Why Is Starting and Sustaining a Clinical Academic Role in Nursing Still So Difficult?

For decades there has been a push towards maintaining and sustaining a critical mass of clinical academics in nursing. Achieving a critical mass, however, remains elusive, with clinical academics reporting ongoing and huge challenges in starting and sustaining their careers. The term clinical academic refers to clinicians that work in both higher education and tertiary institutions while still providing clinical expertise to health care providers and services. Clinical academic roles can be positioned in various ways, including within an organisation, as a joint appointment, or through consultation, each working in different ways to advance clinical research while remaining clinically active (Vessey et al. 2017). Nurses are well placed to conduct research that is grounded in clinical practice issues and address questions that are relevant to service delivery (Paterson and Strickland 2023). However, the challenge for disciplines such as nursing in the development in these roles continues to be the identity transition from a clinician to clinician/academic (Haase et al. 2021) and the ability to combine both positions is hugely challenging. Compared with the rapid advancement of academic nursing since the 1980s, nursing research in the clinical setting has lagged considerably (Kim 2009) and continues to do so, with only approximately 35% of PhD-prepared nurses globally working in a clinical setting (Orton et al. 2022). Yet there is a growing body of literature emphasising the importance of nurses with research training remaining in the clinical setting due to the complexity of patients and the evidence-based nursing care required for them (Andreassen and Christensen 2018; Haase et al. 2021; Orton et al. 2022). The nursing profession has long focused on the importance of striving for evidence-based practice embedded in the best currently available scientific knowledge (Orton et al. 2022). Importantly, research is the foundation of scientific knowledge, and the development of clinical knowledge and expertise is built through a combination of theoretical knowledge and clinical experience (Orton et al. 2022). Therefore, research-prepared nurses with PhD qualifications staying close to clinical service delivery is essential to bridge theory and practice, encourage practice-based research, contribute to the evidence-based design of patient care and apply clinical expertise to university-based curriculum and research (Orton et al. 2022), see Figure 1. Nurses in clinical academic roles contribute to clinical engagement by serving as practice influencers, clinical leaders and educators, while also fostering stronger research cultures (Dobrowolska et al. 2021; Pattison et al. 2022; Trusson et al. 2019). They also influence outcomes at the patient, research, staff and organisational levels (Dobrowolska et al. 2021; Paterson and Strickland 2023; Pattison et al. 2022; Trusson et al. 2019). Furthermore, clinical academic appointments can offer the opportunity for research mentorship and shared resources between academic and clinical partner sites (Ferguson et al. 2021). On one hand, nurses in these roles are seen as an asset to organisations and improve the image of organisations, yet there is still often a failure to understand the benefit they add to clinical practice, including direct patient care, because many in nurse leadership positions may not themselves fully understand research. Therefore, there is an underutilisation of these highly specialised nurses (Orton et al. 2022), which needs to be urgently addressed. Although clinical/academic roles have been championed for decades, ongoing challenges to implementation and sustainability continue. These challenges include organisational and historical nursing culture, unclear entry points, lack of clear career progression and insufficient roles globally (Avery et al. 2022; Baltruks and Callaghan 2018; Dobrowolska et al. 2021; Paterson and Strickland 2023; Trusson et al. 2019). There is also a lack of clarity concerning strategic workforce planning and what constitutes an optimal number of clinical academic nurses to meet service and workforce needs. Ideally, a clinical service will need nurses who can read and interpret research, nurses who can implement new evidence-based interventions and service improvements, and nurses who can win competitive research grants and lead research as independent investigators. For the smaller group of nurses aspiring to become independent investigators, earning a PhD marks only the beginning of their journey. Even fewer clinical academic nurses go on to lead successful research programmes supported by competitive grants. For nursing, direct patient care is the fundamental priority in the health care setting, with nurses at the bedside appreciated differently than those behind a desk (Paterson and Strickland 2023; van Oostveen et al. 2017). Unfortunately, research and education continue to not be equally valued (Paterson and Strickland 2023; van Oostveen et al. 2017). Nurses with PhDs continue to have limited career opportunities in clinical settings and therefore often have no choice but to join universities as faculty members to advance career progression (Dobrowolska et al. 2021). In countries such as the USA, Canada and Australia, formal joint appointment roles are generally at the senior academic professorial level, with limited pathways to develop from early career researcher to professor without moving out of the clinical setting and into academe for a period of time (Avery et al. 2022; Paterson and Strickland 2023). Furthermore, unrealistic expectations placed on clinical academics to meet both university metrics for promotion along with a vigorous organisational programme of clinical inquiry on a wide range of topics using different methodologies are not sustainable (Vessey et al. 2017) (Avery et al. 2022; Orton et al. 2022) particularly when these nurses are also trying to maintain often advanced clinical skills to also provide credibility to the role (Paterson and Strickland 2023). If career development continues to be reliant on historical research metrics for promotion such as funding, publication and research metrics, these nurses continue to be disadvantaged due to their dual focus on both clinical care and research (Gibson 2019). Human resource policy, remuneration structure, financial security and clear career pathways are also ongoing concerns of clinical academics (East et al. 2024; Paterson and Strickland 2023; van Oostveen et al. 2017) which can be further negatively impacted as nursing is a female-dominated workforce and academic gender gaps continue to widen (Iaria et al. 2024). Further to these ongoing challenges, the university sector has been in stress due to serious underfunding, the impact of COVID-19 and a change fatigue and burnt-out workforce (Goedegebuure and Schoen 2014; Paterson et al. 2024). These factors have impacted the continued development and dissemination of clinical academic roles and pathways (Olive et al. 2022). Global issues effecting universities, such as technology expansion, changing demographics, rapid urbanisation, accelerating individualisation, economic power shifts and climate and resource changes (Naughtin et al. 2022) exacerbate the tension for clinical academics to meet both the organisational needs, university expectations and their individual career goals (Vessey et al. 2017). Furthermore, a recent cross-sectional survey of nursing academics in Australia highlighted issues around the aging workforce in academe, mirroring those in industry (East et al. 2024). Interestingly, clinical academic roles were not mentioned as roles by participants in this study—but academic roles that value both clinical and academic expertise will be important to encourage nurses to see the value in gaining PhDs and regarding academia as a career pathway into the future. The importance of developing the next generation to see the value of nurses who have multi-dimensional expertise in clinical practice, teaching and research is therefore critical for the profession moving forward over the next 25 years (Gibson 2019). There is a need for robust and rigorous nursing research supported by peer-reviewed and funded research grants rather than perpetuating small scale and largely unfunded nursing research. In addition, the most benefit to patients is likely to come from the optimal implementation of existing research and evidence-based clinical guidelines and policies to further optimise practice and reduce unnecessary variations and inequalities in outcomes. To achieve translation in practice, there needs to be better workforce planning, and the small number of nurses with PhDs need to be empowered and better supported to further develop as competitive grant-winning principal investigators and implementers of research into practice. Continued cultural evolvement and change in relation to research is essential for the ongoing development and sustainability of clinical academic roles (Dobrowolska et al. 2021; van Oostveen et al. 2017). This requires strong leadership to not only promote but enable combined research, teaching and clinical practice as core nursing roles and responsibilities. Visibility of these roles is also required to facilitate platforms for clinical academic roles to continue to thrive. Nurses need to see that academic nurses are not always solely driven by research but continue to value the clinical aspect of nursing roles and develop the leadership skills to confidently advocate for change and facilitate a platform for these roles to develop (van Oostveen et al. 2017). Embedding clinical research in undergraduate degrees is, therefore, crucial (Henshall et al. 2024). One way that health services are building capacity and developing a culture of research in non-traditional research roles is to implement research internships for various nursing, midwifery and allied health professionals (Miller et al. 2020; Roberts et al. 2024). These clinical academic internships provide an opportunity for nurses to gain exposure to research and gain knowledge and experience from an experienced mentor (Olive et al. 2022), although they require investment and cooperation from academe and healthcare (Miller et al. 2020; Olive et al. 2022). Literature continues to highlight that there is a critical need for consistent national, regional and organisational policies, frameworks and approaches to developing these clinical academic roles and career pathways for nurses (Aspinall et al. 2024; Avery et al. 2022; McErlean et al. 2024). Directors of Nursing and other nursing leaders are in a unique and important position to advocate for the importance of these roles and consider their positioning in ongoing budgets. Supporting these unique and highly skilled roles of clinically active health researchers or research-active clinicians can help to demonstrate to staff how research informs evidence-based practice (Dobrowolska et al. 2021; Hennessy 2023). Yet nursing leadership continues to undervalue the connection between nurse-led research and direct patient care and therefore underuse nurse academics (van Oostveen et al. 2017). Drawing from established infrastructures in other disciplines (van Oostveen et al. 2017) and embedding the clinical academic as an essential nursing position in professional frameworks will help to ensure not only its success but also its sustainability. Although the literature around the clinician academic role continues to grow, huge challenges remain as to how to embed this as an essential role in the nursing culture. For these roles to continue to grow and be sustainable, the key is for targeted recruitment, development and retention of staff who understand and value the importance of research and innovation in their clinical practice and the establishment of a research culture within the workplace (Olive et al. 2022). As a profession, we must strive to develop a new generation of research leaders and raise the profile of nursing research through successful competitive funding, the conduct of high-quality research and improved clear communication of research impact (Ferguson et al. 2021). Clinical academic nursing roles are key to this; however, appreciation of the competing demands of both clinical and academic work is important for their sustainability (Avery et al. 2022). Open access publishing facilitated by Flinders University, as part of the Wiley - Flinders University agreement via the Council of Australian University Librarians. The authors declare no conflicts of interest. The authors have nothing to report.

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