the intervention, content, and context of the particular implementation effort they were designed for, and they may only provide examples and possible guidelines for new studies or implementation efforts. Examples of tools, including some available for download and tailoring, are given in Section II Part 2 of the QuERI Guide to Implementation Research, available online at: hsrd. research. va. gov/queri/implementation. 29.

The primary example we use in this paper comes from a systematic attempt to change processes of clinical care, where the primary agent or target of the desired change may be an individual provider, but the planning for the intervention explicitly acknowledges that the provider operates within the context of an organization, which sets goals, performance standards, guidelines, expectations, and provides resources of various types to assist in getting the task accomplished.

EXAMPLE: APPLICATION OF THEORY TO INTERVENTION DESIGN AND IMPLEMENTATION FROM THE MENTAL HEALTH QuERI.

Fundo.

This example comes from Mental Health QuERI researchers' application of theory to inform the design of a multicomponent intervention, the Antipsychotic Treatment Improvement Program (ATIP). The goal of this effort was to translate research evidence about antipsychotic medication treatment for patients with schizophrenia into routine clinical practice. 30 Specifically, the goal of the ATIP intervention was to improve clinician adherence with schizophrenia treatment guidelines, which recommend the use of moderate antipsychotic doses and newer “atypical” antipsychotic agents for patients who fail to respond to conventional antipsychotics. 31.

Intervention Design and Theoretical Underpinnings.

A central component of the ATIP intervention was the use of physician opinion leaders as key motivators of change within the clinics that participated in the study. Local opinion leaders were identified and trained by Mental Health QuERI staff. The rationale for using local opinion leaders to facilitate the adoption of evidence-based practices was supported by a collection of behavioral theories, including Diffusion of Innovation Theory , 32 Social Cognitive Theory , 33 and Social Influence Theory . 34 In the ATIP project, these theories suggested that opinion leaders who are highly knowledgeable about antipsychotic treatment of patients with schizophrenia, and who are also viewed by their peers as a credible and approachable resource for information and advice about such issues, can be very effective in influencing improvement in clinical practice by encouraging other clinicians to utilize evidence-based practices and by themselves modeling the use of evidence-based practices to their peers.

The ATIP intervention complemented the use of physician opinion leaders with additional intervention tools designed to enhance the intervention's impact, including use of educational materials to inform clinicians about guideline-recommended care for schizophrenia, implementation of electronic clinical reminders, and systematic performance monitoring of clinician prescribing habits with interactive feedback. The selection of these complementary intervention components was informed by the Predisposing, Reinforcing, and Enabling Constructs in Ecosystem Diagnosis and Evaluation (PRECEDE) planning model 35 for influencing the adoption of targeted behaviors. The PRECEDE model stresses the importance of applying multiple strategies to influence the use of evidence-based practices, including: (1) strategies such as the dissemination of educational materials that can help predispose physicians to be able to make desired changes by increasing their knowledge of guideline recommendations; (2) utilizing clinical reminders and/or other clinical support tools to help enable providers to follow guideline recommendations at the point of care; and (3) applying social incentives through performance reporting and feedback to help reinforce providers' implementation of targeted behaviors.

Finally, complexity theory 36 , 37 suggests that although it is very important for researchers to assess and understand the initial conditions in a health care organization to inform the design and implementation of an intervention to influence change, organizations are highly adaptive and change over time. Consequently, initial conditions that led to the selection of specific intervention tools or strategies may change, creating unanticipated challenges to continued use of certain intervention tools or the need for additional tools or strategies that were not included in the original intervention package. Recognizing this, the ATIP intervention included an external facilitation component, 38 which involved a member of the MH QuERI team maintaining regular contact with participating clinical staff to assist them in problem-solving and working through challenges to intervention implementation as they arose.

Study Results and Conclusions.

Study findings showed that the ATIP intervention improved antipsychotic prescribing in concordance with guideline recommendations and also reduced pharmacy costs for antipsychotics. Further, participating clinicians reported positive experiences with the program's educational and support materials. This is an example of how multiple theoretical frameworks were applied in the design and implementation of a multifaceted, multilevel intervention that resulted in improvements in antipsychotic treatment of patients with schizophrenia. Although some may argue toward the development of a single “unified” theory to inform the implementation of evidence-based practices, this example shows that thoughtful consideration of a collection of conceptual models may be useful in designing successful interventions. Table 1 lists select components/tools included in the ATIP intervention, summarizes the rationale for their selection, and identifies the theories that supported their inclusion in the intervention package.

We have outlined an approach to linking theory, models, strategy, and tools to design interventions or sets of interventions to implement planned change. We recognize that this may appear to be a complex, and seemingly unnecessary, process for planning, and conducting desired practice change. Certainly, change to promote evidence-based practices has been accomplished without elaborate conceptualization and planning. However, the results of these prior studies have been mixed, especially when the effort is made to replicate the intervention in a different setting or context. While many factors underlie this mixed set of results, we have found that a consistent theme of inadequately linking action to theory, coupled with inadequate planning, may contribute to mixed outcomes.

A counter to the thesis we are advancing is that there is no widely held unifying theory of human behavior in organizations, or of organizational change supported by evidence from well-designed experiments. As a result, there is no evidence to support our thesis: that tight linkage between theory and models based on theory, strategies based on these models, and tools based on these strategies will result in better outcomes, where better outcomes is defined as a higher probability of success in implementing desired behavior change (for a debate on this point see Rothman 39 and Jeffery 40 ). This is a very valid critique, and can only be countered by the observation that in the experimental work to date in this field, proceeding without a tight theory base has not yielded great success. In the absence of strong evidence, awaiting experimental work in this area, we believe that opening a discussion about the relevance and importance of theory may help stimulate the design of experiments that will provide evidence to support the utility or lack thereof of linkage to theory.

As we note in Fig. 1 , there must be a feedback loop between the implementation efforts and theory development and refinement. It is likely that the inapplicability of current theory is related to the lack of a sustained effort to create and build the feedback loop. There will be cases in which it becomes clear that there are inadequate tools, instruments that link assessment, measurement, and theory together, or inadequate theory. However, many researchers in this field are working collaboratively to develop instruments and tools. PRocess modelling in ImpleMEntation research is an excellent example of this type of work. Their focus is on the individual or dyadic level; similar ventures are needed at higher levels, and across levels, because almost no interaction in health care is free of organizational context.

Agradecimentos.

The work described in this paper was supported by VA Health Services Research and Development Service. The conclusions reached are the responsibility of the authors; the Department of Veterans Affairs does not endorse the statements and conclusions drawn in this paper.

APPENDIX: DEFINING TERMS.

A set of logical constructs that jointly offer answers to the questions “why” and “how,” as in “why would someone change their behavior in this way?” and “how could this behavior/situation/outcome be changed?” Theories can be quite elaborate, or relatively simple. Examples include the theory of reasoned action 41 ‘ 44 ; theories of cognitive dissonance 45 ‘ 52 ; stages of change 53 ‘ 55 ; Roger's Diffusion of Innovation Theory 32 ; Social Cognitive Theory 56 ‘ 61 ; and Social Influence Theory. 18 , 28.

A heuristic framework that joins theory to some specific state or action that is desired or is to be taken. In our construction, models are more specific and concrete than theory, and can usually be shown in a diagram or picture, while a theory may or may not lend itself to graphic display. Models can also be more or less elaborate, but should contain specific elements derived from theory that either predict action or outcome, or contribute in some way to achieving the desired change. Examples of models include Promoting Action Research in Health Services (PARIHS) 19 , 38 , 62 ‘ 66 and Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM). 67 , 68 We use the term “framework” interchangeably with “model.”

Estratégias.

Articulate how to go from the skeleton, in an anatomic analogy, to the physiology of actually making change occur, and may include several different interventions.

Interventions.

The specific steps that translate both model and strategy into action. There are numerous examples within the literature of types of interventions, ranging from types that require re-engineering the delivery system to single-shot educational interventions. 6 , 24 ‘ 28 , 69 , 70.

Concrete items such as educational pamphlets or pocket cards used within an intervention to facilitate the desired action and outcome. They are often highly specific to the intervention, content, and context of the intervention, and may be useful in other studies and contexts, but usually not without considerable tailoring and adjustment. A variety of examples are available on the VA QUERI Guide to Implementation web site. 29.

A framework to evaluate research capacity building in health care.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Fundo.

Building research capacity in health services has been recognised internationally as important in order to produce a sound evidence base for decision-making in policy and practice. Activities to increase research capacity for, within, and by practice include initiatives to support individuals and teams, organisations and networks. Little has been discussed or concluded about how to measure the effectiveness of research capacity building (RCB)

Discussão.

This article attempts to develop the debate on measuring RCB. It highlights that traditional outcomes of publications in peer reviewed journals and successful grant applications may be important outcomes to measure, but they may not address all the relevant issues to highlight progress, especially amongst novice researchers. They do not capture factors that contribute to developing an environment to support capacity development, or on measuring the usefulness or the 'social impact' of research, or on professional outcomes.

The paper suggests a framework for planning change and measuring progress, based on six principles of RCB, which have been generated through the analysis of the literature, policy documents, empirical studies, and the experience of one Research and Development Support Unit in the UK. These principles are that RCB should: develop skills and confidence, support linkages and partnerships, ensure the research is 'close to practice', develop appropriate dissemination, invest in infrastructure, and build elements of sustainability and continuity. It is suggested that each principle operates at individual, team, organisation and supra-organisational levels. Some criteria for measuring progress are also given.

This paper highlights the need to identify ways of measuring RCB. It points out the limitations of current measurements that exist in the literature, and proposes a framework for measuring progress, which may form the basis of comparison of RCB activities. In this way it could contribute to establishing the effectiveness of these interventions, and establishing a knowledge base to inform the science of RCB.

Fundo.

The need to develop a sound scientific research base to inform service planning and decision-making in health services is strongly supported in the literature [1], and policy [2]. However, the level of research activity and the ability to carry out research is limited in some areas of practice, resulting in a low evidence base in these areas. Primary Care, for example, has been identified as having a poor capacity for undertaking research [3-5], and certain professional groups, for example nursing and allied health professionals, lack research experience and skills [5-7]. Much of the literature and the limited research on research capacity building (RCB) has therefore focused on this area of practice, and these professional groups. Policy initiatives to build research capacity include support in developing research for practice, where research is conducted by academics to inform practice decision making, research within or through practice, which encompasses research being conducted in collaboration with academics and practice, and research by practice, where ideas are initiated and research is conducted by practitioners [3,8].

The interventions to increase research capacity for, within, and by practice incorporates initiatives to support individuals and teams, organisations and networks. Examples include fellowships, training schemes and bursaries, and the development of support infrastructures, for example, research practice networks [9-13]. In the UK, the National Coordinating Centre for Research Capacity Development has supported links with universities and practice through funding a number of Research and Development Support Units (RDSU) [14]which are based within universities, but whose purpose is to support new and established researchers who are based in the National Health Service (NHS). However, both policy advisers and researchers have highlighted a lack of evaluative frameworks to measure progress and build an understanding of what works[15,16].

This paper argues for a need to establish a framework for planning and measuring progress, and to initiate a debate about identifying what are appropriate outcomes for RCB, not simply to rely on things that are easy to measure. The suggested framework has been generated through analysis of the literature, using policy documents, position statements, a limited amount of empirical studies on evaluating research RCB, and the experience of one large RSDU based in the UK.

Discussão.

The Department of Health within the UK has adopted the definition of RCB as 'a process of individual and institutional development which leads to higher levels of skills and greater ability to perform useful research". (pp1321) [17]

Albert & Mickan cited the National Information Services in Australia [18] who define it as.

" an approach to the development of sustainable skills, organizational structures, resources and commitment to health improvement in health and other sectors to multiply health gains many times over.'

RCB can therefore be seen as a means to an end, the end being 'useful' research that informs practice and leads to health gain, or an end in itself, emphasising developments in skills and structures enabling research to take place.

A framework for measuring capacity building should therefore be inclusive of both process and outcome measures [19], to capture changes in both the 'ends' and 'means'; it should measure the ultimate goals, but also measure the steps and mechanisms to achieve them. The notion of measuring RCB by both process and outcome measures is supported within the research networks literature [12,20], and capacity building in health more generally [19,21]. Some argue we should acknowledge 'process as outcome', particularly if capacity building is seen as an end in itself [21]. In this context process measures are 'surrogate' [12], or 'proxy' outcome measures[16]. Carter et al [16]stress caution in terms of using 'proxy' measures in the context of RCB, as there is currently little evidence to link process with outcome. They do not argue against the notion of collecting process data, but stress that evaluation work should examine the relationship of process to outcome. The proposed framework discussed in this paper suggests areas to consider for both process and outcome measurement.

The most commonly accepted outcomes for RCB cited in the literature includes traditional measures of high quality research including publications, conference presentations, successful grant applications, and qualifications obtained. Many evaluations of RCB have used these as outcomes [9,10,22,23]. Some argue that publications in peer reviewed journals are a tall order for the low research skills base in some areas of health care practice [5], and argue for an appropriate time frame to evaluate progress. Process measures in this context could measure progress more sensitively and quickly.

However, using traditional outcomes may not be the whole story in terms of measuring impact. Position statements suggest that the ultimate goal of research capacity building is one of health improvement [17,18,24]. In order for capacity building initiatives to address these issues, outcomes should also explore the direct impact on services and clients: what Smith [25]defines as the social impact of research.

There is a strong emphasis within the primary care literature that capacity building should enhance the ability of practitioners to build their research skills: to support the development of research 'by' and 'with' practice [3,26], and suggests 'added value' to develop such close links to practice. A framework to measure RCB should explore and try to unpack this 'added value', both in terms of professional outcomes,[10] which include increasing professional enthusiasm, and supporting the application of critical thinking, and the use of evidence in practice. Whilst doing research alongside practice is not the only way these skills and attitudes can be developed, it does seem to be an important impact of RCB that should be examined.

The notion of developing RCB close to practice does not necessarily mean that it is small scale just because it is close to the coal face. Obviously, in order for individuals and teams to build up a track record of experience their initial projects may justifiably be small scale, but as individual's progress, they may gain experience to be able to conduct large scale studies, still based on practice problems, working in partnership with others. Similarly networks can support large scale studies as their capacity and infrastructure is developed to accommodate them.

The framework.

The framework is represented by Figure ​ Figura 1. 1. It has two dimensions.

• Four structural levels of development activity . These include individual, team, organisational, and the network or supra - organisational support level (networks and support units). These are represented by the concentric circles within the diagram.

• Six principles of capacity building . This are discussed in more detail below but include: building skills and confidence, developing linkages and partnerships, ensuring the research is 'close to practice', developing appropriate dissemination, investments in infrastructure, and building elements of sustainability and continuity. Each principle is represented by an arrow within the diagram, which indicates activities and processes that contribute towards capacity building. The arrows cut across the structural levels suggesting that activities and interventions may occur within, and across, structural levels. The arrow heads point in both directions suggesting that principles applied to each structural level could have an impact on other levels.

The framework acknowledges that capacity building is conducted within a policy context. Whilst this paper focuses on measurement at different structural levels, it should be acknowledged that progress and impact on RCB can be greatly nurtured or restricted by the prevailing policy. Policy decisions will influence opportunities for developing researchers, can facilitate collaborations in research, support research careers, fund research directed by practice priorities, and can influence the sustainability and the very existence of supportive infrastructures such as research networks.

The paper will explain the rationale for the dimensions of the framework, and then will suggest some examples of measurement criteria for each principle at different structural levels to evaluate RCB. It is hope that as the framework is applied, further criteria will be developed, and then used taking into account time constraints, resources, and the purpose of such evaluations.

Structural levels at which capacity building takes place.

The literature strongly supports that RCB should take place at an individual and organisational level [8,15,27,28]. For example, the conceptual model for RCB in primary care put forward by Farmer & Weston [15] focuses particularly on individual General Practitioners (GPs) and primary care practitioners who may progress from non participation through participation, to become academic leaders in research. Their model also acknowledges the context and organisational infrastructure to support RCB by reducing barriers and accommodating diversity through providing mentorship, collaborations and networking, and by adopting a whole systems approach based on local need and existing levels of capacity. Others have acknowledged that capacity development can be focussed at a team level [11,29]. Jowett et al [30] found that GPs were more likely to be research active if they were part of a practice where others were involved with research. Guidance from a number of national bodies highlights the need for multiprofessional and inter-professional involvement in conducting useful research for practice [3,4,6,31] which implies an appropriate mix of skills and practice experience within research teams to enable this [32]. Additionally, the organisational literature has identified the importance of teams in the production of knowledge [18,33,34].

Developing structures between and outside health organisations, including the development of research networks seems important for capacity building [12,24,34]. The Department of Health in the UK [14] categorizes this supra-organisational support infrastructure to include centres of academic activity, Research & Development Support Units, and research networks.

As interventions for RCB are targeted at different levels, the framework for measuring its effectiveness mirrors this. However, these levels should not be measured in isolation. One level can have an impact on capacity development at another level, and could potentially have a synergistic or detrimental effect on the other.

The six principles of research capacity building.

Evaluation involves assessing the success of an intervention against a set of indicators or criteria [35,36], which Meyrick and Sinkler [37] suggest should be based on underlying principles in relation to the initiative. For this reason the framework includes six principles of capacity building. The rationale for each principle is given below, along with a description of some suggested criteria for each principle. The criteria presented are not an exhaustive list. As the framework is developed and used in practice, a body of criteria will be developed and built on further.

Principle 1. Research capacity is built by developing appropriate skills, and confidence, through training and creating opportunities to apply skills.

The need to develop research skills in practitioners is well established [3,4,6], and can be supported through training [14,26], and through mentorship and supervision [15,24,28]. There is some empirical evidence that research skill development increases research activity [23,38], and enhances positive attitudes towards conducting and collaborating in research [39]. Other studies cite lack of training and research skills as a barrier to doing research [30,31]. The need to apply and use research skills in practice is highlighted in order to build confidence [40]and to consolidate learning.

Some needs assessment studies highlight that research skills development should adopt 'outreach' and flexible learning packages and acknowledge the skills, background and epistemologies of the professional groups concerned [7,15,39,41,42]. These include doctors, nurses, a range of allied health professional and social workers. Developing an appropriate mix of professionals to support health services research means that training should be inclusive and appropriate to them, and adopt a range of methodologies and examples to support appropriate learning and experience [15,31,41]. How learning and teaching is undertaken, and the content of support programmes to reflect the backgrounds, tasks and skills of participants should therefore be measured. For example, the type of research methods teaching offered by networks and support units should reflect a range and balance of skills needed for health service research, including both qualitative and quantitative research methods.

Skills development also should be set in the context of career development, and further opportunities to apply skills to practice should be examined. Policy and position statements [14,26] support the concept of career progression or 'careers escalator', which also enables the sustainability of skills. Opportunities to apply research skills through applications for funding is also important [9,10,22,43,44].

At team and network level Fenton et al [34]suggest that capacity can be increased through building intellectual capacity (sharing knowledge), which enhances the ability to do research. Whilst there is no formal measure for this, an audit of the transfer of knowledge would appear to be beneficial. For example teams may share expertise within a project to build skills in novice researchers [45]which can be tracked, and appropriate divisions of workload through reading research literature and sharing this with the rest of the team/network could be noted.

The notion of stepping outside of a safety zone may also suggest increased confidence and ability to do research. This may be illustrated at an individual level by the practitioner-researcher taking on more of a management role, supervising others, or tackling new methodologies/approaches in research, or in working with other groups of health and research professionals on research projects. This approach is supported by the model of RCB suggested by Farmer and Weston [15] which supports progress from participation through to academic leadership.

Some examples of criteria for measuring skills and confidence levels are give in table ​ table1 1 .

Principle 2. Research capacity building should support research 'close to practice' in order for it to be useful.

The underlying philosophy for developing research capacity in health is that it should generate research that is useful for practice. The North American Primary Care Group [24] defined the 'ultimate goal' of research capacity development as the generation and application of new knowledge to improve the health of individuals and families (p679). There is strong support that 'useful' research is that which is conducted 'close' to practice for two reasons. Firstly by generating research knowledge that is relevant to service user and practice concerns. Many argue that the most relevant and useful research questions are those generated by, or in consultation with, practitioners and services [3,11,24], policy makers [46] and service users [47,48]. The level of 'immediate' usefulness [49] may also mean that messages are more likely to taken up in practice[50]. Empirical evidence suggests that practitioners and policy makers are more likely to engage in research if they see its relevance to their own decision making [31,39,46]. The notion of building research that is 'close to practice' does not necessarily mean that they are small scale, but that the research is highly relevant to practice or policy concerns. A large network of practitioners could facilitate large scale, experimental based projects for example. However, the adoption of certain methodologies is more favoured by practice because of their potential immediate impact on practice [47] and this framework acknowledges such approaches and their relevance. This includes action research projects, and participatory inquiry [31,42]. An example where this more participatory approach has been developed in capacity building is the WeLREN (West London Research Network) cycle [51]. Here research projects are developed in cycles of action, reflection, and dissemination, and use of findings is integral to the process. This network reports high levels of practitioner involvement.

Secondly, building research capacity 'close to practice' is useful because of the skills of critical thinking it engenders which can be applied also to practice decision making [28], and which supports quality improvement approaches in organisations [8]. Practitioners in a local bursary scheme, for example, said they were more able to take an evidence-based approach into their every day practice [9].

Developing a 'research culture' within organisations suggests a closeness to practice that impacts on the ability of teams and individuals to do research. Lester et al [23] touched on measuring this idea through a questionnaire where they explored aspects of a supportive culture within primary care academic departments. This included aspects around exploring opportunities to discuss career progression, supervision, formal appraisal, mentorship, and junior support groups. This may be a fruitful idea to expand further to develop a tool in relation to a health care environment.

Some examples of criteria for measuring the close to practice principle are give in table ​ table2 2.

3. Linkages, partnerships and collaborations enhance research capacity building.

The notion of building partnerships and collaborations is integral to capacity building [19,24]. It is the mechanism by which research skills, and practice knowledge is exchanged, developed and enhanced [12], and research activity conducted to address complex health problems [4]. The linkages between the practice worlds and that of academia may also enhance research use and impact [46].

The linkages that enhance RCB can exist between.

• Novice and experienced researchers [22,24,51].

• Different professional groups [2,4,20,34]

• Different health and care provider sectors [4,31,47,52]

• Service users, practitioners and researchers [47,48]

• Researchers and policy makers [46]

It is suggested that it is through networking and building partnerships that intellectual capital (knowledge) and social capital (relationships) can be built, which enhances the ability to do research [12,31,34]. In particular, there is the notion that the build up of trust between different groups and individuals can enhance information and knowledge exchange[12]. This may not only have benefits for the development of appropriate research ideas, but may also have benefits for the whole of the research process including the impact of research findings.

The notion of building links with industry is becoming progressively evident within policy in the UK [54] which may impact on economic outcomes to health organisations and the society as a whole[55,56].

Some examples of criteria for measuring linkages and collaborations are given in table ​ table3 3 .

4. Research capacity building should ensure appropriate dissemination to maximize impact.

A widely accepted measure to illustrate the impact of RCB is the dissemination of research in peer reviewed publications, and through conference presentations to academic and practice communities [5,12,26,57]. However this principle extends beyond this more traditional method of dissemination. The litmus test that ultimately determines the success of capacity building is that it should impact on practice, and on the health of patients and comminutes[24] that is; the social impact of research [25]. Smith [25]argues that the strategies of dissemination should include a range of methods that are 'fit for purpose'. This includes traditional dissemination, but also includes other methods, for example, instruments and programmes of care implementation, protocols, lay publications, and publicity through factsheets, the media and the Internet.

Dissemination and tracking use of products and technologies arising from RCB should also be considered, which relate to economic outcomes of capacity building [55]. In the UK, the notion of building health trusts as innovative organisations which can benefit economically through building intellectual property highlights this as an area for potential measurement [56].

Some examples of criteria for measuring appropriate dissemination are given in table ​ table4 4.

5. Research capacity building should include elements of continuity and sustainability.

Definitions of capacity building suggest that it should contain elements of sustainability which alludes to the maintenance and continuity of newly acquired skills and structures to undertake research [18,19]. However the literature does not explore this concept well [19]. This in itself may be partly due problems around measuring capacity building. It is difficult to know how well an initiative is progressing, and how well progress is consolidated, if there are no benchmarks or outcomes against which to demonstrate this.

Crisp et al [19] suggests that capacity can be sustained by applying skills to practice. This gives us some insight about where we might look for measures of sustainability. It could include enabling opportunities to extend skills and experience, and may link into the concept of a career escalator. It also involves utilizing the capacity that has been already built. For example engaging with those who have gained skills in earlier RCB initiatives to help more novice researchers, once they have become 'experts', and in finding an appropriate place to position the person with expertise with the organisation. It could also be measured by the number of opportunities for funding for continued application of skills to research practice.

Some examples of criteria for measuring sustainability and continuity are gibe in table ​ table5 5.

6. Appropriate infrastructures enhance research capacity building.

Infrastructure includes structures and processes that are set up to enable the smooth and effective running of research projects. For example, project management skills are essential to enable projects to move forward, and as such should be measured in relation to capacity building. Similarly, projects should be suitably supervised with academic and management support. To make research work 'legitimate' it may be beneficial to make research a part of some job descriptions for certain positions, not only to reinforce research as a core skill and activity, but also to review in annual appraisals, which can be a tool for research capacity evaluation. Information flow about calls for funding and fellowships and conferences is also important. Hurst [42] found that information flow varied between trusts, and managers were more aware of research information than practitioners.

The importance of protected time and backfill arrangements as well as funding to support this, is an important principle to enable capacity building [9, 15, 24, 58]. Such arrangements may reduce barriers to participation and enable skills and enthusiasm to be developed[15]. Infrastructure to help direct new practitioners to research support has also been highlighted[14]. This is particularly true in the light of the new research governance and research ethics framework in the UK [59]. The reality of implementing systems to deal with the complexities of the research governance regulations has proved problematic, particularly in primary care, where the relative lack of research management expertise and infrastructure has resulted in what are perceived as disproportionately bureaucratic systems. Recent discussion in the literature has focused on the detrimental impact of both ethical review, and NHS approval systems, and there is evidence of serious delays in getting research projects started [60]. Administrative and support staff to help researchers through this process is important to enable research to take place [61].

Some examples of criteria for measuring are given in table ​ table6 6 .

Conclusão.

This paper suggests a framework which sets out a tentative structure by which to start measuring the impact of capacity building interventions, and invites debate around the application of this framework to plan and measure progress. It highlights that interventions can focus on individuals, teams, organisations, and through support infrastructures like RDSUs and research networks. However, capacity building may only take place once change has occurred at more than one level: for example, the culture of an organisation in which teams and individuals work may have an influence of their abilities and opportunities to do research work. It is also possible that the interplay between different levels may have an effect on the outcomes at other levels. In measuring progress, it should be possible to determine a greater understanding of the relationship between different levels. The framework proposed in this paper may be the first step to doing this.

The notion of building capacity at any structural level is dependent on funding and support opportunities, which are influenced by policy and funding bodies. The ability to build capacity across the principles developed in the framework will also be dependent of R&D strategy and policy decisions. For example, if policy fluctuates in its emphasis on building capacity 'by', 'for' or 'with' practice, the ability to build capacity close to practice will be affected.

In terms of developing a science of RCB, there is a need to capture further information on issues of measuring process and outcome data to understand what helps develop 'useful' and 'useable' research. The paper suggests principles whereby a number of indicators could be developed. The list is not exhaustive, and it is hoped that through debate and application of the framework further indicators will be developed.

An important first step to building the science of RCB should be debate about identifying appropriate outcomes. This paper supports the use of traditional outcomes of measurement, including publications in peer reviewed journals and conference presentations. This assures quality, and engages critical review and debate. However, the paper also suggests that we might move on from these outcomes in order to capture the social impact of research, and supports the notion of developing outcomes which measure how research has had an impact on the quality of services, and on the lives of patients and communities. This includes adopting and shaping the type of methodologies that capacity building interventions support, which includes incorporating patient centred outcomes in research designs, highlighting issues such as cost effectiveness of interventions, exploring economic impact of research both in terms of product outputs and health gain, and in developing action oriented, and user involvement methodologies that describe and demonstrate impact. It also may mean that we have to track the types of linkages and collaborations that are built through RCB, as linkages that are close to practice, including those with policy makers and practitioners, may enhance research use and therefore 'usefulness'. If we are to measure progress through impact and change in practice, an appropriate time frame would have to be established alongside these measures.

This paper argues that 'professional outcomes' should also be measured, to recognize how critical thinking developed during research impacts on clinical practice more generally.

Finally, the proposed framework provides the basis by which we can build a body of evidence to link process to the outcomes of capacity building. By gathering process data and linking it to appropriate outcomes, we can more clearly unpack the 'black box' of process, and investigate which processes link to desired outcomes. It is through adopting such a framework, and testing out these measurements, that we can systematically build a body of knowledge that will inform the science and the art of capacity building in health care.

• There is currently little evidence on how to plan and measure progress in research capacity building (RCB), or agreement to determining its ultimate outcomes.

• Traditional outcomes of publications in peer reviewed journals, and successful grant applications may be the easy and important outcomes to measure, but do not necessarily address issues to do with the usefulness of research, professional outcomes, the impact of research activity on practice, or on measuring health gain.

• The paper suggests a framework which provides a tentative structure by which measuring the impact of RCB could be achieved, shaped around six principles of research capacity building, and includes four structural levels on which each principle can be applied.

• The framework could be the basis by which RCB interventions could be planned, and progress measured. It could act as a basis of comparison across interventions, and could contribute to establishing a knowledge base on what is effective in RCB in healthcare.

Competing interests.

The author(s) declare that they have no competing interests.

Pre-publication history.

The pre-publication history for this paper can be accessed here:

Agradecimentos.

My warm thanks go to my colleagues in the primary care group of the Trent RDSU for reading and commenting on earlier drafts of this paper, and for their continued support in practice.

Nursing Leadership.

Nursing Leadership, 16(4) December 2003: 20-26.doi:10.12927/cjnl.2003.16257.

Research: Evidence-based Nursing Practice: How to Get There from Here.

As a nursing student, I learned to shave patients in preparation for surgery; as a public health nurse, I taught mothers to clean their infants' umbilical cords with alcohol and showed patients newly diagnosed with diabetes how to wipe the skin with alcohol before injecting insulin. Since then, high-quality research has shown that pre-operative shaving increases rather than decreases post-operative infections (Kjonniksen et al. 2002), that cleaning umbilical cords with sterile water shortens the time to cord separation without increasing infections (Medves and O'Brien 1997) and that insulin can be safely injected through clothing (Fleming et al. 1997). These are only three of innumerable examples of how high-quality studies of nursing care can influence our practice.

And while it is heartening to know that new evidence is constantly emerging to inform our nursing practice, it is disheartening to learn that many nurses continue to rely on the increasingly dated knowledge they acquired as nursing students (Estabrooks 1998).

In this paper, I will describe how high-quality evidence fits into clinical decision-making in nursing practice, and I will call upon key professional groups, such as associations of nursing educators, executive nurses and national nursing organizations, to combine forces and create blue ribbon panels or task forces charged with making recommendations for changes in nursing education and practice that will advance us towards full development as an evidence-based profession.

Evidence and Clinical Decision-making.

"Best research evidence" refers to methodologically sound, clinically relevant research about the effectiveness and safety of nursing interventions, the accuracy and precision of nursing assessment measures, the power of prognostic indicators, the strength of causal relationships, the cost-effectiveness of nursing interventions and the meaning of illness or patient experiences. Research evidence alone, however, is never sufficient to make a clinical decision. As nurses, we must always trade the benefits and risks, inconvenience and costs associated with alternative management strategies, and in doing so consider the patient's values (DiCenso et al. 1998). Patient values and preferences refer to the underlying assumptions and beliefs that are involved when we, along with patients, weigh what they will gain - or lose - when we make a management decision. The explicit enumeration and balancing of benefits and risks that are central to evidence-based nursing (EBN) bring into bold relief the underlying value judgments involved in making management decisions.

The skills necessary to provide an evidence-based solution to a clinical dilemma include defining the problem; conducting an efficient search to locate the best evidence; critically appraising the evidence; and considering that evidence and its implications in the context of patients' circumstances and values. Attaining these skills requires intensive study and frequent, time-consuming application (Guyatt et al. 2000).

The majority of nurses have a positive attitude about evidence-based practice (Upton 1999). However, there are substantial barriers to EBN at both the individual and organizational levels.

At the individual level, nurses lack skill in evaluating the quality of research (Parahoo 2000), are isolated from knowledgeable colleagues with whom to discuss research (Nilsson Kajermo et al. 1998) and lack confidence to implement change (Parahoo 2000).

Organizational characteristics of healthcare settings are overwhelmingly the most significant barriers to research use among nurses (Parahoo 2000). Nurses speak about not having enough time to go to the library to read or to implement findings from research (Upton 1999). Related to this complaint is the inadequacy of library holdings in healthcare institutions, with many lacking nursing research journals (Mitchell et al. 1995). Nurses have identified a lack of organizational support for EBN, noting lack of interest, lack of motivation, lack of leadership and lack of vision, strategy and direction among managers (Parahoo 2000). Yet, this organizational support is crucial in situations where nurses do not believe they have the authority or autonomy to implement change in patient care (Parahoo 2000). For example, a physician may read about the effectiveness of a new pain medication and may choose to begin prescribing it immediately; nurses who identify a new, effective nursing intervention for pain management must often obtain approval from nursing administration before implementing it.

Clinicians and patients recognize that while not the sole consideration, current, accurate information is a vital component of clinical decision-making. With advances in information technology and reporting of research findings in the media, patients, armed with "facts" they have read on the Internet or in the newspaper, are beginning to ask their care providers about the applicability of research findings to their particular health problem. A vivid example is the widely publicized study of the risks and benefits of estrogen and progestin in post-menopausal women that was stopped early because the investigators found a higher incidence of cardiovascular disease and breast cancer in women taking the combined hormones when compared to women taking placebo (Writing Group for the Women's Health Initiative Investigators 2002). Physicians and nurse practitioners have been deluged with patient inquiries about whether they should discontinue their hormone replacement therapy, requiring these clinicians to be sufficiently aware of the study methods to judge the validity of the results and their applicability to individual patients.

Grounding nursing practice in evidence, rather than tradition, is necessary to meet nursing's social obligation of accountability, to gain and maintain credibility among other health disciplines and to build a nursing knowledge base that can be used to influence policy at agency and governmental levels (Rafael 2000). Governments around the world are encouraging evidence-based practice. In Canada, the National Health Forum, a federally funded group charged with making healthcare recommendations, has stated that "a key objective for the health sector should be to move rapidly toward the development of an evidence-based health system, in which decisions are made by healthcare providers, administrators, policy-makers, patients and the public on the bases of appropriate, balanced and high quality evidence" (National Forum on Health 1997). In the United Kingdom, the Department of Health has stipulated that, to enhance the quality of patient care, nursing, midwifery and health visiting, practice needs to be evidence based (UK Department of Health 1999).

In the United States, the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), leads national efforts in the use of evidence to guide healthcare decisions through funding of Evidence-Based Practice Centers that undertake systematic reviews on selected clinical topics, sponsoring a National Guideline Clearinghouse of abstracts of evidence-based practice guidelines (guideline. gov) and funding studies that evaluate strategies for effectively disseminating research findings to practitioners and policy makers (Titler 2002). In December 2002, the Board of Directors of the Sigma Theta Tau International Honor Society of Nursing adopted a position statement supporting the development and implementation of EBN and committing itself to working closely with key partners to provide nurses with the most current and comprehensive resources to translate the best evidence into the best nursing research, education, administration, policy and practice (Honor Society of Nursing 2002).

Towards Full Development as an Evidence-based Profession.

Various activities have been initiated to facilitate EBN practice, including the development and offering of undergraduate courses on locating and critically appraising research evidence (Kessenich et al. 1997), the development of clinical practice guidelines (Grinspun et al. 2002), the development of EBN committees in clinical settings and research to identify the most effective strategies for disseminating research findings to nurses. But there is a long way to go. How do we create a culture shift that ensures that a nursing student knows how to search the literature for high-quality studies as proficiently as she can measure a patient's blood pressure, and that a staff nurse has access to the best research evidence to incorporate into clinical decision-making?

Let's begin by considering changes to nursing education programs. A number of ideas come to mind related to curriculum development, faculty development, librarian resources and accreditation criteria. Rather than isolating the teaching of critical appraisal of research in its own undergraduate course, can we re-examine our nursing curricula and consider how critical appraisal of research can be integrated into each and every learning experience, whether learning of clinical skills such as taking blood pressure, or in-class nursing courses, or clinical experiences in healthcare settings? Can we see a world where students in classrooms or in clinical settings go off to learn about a specific patient or health problem and return with a clearly stated question, the search strategy they used and the strengths and limitations of the highest-quality study they found on the topic? If this were the approach to every course students took and every clinical experience they had, would consideration of best research evidence in their clinical decision-making become second nature for these future nurses? Clearly, none of this will happen if nursing faculty are not comfortable with critical appraisal skills.

To be fair, the opportunities to develop these skills have been relatively scarce. There is much to be done in this area. Various models can be explored for faculty development; for example, at McMaster University, an interdisciplinary, week-long, intense workshop on How to Teach Evidence-based Clinical Practice is conducted every June that attracts clinician educators from around the world. To ensure that nurse educators of the future are prepared to teach in an EBN curriculum, it is vitally important that the graduate nursing programs include required courses on critical appraisal and application of research evidence.

Librarians are an indispensable resource to evidence-based practice. In a number of undergraduate and graduate nursing courses at McMaster University, a health sciences librarian has set up course-specific Web Sites providing ready access to numerous sources of evidence-based material. As well, she spends a half day with the students in the computer laboratory providing hands-on experience in efficient advanced searching strategies to locate high-quality research evidence and to link with resources that can automatically notify the student when new studies are published in a specific area of interest. She is also available to meet individually with students.

These ideas, while promising, cannot be implemented without the buy-in and support of the deans and directors of schools and faculties of nursing. These are not resource-free ideas; instead, they are ideas that likely require financial and human resources as well as a supportive environment for change. Incorporation into the accreditation process of specific objectives and recommendations for transforming nursing education programs into evidence-based education programs are key to helping deans and directors obtain assistance with required resources from the university or college administration.

In clinical settings, let's consider computer and librarian resources, development and introduction of the nurse educator/practitioner/researcher role, journal clubs, interdisciplinary rounds and accreditation. Asking nurses to practise nursing without the tools to locate best evidence to inform their clinical decision-making is comparable to asking them to take a blood pressure measurement without a stethoscope. Many nurses, while highly motivated to become evidence-based practitioners, have not had any opportunity in their nursing education to learn searching and critical appraisal skills. To complicate matters further, time is more limited than ever.

There exist, however, numerous secondary sources of pre-appraised evidence that provide immediately applicable information for decision-making. Administrators of clinical settings can make a significant contribution to the development of evidence-based practice by providing access to these resources, along with opportunity for nurses to learn how to track down and efficiently use them. Such resources, which apply a methodological filter to original investigations and therefore ensure a minimum standard of validity, include Clinical Evidence, The Cochrane Library, Evidence-Based Nursing (and other discipline-specific abstraction journals, such as Evidence-Based Mental Health ), high-quality clinical practice guidelines and an increasing number of computerized decision-support systems. Ready access to computers in the clinical setting and librarians is key. At a minimum, librarians can teach nurses how to frame an answerable question and how to use the secondary sources of pre-appraised evidence efficiently. The librarian becomes, in effect, a knowledge broker who is expert in sources of high-quality information and in teaching others how to access them efficiently.

For the most part, nursing educators are not active clinicians, and nurse clinicians are not nursing educators. At Rush University College of Nursing, they have developed the nurse educator/practitioner/researcher role in which faculty members have an ongoing research involvement and clinical practice alongside their responsibilities as educators, lecturers and advisers ("Inside the Rush Model" 2003). Picture clinical settings in which the nurse educator/practitioner/researcher works closely with nursing staff to produce and disseminate new knowledge and, as an advanced practice nurse, models and facilitates evidence-based practice.

Should we consider bringing together, in the clinical setting, the nurse educator, the students and the nurse clinicians in the form of a journal club? Together, they can identify a patient problem; volunteers can then offer to search out the best evidence and bring it back for presentation and discussion with the group. This might provide a forum for learning from one another while at the same time helping nurses in the clinical setting, who lack time and critical appraisal skills.

There is an increasing awareness of the importance of interdisciplinary learning to facilitate the effective working of the multidisciplinary healthcare team in service delivery. We are beginning to see how challenging it is to promote interdisciplinary service when learning has occurred in unidisciplinary silos. Is there an opportunity in the clinical setting to bring together students from programs such as nursing, midwifery, medicine, occupational therapy and physiotherapy to consider a common patient problem and to search out and discuss relevant research findings? For example, at McMaster University, a multidisciplinary team has been awarded funds from the provincial government to develop models for collaborative education and collaborative service delivery in long-term care, including family medicine residents, nurse practitioner students and pharmacy students. It is envisioned that both models will include the opportunity for these interdisciplinary learners and clinicians to work together through patient problems, identifying and using best evidence in their clinical decision-making.

Very little of this is possible without the support and provision of resources by the administrators of healthcare settings. Nurse managers may want to consider lobbying for inclusion of standards related to EBN practice in the accreditation mechanisms for their clinical settings. This action would appropriately highlight the importance of evidence-based practice and would ensure that essential resources be allocated to its development.

The ideas offered above are merely suggestions. The development of an evidence-based profession is an extremely important initiative in nursing, one that warrants national attention and collaboration. I encourage key nursing groups, including associations of nursing educators, executive nurses and national nursing organizations, to combine forces and create blue ribbon panels or task forces charged with making recommendations for changes in nursing education and practice that will move us rapidly towards full development as an evidence-based profession.

Enthusiasm for evidence-based practice is growing in the nursing community. We must now develop, implement and evaluate a plan to make it happen.

Sobre o autor.

Alba DiCenso , RN, PhD.

Professor, Nursing and Clinical Epidemiology and Biostatistics.

Director, Ontario Training Centre in Health Services and Policy Research.

CHSRF/CIHR Nursing Chair in Advanced Practice Nursing.

McMaster University, Hamilton, ON.

Past Lead Editor, Evidence-Based Nursing Journal.

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Nursing Research and Practice.

Indexed in Web of Science.

Advanced Practice Nursing Education: Challenges and Strategies.

1 College of Nursing, Washington State University, Spokane, WA 99210-1495, USA.

2 Family and Child Nursing, University of Washington, Seattle, WA 98195, USA.

3 College of Nursing, Seattle University, Seattle, WA 98122, USA.

Received 15 August 2018; Accepted 10 October 2018.

Academic Editor: Sally Brosz Hardin.

Copyright © 2018 Cynthia Fitzgerald et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nursing education programs may face significant difficulty as they struggle to prepare sufficient numbers of advanced practice registered nurses to fulfill the vision of helping to design an improved US healthcare system as described in the Institute of Medicine's “ Future of nursing ” relatório. This paper describes specific challenges and provides strategies to improve advanced practice nursing clinical education in order to ensure that a sufficient number of APRNs are available to work in educational, practice, and research settings. Best practices are identified through a review of classic and current nursing literature. Strategies include intensive interprofessional collaborations and radical curriculum revisions such as increased use of simulation and domestic and international service work. Nurse educators must work with all stakeholders to create effective and lasting change.

1. Introduction.

National and international reports, including one published recently by the Institute of Medicine [1], describe the potential for advanced practice registered nurses (APRNs) to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform [2, 3]. Preparing APRNs for practice and fostering the role of APRNs in a variety of educational, clinical, and research settings are necessary steps toward achieving this vision. Given the current economic and political climate in the United States, however, success may be elusive. At present, a shrinking number of nurse educators carry an increasingly large responsibility for educating a declining number of APRNs [4, 5]. In many settings, outdated regulations, policies, and biases prevent APRNs from practicing to the fullest extent of their education, skills, and competencies [6‘8]. Some US-based physician organizations have mounted campaigns aimed at discrediting APRN education and practice and decrying the potential of APRNs to provide cost-effective and clinically efficient care [9, 10].

While barriers to practice are significant, innovative approaches to clinical education and curricular transformation offer promise to nursing administrators, nursing educators, and practicing APRNs who are committed to preparing a highly qualified APRN workforce that will serve future generations of Americans. The rapid development and establishment of the practice doctorate has generated cautious enthusiasm among many nurse educators who are eager to help APRNs achieve their fullest potential in clinical practice. The purpose of this paper is to describe challenges in providing APRN clinical education and to propose achievable strategies for educating future APRNs to participate fully in transforming the United States healthcare system. We argue that the time is right to identify and implement educational practices that will lead to the optimal development of clinical skills, knowledge, and practice acumen and help meet the goals endorsed by national nursing organizations and set forth in the “ Future of nursing ” report published in 2018 [1]. While the IOM report is extraordinarily thorough, its scope does not include suggestions for specific strategies for improving APRN clinical education, a gap this paper seeks to fill.

2. Background.

Advanced practice registered nurses include nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs). APRNs represent an underutilized source of quality health care providers [1]. Only 3.8% of the 2.4 million US registered nurses (RNs) are NPs, 0.3% are CNMs, 1.1% are CRNAs, and 0.9% (down from 1.2% in 2004) are CNSs [11]. While the nurse anesthetist was the first advanced practice role to emerge in the late 19th century, formal APRNs education programs did not start until the 20th century. The first nurse-midwifery program began in 1932 at the Maternity Care Association in New York, and in 1954, Rutgers University offered the first CNS graduate program with a specialty in psychiatric and mental health. The role of the nurse practitioner then developed in the 1960s with the increase in federal funding for advanced nursing education in order to fill the need for primary care providers [12]. Since the various roles have emerged, APRNs consistently provide high-quality, cost-effective patient care in a variety of healthcare settings [13]. Today, the majority of APRNs are employed in primary care settings, with most providing women’s health, obstetrics, and mental health services [11]. One hallmark of APRN practice is the provision of care directed at illness prevention, health promotion, and improved patient care outcomes [14]. APRN practice represents one aspect of the nursing profession’s ongoing efforts to provide high-quality healthcare to diverse populations. Overcoming barriers to APRN practice in today’s healthcare environment will lead to improvements in health care for many, especially among traditionally underserved populations.

We define many challenges associated with providing effective APRN clinical education, particularly in clinical practice settings. Our analysis of the challenges in Table 1 led us to identify innovative educational and programmatic strategies with potential to improve APRN education. The strategies we present include both internal (those related to educational institutions) and external (those related to social, political, and interprofessional practice issues) factors.

3. Internal Challenges.

For the purpose of this paper, we defined internal challenges as those existing within the profession and/or within educational organizations responsible for preparing APRNs for practice. When considering these internal challenges, we discovered, not surprisingly, that the literature was dominated by information about the critical role of the growing nursing and nursing faculty shortages. Clearly, not enough qualified nursing faculty are available to meet the nation’s need for increased numbers of APRNs, and the projections describing future shortfalls are bleak [15, 16]. While the nursing faculty shortage has been well described in the literature, some aspects of it are germane in a discussion about APRN education, especially given the relatively large numbers of potential students unable to gain admission because of limited faculty resources [17].

Educational organizations find it increasingly difficult to attract qualified APRNs willing to serve in faculty roles. The demand for APRNs in both educational institutions and in a variety of practice settings has increased simultaneously, but educational institutions are disadvantaged by their inability to offer competitive compensation packages. Constrained budgets result in compressed salaries throughout higher education systems, increasing the gap between salaries available in practice and those offered for teaching positions.

When APRNs do pursue education at the PhD level, they often graduate only to face the reality of the tenure process in research-driven educational institutions. Emphasis on the role of faculty in conducting research and generating research-related revenue limits the availability of PhD-prepared APRN faculty to participate in direct clinical supervision of APRN students. One result is that the primary responsibility for APRN clinical education falls to faculty not eligible for tenure [18] and whose salaries are typically lower than those available for APRNs in clinical practice [19]. Educational institutions without established faculty practice plans face additional barriers for supporting and retaining faculty who need to practice to maintain certification and licensure, in addition to teaching and meeting tenure criteria.

As many schools of nursing transition to the Doctorate of Nursing Practice (DNP), existing advanced practitioner faculty without a doctorate may find that they are underqualified [20]. Institutional requirements for supervisory committees of doctoral students may require faculty to hold equivalent doctorates, and supervision of DNP students may increase faculty workloads. PhD-prepared nursing faculty may lack the advanced practice qualifications to teach specialty content in APRN programs. Smaller educational institutions may not have the institutional structures or additional faculty necessary to support the development of DNP programs [21]. While the development of DNP preparation and practice offers much promise for preparing the future workforce, the transition process may temporarily exacerbate the shortage of available clinical faculty and result in decreased numbers of APRN graduates. It is too soon to tell whether these transitional challenges will affect the quality of APRN clinical education. The net result may be additional reductions in the available supply of APRNs at precisely the time when they are most needed to address the challenges of healthcare reform in the US [21].

The number of annual graduates from APRN programs has fallen from a peak in 1998 [17]. This decline is multifaceted, relating to a variety of barriers facing nurses who might otherwise pursue graduate education. Admission to APRN educational programs can be difficult. As many as 17% of graduate nursing programs are highly selective, and there are insufficient openings for qualified applicants [22]. Program costs present challenges to potential applicants whose educational plans are altered by the recent economic downturn in the US as well as by declines in available employer tuition-reimbursement programs; in 2009, 15% of masters of nursing programs cited affordability as a commonly stated reason for students not enrolling [22]. Program location can be a deterrent to nurses who are place bound by responsibilities to support family and provide income. Although the need for more APRNs in rural communities is critical, APRN programs are less accessible to nurses in rural areas, where there are fewer nurses, and nurses must contend with lower salaries and longer commutes [23]. In some areas, there are vacancies in some nursing programs, while others may turn away qualified applicants. Additionally, there are significant shortages of Hispanic, Native American, and men in nursing and in APRN programs. White, non-Hispanic women make up over 83% of APRN nurses [11]. The result is a professional nursing community that does not reflect the diversity of the US population [24].

Since World War II, educational programs offering Associate Degrees have proliferated and graduates of those programs have become Registered Nurses (ADNs) in increasing numbers. In turn, this internal challenge has influenced the shortage of APRNs, given that nurses prepared in ADN programs are less likely than bachelor’s prepared nurses to obtain graduate degrees [4]. If ADNs do pursue graduate education, time to completion of an APRN program expands, given the requirement for ADNs to complete bachelor’s education before entering a graduate nursing program. Such problems clearly bring the APRN supply needs back to nurse educators and leaders at all levels.

4. External Challenges.

The primary challenge facing APRN education from outside educational institutions is the limited number of available clinical sites and preceptors [22]. To increase the number of APRNs prepared to practice independently and to the fullest extent of their scope of practice, nursing education programs must increase both the number and quality of available preceptors and sites. Since many existing faculty practice settings are inadequate to meet this need, educational institutions must rely on cooperative, volunteer community preceptors. There is a shortage of APRN preceptors, particularly in acute care or hospital-based specialties (i. e., CNMs, neonatal nurse practitioners (NNPs), and acute care nurse practitioners). Often, APRN specialties require that preceptors hold the same specialty certification. For example, certified nurse-midwives (CNMs) must provide education to CNM students [25]. While there is a great need for APRN graduates to serve rural areas, there are even fewer preceptors and role models available in these underserved locations.

The limited supply of potential preceptors and clinical sites is exacerbated by competitive forces. Medical resident preparation dominates the use of available clinical sites in hospitals. Federal funding through the Medicare program supports resident education, but not APRN preparation. In many academic medical centers, APRNs are employed for medical student and resident education, further reducing the field of potential preceptors for APRN students [26]. Nursing educational institutions are concentrated in large urban areas near hospitals and may compete with other nursing educational institutions for clinical sites and preceptors.

State regulations and specialty certification agencies place additional requirements on educational institutions that further limit the capacity to prepare APRN students. Direct supervision of students limits the number of students individual preceptors may have at any given time. The requirement for low student-faculty ratios in clinical courses makes APRN education expensive. For example, the National Task Force on Quality Nurse Practitioner Education recommends faculty-to-student ratios of 1 : 6 in situations where there is indirect clinical supervision [27]. Requirements for supervised student clinical practice in most APRN programs are typically established at a minimum of 500 hours, and the DNP requires at least 1000 hours of clinical practice [19]. This increase in DNP student practice hours will increase the need for qualified and willing preceptors.

The limited availability of national funding poses a significant external challenge to successful APRN education. Increasing the capacity of educational institutions to educate APRNs requires additional funding. The current prioritization for medical education and residency training through federal support makes increasing funding for nursing education difficult. Furthermore, current research funding priorities by the National Institute of Nursing Research do not support the investigation of nursing education issues, nor do they support research about the implementation of innovative practice education models at the graduate level. In many research organizations, nursing faculty pursuing academic careers and tenure are discouraged from pursuing clinical education research as a funded line of inquiry. Among potential APRN preceptors, there may be a lack of willingness to precept APRN students due to a lack of incentives beyond the ideals of serving the profession. Most educational institutions are unable to compensate preceptors financially for their teaching roles and are limited in the nonfinancial benefits they may provide preceptors such as faculty titles and access to educational resources. Potential preceptors may see the challenges to practitioner productivity or the additional time commitments of being a preceptor as disincentives to assuming the role. The lack of formal preparation and support for the teaching role may further discourage APRNs from being a preceptor. While direct or graduate entry training is increasingly used as a mechanism for increasing the supply of APRN graduates, potential preceptors may be resistant to training students with little or no health care experience.

The final challenge to increasing the preparation of APRNs is closely tied to the profession’s relationship with the citizens who are served. Nursing continues to be a profession dominated by Caucasian women, a limitation that affects the profession’s negotiation of relationships with other more male-dominated professions. In addition to the chronic underrepresentation of men, diverse populations, and rural inhabitants in the nursing workforce, advanced practice nursing continues to contend with an identity crisis among the US population as a whole, who suffer from a knowledge deficit regarding the skills and abilities of APRNs. Historically, nurses work at the direction of physicians, and cultural and occupational patterns that reinforce this dependent relationship are slow to change. While it is not clear the American Medical Association’s efforts to counter the IOM’s Future of Nursing Report will be entirely successful [28], the lack of support for full-scope APRN practice from this influential organization is disappointing to those with a vision for the provision of collaborative care in an efficient and effective interprofessional model. Negotiating a new position in health care for nurses and APRNs will continue to be complicated by gender politics as well as power positioning.

5. Strategies and Solutions.

The IOM report presents an unparalleled challenge to nursing educators, that is, to foster the development of an “improved education system that promotes seamless academic progression” [1, page 164]. Significant innovation and change are needed to accomplish this vision and to increase the number of APRN graduates. While some of what is required must be implemented on a nation-wide scale, there is strong potential for nursing education programs to implement local and regional strategies that will increase the numbers of APRN graduates prepared to practice at the fullest extent of their education and licensure.

In preparing this discussion of strategies and solutions described in Table 2, we considered our own experience as educators in graduate nursing programs and explored recommendations from multiple authors describing approaches that have been successful in enhancing the education of APRNs. Taken individually, each of these strategies has the potential to help programs make incremental improvements in the recruitment, retention, and preparation of graduate nursing students. In combination, these strategies offer the promise of helping nursing education affect transformation in the preparation and practice of APRNs.

For the purposes of this paper, internal strategies are those that can be undertaken within nursing education programs and the universities that house them, while external are those that reflect some level of engagement with other organizations including other nursing education programs and healthcare organizations.

5.1. Internal Strategies.

As noted above and in the IOM report, the expansion of advanced nursing education programs is hampered by a faculty shortage that represents the convergence of multiple factors. These include supply-side problems related to the nursing shortage itself as well as to competitive factors that reflect, among other things, the relatively high cost of graduate nursing education when compared to the earning potential of nurse educators. Like prelicensure nursing education, advanced practice nursing education is resource intensive, requiring sophisticated laboratory settings, computer equipment, and high faculty-to-student ratios.

One approach with potential to aid in the nursing faculty shortage and to make more clinical resources available for APRN education involves internal efforts by educational institutions to develop and strengthen collaborative partnerships. The American Association of Colleges of Nursing [16] and the Robert Wood Johnson Foundation [29] recommend that educational organizations work with one another as well as with hospitals and healthcare organizations to develop innovative capacity expanding approaches for preparing nurses and nurse educators and to foster the expansion of nursing education programs. These programs are likely to be costly, but if the benefits can be well-described, educational institutions, hospitals, and healthcare organizations may be willing to invest in their success. As one example of innovative collaboration between university programs, Siewert and her colleagues from the University of Iowa College of Nursing report on collaborative efforts with the University of Missouri at Kansas City that allows for dual enrollment of neonatal nurse practitioner students and helps to optimize faculty resources and enhance student learning opportunities at both institutions [30]. An innovative array of academic and service partnerships linking Bassett Medical Center in Cooperstown, New York, with educational programs at the State University of New York Institute for Technology in Utica, New York now offers tuition support for advanced practice nursing preparation with an emphasis on improving care in a large rural community [31]. These programs and others like them offer much promise in addressing faculty shortages and other challenges while offering innovative contemporary APRN education to place-bound students.

In almost every aspect, curriculum, teaching, and learning must undergo radical transformation, as Benner and her colleagues asserted in 2018 [32]. Nursing programs have traditionally been content driven, but the needs of students and faculty are changing along with those of the workplace [1]. At the core of these new and revised curricula is an emphasis on integrating established educational and professional competencies with educational strategies that encourage problem solving and that enhance students’ critical thinking abilities. Such curricula will encourage the simultaneous development of innovative learning activities, ensure effective student evaluations, and provide clinical experiences that emphasize the optimization of student practice outcomes [33]. Competency-based education may have additional advantages including the development of more learner competence, confidence, and compassion [34, 35].

Problem-based learning can be integrated within a competency-based framework or as a stand-alone strategy to enhance the development of critical thinking and hypothesis-testing skills [36, 37]. Problem-based learning (also known by other terms with slightly different applications, including case-, practice-, or concept-based learning) helps students ground learning in relevant clinical experiences [38, 39]. As students engage closely with faculty in exploring new concepts and identifying new solutions, the process of discovery can lead to the development of improved clinical judgment [40].

The use of simulation in nursing education is becoming increasingly popular for its ability to enhance the critical thinking of advanced practice nursing students and because it provides a useful evaluative tool for faculty [41]. Through the use of high-fidelity computerized simulation models, APRN students safely develop new knowledge and skills about high-risk, low-volume practices [42]. Other simulation activities involving scripted patients or rotation through skill-based practice stations in laboratory settings also offer enhanced opportunity for student learning and faculty participation. Clinical simulation activities can add greater value by linking APRN students with medicine, pharmacy, and rehabilitation students across the health sciences [43].

Interprofessional education offers the potential to enhance efficiency in the provision of clinical education for all students [44] and fosters collaborative practice beyond the educational period. Success has been demonstrated when APRN education has been integrated with specialty and generalist physician practice in a mental health practice setting, as described by Roberts and her colleagues [45] and likely has much potential to improve education and patient care in a variety of other settings. While mistrust by physicians of the APRN role threatens to constrain the development of collaborative educational models, the promise of interprofessional education also has the potential to unite APRN and physician practice. Such efforts to integrate education and training hold much promise for the US healthcare system as a whole.

Distance education helps create opportunities for otherwise place-bound nurses to pursue graduate studies to become APRNs by extending the reach of nursing education programs beyond traditional boundaries. Improvements in online course management software and evidence-based distance teaching pedagogical approaches provide a foundation for the asynchronous delivery of high-quality and engaging course content. The use of streaming media and a wide range of unified communication technologies (e. g., video cameras, instant messaging, web-connected whiteboards, etc.) enhance faculty-student and student-student engagement. Despite the obvious challenges of providing adequate supervision for APRN students who may be completing coursework from remote areas and with little direct faculty contact, the rewards of accessing optimal professional education using distance education technologies can be great for place-bound students living in underserved communities. To help these programs and students to succeed, educational programs can develop innovative faculty hiring agreements, hiring APRNs who live in the students’ home communities to provide supervision for didactic learning experiences as well as for clinical practice and evaluation. The education and support these faculty members may require can be provided in part by professional development or continuing education programming.

5.2. External Strategies.

Not all responsibility for enhancing advanced practice nursing lies with classroom or faculty-driven learning activities. As the number of available clinical sites and preceptors has declined, the need to consider effective alternatives for APRN clinical education has increased. Nursing education programs must “aggressively pursue alternative clinical learning sites and experiences” if they want to assure that students participate in appropriate patient-centered learning activities [46].

The development of partnerships with a broad range of community organizations and providers can create mutual benefits and provide additional learning opportunities for APRN students. While faculty may believe that an ideal clinical placement would pair students with preceptors in one-to-one relationships with clients arriving at set appointment times, there may be great value in developing partnerships with agencies and individuals who provide care in different models and settings [47]. The development of community partnerships with a service-learning framework can provide APRN students with innovative opportunities to engage in health promotion, physical and mental health assessments, and intervention with individuals who might not otherwise receive healthcare services in a given setting. For example, assignment of students to a correctional facility could offer students the opportunity to engage with individuals in need of health assessment or behavioral intervention [48], even in the absence of a formally organized on-site health clinic. Assigning students to work with clients through a variety of community agencies can enhance learning opportunities for APRN students and improve care for individuals seeking nonhealthcare services such as meal delivery or day care [49]. Facilitating student engagement in homeless centers can provide a variety of learning opportunities while serving to increase student understanding of social conditions and mental illness [46]. These innovative learning opportunities can provide students with opportunities to build personally meaningful collateral skills even when the emphasis is on accomplishing practice-related learning objectives [50, 51].

In 2004, Connolly and her colleagues described the innovative creation of a collaborative approach to nursing education [52]. Although writing about associate degree nursing education, key concepts have the potential for application in advanced practice education. These include the introduction of interprofessional collaboration that links nursing, medicine, and allied health personnel education within single community health settings, allowing the development of knowledge and skills that are essential to advanced practice nursing.

Academic health centers that integrate faculty practice opportunities with clinical education experience opportunities may well provide ideal environments for APRN education. Not all graduate nursing programs are situated on campuses that house such centers, however. Heller and Goldwater suggest that the development of innovative patient-driven programs, designed to improve access, may also offer enhanced clinical education opportunities for advanced practice students [53]. Their experience with the development of a mobile clinic offering primary care services by APRNs and their supervising faculty, dubbed the “Wellmobile,” illustrates a comprehensive and innovative approach to clinical care. In addition to providing a structured environment that places emphasis on the clinical education of APRN students, the “Wellmobile” also offered students the opportunity to develop strong business and management skills [53].

Although they can be costly and somewhat difficult to coordinate and offer, domestic and international healthcare missions do offer APRN students and faculty innovative opportunities to provide care to the underserved. While many available international opportunities are useful for student enrichment alone, with secure funding, careful planning, and rigorous attention to the management of learning and evaluation, successful programs can extend clinical education beyond local limits [3]. Participation in mission-driven clinical experiences offers students opportunities to provide care for vulnerable populations and can serve as cultural immersion experiences, enriching students’ cultural competence. They may also provide opportunities for students to develop skills in leadership and practice inquiry, cornerstones of DNP practice.

Finally, funding must be made available to support the vision that advanced practice nurses will assume a large measure of responsibility for the success of healthcare reform in the United States. Improvement in the healthcare system requires the collaborative effort of many disciplines. At present, the current “system of medical education and graduate training… is not aligned with the delivery system reforms essential for increasing the value of health care in the United States.” [54, page 103] The current system of funding graduate medical education does not provide sufficient resources to support the education of nurses in clinical practice settings. While it is typical for medical residents to be supported with salaries, stipends, living allowances, and even resources such as equipment and textbooks, responsibility for APRN clinical education rests solely with the students themselves. Educating an effective nursing workforce is a responsibility that must be shared by nursing programs, academic institutions, and government agencies with support from policy makers who will stand firm in sponsoring a coherent and appropriate approach to the education of a collaborative workforce [55]. It will not be sufficient to simply provide increases in available loans or to improve loan repayment programs; for APRN clinical education to be on par with medical education, nursing classroom and clinical education must receive full financial support. Further, there must be improvements in Medicare compensation for services provided by APRNs, including those related to performance as clinical preceptors and research mentors. Funding for improved and financially supported residency programs for APRNs could come from federal programs that accept a mandate to provide healthcare services to all citizens or that compensate physicians at greater rates than APRNs for the provision of equal services [56].

6. Conclusions.

The Institute of Medicine Report on The Future of Nursing [1] calls for increasing the supply of highly educated and clinically skilled APRNs who can practice to the fullest possible extent of their scope of practice. Clearly, APRNs have the potential to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform in the United States. If this vision is to be accomplished, however, numerous challenges inherent in the current APRN educational process and barriers in the practice environment must be overcome. This paper has identified challenges that specifically hinder the clinical education of APRNs and proposed strategies and solutions to help educational institutions address them. In preparing this paper, we considered our personal experience and explored the literature describing innovative approaches and strategies that have been successful for others. These approaches to APRN clinical education can affect a radical transformation in the preparation of APRNs and help ensure the healthcare needs of US citizens are met by a diverse and collaborative workforce of professionals united in a vision to optimize the practice potential of all practitioners. It is imperative that nurse educators work with all stakeholders to improve the education of APRNs through the identification and implementation of best practice clinical education strategies designed to overcome the current barriers to the provision of high-quality clinical experiences.

Acknowledgment.

The authors would like to thank Dr. Ruth Bindler for her support.