Constraints for nursing in developing a framework for cancer care research SHEILA PAYNE, RGN Dip N., BA, PhD, Lecturer in Psychology and Health, Department of Psychology et, Southampton University College of Nursing and Midwifery, Southampton, UK

PAYNE, S . (1993) European Iournal of Cancer Care, 1993, 2, 117-120 Constraints for nursing in developing a framework for cancer care research

Oncology nursing has become an important and popular specialist area of care. Evidence indicates that there is a disappointingly low level of funded research. This paper seeks to identlfy some of the key constraints which have inhibited the development of cancer nursing research. It is proposed that there are two priorities to promoting research. First, there is a need to produce the next generation of research trained cancer nurses. Secondly, the need for a coorlnated programme of basic and applied cancer nursing research. This paper discusses the difficulties of obtaining research funding and adequate supervision for higher degrees. In adl t ion, key constraints in clinical nursing and nurse education are identified. In conclusion, it is proposed that there is an urgent need for specific cancer-care research funded studentships and the establishment of a coordinated programme of research.

Keywords: cancer care, research, research training.

INTRODUCTION

Nursing research in Britain has grown from humble beginnings over the last 20 years. Whle this may be regarded as a mere start by some sciences such as chemistry, which have a research trahtion spanning centuries, we can be confident that a start has been made (e.g. Wilkinson, 1991). However, nursing research has yet to make a significant impact in some areas of patient/ client care. One of these areas is in cancer nursing. A survey undertaken by Comer (1992) identhed just 10 funded research projects in cancer care, the majority being only partially funded. Moreover, eight of the 10 projects were being undertaken to fulfil the requirements of a higher degree. This implies that the researchers were relatively inexperienced.

In this paper, I plan to identlfy some of the constraints which have limited the development of cancer-care research, especially in relation to the profession of nursing. However, the issues raised will in many ways

European Iournal of Cancer Care, 1993, 2, 117-120

be relevant to other health professions such as radio- graphy, physiotherapy and occupational therapy. In Britain, these professions have developed or are develop- ing initial professional qualifications which are at first degree level. It may be anticipated that some of the graduates of these new courses will seek to establish professional research careers.

This paper will address the requirements for a research training which will equip professionals to build a body of research-based knowledge for practice. Secondly, I will identlfy impediments to research growth in the following areas: clinical nursing, nurse education and higher education. Finally, I will present some suggestions for promoting cancer-care research. I aim to raise issues for debate which will be of interest to all those who wish to see better quality and quantity of research in cancer care.

RESEARCH TRAINING

To develop any skilled activity one must have access both to tuition and practice. Basic level nursing programmes at

PAYNE Nursing constraints in cancer care research

both diploma and degree level make provision for leaming about research slulls, methodologies and statistics. The amount of practice of these skills offered to students varies both between types of course and between institutions. For example, Bachelor of Nursing programmes often require students to undertake a small empirical study in the final year of their course. However, research knowl- edge and skdls are unlikely to develop beyonc) a basic level whch may perhaps be characterized as learning to ‘play‘ with research. T h ~ s is not to denigrate the input offered to nursing students as I regard ’play’ as a very important developmental stage. Thus, newly qualified nurses now have the benefit of research appreciation, and they are aware of the terminology and methods used. They can critically evaluate research findmgs and begin to apply them in clinical practice. Likewise, taught Masters programmes usually require the submission of a disserta- tion which may be based on empirical work. All these activities lead to research awareness and, hopefully, to the implementation of research findings in clinical practice. However, I would argue that they do not provide an adequate research training for competent, independent nursing research. The uncritical acceptance of research performed at this level by people who are not fully trained does nursing research no service. This is especially the case when we wish nursing research to gain wider acceptance and fun- in competition with our aca- demic peers in medicine, and the applied and basic sciences. In my opinion, ‘real’ research starts at the hgher degree

level. Its aim is to contribute to the body of knowledge in cancer care. As such, it trivializes research to regard it as a short-term activity whch takes perhaps a few weeks or at best a few months. The academic training in research whch is provided by hgher degrees is the foundation upon whch the development of cancer care research depends. Individuals who undertake such training are equipped to pursue post-doctoral research and ultimately develop research programmes which systematically investigate a topic or issue. Of course, indwiduals may find it difficult to prosper alone and we should look to establishing centres of excellence where there is a ’critical mass’ of researchers. In Britain, there are already notable examples of good quality and academically rigorous nursing research units.

It is clear that within cancer care research, we currently lack a distinct research training pathway. There are four main issues in research training: fundmg, supervision, theory and methods. I propose to confine this paper to dealing with the first two issues: theory and methods are major topics which space does not permit adequate discussion of here.

FUNDING

Doing research is hard work, time-consuming and expensive. Very few people can afford to be self-support- ing throughout a higher degree, even if it is undertaken part time. Higher degrees may be either a Master of Philosophy (MPhil) which generally requires 2 years full- time work or a Doctor of Philosophy (PhD) level which takes between 3 and 4 years of full-time work. Both degrees may be undertaken part-time which consequently increases the time involved in their completion. Thus, most people will require some level of financial support for tuition fees and living expenses.

There are, broadly, two alternatives to obtaining funding: a hgher degree may be undertaken in conjunc- tion with paid employment or on a studentship. Let me deal with the former first. This scenario involves negotiations with one’s employer to obtain time and/or money to do research concurrently with a job. Certain jobs lend themselves to this, such as research nurse posts which involve data collection for an established research- er. The advantage of this arrangement is that one maintains a salary, but one needs to beware of the contract. It is wise to consider carefully some of the following issues:

0 amount of teaching and/or clinical work involved; 0 time available to collect your own data; 0 what research training is provided? 0 will you have any input into the research design? 0 ownershp of the data; 0 acknowledgement in publications.

How far individuals gain or are exploited by these arrangements is debatable. Evidence from a survey conducted by Comer (1992) identified more than 45 nurses in cancer-related research which was medically led. This is an important group of nurses who may wish to develop adhtional skills to undertake future independent research.

An alternative source of fundmg is to obtain a student- ship or research funding. Most studentships are pitifully inadequate in financial terms and the competition for acquiring them is high. The important exceptions are the Department of Health Nursing Studentships which are awarded each year. These are generous relative to other studentshps, as they are in the region of a €12000 salary for 3 years. This, of course, may not seem to be much to an experienced nurse. However, studentshps awarded by the Research Councils (such as the Economic and Social Research Council, the Medical Research Council), although very prestigious and htghly competitive, are currently worth much less in financial terms. A further

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source of potential fundings are charities. It may be worthwhile contacting specific charities to determine their funding policies; some restrict application to those with medical degrees, but others are more open-minded such as the British Heart Foundation and the Wellcome Foundation.

SUPERVISION

The second, but perhaps most important, element in obtaining a higher degree is supervision. Everyone who registers with an institution of higher education for a higher degree will be allocated a member of staff who will oversee their research. He or she will offer advice, criticism and support. This is a vitally important relation- ship. However, in cancer-care research are there enough experienced researchers available to act as supervisors? It seems at this stage there may not be, except in a few centres. My suggestion to resolve this ddemma would be to offer joint supervision, where one supervisor may have clinical/practical experience and the other supervisor the necessary academic, theoretical and methodological knowledge to guide the student to a successful conclusion.

Not only are the personal and academic qualities of the supervisor essential, but people doing hgher degrees should have research methods training. One good aspect of the Department of Health studentshps is the level of monitoring, support and training which are inherent components of the scheme. Likewise, the Research Councils require evidence of taught research methods courses in institutions where these studentships are held.

C O N S T R A I N T S F O R R E S E A R C H D E V E L O P M E N T I N C L I N I C A L C A N C E R NURSING

Having struggled through a higher degree, why do many nurses not continue to do research? Cancer-care nursing is an active, progressive specialism. There are excellent courses at Masters level. There is innovation and expertise in clinical practice (David, 1992; Reynard et al., 1991). Nurses and other health professionals seem eager to learn and share developments as exemplified by the recent publication of two new journals in this field. Yet evidence cited by Comer (1992) indicates that the level of funded independent nursing research is disappointingly low. What constrains the expansion of cancer-care research? I wish to propose that explanations may lie at both the personal and structural level.

In personal terms, there are possibly a number of reasons that nurses do not engage in more research. Crudely, there is no money or status to be gained for the majority of

nurses. Indeed, the powerful anti-intellectual ethos (Mackay, 1989) that is apparent in some parts of nursing may militate against the development of research. In adltion, research expertise is not a fundamental require- ment for career progression in nursing, as it is in melcine for example. On the contrary, in some institutions, a period spent as a research nurse may be seen as a barrier to promotion rather than the reverse.

There are also powerful structural and organizational reasons why cancer care research has not proliferated. As I have already indlcated; research is expensive and often fairly slow, if it is well done. Yet in clinical practice, results are often wanted immediately or sooner! There has been a recent increase in senior nursing posts whch carry a label of research, but many appear to be primarily involved in quality assurance and clinical audit.

Perhaps the real challenge for clinical nursing is to implement current findings and to test them empirically. In this way we generate new research questions. Ideally, there should be a lalogue and exchange between clinical nursing and research units both in ideas and personnel. The changing pattern of funding in the National Health Service now identifies funding specifically for research and development at Regional level. Will this be directed towards cancer care research? Perhaps, if we can demon- strate the value of such research in clinical practice and compete for it actively.

CONSTRAINTS FOR RESEARCH I N NURSE EDUCATION

Many nurse teachers have or are studying for first and/or higher degrees. They are often undertaking these studies in less than ideal circumstances. I wish to propose a rather different strategy than that now commonly applied. First, that certain selected nurse teachers do higher degrees in optimal conditions by being fully funded, working at their s tu les full-time and being well supervised. Secondly, that senior appointments should be made on criteria that include research expertise and publication record, and to maintain these skills, that some nurse teacher’s contracts include the expectation of research activity as an essential part of their job. Research is not a luxury for a few high flyers in academic nursing units, but a part of basic nurse education.

The integration of colleges of nursing and midwifery with institutions of higher education has to some extent lessened the demarcation between nurse teachers based in these colleges and academic nursing studies departments based in universities and the former polytechnics. Certainly, some nursing studies departments have pio- neered high quality nursing research. These departments

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have the difficult task of maintaining credibdity in two areas; in professional nursing and in academic research. Moreover, they have to compete for funds in their institutions on the basis of their research rating as graded by the 1992 Research Selectivity Exercise. This was a national exercise which graded each department on a five- point rating scale. The actual gradmg achieved is not only important for departments in terms of academic standing, but it has financial implications. This internal competi- tion for limited resources may have an undesirable impact on future research in cancer care, as some nursing departments may elect to become or may be forced to become merely teaching departments.

THE WAY FORWARD

It is not my intention to paint too gloomy a picture. Cancer care research has potential which needs fostering. Of course, it will depend upon individual initiative and effort, but organizational changes are also needed. L would like to see the establishment of a research studentship hnded specifically for cancer nursing research. This should be a full-time, well-supervised appointment, funded for 3 years. If such a studentship were available, there would be a slow but steady growth in number of research-trained cancer-care specialists. These people would become the research supervisors of the next generation. Such an investment, as already demonstrated by the Department of Health Nursing Studentships, wdl be immensely influential in shaping academic nursing in Britain.

It is recommended also that a nationally coordinated major research programme in an aspect of cancer care is

established. This would involve the collaboration of key researchers in multi-centre studies. The time is also right for multi-national studies, perhaps in European Common Market member countries. The potential benefits of such a programme would be not only in the growth of research- based knowledge, but in the generation of further hypotheses and the potential to systematically explore a range of specific issues. Of course, I have my own agenda in the area of breast cancer care (Payne, 1990, 1992), but a

consensus view should prevail. Obtaining core funding for a substantial programme of cancer care research is a key priority.

In the meantime, we as individuals need to be proactive in working towards a greater volume of cancer care research while maintaining the necessary scientific rigour.

References

Comer J. (1992) Developing a framework of cancer care research for nursing. Paper presented at the Second Cancer Research Campaign Meeting 'Promoting Nursing Research in Cancer Care', London.

David J. (1992) A survey of the use of syringe drivers in Mane Curie Centres. European Iournal of Cancer Care 1(4), 23-29.

Mackay L. (1989) Nursing a Problem. Open University Press: Milton Keynes.

Payne S. (1990) Coping with palliative chemotherapy. /oumal of Advanced Nursing 15,652-658.

Payne S. (1992) A study of quality of life in cancer patients receiving palliative chemotherapy. Social Science and Medi- cine 35, 1505-1509.

Reynard C., Badger C. & Mortimer P. (1991) Lymphoedema Advice on Treatment, 2nd edn. Beaconsfield Publishers, Beaconsfield.

Wilkinson S.M. (1991) Factors which influence how nurses communicate with cancer patients. lournal of Advanced Nursing 16, 677-688.

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