Understanding the value of a PhD for post-doctoral registered UK nurses: A survey.

AIMS: This study investigated, 'What is the perceived value of a PhD to doctoral and postdoctoral nurses in the UK?'
BACKGROUND: Little is known about what happens to the careers of nurses who undertake a doctorate and whether they use these skills in the next career steps.
METHODS: Nurses (n = 47) with doctorates were recruited via professional networks and twitter (@NMAHP_DoctorateStudy). Qualitative responses from the nurses were analysed using thematic analysis.
RESULTS: Three themes emerged from qualitative analysis: impact on career, utilization and value, and impact on self.
CONCLUSIONS: This study provides one of the few insights into how doctoral trained nurses understand and experience the value and utility of their studies to themselves and others. IMPLICATIONS FOR NURSE MANAGEMENT: Nurse managers can play a crucial role in generating a research-led culture within their clinical setting. This would include promoting an understanding of research as something directly related to patient benefit rather than an abstract, intellectual activity.

INTRODUCTION

Undertaking doctoral studies alongside clinical practice in nursing has been advocated for many years and has gained momentum over time being supported by academic infrastructure and policy levers (Moule et al., 2017). Advocates, such as Kitson (1999), have argued for doctorate level education to be developed in order to build a stronger culture of inquiry in clinical nursing practice. There has been an increase in the number of nurses undertaking doctorate level research in many countries including the Australia, Scandinavia, the United Kingdom and the United States of America (Carrick‐Sen et al., 2019; Henshall et al., 2021; Wilkes et al., 2015). In the UK, the ‘Shape of Caring’ review reiterated these earlier messages and highlighted that nurses who are educated to doctoral level should form an integral part of the clinical workforce in order to generate a research culture in practice and provide the foundation architecture to make the necessary change (Health Education England, 2015). This resulted in an approach to developing research alongside clinical practice through a designated Clinical Academic Pathway Framework, which was established in England for the nursing, midwifery and Allied Health Professional (NMAHP) workforce and delivered through the National Institute of Health Services Research (NIHR). However, the number of professionals developed through this route is small. Further opportunities such as access to the pre‐doctoral and doctoral fellowships have been made available for these professionals through other parts of the NIHR infrastructure tasked with delivering research capacity (Cooke et al., 2016). Some argue that we are at the tipping point to sustained progress in clinical academic pathways for these professional groups (Carrick‐Sen et al., 2019).

Despite these developments, there is some evidence that this increase in training opportunities has not been matched by parallel developments of infrastructure in the clinical and practice context. For instance, NMAHP progress compared to that of medics has been slow with fewer clinical academic career opportunities where research is routinely expected and undertaken as part of practice (Henshall et al., 2021). A bottle neck reflecting poor post‐doctoral progress in career pathways has also been noted, particularly in nursing (Dickinson, 2017). Carrick‐Sen et al. (2019) acknowledge these limitations and gaps to progress, noting particular concerns around nursing and clinical leadership to support clinical academic careers. Cooke et al.'s (2016) mapping of research capacity activities supporting non‐medical professionals found that NMAHP managers have little experience of supporting clinical academic pathways. It further found that NHS career structures for clinical academic posts are inconsistent at best and non‐existent as the norm. Similarly, a small study based in Holland (van Oostveen et al., 2017) highlighted that there is an absence of supporting structures for nurses who combine clinical and academic work. They describe a culture of ‘misfit’ between academic and direct patient care in nursing practice and highlight a lack of leadership in the profession to support the ambition of clinical academic careers. They also found that nursing managers did not strategically plan for clinical academic roles in services. Similar issues have been identified in Sweden where managers did not understand the competencies of nurses who have a doctorate (Orton et al., 2019). Conversely, a systematic review of interventions and strategies for supporting clinical academic pathways for nurses highlighted the importance of robust clinical and academic leadership with a clear strategic vision for success, shared partnership models between academic and service provider organisations and the need for role models and well‐defined strategic goals and outcomes (Henshall et al., 2021). Despite this, most doctoral graduates continue to work in the academy rather than clinical practice (Wilkes et al., 2015), a situation which was not the ambition of the Shape of Caring review.

BACKGROUND

The study reported here set out to examine the experiences, outcomes and motivations to study in nurses who have completed doctorates. The research was developed in partnership with a community of practice (CoP) of senior research managers and lead professionals (including nurses) in the NHS. The project aimed to inform research‐practice career pathways ‘close to practice’ in the NHS. Unlike medical colleagues, such pathways were poorly established in NMAHPs. The CoP had developed a cohort of NMAHP clinical academic fellowships who were at the start of a 4‐ to 5‐year programme of work. The CoP wanted to collect information about how to support such individuals after their doctoral training. Consulting with NMAHPs with prior doctoral experience was therefore proposed as a helpful step in exploring what the support needs were and how they might be met and to help map destinations for such career pathways. A PhD is considered to be the gold standard and mark of an independent researcher (Powell & Green, 2007), and conversations within the CoP suggest that it could and should be the ‘gateway’ to an integrated clinical and research career.

Our study sits in the broader context of a UK national focus on increasing and improving doctoral level study (Great Britain Department for Education, 2017; The Royal Society, 2010). This is underpinned by economic theory on the role of doctoral‐level study in developing knowledge economies and the benefits of this to both society and the individual (Diamond et al., 2014; Neumann & Tan, 2011). Specifically, this paper addresses the question, ‘What is the perceived value of a PhD to doctoral and postdoctoral nurses in the UK?’

METHOD

Following ethics approval (reference number 023667), nurses and allied health professionals with doctorates from across the UK were recruited to the study via professional networks with support from the Collaboration and Leadership for Allied Health and Care Research for Yorkshire and Humber (CLAHRC‐TH). A twitter account @NMAHP_DoctorateStudy was set up for the purpose of the study, and a link to an online survey was disseminated via this twitter feed. Within twitter, accounts that were run as representative bodies or Communities of Practice (such as @PICSNurses) were targeted and these ‘organisations’ actively retweeted. The online survey was active for just over a month (5 February 2019 to 15 March 2019). Twitter users were asked to retweet and share the questionnaire link within their twitter networks. The sample is therefore a convenience sample with diversity being achieved through the snowball technique that retweeting facilitated.

The survey questions were bespoke to the aims of the study and included closed questions about professional background, motivation for undertaking a doctorate and the risks and benefits of the degree drawing on issues raised within the literature (Bryan & Guccione, 2018; Diamond et al., 2014; Wilkes et al., 2015). These questions were sense checked and amended in consultation with CoP members. The survey also included a number of open questions for respondents to provide more detail about their experiences and views (Table 1).

TABLE 1

Open questions

“To what extent are you able to utilize the benefits from your PhD in your current role?”

“Please describe how these PhD skills are valued or not by your employer”

“Could you tell us a little about your career pathway. In particular, we'd like you to reflect on how you feel your doctorate has (or has not) impacted on this career”

“Please add any other comments about your doctoral studies”

Given the research question reported in this paper, data from nurses were separated from the clinical scientists and AHPs and analysed descriptively. Qualitative responses from the nurses were analysed using thematic analysis, and this was supported by Quirkos© software. Initial coding was undertaken independently by SR and sections of this checked by AT and RK. Further coding, categorizing and initial theme development was completed collaboratively by these three co‐authors, and then, final themes were refined in discussion with the whole research team.

FINDINGS

There were 214 respondents from across the UK of which there were 47 nurses (including 33 adult nurses, 4 mental health nurses, 6 children's nurses, 2 health visitors and 2 midwives).

Quantitative data

Nurses were motivated to undertake PhD study by several factors, including professional development 34 (72%) n = 47, intellectual curiosity 32 (68%) n = 47, seeking a career in academia 12 (26%) n = 47 and other reasons 13 (28%) n = 47. Other reasons included already working in academia and the PhD being expected/needed, answering a clinical problem, serendipity and personal development.

Five nurses worked in academia prior to starting the PhD, and 12 were seeking a career there (17/47 or 36%). However, 24/47 (52%) are currently working in academic posts with another 10/47 (22%) being clinical academics.

Qualitative data

Three themes emerged from analysis of the open questions: impact on career, utilization and value of the doctorate and impact on self.

Impact on career

When describing the route to PhD, many outlined a gradual progression to doctoral level study rather than it being part of an established career plan. It was also often linked with a move into the academic setting: For many working, or wanting to work, in Higher Education Institutes (HEI), the PhD was not only seen as a requirement but was recognized as an important part of career change or progression:

I started my career as a [specialism] nurse and completed courses to support that role, including a [specialist] nursing course and Masters degree. I developed a [specialist] nurse educators post before moving to Practice Education. I completed a NMC recognised teaching qualification during this time before moving to academia. The opportunity to complete doctoral studies was one of the factors which encouraged me to move to the university. RN14

I undertook a PhD largely to facilitate a career change and it did this. I did a PhD then secured funding for a post‐doc and I'm now a Senior Lecturer who undertakes teaching and research. I could not have got into this position without a PhD. RN7

However, this was not the case for all of those who worked in HEIs with others suggesting it was not always linked to progression:

I could have gotten into my current job role without a PhD. I found out that academics in nursing education can operate at Bachelors, Masters and PhD level. That was a huge demotivator, especially given the volume of work that goes into it. RN16

For some in HEIs, completing a PhD represented a backward step (at least initially) in terms of career progression, status and/or salary as they moved away from clinical practice and tried to progress:

The biggest problem for me post‐doctorally was that I was starting again at the bottom of the ladder as a career researcher and it has taken me far too long to be able to get to the point I now am […] I have been offered jobs at lower grades and lower salaries than I left the NHS with. RN12

Such challenges around salary and progression were also noted by those who stayed in clinical practice or who had a clinical academic role:

Three years after graduation I'm still not back to previous salary. I'm also penalised for remaining in clinical practice as I am part time at university and cannot take on senior academic roles therefore do not fit the promotion criteria […] undervalued clinically, paid as a band 6 with no prospects of improvement in NHS, only progression possible is in academia unfortunately. RN13

These narratives around the challenges to career progression, both in HEI and clinical roles, raise questions about how, when and by whom the doctorate is utilized and valued.

Utilization and value of doctorate

In response to the question on the extent to which the PhD benefits their current role, the majority of participants were positive with responses such as fully utilize, completely significantly, and use them every day. This utility was noted in terms of enhanced confidence, the benefits of critical thinking skills, in supporting clinical work and in fulfilling educational roles:

Informs my critical decision making on a daily basis. RN6

Enhanced confidence, has removed some of the ‘imposter syndrome’ I frequently experienced. RN31

At its most positive, it was described as transformational:

I use all of these on a daily basis. I could not have anticipated how much of a personal and professional impact that gaining my Doctorate would have been. Although I have only had it for a short period of time, it has been transformational. RN15

For a few, however, particularly those in teaching only or clinical roles, there seemed less opportunity to utilize and further develop skills gained through the doctoral journey:

So far there has been little opportunity to use the benefits in my current role. RN14 [Nurse lecturer]

It is not required for my current role. RN17 [Specialist nurse practitioner]

This lack of opportunity to utilize skills developed was frequently linked to a lack of recognition and valuing of the doctorate by others, which limited or stifled opportunities. This seemed particularly marked in the clinical setting leading some to end up working in academic roles even when this was not the intended career trajectory:

The personal benefits from undertaking a PhD result in a great deal of frustration in the workplace because the environment, your colleagues, the context within which you work and the way you are regarded do not change. You are equipped with greater insight, a more curious mind and a better ability to problem solve and critically analyse but the culture of the NHS is not ready for it. RN10

Having a doctorate has made me into a researcher, which was not my intention. My intention was to be a consultant nurse specialist […] I had planned to return to the NHS with my PhD but my skills were not valued in that setting and I have never been able to find a job in clinical practice that valued what I could bring as a doctorally prepared nurse. RN12

There was a strong implication here that such lack of recognition was particularly prevalent among nurses own colleagues and profession. This was seen as part of a cultural denial of the importance of academic skills and a dissociation of this from clinical care:

In the past, being interested in academic study was a bit of slur in the clinical area and I seemed to be regarded as someone not committed to the clinical area or not having strong practical skills. RN2

This contrasted with how medical colleagues valued what doctoral study could bring to the clinical setting:

Significantly undervalued by the senior nursing executive, and interestingly highly valued and regarded by medical colleagues. RN24

It is interesting, of everyone I worked with I think my consultant colleagues were actually the most respectful of my doctoral qualification. They definitely spoke to me and communicated differently when they knew I was doing a doctorate and once I graduated and they really made me feel it was recognised. RM1

While the PhD was seen as beneficial and well utilized by participants themselves, recognition of its value by others, especially by peers in clinical contexts, was clearly variable.

Impact on self

Outside of the impact of the PhD on career, there was a range of impacts from doctoral and post‐doctoral experiences on participants themselves. Many experienced disappointment and stress during their doctoral studies often related to a lack of support and the challenges of completing doctoral study while working:

Isolated as a PhD student whilst working full time, felt unsupported at times, acute anxiety in final year pre/post VIVA. RSCN1

I was apprehensive about starting a PhD given the amount of studying I knew it would require. Therefore I moved my family 200 miles to another HEI where I was aware the support and funding was more robust. (RM2)

Employer probably does not understand how challenging it is to undertake a PhD and run a Trust‐wide clinical service. RN25

Notably, for some, similar feelings persisted in the post‐doctoral phase being linked to the lack of recognition and value attached to the doctorate as well as to work pressure and expectations:

In HEI, in nursing in particular, the university wants you to teach, supervise, mark, manage modules, generate income, publish world leading outputs, supervise doctoral students etc. Do I feel valued? No. I just feel the demands are unrealistic. They want the penny and the bun. It's actually depressing for me and I'm increasingly disillusioned. RN7

However, despite these challenges, there was clearly a huge sense of pride and achievement attached to completing the PhD even when it did not seem to advance career or to be valued and recognized by others:

This has given me great kudos and respect outside my clinical team—and I am still able to undertake outcomes research in my field of expertise both individually and collaboratively on an international ‘stage’. It's still the best thing I ever did! RSCN5

The personal impact of the doctoral and post‐doctoral journey clearly varied then not only between participants but for the same participants at different points in the journey.

DISCUSSION

Key points emerge from this study. While the majority of participants could and did utilize the learning from their doctoral training, the opportunity to maximize the value of this was seen as more limited for those who remained in clinical settings. Other career opportunities, particularly in clinical settings, were seen as limited at best. These findings reaffirm research from the Netherlands (van Oostveen et al., 2017) where a nursing culture that emphasizes direct patient care is perceived as an academic misfit and where insufficient leadership and supporting structures were seen to stifle clinical academic opportunities. Bullin (2018) describes this misfit as being (at least partly) a result of differences in epistemic cultures between professional nursing communities (based around discipline specific knowledge for clinical practice) and educational settings (based on critical thinking and transformational learning).

This cultural rift has been recognized in other empirical work. For example, a study from Australia (Borbasi & Emden, 2001) conducted interviews with nurses in positions of responsibility for employing nurses. While these employers recognized many of the same skills developed through doctoral study that our participants outlined, results also suggested a discrepancy between these skills and those required in practice and a ‘high degree of scepticism as to the usefulness of the degree for the workplace’ (Borbasi & Emden, 2001, p. 192). Similarly, research from the US among Chief Nursing Officers found that while those surveyed had mainly positive perceptions of the doctorate, only 19% felt that nurse executives should pursue a doctorate of nursing, and only 9% believed that a doctorate should be the recommended degree option for nurse executives (Swanson & Stanton, 2013). There is an on‐going challenge then in helping colleagues and organisations recognize the link between skills developed through doctoral study and benefits for the clinical setting and patient care.

Our findings further highlight the financial and personal sacrifices that nurses often make when pursuing doctoral study. These sacrifices are not only made during the period of the PhD but, importantly, any career benefits that do accrue are frequently preceded by a (sometimes prolonged) post‐doctoral period of reduced salary and diminished status. The personal challenges of completing doctoral study while continuing to work, and the sacrifices made in doing so, have been well documented (e.g., Baldwin, 2013; Trusson et al., 2019), but less attention seems to have been paid to the positive personal impact. Both Baldwin (2013) and Trusson et al. (2019) do, however, note the sense of personal achievement and increased confidence highlighted by our participants. The extent of the financial and personal sacrifices noted in our current study is likely, in part, to be a result of limited nurse leadership and a still underdeveloped infrastructure to support and develop clinical academic pathways for nurses in ways comparable to their medical colleagues.

Finally, findings here suggest that when such leadership and support are present, when nurses feel their doctoral skills are valued by their organisation and within their clinical setting, then doctoral study is seen as less of a risk (and therefore more attractive). Leadership and support can help bridge the cultural rift noted above. While recognizing how accessing funding and training (such as that provided by NIHR) is beyond the reach of many nurses at the point‐of‐care delivery, Cooper et al. (2019) highlight a range of practical, applied examples for supporting clinical career development for NMAHPs. These focus on strategic commitment, generating structures to engage, enthuse and empower, and realizing benefits for staff and patient experience—the very areas our participants thrived off when present and experienced as serious challenges when they were not.

LIMITATIONS

This study makes important contribution but is not without limitations. The recruitment routes for the study generated a convenience sample that may not be representative of UK doctoral nurses—although there is a reasonable spread across the four nations of the UK and across the fields of nursing practice. Caution should therefore be exercised in regard to the generalizability of these findings.

Finally, all data collected relied on self‐reported information. Such reporting is, by nature, subjective. However, as the aim of the study is to explore the perceived value of a PhD to nurses, it is the very substance of these subjective accounts that constitute the intended focus of the data.

CONCLUSIONS

This study provides one of the few insights into how doctoral trained nurses understand and experience the value and utility of their studies to themselves and others. Despite attempts in the UK to develop research alongside clinical practice, findings suggest that there remain barriers for nurses wishing to develop clinical career pathways through doctoral study. In particular, a cultural rift in how the skills and knowledge gained through doctoral study might benefit patients, clinical settings and organisations often leads to an undervaluing of the PhD and a concomitant loss of doctoral nurses from clinical settings to academia even when this is not a personally desired outcome for nurses embarking on such study. However, where organisational infrastructure and leadership recognize, support and value what doctoral skills can bring then the opportunities and benefits known to accrue from research‐led clinical environments are more likely to emerge and clinical‐academic pathways become more embedded.

IMPLICATIONS FOR NURSE MANAGEMENT

Nurse managers can play a crucial role in generating a research‐led culture within their clinical setting: a culture that helps bridge the current misfit between clinical practice and critical thinking. This would include promoting an understanding of research as something directly related to patient benefit rather than an abstract, distant, intellectual activity.

CONFLICT OF INTEREST

There is no conflict of interest.

FUNDING INFORMATION

This study was funded by the National Institute for Health Research (NIHR) Collaboration and Leadership for Allied Health and Care Research for Yorkshire and Humber (CLAHRC YH). The analysis and reporting for this paper were further funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance between the RCN and the University of Sheffield.

ETHICS STATEMENT

Ethical approval was gained from the University of Sheffield, School of and Health and Related Research: reference number 023667.