Nurses in the clinical area: Relevance of a PhD
Article Outline
Summary
This project aimed to explore the application and relevance of a PhD to nurses working in the clinical area. The complexity of nursing practice requires clinical nurses to be competent as investigators and professional leaders who could help structure nursing practice in more efficient ways. Research proposes that a PhD offers limited employment opportunities, is mainly research oriented and tends to direct a nurse away from the clinical field. A mixed method study design utilising surveys and interviews was chosen to collect data for this study. Participants were nurses with a doctoral degree working/having worked in a clinical area after obtaining their PhD Nurses were recruited through student databases from Australian universities that offer doctoral degrees in nursing and also by using a snowball sampling technique. The majority of the 19 nurses who participated in the study had: varied expectation of doing a PhD; maintained their clinical positions after obtaining their doctoral degree, considered that the degree helped them to obtain better jobs/promotions and acknowledged the value of the PhD in patient care, in improving research and informing health policy. This study has exposed the positive aspects of completing a PhD and identifies its constructive application in the clinical area. It is essential to provide support and opportunities for nurses working in the clinical area to pursue doctoral degrees in order to enable them to enhance knowledge and build confidence and leadership skills and contribute to the improvement of nursing practice and the continued development of the profession.
Keywords: Nursing, Doctoral degree, Research training, Doctorate, Clinical practice
Introduction
PhD programs for nurses in Australia, have been mainly research oriented with only minimal, if any course work component. This pattern is consistent with reported studies (e.g. Boore, 1996; Funk, Champagne, Weise, & Tornquist, 1991; Pignataro, 1997) from the United States of America (USA) and United Kingdom (UK). The concerns raised by these authors from previously reported studies, indicate that PhD programs tend to direct the candidate away from the clinical field. The need for PhD programs in nursing to be tailor-made to meet the needs and interests of individual students and their particular specialities has also been advocated (Henry, 1997, Pignataro, 1997, Spear, 1997). Pearson, Borbasi, and Gott (1997) also argued that PhD programs have neither prepared nurses as team leaders who could engage in research from a variety of paradigmatic positions, nor as professional leaders who can advance the theory and practice of the nursing discipline (Pearson et al., 1997). Yet there is no recent research available to confirm this view. This paper reports the findings from a study, which aimed to describe the relevance of a doctoral degree to nurses working in the clinical area.
Literature review
There is a growing body of research that highlights the need for advanced practitioners in nursing (Boore, 1996, Pearson et al., 1997; Wendy & Waldspurger, 2005). The complexity of practice, the level of decision making in implementing new health care approaches, as well as the evaluation of effectiveness, all warrant health care practitioners and especially nurses to be educated to an advanced level (Meleis, 1994). Nursing is in constant and continuing need of clinical leaders who have competence as investigators, collaboraters, communicators and disseminators (Pearson & Borbasi, 1996). The World Health Organisation (WHO) has acknowledged the contributions that well educated nurses can make, in delivering cost-effective health care (WHO, 1996) and Carter (1997) has argued that nursing has been deprived of the contributions of doctorally educated clinicians, who could help structure nursing practice in more efficient ways. Despite these acknowledgements, the nursing profession, particularly nurse leaders in the clinical service sector do not value the importance of postgraduate research degrees as contributors to the improvements in nursing practice and clinical outcomes. In addition, Australian reports (Burrows & McLeish, 1995; Edwards, Chapman, & D, 2002) have identified the continuing marginalisation and devaluing of research activities by the majority of nurses, especially clinicians who view higher education and research as separate to clinical practice and actively maintain perceived boundaries between these areas.
The PhD has been viewed as lacking in terms of its contribution to the development of professional and evidence-based practice within nursing (Boore, 1996, Pearson, 2002). It has also been perceived that graduates from conventional PhD programs lack the ability to adapt to workplace realities and satisfy the needs of the profession (Adams & Mathieu, 1999; Pearson et al., 1997, Spear, 1997). In addition many nursing PhD programs are viewed as not being clinically focussed and accused of having a plethora of research methods as the centrepieces of various PhD outputs (Christman, 1998, Funk et al., 1991).
One of the difficulties reportedly encountered by doctorally prepared nurses is the limited employment opportunities where they can consolidate their experience (Hale, 2002). Pearson et al. (1997), state that PhD programs are only suitable for nurses who aspire to an academic position or a research post and it is considered problematic that some of these positions often also require further generic education and training (Kenkre & Foxcroft, 2001).
The need for practice-focussed doctoral preparation in nursing has been emphasised by academics (Diers, 1980, Fitzpatrick, 1989, Henry, 1997; Veeser, Stegbauer, & R, 1999) and one way of addressing these perceived shortcomings in the PhD programs associated with professionally related disciplines has been the introduction of the Professional Doctorate in many Australian universities (Ellis & Lee, 2005; Spear, 1997; Trigwell, Shannon & Maurizi, 1997). According to the Australian quality framework (AQF) the professional doctorate, may be undertaken through varying combinations of coursework and research, and requires significant professional practice either prior to and/or as part of the program (AQF, 2008). This degree has been developed specifically to provide extended and advanced training in certain professional fields (Trigwell et al., 1997, with the stated aim of linking the profession, academia and the workplace (Malfroy & Yates, 2003).
Inevitably comparisons between the PhD and the Professional Doctorate have raised several issues with some critics, who have considered the Professional Doctorate as being less rigorous and demanding than the PhD, while also questioning the credibility of the supervision arrangements (Spear, 1997). It is also argued that the completion rates for Professional doctorates are less than those required for the maintenance of viable programs (Evans, Peter, Pearson, & Tregenza, 2004). Even though many Professional Doctorate candidates conduct research in or about their workplace, a lack of deep workplace engagement as part of their doctoral degree is a common feature of many programs (Malfroy, 2004). Such concerns have also sparked discussions about the justifications provided for the propagation of Professional Doctorates and whether the needs of the industry and profession could also be addressed through some modification of the existing PhD framework (Evans, 2000). While this debate continues it is interesting to note that PhDs in professional fields have proved to be more attractive in terms of higher enrolment in Australian universities and that the PhD continues to be the preferred choice of research degree (Evans et al., 2004, McWilliam et al., 2002).
While the argument continues as to what is the better degree for nurses working in the clinical arena, the lack of evidence as to the benefits (or otherwise) of PhD programs for nurses who work in the clinical area is clear. In Australia the first degree from specifically identified nursing PhD programs were conferred in the late 1980s. Due to the continuing small number of Professional Doctorate (PD) programs in Australia, the majority of doctorally prepared nurses are still graduates of PhD programs. Currently there are no published statistics on nurse graduates of doctoral programs in Australia. In addition, there are no published findings on the relevance of existing PhD programs for nurses who have continued to practice clinically within the Australian health care system following the award of a doctorate. The determination of baseline knowledge in this important area is therefore the aim of this study.
Method
Design
This descriptive study used surveys and interviews to collect data from doctorally prepared nurses who were currently working (or had worked) in the clinical area after obtaining their degree.
Sample
The sample for this study comprised of nurses with a PhD who were working in the clinical area.
Recruitment of participants
Participants were recruited through Australian Universities, which offered doctoral degrees in nursing. Out of 22 universities that were contacted, seven responded and volunteered to send out the survey packages to nurses who had attained doctoral degrees from their respective university. A total of 136 survey packages were sent out through the postgraduate administration offices of the seven universities. In addition, nursing faculties in 20 Australian Universities were contacted to help in the recruitment process. Eligible participants, notified by these faculties of the project, contacted the researchers indicating their interest to participate in the study. A snowballing technique was also used to aid in the recruitment process (Maykut & Morehouse, 1994), by asking participants to inform their colleagues about the study and asking those who were interested in the study, to contact the research team directly. After completing the survey, participants were also invited to provide their contact details if they were interested in taking part in an interview to further explore their views.
Research instrument
A 16-item survey was developed to collect information from participants. The survey comprised both open and closed ended questions addressing demographic information, employment before and after graduation, their expectations of doctoral candidature, the importance of using the awarded title of Dr., the perceived value of the degree to patient care and their career, and their perceptions of the personal and professional impact of undertaking a doctorate.
Data collection
Data collection occurred over a period of ten months from April 2004 to January 2005. 152 surveys were sent out to various universities and government organizations across Australia. A self-addressed envelope was provided for the return of completed surveys. A total of 19 surveys were returned and out of these, 13 participants volunteered to be interviewed. Interview data (telephone interviews) were recorded on audiotapes.
Data analysis
Data were analysed descriptively, using the statistical software package, SPSS, Version 13 (SPSS Inc., 2003). Data were tallied; frequencies and percentages were calculated and tabulated. Interview data along with comments from the surveys were analysed thematically using NVivo (NUDIST, 1999). Content analysis of text was conducted and responses were categorised under each question.
Ethical considerations
Ethics approval for the study was obtained from the University of Western Sydney's Human Research Ethics Committee. Pseudonyms were used for all interview data to maintain anonymity and confidentiality.
Findings
Respondents
Out of 136 survey packages, a total of 19 surveys were returned and of these 13 were interviewed. Table 1 provides a description of demographic data obtained from the 19 survey respondents, none of whom had undertaken a Professional Doctorate. Data indicates that the type of employment changed slightly after graduation with some increased involvement in management and research roles. The majority of the respondents however had maintained their clinical positions as either full or part time roles.
Table 1. Demographic characteristics of nurses (n
=19)
| Characteristic | Finding | |
|---|---|---|
| N | % | |
| 1. Demographics | ||
| Age | ||
| 35–44 | 7 | 36.8 |
| 45 and above | 11 | 57.9 |
| Did not respond | 1 | 5.3 |
| Gender | ||
| Male | 3 | 15.8 |
| Female | 16 | 84.2 |
| Year PhD awarded | ||
| 1995–1999 | 5 | 26.3 |
| 2000–2005 | 14 | 73.7 |
| 2. Employment area pre PhD | ||
| Education | 8 | 42.1 |
| Research | 3 | 15.8 |
| Nurse management | 2 | 10.5 |
| Clinical | 5 | 26.3 |
| No information | 1 | 5.3 |
| 3. Employment area post PhD | ||
| Education | 4 | 21.1 |
| Research | 6 | 31.5 |
| Nurse management | 5 | 26.3 |
| Clinical | 4 | 21.1 |
Table 2, Table 3 provide summary data on the remaining issues of interest.
Table 2. Nurses’ perceptions of the relevance and value of PhD (n=19)
| Always | Sometimes | Never | Not answered | |||||
|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | N | % | |
| Use title Dr. | 3 | 15.7 | 15 | 79 | 1 | 5.3 | ||
| People use title in workplace | 2 | 10.5 | 15 | 79 | 2 | 10.5 | ||
| PhD helped in improving employment aspects | 10 | 52.6 | 6 | 31.6 | 2 | 10.5 | 1 | 5.3 |
| PhD valuable for career | 15 | 78.9 | 2 | 10.5 | 1 | 5.3 | 1 | 5.3 |
| PhD value to patient care | 12 | 63.1 | 4 | 21.1 | 2 | 10.5 | 1 | 5.3 |
| PhD relevant to current position | 15 | 79 | 3 | 15.7 | 1 | 5.3 | ||
Table 3. Impact of doing a PhD on nurses (n=19)
| Yes | No | Not filled in | ||||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Regret doing PhD | 1 | 5.3 | 18 | 94.7 | ||
| PhD expectations met | 17 | 89.4 | 1 | 5.3 | 1 | 5.3 |
| PhD change you personally | 12 | 63.2 | 7 | 36.8 | ||
| PhD changed you professionally | 17 | 89.4 | 1 | 5.3 | 1 | 5.3 |
The majority of respondents (78.9%, n=19) used their title sometimes, with one person never using it (Table 2). Interview data indicated that there was a general feeling of apprehension about the use of the title in the clinical area. Concerns about possible confusion with medical colleagues and the belief that the use of title was only appropriate in the academic arena were expressed. As one participant (Rea) reflected “I will not use it in clinical area but would use it when presenting academic papers and in correspondence.” Another: “I don’t want to get confused with medical doctor. Think PhD after my name is enough” (Melanie).
When discussing the importance of using the title, most of those interviewed felt it unimportant, however a few commented that it did contribute to their credibility in academia or when working with medical colleagues; for example: “It depends on circumstances but certainly useful especially when undertaking work in conjunction with medical profession” (Bruce). Rea stated she felt embarrassed using it, although she thought: “It is important to use it [title of Dr], as it heightens the status of nursing—I guess I lack the confidence and it can be confusing to use title for parents and very confusing to staff” [in the clinical area].
Use of title by othersAgain most respondents stated their title was only used sometimes in their workplace by other people (Table 2). Very often this was on formal occasions and most felt that this use of title was not an important issue as first names were used in the work place. Most respondents also indicated that their successful completion of a doctoral degree was acknowledged by work colleagues without the constant use of the title.
Improved employment prospectsMost respondents thought that completion of a PhD did help in getting a better job (Table 2). This view was supported by interview statements such as:
“It [PhD] makes you more competitive, and it opens up many many opportunities” (Helen) and
I had done research and I had extended qualifications [PhD] I assume was a key factor in me getting current position—{professorship} … but not only factor … also fact I had been in academic system where I have been teaching (Linda)
Another respondent acknowledged that having a PhD helped with promotion from senior lecturer to professor and another believed she had obtained her research position because of her PhD.
Value for careerSimilarly the majority of respondents felt that the PhD had been valuable for their clinical career (Table 2) supporting this position with interview statements such as:
“My PhD was clinically focussed – my clinical practice has improved and I can challenge colleagues (Emily), … it [PhD] has given enhanced credibility to me” (Bruce). Melanie stated: “It has made me more competitive” and Lis remarked: “My PhD has meant that my opinion is valued in the clinical realm, as I am considered an expert in the field by my peers.”
Value for patient careA range of views were expressed here with interview comments confirming the role of PhD in improving patient management, providing evidence for practice, informing health professional and community education as well as improving research and informing health policy. As Helen stated: “The recommendations made from the project …[identifying children at risk of hypoglycaemia]… already have started making practice changes which directly impact on patient care and the information they receive.” Sawin stated: “My research interest [is] in infant care practices [basis of PhD] and this directly impacts upon policies of hospital where I work.”
One respondent felt her doctoral work did not directly influence patient care largely due to the area or research: “It [PhD] has no value only on the fact that it has described the origin of a nursing and medical speciality in Australia. It does not have the potential to influence patient care” (Linda).
Expectations of a doctoral degreeAt interview, the respondents reported having varied expectations of doing a PhD These included personal satisfaction, improving job opportunities, enhancing research knowledge and skills, improving knowledge related to a particular research area and pursuing a logical progression in academic work on completion of a masters degree in nursing. Two felt they had no expectations before they started their PhD, that it would make a difference to clinical practice. In summation, as Helen stated: “I did not see it [PhD] as a means to an end, I saw it as being able to prepare myself for a career in which I would continue to undertake research.” As indicated in Table 3 for the majority of participants (89.4%, n=17), their expectations were met. This is confirmed by the data in Table 3 where almost all of the respondents (94.7%, n=18) had no regrets about doing their PhD However some commented on their regrets at the time missed with family while doing their PhD.
Participants perceived that the experience of completing a PhD had made them more self and intellectually confident and given them humility. Only two felt they had not experienced personal growth during their degree and remained the same as when they entered program. The positive comments included: “I have matured over time (Melanie), I have a sense of intellectual confidence and humility (George), I have learnt the value of contemplation, it [doing a PhD] has given me patience” (Rea).
The majority of respondents (89.4%, n=17) felt they had changed as a professional (Table 3). The degree had given them credibility as a health professional, knowledge, critical thinking skills, and greater sense of confidence—“I can argue things better and argue for things, made me more potent—I have been given leadership skills” (George) In sum as one respondent stated: “I am far more conscious of evidence based practice and moral imperative that as nurses we need to write more about what we do” (Helen) and “Very proud to be a nurse who achieved postgrad qualifications recognised by the academic sector” (Helen).
Participants were asked at survey and at interview if they thought they would have been advantaged by completing a Professional Doctorate instead of the PhD All responded “No” although three stated they may have considered the alternative if they were younger, or if it had been available when they started: “No not at my stage. 20 years earlier yes. I graduated aged 60. It really would have made a difference then” (Amelia); “If I have started about three or four years later I may well have considered the professional doctorate. The fact that I did it the way I did it is perfectly okay” (Emily) and “At times I have thought a professional doctorate might have had advantages. However my PhD was so clinically focussed that it has been ideal for me.” (Emily)
Mary felt the outcome would not have been any different: “I don’t think it [PhD or Professional Doctorate] would have made any difference, I could have gone either path but still done the same topic and methodology, I don’t think it would have made any difference.”
Two participants expressed their belief in the more traditional view that the PhD was of more value than the alternative and that higher degrees have more value than the professional doctorate: “Definitely not. I am a traditionalist. I believe higher degrees should be research degrees” and “No I have fairly traditional views about PhD, they should be by research, and that in some respects lesser degrees devalue the research higher degrees” (Adele). George extended this perspective by stating that in his view: “there is a much stronger sense of cultural importance to a PhD than a professional doctorate at this point. Most people when they say I have a got a professional doctorate they say what is that.”
Discussion
The lack of a reliable nursing database and statistical data that identifies nurses with a doctoral degree and those working in the clinical area was possibly responsible for the difficulties encountered in recruiting participants for this study. The participants in this study felt that their expectations of doing a PhD were met. Although this is consistent with the report by Sterling and McNally (1999) there is no other recent work that supports this finding. In a Swedish, cross-disciplinary survey of 273 PhD students (Appel & Dahlgren, 2003), the positive aspects were reported as “feelings of freedom” and “doing research.” The current findings therefore amplify these findings by identifying the benefits of PhD programs for nurses. The participants in the current study, highlighted the positive impact in the clinical area of their obtaining a doctoral degree, particularly in relation to the perceived value of the PhD for improving patient care, directly or indirectly in areas of patient management, evidence based practice, informing health professions and health policy. This finding thus supporting the acknowledged need for well educated nurses in leadership role, capable of and prepared for effectively structuring nursing practice and health service delivery (Carter, 1997, WHO, 1996)
The reported ambivalence towards the use of title “Dr.” in the clinical area possibly reflects the newness of the phenomenon of doctoral qualifications for registered nurses, the possible attitude of the bureaucracy of health care and also may indicate that it is not something that the nurses themselves considered to be major. It is of interest though that in many states in the USA there are state regulations that restrict the use of the title “doctor” by nurses when providing patient care (Dracup, Cronenwett, Meleis, & Benner, 2005) and it is possible that this may yet be an issue that requires further consideration within Australian clinical settings.
Many of the nurses in this study had accepted academic positions in universities while also continuing to work in the clinical area. In particular, obtaining a doctoral degree had helped a nurse to progress in her career by being promoted to a senior position in her conjoint role with the hospital and university. Therefore nurse academics who maintain their clinical roles have opportunities to be placed as efficient leaders in the health care arena, due to their capacity to integrate research evidence with best practice. Although the increase in university employment positions for clinical nurses with a PH.D. may be seen by critics as evidence that the PhD moves nurses away from the clinical area (see, for example, Pearson et al., 1997), nurses working at the bedside do not have time to conduct research given their high clinical workload (Hicks, 1995, Jolley, 2002). Also it is true that not all nurses can conduct research and the profession needs educated research nurses in the clinical arena (Pearson et al., 1997). Therefore nurse academics who also maintain their clinical roles would be well suited to identify day to day clinical issues and also have the research knowledge and skills to explore these issues.
Contrary to the often-expressed view of the critics of clinicians undertaking doctoral study (Boore, 1996, Funk et al., 1991, Pearson et al., 1997, Pignataro, 1997), most of the nurses in this study felt the PhD complimented their knowledge, leadership skills and clinical competence. Completing a PhD also provided participants with the opportunity to explore new horizons. However the current political/professional culture of Australian nursing does not emphasise or seriously encourage higher education for clinical nurses. Other factors such as short staffing and increased nursing workloads further escalates the situation to the point where clinical nurses find it extremely hard to meet the goals and expectations of doctoral level studies. Without the support of nurse leaders in the clinical arena it is impossible for clinical nurses to pursue higher education at the doctoral level. Partnerships between the health industry and education sector in Australia are essential for nurses to achieve such goals in postgraduate education (Australian Nursing Federation, 2002). Such partnerships could assist in achieving more flexible modes of education as well as greater flexibility for work, provision of scholarships and recognition and ongoing support from nurse managers, for those who want to undertake doctoral level education (Australian Nursing Federation, 2002).
If nurses are to measure and critique the outcomes of nursing care, conduct research into evidence for best practice and enure research outcomes are developed into policy at both local and national levels, it is essential to provide them with increased financial support to participate in research and postgraduate education. To achieve this, there are suggestions that health resource allocation budgets should make provision for costs of postgraduate nurse education by ensuring availability of subsidies, scholarships and salary incentives for nurses (Commonwealth Department of Education, Science & Training, 2001). Joint appointment of clinical nurse academics in the education and health service sector will enable tertiary education for nurses and evidence based clinical practice.
The findings from this study may reflect the time in nursing history in Australia where clinical nurses moved to the academia once they obtained their doctoral degrees. This seems to be gradually changing with the establishment of conjoint area health service and education sector appointments for clinical nurses with a PhD Although the nurses in this study felt that they would not have completed a Professional Doctorate instead of their PhD, the data suggest that in the future there may be a consolidated place for these degrees. While some disagree (Newman, 1997, Pearson, 2002), Dracup et al. (2005) warn that the influx of Doctorates in Nursing Practice in the USA poses a threat to nursing's fragile hold in both academia and science by reducing the number of nurses prepared at the PhD level. As the number of professional doctorates increase in Australia it is vital that these degrees maintain their research base and do not replace Masters programs as the site for the preparation of advanced practice nurses. The professional doctorate with its emphasis on nursing practice, can prepare nurse leaders who can lead the nursing profession in the 21st century (Pearson et al., 1997).
Limitations of the study
The low response rate from mail outs sent through the universities could be due to a number of reasons. Either the postal addresses of doctoral graduates could have changed or eligible participants were not interested in completing the survey. However, a major reason for non-response could be due to the fact that these nurses had/were not working in a clinical area after obtaining their PhD This would confirm the speculations of Pearson et al. (1997), who state PhD is only suitable for nurses in academia.
Conclusion
This study has for the first time provided insights into the positive aspects of doing PhD for nurses working in the clinical area. Although for some nurses, the topic of their PhD was not directly relevant to their clinical area, the process of undertaking the degree indirectly enhanced their leadership and decision making skills. These skills will not only help nurses to progress in their profession, but will also make a difference to clinical practice and the quality of patient care.
Nurses working in the clinical area need to be provided with more support and facilities to enable them to pursue a PhD or a professional doctorate in their areas of work/interest. This will help enhance the number of nurse clinicians who can become more confident and efficient leaders not only on their clinical area of practice but also in implementing policies that enhance nursing practice and profession. However this can only be achieved by addressing issues within the nursing profession, where nurse leaders stress the importance of tertiary education and provide avenues for nurses through scholarships and flexible working hours.
Statistical data in relation to number of nurses with a PhD and percentage of these nurses employed in the clinical area are important to write necessary propositions of need. A national database of nurses including demographic details (such as area of employment, age gender, etc.) of nurses who obtain their doctoral degree is necessary.
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PII: S1322-7696(08)00043-7
doi:10.1016/j.colegn.2008.05.001
© 2008 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
