Dr. Cleary is Clinical Nurse Consultant, Research Unit, Sydney South West Area Mental Health Service, New South Wales, Australia. Dr. Walter is Professor of Child and Adolescent Psychiatry, University of Sydney, and Area Clinical Director, Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health, New South Wales, Australia. Dr. Horsfall and Ms. Matheson are from the Research Unit, Sydney South West Area Mental Health Service, New South Wales, Australia.
Supported by an educational grant from Janssen-Cilag.
Address correspondence to Michelle L. Cleary, RN, BHlthSc(Nurs), MHlthSc(Nurs), PhD, Level 1 Executive Unit and Administration Support, Concord Centre for Mental Health, Concord Hospital, Hospital Road, Concord, New South Wales, 2139, Australia.
Much of the international literature on health research careers assumes an uncomplicated path from interested student to committed research fellow and from junior investigator to independent researcher via a process of further education and linkages with other researchers and clinicians. This presumed “pipeline” trajectory is not always straight or practicable. Even with associated infrastructure, financial support, and mentoring, it often becomes a funnel, with fewer making the necessary transitions from one stage to the next (Bruce, 2003; Kupfer, Hyman, Schatzberg, Pincus, & Reynolds, 2002). This may occasionally be due to individual choice, but it is often related to the limited number of permanent research positions, particularly in specialized areas.
In the U.S. milieu, researchers argue that the notion of an independent researcher is increasingly anomalous (Whyte, 2005). One author’s successful independent investigator (Bruce, 2003) is another’s dinosaur who will invariably flounder, wasting countless hours in a mass of unassimilated but important information and essential skill sets (Nathan, 2002). Keeping such viewpoints in mind, this article aims to set out some international parameters that establish the backdrop against which most career nursing researchers will eventually be working. Individual early- to mid-career researchers in countries where the research culture is not entrenched and the infrastructure is attenuated may wonder if the questions they ask themselves and their mentors are the right questions, or even whether they are answerable by only considering the local context. Such questions include “Should I specialize or pursue a broad health research pathway and employment?” This article provides an overview of some background factors that impinge on this and similar questions.
Careers and career preference do not exist in isolation, but are heavily influenced by prevailing paradigms. When examining research careers in the past 15 years, the international imperative for evidence-based practice has propelled the randomized controlled trial to the top of a hierarchy of research-based data required for health practice decision making. Systematic reviews of several randomized controlled trials are considered ideal for judging the benefits of a specific intervention (Barton, 2000). Therefore, systematic reviews and randomized controlled trials are at the summit of the evidence hierarchy, with controlled observational studies in the middle and case series and pre- and post-test uncontrolled studies at the bottom (Barton; Grimes & Schulz, 2002; Leach, 2006). Studies have shown that observational (non-randomized) research found greater positive effects for a tested treatment than randomized controlled trials (Barton) and that positive outcomes are overrepresented in case reports (Walter, Rey, & Dekker, 2001). Ultimately, the evidence hierarchy is “merely a conventional rule of thumb” and “small inadequate [randomized controlled trials] do not automatically trump any conflicting observational study” (Barton, p. 256). Nevertheless, the randomized controlled trial has not lost its gold standard position.
Establishing a gold standard and perfecting the planning, implementing, and reporting of randomized controlled trials is not an end in itself in health research. The raison d’etre for high-quality research standards is to produce evidence for decision making in practice. Presumably, decisions have been made in health care with the expectation of best outcomes. The drive during the past decade has been to move decision making away from interventions emanating from “tradition, intuition, authority, unsystematic clinical experience and pathophysiological rationale, to a situation where decisions are guided and justified by the best available evidence” (Leach, 2006, p. 248). Therefore, evidence-based practice is now the health care practice gold standard.
In reality, clinical decision-making processes commonly precede the need for evidence, in that the problem has to be clarified and delineated before appropriate questions that require evidence can be asked (Thompson, Cullum, McCaughan, Sheldon, & Raynor, 2004). It has been incumbent on the practitioner to search for, collect, and evaluate the evidence for validity, relevance, or the generalizability of the results (Culpepper & Gilbert, 1999; Leach, 2006; Sackett & Rosenberg, 1995). Then, the data must be synthesized and rendered specific to be applied in a clinical situation with a specific patient (i.e., for evidence-based practice to occur). Furthermore, those who design and perform clinical trials may not be cognizant of the context and complexity of situations in which clinicians have to make crucial decisions. In the face of medical objections, the practitioner’s clinical knowledge and available resources and the patient’s values and preferences quickly became integral aspects of the evidence-based practice decision-making matrix as well as quality research evidence (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996; Thompson et al.).
Proponents offer a range of reasons for the superiority of evidence-based practice, including more transparent decision-making processes, connotations of greater clinician accountability, and the possibility of superseding inadequate information from peers and procedure manuals (Leach, 2006; Tunis, Stryer, & Clancy, 2003). Evidence-based practice is expected to reduce medical errors, improve patient treatment, and, concomitantly, cut costs. If evidence-based practice was practiced by all health care practitioners in all settings, treatment inconsistencies and differential outcomes across institutions and states would be decreased, presumably with greater efficacy and efficiency (Sackett & Rosenberg, 1995; Tunis et al., 2003). Routinized evidence-based practice could also facilitate a timelier uptake of proven clinical innovations (Leach).
Seeking evidence at the upper end of the research hierarchy requires significant levels of financial support. The National Institutes of Health (NIH) is the major medical research funding body in the United States, and its modus operandi may set the standard pattern for health research in many Western nations. Tunis et al. (2003) proclaim “the widespread gaps in evidence-based knowledge suggest that systematic flaws exist in the production of scientific evidence” for provision of health care (p. 1624). In the United States, this is against a backdrop of significant increases in public and private funding for medical research in the past three decades. Nathan (2002), a member of the NIH Director’s Panel on Clinical Research, considers that the future of clinical research is interdisciplinary collaboration wherein no team member knows all of the research implementation, results, and analysis details.
Insufficient patient-oriented translational research in the United States is sheeted home to NIH funding priorities whereby basic research predominates and clinical research attracts only 10% of the budget (Nathan, 2002; Schechter, 1998). Some clinicians consider that practical clinical trials are necessary to study clinically relevant interventions, compare different treatment groups within a diverse population, recruit across a variety of practice settings, and measure broad health outcomes (Tunis et al., 2003). As the elderly are frequently the recipients of multiple medications, trials that exclude them or individuals with multiple diagnoses may have research results that are not helpful for clinicians treating more complex patients. Practical clinical trials aim to take these and other realistic circumstances into account.
Patients treated in primary care settings may have a different health status overall from those being treated for the same conditions in a hospital setting. If randomized controlled trials only test patients from either setting, the results may not be applicable across the board. When randomized controlled trials focus on measuring a decrease in a few specified symptoms, results may not be congruent with the practical concerns of patients. Therefore, outcomes that include validated quality of life measurements or ease of mobility can be more pertinent.
Similarly, randomized controlled trials are more likely to target treatment of symptoms that are responsive to interventions, whereas many patients are on a care-rather-than-cure trajectory (Culpepper & Gilbert, 1999). Neither the patient nor the practitioner is at the center of the focus of most randomized controlled trials and this is the fundamental reason for gaps in clinical evidence.
Patient-oriented translational research should follow research subjects for longer periods, as non-intervention can lead to equivalent survival rates for patients with certain diagnoses. Realistic cost comparisons are also pertinent to clinical decision making when providing care to individuals with long-term conditions.
These claims and arguments about research, evidence, and clinical decision making provide a background environment that all health researchers inhabit. Governments, as significant research fund providers, are increasingly demanding that these public monies be used effectively. If researchers are not always sensitive to practitioner concerns about the relevance of evidence and gaps in evidence, they may have to be more responsive to government-determined research priorities and project assessment criteria vis-à-vis funding.
Nurse Collaboration and Teamwork
It is inevitable that the shift to evidence-based practice and focus on outcomes will result in changes in professional development and roles and promote strong networks and partnerships. As previously mentioned, Nathan (2002) considers that the future of clinical research is interdisciplinary collaboration. Therefore, it is important that team members communicate effectively to ensure smooth and efficient project management. Members must continue to appraise themselves of developments in clinical practice and research protocols (Engelke & Marshburn, 2006), such as changing research processes to incorporate patient and stakeholder requirements.
It is important that continuing education opportunities be provided to all team members so that research competence can be gained in a range of areas and the team “grows.” Effective collaboration and teamwork adds to any project as research ideas are developed and tweaked through the input of all members.
Conducting research offers opportunities to learn detailed aspects of research phases from team leaders and colleagues. For example, applying for grants with other staff can provide learning opportunities regarding succinct and clear writing, budgeting, breaking a large project into a logical sequence, and efficiently planning time. This builds practical research skills and confidence. Participation in successfully funded projects provides learning experiences regarding the processes that are necessary to steer such projects from inception to successful conclusion.
Being part of a high-quality research team is an important career-enhancing factor, for both early and seasoned nurse researchers. Collaborative exchange allows communication of the most recent research findings between academic and clinical settings. Such interactions also increase awareness of professional development and continuing education opportunities. Over time, building a team and forging international partnerships will prove valuable for both research and learning (Bosworth et al., 2006; Callister et al., 2006; McGrath, Mowry, & Whiteford, 2004).
Career Path: Some Aspects of Professional Development
The value of research within health care organizations has grown as the focus on assessing quality and outcomes for patients has become more highly valued. Continuing professional development has an important role, first, in educating researchers about the quality and outcomes focus of a modern health care organization and, second, in suggesting to clinicians and others affiliated with health care organizations that various research methodologies may assist them in completing their tasks and satisfying various “performance indicators.” Evidence and clinical decision making provide a background environment that all health researchers inhabit.
The high status of randomized controlled trials may appear irrelevant to a group performing action research in a local setting or mid-career researchers applying for a grant to maintain the observational studies relevant to their health service. However, as a range of trends from the United States often impact other countries, research standards and implicit priorities are also likely to do so. Nursing staff development educators also have an important role. Continuing professional development short courses and other formats enable nurse researchers to become familiar with policy shifts, clinical developments, and emerging best practice approaches.
Further professional development may seem challenging, especially to those who are “time-poor,” poor time managers, or constrained by graduate incomes (Insel, Volkow, & Li, 2006) and student loans (Kowalski et al., 2007; Straus, Straus, & Tzanetos, 2006). However, long-term rewards gained from further education can far outweigh any short-term difficulties. A career in health research can be immensely rewarding, particularly with the satisfaction gained from making a contribution to a knowledge base benefiting patients and clinicians (Joyce, 2002).
The formal preparation for a research career consists of graduate education, and, increasingly, a doctorate is necessary for career progression. Rarely would a nursing researcher have a specific program of research without a doctorate in nursing. This doctorate is the terminal degree for nursing research for employment in academic health centers. Early career researchers should also acquaint themselves with post-doctoral opportunities to further facilitate the transition to independent researcher, if this formal pathway is desirable and available. These post-doctoral posts are highly regarded and competitive, while providing positive learning experiences within supportive environments.
Finding a good mentor to provide guidance and support can be an important step in professional development and career transitions (Steiner, Curtis, Lanphear, Vu, & Main, 2004). For example, early career researchers who are unsure how to further their careers and maximize employment and earning potential in an area of interest may benefit from discussing the following aspects of professional development with a mentor:
Are there obvious gaps in research not covered by colleagues, and is it feasible to address one such gap? If so, where is the most logical place to start?
While undertaking a more comprehensive review of the literature about a selected topic, are there also opportunities to become acquainted with the subject (e.g., can a mentor direct one to colleagues or collaborators, relevant short courses, workshops, formal subjects at a university, or online resources)?
If one’s present research has a narrow focus, how might one choose and pursue courses in other areas? Is there a short list of such topics that could be discussed with the mentor?
If one’s present work involves a broad topic and a large team, an in-depth course can diversify skills and increase knowledge (e.g., sampling, statistics, or modeling effect contributions). What are reputedly the best and most appropriate courses?
It is imperative that mentor and mentee be able to communicate openly and clearly, and that both allocate enough time to touch base regularly, face to face and via telephone and e-mail. Having a good mentor should ensure less frustration, which is invariably encountered at some stage during research projects.
Good mentors provide appropriate guidance regarding research ideas and direction, methods, ethics approval, grant applications, and editing written material. They also offer another way to develop expertise and skills to further professional career pathways (Bauer-Wu, Epshtein, & Ponte, 2006). Mentors may have up-to-date knowledge of useful courses and practical workshops.
Forums can also be a useful venue for researchers to present “works in progress,” receive scholarly feedback, and consider suggestions from others. They also generate fertile interactions, knowledge development, awareness of resources, and the chance to forge cross-disciplinary or cross-organizational links (Callister et al., 2006; Smith & Delmore, 2007). A good mentor will also offer advice about continuing education and professional development opportunities (e.g., conferences to attend or courses or workshops in which to enroll) that inevitably emerge. Some forums and seminars are held in high regard in the academic community and are “musts” to attend, whereas others may have a lesser reputation. All, however, offer networking and further professional development opportunities. So for an individual nurse researcher, is it better to have broad research experience in a generic position, team, or organization, or to continue employment in a facility that focuses on a specific topic or methodology?
The Individual Researcher: Specialization Versus a Broader Focus
Like any successful career, a career in health research requires that many decisions be made along the way. One important decision that researchers face is whether to seek broad research experience in a generic position or organization, or experience in a specialized research facility. The Table offers a summary of the advantages and disadvantages of the two platforms.
Table: Advantages and Disadvantages of Specialist and Broad Research Platforms
Broad Research Pathway and Employment
Engaging in a broad range of research projects can provide an ongoing source of stimulation that can also enhance job opportunities if the researcher is able to seize opportunities and learn from doing, listening, and observing. Working on diverse projects with a range of subjects and topics facilitates knowledge development, including a familiarity with different theoretical perspectives and methods. Further, investigations in one particular field may have unanticipated benefits for another (McGrath et al., 2004). Over time, knowledge of helpful material and personnel resources is acquired and a network of researchers, clinicians, and academics with complementary skills can be established.
Adopting a broad research approach while developing a career pathway (Whyte, 2005) can result in research multiskilling (e.g., becoming familiar with various research methodologies) and raise awareness of clinical challenges. Working on a range of projects with a variety of individuals (e.g., children, the elderly, or those with psychosis) also enhances skill and knowledge development. This type of research enhances opportunities if researchers are skilled in lateral and creative thinking, and in presenting their research experience as an indicator of being adaptable and “well rounded.” Conducting varied research projects can offer ongoing stimulation and allow researchers to showcase their resourcefulness, interpersonal skills, and adaptability. With a diversified research agenda, grant applications can be submitted to a variety of funding sources.
Researching a range of topics via various methods also has a downside. The variety and ensuing challenges for broad-based researchers may be interpreted by prospective employers as suggesting they have inadequately developed expertise. Applications to a cross-section of funding bodies may be viewed as an inability to focus and pursue a defined agenda. Moreover, a specialized research domain is virtually essential for leadership in the field.
Specialized Research Pathway and Employment
Specialized researchers have increased awareness and understanding of their topic and usually concentrate skills in one productive area for which they seek specific answers (McGrath et al., 2004). Researchers focusing on a narrow or specialist area are often considered to be expert in their field, nationally or internationally, and this can increase their chances of successfully competing for funding. Such researchers are commonly aware of, and critique, others’ contributions and are informed and up-to-date regarding initiatives and research in their selected field.
Their knowledge often extends beyond the published literature to pre-publication data through an awareness of presentations at recent conferences, “in press” articles, and research “in progress,” for example. Their area may be a subdiscipline specialty with a particularly narrow context of study, such as a particular service delivery model (e.g., compulsory treatment of individuals with eating disorders) or issues regarding etiology (e.g., genetic markers of a specific disorder, such as schizophrenia). These researchers—through their own research and the close networks they form—are known to have their finger “on the pulse” and can be called on to give an expert opinion about a news story (e.g., death of a celebrity with an eating disorder) or a scientific breakthrough (e.g., genetic discovery) relevant to their specialization. Further, they are likely to be invited to be a member or chair of a specialist committee or expert panel on their topic. Through various links, further research opportunities may arise, resulting in growing national and international collaborations.
Specialized researchers can be employed in named or branded centers or institutes, with projects in the “top drawer,” ready for submission should unexpected funding become available. An established research platform can allow for continuation of the specialized area of interest and can be professionally satisfying. Novice researchers can seek advice and establish links with the specialized research team. Collaboration in one project can result in invitations to participate in others.
Again, there may be pitfalls associated with specialization. One may feel as if one is “married to a topic for life,” reducing the time available for investigation of other areas that may be of interest. Focusing on a narrow topic may eventually impede the ability to consider that topic from new perspectives. Associating with like-minded researchers who share one’s passion may unwittingly encourage this. Therefore, for those who choose a narrow specialization, it is important to remain open to other ideas and approaches to furthering the knowledge base in that area.
Unless researchers’ expertise exactly matches what employers are seeking, being very specialized could result in curtailed job opportunities and force specialists to seek employment abroad (which may or may not be desired). Furthermore, some research domains may be more prone than others to outside influences, such as policy or management changes, and funding may diminish precipitously. From a professional point of view, starting all over again with new networks and collaborations—even in this age of the “global village”—is time-consuming and energy intensive. Whether one chooses a narrow or a broad research career, participation in ongoing education and professional development remains important. Even the specialist researcher with an international reputation will benefit from such opportunities, particularly as new discoveries are made and new techniques (e.g., brain imaging or gene analysis) are devised.
With the continuing need for a sound knowledge base and the valorizing of evidence-based practice, research projects aligned to national priorities should continue to flourish and provide individuals with a range of exciting career choices. A successful, balanced career should evolve if constraining outside influences and one’s own strengths and passions are harnessed along with patience, creativity, and commitment (Callister et al., 2006; Levinson & Linzer, 2002). Availing oneself of opportunities for further professional development—regardless of one’s career stage and areas of interest—will inevitably lead to up-to-date knowledge and skills along with a fulfilling and productive career. For the novice researcher, it is prudent to seek advice from supervisors and mentors about the merits of particular educational opportunities.
Overall, the general trend from the health research literature is that there is a need for early nurse researchers to pursue postgraduate degrees and post-doctoral training with supported transitions toward specialization within a nursing or multidisciplinary team. A rewarding research career may be achieved by combining the “best of both worlds” (i.e., a combination of broad and specialized research approaches). The broad pathway enables researchers to remain familiar with the overall field, be flexible, and not lose touch, whereas having very specific expertise allows researchers to significantly impact their given domain.
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Advantages and Disadvantages of Specialist and Broad Research Platforms
|Potential Advantages||Potential Disadvantages|
|Broad research||Establish a track recordRewarding; contributes to knowledge developmentEncourages collaboration with a range of individuals and teamsGrant applications readily submitted to a variety of sourcesAssociated with familiarity with different perspectivesEncourages wide network of helpful resources and personnelEnables research multiskillingAssociated with varied research projects, ongoing stimulation||Associated with limited developed expertise in any one areaResearchers may be viewed as unable to focus and pursue a defined agendaLess likely to be associated with expert status|
|Specialized research||Establishes a track recordRewarding; contributes to knowledge developmentAssociated with named, branded research centersFocuses on few topicsKnowledge extends beyond published literatureAssociated with expert statusLeads to invitations to provide opinion pieces (e.g., media) Generates invitations to chair key committees or panels||More vulnerable to policy and funding changesGrant applications submitted to limited and fewer sourcesAssociated with limited job opportunities if expertise does not match skill set employer is seeking|