Barriers and enablers to scholarship for post basic nursing students in clinical service

Background Clinical scholarship is defined as an approach that enables evidence-based nursing and the development of best practices to meet the needs of clients efficiently and effectively. However, there are many barriers that impede its progress. Objective This study aimed to identify the barriers and enablers to scholarship for post basic nursing students in clinical service areas. Method This multimethods study used a structured questionnaire followed by semi-structured individual interviews of post basic nursing students and their lecturers (nurse educators). Results The 81 students who completed the questionnaire indicated a lack of support or funding assistance and mentoring, as well as no mechanisms to reward or recognise scholarship as top barriers to clinical scholarship. Top enablers were noticed as reward mechanisms in place, more protected time and availability of role models and mentoring. Twelve respondents engaged in the qualitative phase and three categories emerged from the data, namely (1) resource dependent, (2) ‘what’s the use of research’, (3) making a change. Conclusion It has been shown that there is a need to adopt and promote a culture of clinical scholarship to ensure that the best available evidence is being utilised by nurses to effectively manage their patients; however, to support clinical scholarship, resources are needed. Contribution This study highlighted the lack of funding and resources as being a major barrier to scholarship, together with an institutional culture that did not promote clinical scholarship. Providing protected time, mentoring and criteria for promotion and reward based on scholarship is viewed as enabling.


Introduction
Clinical scholarship is defined as an approach that enables evidence-based nursing and the development of best practices to meet the needs of clients efficiently and effectively (Wilkes, Mannix & Jackson 2013, Zullig, Deschodt & De Geest 2019. Although among nurses, the definition of clinical scholarship is not well understood (Carter et al. 2017;Wilkes et al. 2013), efforts should be made to encourage them to engage in scholarship thereby improving patient care and, ultimately, patient outcomes (O'Connor & Peters 2014;Roets, Botma & Grobler 2016;Weston & Hudson 2014;Wilkes et al. 2013).
Clinical scholarship should not only be viewed as clinical research or clinical proficiency but also as a check point that seeks to address pertinent questions about patient care. The hallmark of clinical scholarship questions traditional notions of nursing, which may then be systematically challenged so that improved patient care outcomes may be forecasted (Sigma Theta Tau International Clinical Scholarship Task Force 1999;Sigma Theta Tau International 2015). Weston and Hudson (2014) agreed that clinical scholarship should be the 'nucleus' of nursing practice, creating opportunities for learning, leading to improved clinical practice and care enhancement. Clinical scholarship embraces knowledge from other disciplines to expand understanding and highlights the need for peer-reviewed documentation, logical presentation and effective dissemination; also creating opportunities for clinical nurses to integrate nursing theories in practice (Papathanasiou, Tsaras & Sarafis 2014). Weston and Hudson (2014) emphasise that clinical scholarship is not just about solving immediate issues related to illnesses but it also explores how nurses can improve clinical practice on a broader scale.
Nurses working in the clinical service areas should be encouraged to appreciate and embrace clinical scholarship as an essential element of the nursing profession to guide and give answers to important issues in the clinical arena and practice (Carter et al. 2017;Weston & Hudson 2014). Clinical scholarship is an approach that achieves positive patient outcomes (Makic et al. 2013).
Despite this, the application and promotion of clinical scholarship in the clinical arena has been limited. Although recently efforts are underway in some countries to promote clinical scholarship, clinical nurses globally have reported on the numerous individual and organisational obstacles (such as a lack of research knowledge, skills, time etc.) to conducting research in the clinical areas thus making clinical scholarship difficult to conceptualise and implement (Carter et al. 2020;Wilkes et al. 2013). A need to focus on clinical specialist nurses in this regard has emerged as they are perfectly positioned between the clinical and academic worlds and best situated to be asking questions to address important clinical problems (Oster, Ludwigson & Lewis 2020) and are thus able to provide insight into barriers and enablers to clinical scholarship.

Aim of the study
The aim of this study was to identify the barriers and enablers to clinical scholarship for post basic nursing students in clinical service areas.

Methods
This multimethods study (Anguera et al. 2018) comprised a non-experimental, quantitative descriptive survey as well as individual semi-structured interviews with students and lecturers. Boyer's Framework of Scholarship (Boyer 1990) was used to guide the study as it proposes that a scholar engages in four essential and interrelated areas of scholarship in the pursuit of knowledge. These are scholarship of discovery (searching for problems and explanation of research); scholarship of integration (interpreting the findings of the research and sharing with and across the discipline); scholarship of teaching (creating interaction between the one delivering the knowledge and the one receiving the knowledge) and scholarship of application (translating the knowledge so that it impacts positively on society). Smith et al. (2012) agree that incorporating these four components could assist nurses to engage in the activities of clinical scholarship.

Research setting and respondents
The research was conducted at a selected university offering a wide variety of nursing programmes located in KwaZulu-Natal, South Africa.
The study targeted all registered post basic (post registration) nursing students and their lecturers (nurse educators) involved in the following undergraduate (a comprehensive practice degree for post registration nurses) or postgraduate clinical programmes, for example, Critical Care and Trauma (n = 46), Oncology and Palliative Care (n = 21), Advanced Midwifery and Neonatal Nursing (n = 39) and Nursing Management (n = 56). Following advice from a statistician and considering the small population size, a census sampling strategy was identified and all eligible respondents (n = 162) were invited to participate in the study.

Research tool
Guided by Boyer's framework (1990), the researchers developed a questionnaire adapted from a previous study by Smesny et al. (2007).
The questionnaire was made up of the following sections: (1) demographics (7 questions), (2) barriers to clinical scholarship (13 questions) and (3) solutions or enablers to these barriers (16 questions). The tool asked the respondents to rate their responses on a 4-point Likert scale ranging from 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. Owing to minimal responses in some categories, the 4-point Likert scale was condensed to form a 3-point Likert scale where responses of 'strongly disagree' and 'disagree' as well as 'agree' and 'strongly agree' were grouped together to improve stability and generalisability (Boone & Boone 2012).
The interview guide for the qualitative interviews was developed using Boyer's framework (1990) and asked respondents to describe barriers and facilitators to the different components of scholarship, as well as responses from the questionnaire, which needed additional probing.

Data collection process
Data collection took place after ethical clearance and permission was obtained from the university research ethics committee as well as the registrar of the university and head of nursing. In collecting the quantitative data, the researcher (J.-P.A.), a postgraduate student himself not registered in any of the programmes involved in the study organised to meet with the lecturers of the respective programmes to arrange a convenient time and venue to meet the nursing students. Data were collected during the students break time or after class and the survey took approximately 15-20 min to complete. Questionnaires were distributed to the respondents after obtaining written informed consent and all questionnaires were distributed and collected on completion by the researcher (J.-P.A.) The individual semi-structured interviews were held with eight students and four lecturers who indicated their willingness to be interviewed. These interviews asked the respondents about barriers to clinical scholarship and to also suggest ways to promote clinical scholarship in the clinical service area. The respondents were contacted individually and a convenient time was arranged. The interviews were conducted in a quiet venue on campus and were audio recorded with the respondent's permission. The researcher (J.-P.A.) faced unexpected challenges during this phase as university strike action meant that respondents were not available on campus and thus interviews were delayed by a few weeks. The decision that data redundancy had been reached was decided on by the research team through extensive discussion.

Data analysis
Using the Statistical Package for the Social Sciences (SPSS), version 23, and with the assistance of a statistician, descriptive statistics consisting of frequencies and percentages were carried out. The analysis of the qualitative data was performed manually using qualitative content analysis (Graneheim & Lundman 2004, Erlingsson & Brysiewicz 2017 where the data collected were collected and transcribed verbatim by the researcher (J.-P.A.), thereafter coding and development of categories was undertaken by the whole research team (the student and his two research supervisors).

Rigor
A pilot study of the questionnaire, involving nursing students (five) from the sample, showed no difficulty in answering the tool, thus no changes were made and their data were not included in the final analysis. Cronbach's alpha was calculated at 0.94, indicating excellent internal consistency (Clark & Creswell 2015). Face validity was achieved through consultation with two nursing clinical and research experts from the research setting and no changes were made.
For the qualitative data, the research team attempted to make the transcripts of interview materials (the 'respondent voices') available in sufficient detail in the text to provide the reader with an opportunity to follow the researchers' move from data collection to data interpretation. Data analysis was carried out independently by the researcher (J.-P.A.) and then discussed and interrogated in detail by the research supervisors (W.E. & P.B.), who are experienced qualitative researchers. The researchers also attempted to provide sufficient detail of the research process (Lincoln & Guba 1985) and the findings were validated by the respondents.

Ethical considerations
Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (No. HSS/1550/016M) and gatekeeper permission from the university registrar and head of nursing was obtained. Respondents were made aware of the purpose of the research and that they are under no obligation to participate in the research, and that refusal would not affect their studies in any way. All data collected from respondents were de-identified and stored securely in a locked cupboard and password protected computer; only accessible to the research team. Data were stored with the research supervisors for a period of 5 years.

Quantitative survey
A total of 81 nursing students completed the questionnaire indicating a response rate of 50%.

Demographic data
There were 81 nursing students (only 2 males) who ranged in age from 20 to over 41 years old. Forty-five of the respondents had between 0 and 10 years of experience in nursing and 71 were post registration undergraduate nursing students and 10 were postgraduate students (see Table 1).

Barriers to clinical scholarship
The top-rated barriers for clinical scholarship that were report and need to be considered were; lack of support or funding mechanisms to support scholarship of application or teaching in funding agencies or organisations (n = 64, 84.0%), clinicians need assistance or mentoring in writing publications or other mentoring activities related to scholarship (n = 67, 82.7%) and no mechanisms to reward or recognise scholarship of teaching or scholarship of application locally or nationally (n = 64, 79.0%). The lowest rated barrier was: clinical services requirements and teaching reduce opportunities for scholarship (n = 47, 58.0%) (see Table 2).

Enablers to clinical scholarship
The top enablers to clinical scholarship were: re-examined criteria for promotion and reward on scholarship (n = 75, 92.6%), provide more protected time and/or uninterrupted time and resources to perform scholarship of all types (n = 74, 91.4%) and using lecturer role models, create a collaborative mentoring programme which may include training on how to approach writing papers and grantsmanship (n = 74, 91.4%). The item with the lowest score was using Boyer's Model of Scholarship (n = 66, 81.5%).

Qualitative individual interviews
The 12 individual semi-structured interviews were held with eight students and four lecturers (respondent code; NS =  'What's the use of research?' The second category that emerged as a barrier to clinical scholarship described how some nurses do not see the relevance and importance of research and its value in clinical practice at the bedside, as one respondent, a nurse educator, explained: '

Making a change
In order to enable and promote clinical scholarship, the respondents described how it is important to foster a change in the way in which nurses view research and clinical scholarship activities. There are however difficulties with this as one respondent explained: 'Some [nurses] don't feel comfortable with changing, because they like doing their comfort thing, they are comfortable in their old attitude and ways of doing things, which they developed their routine that they don't want to change …' (NS 3, > 41 years old, 10 years experience) One respondent admitted that another problem for nurses in developing clinical scholarship is that they are not confident and assertive enough to defend their own research: In considering solutions to this problem a respondent explained: 'I think the division between education and clinical practice is one important thing that must be avoided. That distance between clinical and the theory of college or university, that distance must be narrow.' (CE 3, > 41 years old, 39 years experience)

Discussion
The quantitative data indicated that the top-rated barriers to clinical scholarship included the lack of support or funding mechanisms, the need for assistance or mentoring in various activities related to scholarship and no mechanisms currently available to reward or recognise scholarship. The top enablers cited were to institute criteria for promotion and reward regarding clinical scholarship, provide more protected and/ or uninterrupted time and resources to perform scholarship, as well as to provide experts and mentors to guide and assist in various scholarship activities.
The qualitative data revealed that the respondents viewed a major barrier to their own clinical scholarship development being the lack of appropriate resources such as money for studies and research as well as having access to people with expertise to guide them in the process of evaluating their nursing care in order to institute improvements where necessary. An additional barrier to clinical scholarship was that nurses struggle to see the relevance and importance of research and its value in clinical practice. The respondents went further to suggest that in order to enable clinical scholarship, it is important to foster a change in the way in which nurses view research and clinical scholarship activities.
From the study's finding, it has been highlighted that a lack of funding and resources were identified as being a major barrier to scholarship in limiting the nurses' involvement in scholarly activity and Anderson et al. (2013) agree that this is often a major setback. In an Australian study, more than 90% of the respondents were unable to pursue further educational training towards scholarship development because of a lack of financial aid (O'Connor & Peters 2014). Pintz et al. (2018) suggest that it is necessary to establish and/or sustain a designated budget with funds to recognise, support and reward nursing research activities and accomplishments.  (2015) and Siedlecki and Albert (2017) state that having a good role model or mentor is needed to assist in providing important guidance in helping clinical nurses to integrate research and practice. Carter et al. (2020) suggests that partnerships between practice and academic institutions may be a way forward to build and support research capacity in clinical nurses such as a joint nurse scientist role, which then fosters a partnership between academia and service.
Siedlecki and Albert (2020) do however caution that removal of the barriers does not guarantee an increase in research activities; clarity regarding the understanding of clinical scholarship is needed and attention should be a given to ensuring that the elements and qualities of a clinical scholar is clear to nurses. Casamitjana et al. (2022) also suggest that in order to achieve scientific equity in health research, gaps in individual and institutional capacity and infrastructure in low-and middle-income countries must be addressed.

Limitations of the study
A major limitation was the sample size that affects the generalisability of the study, however the researchers attempted to overcome this through the use of multiple methods. The second limitation identified was that the study included only one setting, thus different areas may be experiencing different challenges. The developed research tool used in the quantitative aspect of the study needs further validation and wider use.

Recommendations
It is recommended that a study with a larger sample size and incorporating different research settings should be conducted to enable generalisability of the findings. Current nursing curricula should be interrogated to ensure that they are providing sufficient understanding of clinical scholarship, its essential role within the nursing profession and ways to support it within the clinical service arena. The clinical settings should work towards creating a conducive environment for clinical scholarship development and there should be more emphasis placed on the importance of integrating research into clinical practice, as well as research utilisation in the clinical arena.

Conclusion
This study has highlighted the barriers and enablers towards clinical scholarship. Nurses are the most dominant cadres in a healthcare system and are key role players in providing patient care. For this reason, nurses need to embrace and promote a culture of clinical scholarship, thus ensuring best available evidence is being utilised to best manage their patients, however resources are needed in order to make this a reality.