Empowering nurses through inclusive leadership to promote research capacity building: A James Lind Alliance priority setting Partnership in Community Nursing

Abstract Aims This paper focuses on the benefits of inclusive leadership when undertaking a priority setting partnership in community nursing, through providing a collaborative and committed nurse‐led forum for initiating impactful changes, identifying evidence uncertainties and driving research capacity‐building initiatives. Design This is a Discussion paper. The project was undertaken between 2020 and 2021. Data sources This paper is based on shared reflections as 70@70 Senior Nurse Research Leaders and is supported by literature and theory. It draws on issues relating to collective leadership, stakeholder engagement, diversity, inclusivity and COVID‐19. Implications for nursing The James Lind Alliance Priority Setting Partnership catalysed the development of a rigorous evidence‐base in community nursing. The collaborative opportunities, networks and connections developed with patients, carers, nursing leaders, policy makers and healthcare colleagues raised the profile of community nursing research. This will benefit nursing research, practice, education and patients in receipt of community nursing care. Collective buy in from national leaders in policy, education, funding and commissioning has secured a commitment that the evidence uncertainties will be funded. Conclusion Four key learnings emerged: collective leadership can ensure learning is embedded and sustained; developing an engaged stakeholder community to promote community nursing research is essential; a diverse membership ensures inclusivity and representation; and insights into the impact of COVID‐19 aid progress. The process increased research engagement and created capacity and capability‐building initiatives. This will help community nurses feel empowered to lead changes to practice. Sustained engagement and commitment are required to integrate research priorities into community nursing research, education and practice and to drive forward changes to commissioning and service delivery. Impact The study promoted research capacity building through inclusive leadership. This can increase community nurses' research engagement and career development and patient care quality and safety; this can incentivize funders and policy makers to prioritize community nursing research.


| INTRODUC TI ON
Globally, patients who participate in a research report greater satisfaction with care and improved clinical outcomes (Ozdemir et al., 2015). Similarly, research-active healthcare organizations have lower mortality rates and higher quality care outcomes, highlighting the positive effects of healthcare research at an international level (Royal College of Physicians, 2020).
Nurses are the largest group of healthcare professionals worldwide and are continually engaged in innovative practice (Hughes, 2006), providing more patient-facing care than other healthcare professionals. Because of their close proximity to patients, nurses are able to rapidly adapt and respond to international public health challenges adeptly and with expertise (Hughes, 2006); the recent COVID-19 pandemic has illustrated this. This places nurses in a prime position to contribute to, and shape, healthcare policy and practice through the utilization of research knowledge, skills and practice to improve service delivery and care outcomes.
However, this ability to respond to challenges has been less evident in a research context.
Despite their positioning, nurses often lack the research expertise, confidence or engagement required to lead others in the healthcare system. Reasons for this are multifaceted and include a lack of protected time to undertake research training, unstructured career progression pathways to support them, a lack of mentorship and role-modelling and limited buy in from partner organizations (Henshall, Greenfield, et al., 2020;Henshall, Kozlowska, et al., 2020).
This problem is exacerbated in community nursing where there is a lack of clinical academic nurses and sub-optimal use of the evidencebase in clinical decision-making (Bowers, 2018). This is in part due to specific challenges community nurses face in engaging with research; a recent systematic review found that practical barriers in implementing evidence-based practice in community nursing settings included research implementation challenges, organizational and infrastructure changes, research uncertainty and research being perceived as incompatible with community nursing roles (Mathieson et al., 2018). This combined with a lack of time, heavy patient caseloads, staff shortages and autonomous working practices means that the research component of the community nurse's role is often lacking (Brooke & Mallion, 2016). However, these autonomous working practices make it even more important that community nursing practice is embedded in the evidence base, as community nurses often lack the peer-to-peer support in decision-making that many of their hospital-based nursing colleagues benefit from. With changes to community nursing practice evolving rapidly, community nurses need support to help them meet the outcomes that matter most to patients and carers (Kenkre et al., 2013).
Many different definitions of community nursing exist, with a lack of clarity around their role. Community nurses are often described as 'nurses who care for people in their own homes' (Mathieson et al., 2018). However, in the UK, the boundaries are much more blurred with community nurses acting as the conduit between community, primary and secondary care settings, as well as working closely with social care services and local authorities to ensure the holistic needs of patients are met. Community nurses have long been leaders in promoting this kind of partnership working and the benefit this can bring to patient and service outcomes across healthcare systems have been identified in recent policy documents (NHS, 2021). The National Health Service's (NHS) Long Term Plan sets out its vision for implementing integrated care systems (ICSs) across England by 2021. ICSs promote the dissolution of traditional divisions between hospital and home care, with a view to providing coordinated support across the NHS, social care services, local councils and the voluntary sector (NHS, 2021).
Despite the recognition by the UK government that coordinated working between hospital and community settings is imperative for optimizing patient care outcomes (NHS, 2021), there remains a substantial lack of research investment in community settings, with anecdotal evidence suggesting a disproportionate amount of research funding is directed towards acute hospital care settings.
This lack of research funding has had a detrimental effect on community nursing research, adding yet another barrier to community nurses' abilities to engage with the evidence base. These barriers persist at an international level, with an American study reporting on barriers to research nursing utilization in a Magnet community hospital. The study found that barriers included a lack of a supportive environment for research, a lack of research access and availability, a lack of research education and communication and minimal practical application of research (Karkos & Peters, 2006). Furthermore, an Australian study surveying current practice and guideline use in adult cancer pain assessment and management by community nurses found that a range of healthcare system, health professionals and consumer barriers limited access to the best available treatment.
The study recommended that an evidence-based clinical pathway was required to enable community nurses to ensure their patients had access to the best available care (Philips & Lovell, 2015).

Despite efforts by the International Collaboration for Community
Health Nursing Research (ICCHNR) to provide support for and patient care quality and safety; this can incentivize funders and policy makers to prioritize community nursing research.

K E Y W O R D S
community care, leadership, nursing, nursing research, professional development, research in practice community nurses on a global level through building an international network of nurse researchers, hosting conferences and funding scholarship awards (ICCHNR, 2021), engagement in evidence-based practice remains less than satisfactory (Bowers, 2018), with a lack of studies in community nursing (Bowers, 2018). This has potentially devastating consequences for the future of the community nursing profession and its ability to keep up to date with changes across healthcare systems, with resulting implications for the retention and recruitment of staff and the quality and safety of patient care.
To address some of the issues described above, a group of senior nurse and midwife research leaders (SNMRLs) undertook a James Lind Alliance Priority Setting Partnership (JLA PSP) bringing together carers and clinicians in Community Nursing (James Lind Alliance, 2021a), between March 2020 and September 2021, to identify the top 10 evidence uncertainties in this area. This was done to raise the profile of community nursing research and to attract more research funding to this area of healthcare; JLA PSPs focus on issues that are of direct relevance and potential benefit to patients, their carers' and healthcare professionals (James Lind Alliance, 2021b). To work together as a collective with a view to empowering other nurses in the community nursing landscape, concepts and theories from the literature around inclusive leadership were studied and used as a framework with which to conduct the PSP. Table 1 shows how the theoretical concepts underpinning inclusive leadership were reflected on and interpreted by the SNMRLs before being applied to the JLA PSP. Inclusive leadership can be defined as 'words and deeds by a leader or leaders that indicate an invitation and appreciation for others' contributions', with inclusive leaders shaping situations where 'voices are genuinely valued' (Nembhard & Edmondson, 2006). Furthermore, positive correlations have been found between inclusive leadership styles, innovative work behaviours and psychological empowerment (Javed et al., 2018). Through the provision of a supportive climate and attempts to include others in discussions and decisions where their TA B L E 1 Reflections on inclusive leadership theory and its application to the JLA process voices and perspectives might otherwise be absent (Nembhard & Edmondson, 2006), this model of leadership was applied to the JLA PSP in an attempt to empower and inspire others to engage in reallife issues surrounding community nursing practice.
This paper focuses on the benefits of inclusive leadership in providing a collaborative and committed nurse-led forum for initiating impactful changes across community nursing, by identifying evidence uncertainties, raising the profile of these uncertainties and driving forward research capacity-building initiatives in community nursing on a national and international level.

| BACKG ROU N D
The project sought to address a gap in nursing knowledge by undertaking a JLA PSP in community nursing, to promote and increase engagement amongst community nurses in research at a national level.
The JLA is a non-profit making initiative that brings patients, carers and clinicians together in PSPs. PSPs identify and prioritize evidence uncertainties, or unanswered questions relating to a specific area of healthcare, to ensure that health research funding bodies consider which research questions to prioritize (James Lind Alliance, 2021b). wives (Henshall, Greenfield, et al., 2020). SNMRL cohort members were provided with 2 days' protected time each week as part of the 70@70 Programme to drive forward research innovations and initiatives to generate, lead and support research activity, as well as informing research priorities at a local, regional and national level (Henshall, Greenfield, et al., 2020).

| Data sources
This discussion paper is based on shared reflections, through extensive note-taking after meetings and frequent team discussions (Gibbs, 1988), supported by relevant literature and inclusive leadership theory (Bortini et al., 2018). The paper draws on four main areas that emerged relating to the PSP. These were collective leadership, stakeholder engagement, diversity and inclusivity and the impact of COVID-19.

| Collective leadership
Many collective benefits emerged from the PSP, not least the ability to influence and lead through collaboration. As a core team of

| Stakeholder engagement
Increasingly, there is a requirement in research funding applications for patients and the public to be an integral part of the research design, delivery and dissemination process. Lack of involvement and engagement from these individuals can have a negative impact on successful outcomes, as an application's perceived value and credibility are undermined (Horrocks et al., 2018). This meant that in the JLA PSP, the research priorities of healthcare professionals' patients' and the public needed to be identified, listened to and heard, to appreciate the true complexities and context of the area under investigation (Schot et al., 2019). The JLA PSP process epitomizes this concept through its collaborative nature, working with patient and clinical communities, without imposing a top-down, inflexible set of rules. Whilst the JLA PSP leaders' imposed structure and process to the project, the stakeholders contributed knowledge, experience, insights, networks and personal and professional investments TA B L E 2 An outline of the steps involved in the James Lind Alliance priority setting process

The priority setting partnership process
Create a steering group with equal representation of patients, carers and clinicians and strong links to relevant partner organizations; and raise awareness of the project to maximize support and participation.
Gather evidence of uncertainties by asking patients, carers and clinicians to respond to a survey asking what questions they have for research, and by searching existing literature to identify gaps.
Refining questions and uncertainties -the steering groups work with a JLA information specialist to create a long list of summary questions from the survey responses.
Evidence checking-the long list of summary questions is checked against the existing research evidence to ensure that they have not previously been answered by research.
Interim prioritization -through consensus, the steering group prioritizes the identified uncertainties by asking patients, carers and clinicians to complete a second survey to rank the research questions.
Final prioritization -this is generally a one-day workshop facilitated by the JLA and with input from the steering group; up to 30 patients, carers and clinicians will participate in discussion and ranking to determine the top 10 questions for research.
Publish and promote Top 10 research priorities -the Top 10 is announced and published and a publication and promotion plan is implemented to disseminate the results and influence researchers. in future research, in and across their spheres of interest. This led to a sense of empowerment as the shared research priorities generated from the PSP belonged to everyone involved (James Lind Alliance, 2021b).
Throughout the PSP, it was anticipated that community nurses at a local and national level would engage with, enhance and expand their involvement in research and start to critically analyse their own clinical practise to ensure its alignment with up-to-date evidence.
The collaborative, inclusive approach generated by the SNMRLs was and influence (Nembhard & Edmondson, 2006). This was achieved by understanding the views and needs of the people involved in the process and by actively drawing on the diversity and richness of different perspectives, backgrounds and experiences (Amin et al., 2018).
This enabled the SNMRLs to become more adept at including the wider stakeholder group in PSP discussions and decision-making and to facilitate a supportive environment to encourage sharing of opinions and perspectives (Nembhard & Edmondson, 2006) (Table 1).

| Diversity and inclusivity
The four SNMRLs held a broad variety of roles including Lead  (Witham et al., 2020). In terms of the PSP, every effort was taken to ensure that a representative mix of steering group members and survey responders with different genders, ethnicities and geographical locations was obtained; however, this was not without its challenges. The steering group meetings included representation from a variety of ethnicities and cultures, which led to meaningful discussions relating to survey development. For example, the survey wording was altered to reflect the fact that in some cultures, family members do not identify as 'carers', but maintain their identity as a husband, wife or family member (Hughes et al., 2013). These insights supported the group to develop a survey that was as inclusive as possible. This collaborative nature of the group also meant that relationships and confidence grew over time, with a growing focus on the purpose of the team's shared objectives.
In terms of the survey, contributions from patients and carers were continuously monitored to promote inclusivity and diversity of the responders (Figure 1). During the dissemination of the first survey, it became clear that certain sectors of the population were underrepresented. However, with regard to gender, this was not the case. The NMC register to practice, records more women (89%) than men (11%) on its nursing register (NMC, 2021). This is in line with our survey findings which recorded 92% of responses from women and 8% from men, largely representative of the nursing workforce.
Geographically, there was representation from all areas of England, although 62% of all respondents came from the North. Most survey respondents were people who identified as being of White ethnicity (94%). The remaining 6% were from a range of ethnically diverse backgrounds including Black, African, Caribbean, Black British, Asian British (1.7%), Asian (1.4%), Mixed, multiple ethnic groups (0.8%) and other (0.5%) with the remaining 1.6% preferring not to say. Diversity was monitored throughout the PSP process, however, due to the challenges of non-face-to-face contact and an inability to target specific religious groups during the COVID-19 pandemic, we were unable to achieve the level of diversity that we would have liked.
Efforts to rectify this included snowball sampling, utilizing personal contacts to increase diversity at the start of the process and the identification of community gatekeepers to explain the value and purpose of the research to hard-to-reach communities (Lee, 2005).
Other strategies included utilizing social media platforms and targeting communications to key stakeholder groups, as well as connecting with individuals via email as a means of building the PSP network and staying connected virtually. Despite these outreach initiatives, limited progress was made. This may be partly due to the COVID-19 pandemic which meant that many community nurses were under enormous workplace pressures and were unable to prioritize the dissemination of the surveys to community groups.

| The impact of COVID-19
Despite the challenges faced, with the UK having one of the highest rates of infection globally at certain timepoints during the pandemic

| Implications for nursing
An international study investigating how nursing leaders promote evidence-based practice found that the involvement of patients was lacking throughout this process (Kitson et al., 2020) This can lead to widespread benefits for nursing research, practice and education, and most importantly, for patients who will be in receipt of community nursing care in the future.
Collective buy in and engagement with the JLA PSP from national leaders in areas such as policy, education, funding and commissioning has resulted in a commitment that the evidence uncertainties identified will be funded and focused on in the future. However, in addition to funding the evidence uncertainties, more widespread action is required to ensure the legacy of the PSP is long-lasting and influential. The creation of research strategies developed to support community nursing research, such as the Welsh Community Nursing Research Strategy (Kenkre et al., 2013), is one way to facilitate the embedding of evidence in community nursing, by supporting nurses with the right research infrastructure and encouraging them to play an active part in developing community nursing research and evidence-based practice (Kenkre et al., 2013).

| CON CLUS ION
The 70@70 SNMRL programme facilitated a shared platform for nurses working across different healthcare boundaries, with different healthcare priorities, to raise the profile of community nursing research, with international implications for nursing practice.
The programme promoted inclusive leadership and empowered SNMRLs to initiate capacity and capability-building strategies that were made possible due to the profile and connectivity resulting from it. The diversity in leadership, organizational representation, networking and geographical scope of the PSP provided an opportunity to benefit those working and living in the community in the long term.
Revitalizing an area of practice to address the lack of evidence underpinning the activities of a profession requires a truly collaborative and inclusive effort to be effective. Seen through the lens of inclusive leadership, contributors to the process were encouraged to raise the voice of less represented views and to challenge their own biases and preferences. The value of applying the theoretical principles of inclusive leadership to practice (Table 1), and the national collaborative effort this entailed, led to the creation of a national network of nurses, patients and carers that developed research priorities to change the way community nurses' practice. An inclusive leadership approach was effective in generating momentum in community nursing research and transcended the outcomes of the PSP itself. The sustained engagement that has been harnessed from the process can be applied across practice, research and education, with a focus on discovering the best ways of translating and applying research findings into practice and vice-versa. This model of inclusive leadership can be applied to other areas of nursing outside of community settings and across international nursing contexts and cultures, by prioritizing shared decision-making and empowering others to develop tangible outputs that can change practice for the better.
Through its inclusive approach the JLA PSP has ensured that its legacy goes further than solely ascertaining funding to deliver research on the top 10 evidence uncertainties; it has also increased engagement, created capacity and capability-building initiatives and raised the profile of community nursing research. This is essential to ensure that research becomes a core part of the practice and that community nurses feel empowered to lead changes to practice through questioning the evidence base. Continued, sustained engagement and commitment is required to influence funders of research, integrate research priorities into community nursing research, education and practice and drive forward changes to commissioning and service delivery as a means of optimizing patient care.

ACK N OWLED G EM ENTS
We would like to thank all the patients, carers and healthcare profes-

FU N D I N G I N FO R M ATI O N
This study was funded by the National Institute for Health Research Applied Research Collaboration.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15342.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.