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Scand J Caring Sci. 2021;00:1–11. wileyonlinelibrary.com/journal/scs

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BACKGROUND

Healthcare deficiencies cause unnecessary suffering for pa-tients and entail increased costs for the healthcare system.

Research shows that approximately one third of all patients fail to receive scientifically based care, while about one quarter either receive unnecessary care or care that may be injurious to their health (1,2). To minimise patient risk,

R E V I E W

Roles and functions in clinical care for registered nurses with a

PhD— A systematic literature review

Marie- Louise Orton RN/RM, Doctoral Student

1,2

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Nina Nelson Follin MD, PhD, Professor

1,2,3,4

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Petra Dannapfel PhD, Strategic Business Developer

2,5

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Yvonne Wengström RN, PhD, Professor

1,6

This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made.

© 2021 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.

1Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden 2Karolinska University Hospital, Stockholm, Sweden

3Division of Children's and Women's Health, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden 4National Specialized Medical Care, Stockholm, Sweden

5Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

6Theme Cancer, Karolinska University Hospital, Stockholm, Sweden

Correspondence

Marie- Louise Orton, Nya Hemmet T5, Karolinska University Hospital, SE- 17176 Stockholm, Sweden. Email: marie-louise.orton@sll.se

Funding information

This research was not funded by any grants from public, commercial or non- profit entities. The study was conducted with support from Karolinska University Hospital.

Abstract

Background: Nurses are responsible for nursing care and their expertise is crucial for

quality of care. One factor important to successful delivery of evidence- based care is availability of staff with the expertise to support their colleagues in this endeavour. RN/ PhDs versed in scientific research with a thorough knowledge of their disciplines have the potential to help narrow the gap between theory and practice. The roles and functions of RN/PhDs involved in clinical care have not yet been well defined.

Aim: To explore publications concerning clinical contributions from registered nurses

who hold a PhD (RN/PhDs) regarding impact on quality and improvement of care.

Method: A systematic literature review was conducted and qualitative content analysis

was applied to the data obtained from the included studies.

Findings: The leadership role is considered essential for RN/PhDs, where the focus is

on the pursuit of evidence- based practice and the improvement of nursing practices. The opportunity to combine the clinical and academic aspects of nursing is considered crucial in order for RN/PhDs to influence and improve care, yet few such positions are currently available. RN/PhDs cited limited career opportunities as one important reason for not combining clinical and academic work.

Conclusions: In order for nursing practice to reach full potential, clinical positions with

clearly defined job descriptions for RN/PhDs are needed. To fully leverage their exper-tise, it is important to allocate sufficient time to conduct relevant research, as well as to support colleagues and students in the improvement of clinical practice.

K E Y W O R D S

registered nurses, doctoral degree, clinical practice, clinical research, evidence- based practice, leadership, systematic literature review

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it is important to strive for evidence- based nursing care. Evidence- based practice (EBP) refers to care that is rooted in the best currently available scientific knowledge, while taking into account the unique conditions and preferences of the patient, as well as professional clinical knowledge (3). Scientific knowledge is based on research; professional clin-ical knowledge is based on theoretclin-ical knowledge combined with knowledge derived from clinical experience. These per-spectives must be integrated to deliver high- quality individu-alised patient care.

A key task for healthcare managers is to ensure that patients receive safe, high- quality care. One important prerequisite is that employees have the skills appropriate to the tasks they per-form. Nurses are responsible for nursing care and their expertise is crucial for delivery of high- quality care (4– 6). Level of nurs-ing education (master's degree or higher) is linked to implemen-tation of research results (7). An association between research and improved quality of care has been confirmed (8).

Today, about 1700 registered nurses (RNs) in Sweden hold a PhD degree, corresponding to approximately 1% of the nursing workforce (9). Efforts have been made to increase this number, since RNs who hold a PhD in a scientific field and are thoroughly versed in their subjects are expected to improve quality of care (10).

Despite the steadily rising number of RN/PhDs, few main within the clinical care setting— a trend that is also re-flected internationally (11,12). This situation poses a risk that nursing care will fail to develop to its full potential due to the paucity of academically trained RNs pursuing clinical care.

One factor important for the development of EBP is access to staff with the expertise to support their colleagues in clinical care, for example by searching databases for relevant knowl-edge, developing guidelines, and reviewing and/or testing care interventions and procedures (13,14). Such tasks are integral to the work of many RN/PhDs in clinical care (15– 17). RN/PhDs possessing scientific expertise and thorough knowledge of their disciplines can potentially narrow the gap between theory and practice in health care. Currently, the roles and functions of RN/ PhDs working in clinical care, including their contributions to healthcare delivery, have not yet been well defined (15,18).

AIM

The overall aim of this paper is to explore published articles concerning clinical contributions from RN/PhDs regarding their impact on quality and improvement of nursing care.

Research questions:

1. What tasks/duties performed by RN/PhDs active in the clinical setting foster improvement of care?

2. Specifically, how does their expertise contribute to quality and improvement of care?

3. What impact does PhD- level nursing expertise have on quality of care and patient outcomes?

METHOD

We conducted a systematic literature review according to the Cochrane definition (19) of a systematic review:

… to identify, appraise and synthesize all the em-pirical evidence that meets pre- specified eligibil-ity criteria to answer a specific research question.

(20,21) Our method was based on a systematic literature review of data compiled from scientific studies published between 1986 and 2020 relating to our research questions in order to improve our understanding of these issues.

At the international level, two types of doctoral degrees are offered for RNs: the traditional Doctor of Philosophy (PhD) and the Doctor of Nursing Practice (DNP), which is a professional doctorate, also referred to as a clinical doctorate (22). The focus of this systematic literature review is RN/PhDs, defined as RNs who hold a PhD and who are actively employed in clinical care (full- time or part- time), regardless of position held.

Search strategy

Initially, database searches were conducted to identify rel-evant search terms related to the aim and research questions. In addition to using ‘MeSH terms’ (PubMed) and ‘subject terms’ (Cinahl), terms that appeared in titles and abstracts were examined for relevant studies and how studies were in-dexed. The searches, which were designed with support from a specialised librarian at Karolinska Institutet, explored se-lected issues and different databases.

The Boolean operators AND and OR were used to iden-tify and combine relevant search terms. Searches, which were filtered by title, abstract and publication in the English language, were adapted to the requirements of the two data-bases, PubMed and Cinahl. For detailed information about the search strategy, see Table 1.

In addition, a manual search was conducted by ex-amining the reference lists of all included publications. Duplicates (n  =  98) were excluded before reviewing the abstracts.

Inclusion/exclusion criteria

Published scientific studies from peer- reviewed journals (regardless of methodology) describing the duties and work

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situation of RN/PhDs who are actively employed (full- or part- time) in clinical care were included. Studies were lim-ited to those published in English that had an abstract in the database; no restrictions were placed on country of origin or publication date. Table 2 presents the included studies. Studies such as those that only described education and roles for RN/PhDs were excluded, as were those in which RN par-ticipants did not hold a PhD.

Types of studies

Of 12 studies deemed to meet the inclusion criteria, ten were conducted using qualitative methodology and two using mixed methodology (see Table 2). Six stud-ies (11,17,23,24,25,26) were interview studstud-ies, three (15,16,27) used surveys, one (28) was a collective case study with written cases, while one of the two ‘mixed methodology’ studies (12) combined interviews with ques-tionnaires and the other (29) combined interviews with a literature review. The number of participating informants in the different studies ranged from 5 to 166 (except for one case study that had three participants). The participants came from a variety of care settings (ranging from primary care to university hospital) and held different kinds of po-sitions. Purposive sampling was used to select participants for most studies, while snowball sampling was used for three studies.

Selection of studies

The first and last author independently screened all titles and abstracts identified in the database search to deter-mine if they met the eligibility criteria. Full- text copies were obtained for all potentially relevant articles, as well as for those where information was insufficient to take an initial decision. The selected articles were independently assessed for adherence to the inclusion criteria by the first and second author; discrepancies were resolved through discussion and adjudication with all authors of this paper. Figure 1 presents a flow chart diagram listing the number of articles identified as relevant.

Quality assessment

The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) template for assess-ment of qualitative studies was used to verify the methodo-logical rigour of each included study (21). The first, second and third author each independently conducted the quality assessment of all included articles; disagreements were re-solved through discussion. The twelve studies were judged to be of medium or high quality. No studies were excluded based on quality assessment.

Data extraction

All authors read the selected full- text articles. A review tem-plate was used to document the following relevant criteria: author and country, title, publication year, aim, study design/ method/context, main findings and quality. The first author extracted the data from all included articles, which the other authors verified for accuracy.

Data analysis

Data from the included studies were subjected to manifest qualitative content analysis (30) in order to gather and cat-egorise information concerning clinical contributions from RN/PhDs with respect to impact on quality and improvement of care.

The three main phases of the analysis were preparation, organisation and reporting. The analytical unit was the spe-cific full- text article, which was then subjected to manifest analysis. All authors read each article to gain an understand-ing of the content and results of the studies.

Structured analysis was conducted throughout the reading process using open coding in which notes and headings de-scribing content were written in the article margins. The cod-ing results were recorded on a codcod-ing sheet, after which they were generalised into subcategories and categories. Each cat-egory includes abstractions of data content and is assigned a name using content- characteristic words.

Database Search strategy Result

PubMed (((nurse*[Title/Abstract] OR registered nurse[Title/Abstract])) AND (doctoral degree[Title/Abstract] OR doctorate[Title/Abstract] OR PhD[Title/Abstract])) AND (clinical practice[Title/Abstract] OR clinical setting[Title/Abstract] OR clinical[Title/Abstract])

Filter: abstract and English

141

Cinahl AB (nurse* OR registered nurse) AND AB (doctoral degree OR doctorate OR PhD) AND (clinical practice or clinical setting or clinical)

Filter: abstract and English

232

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TABLE 2

Review protocol, articles included

Author, country, year

Title Aim Study design/method Participants/context Main findings 23

‘We´re at a watershed’; The positioning of PhD nurses in clinical practice To explore how PhD nurses are positioned in the clinic with a special focus on how they contribute to nursing practice. A qualitative research design with semi- structured interviews. Purposive sampling was used to recruit informants. Data were analysed using positioning theory. Six PhD nurses, nine nurse colleagues without PhD and six clinical nurse leaders. A University hospital and three regional hospitals in central Denmark Region The PhD nurses were responsible for implementing

based practice in

the clinic and in nursing culture as such.

Emphasis was placed on the importance of PhD nurses staying close to the clinic to conduct

based research of immediate

benefit to patient care.

24

The roles of Australian chairs in clinical nursing

To describe the goals, obstacles, facilitators and outcomes of joint appointments at the professorial level with links to both the academic and clinical settings in the Australian context.

Qualitative study using

structured

telephone interviews.

The interview notes were analysed for common themes. Using constant comparison, data analysis commenced concurrently with data collection. Purposive sampling. Six professors. The professors were selected from the membership list of the Royal College of Nursing, Australia; special interest group for clinical chairs. The arrangements between university and health sector partners in establishing the roles differed. All roles included components of education, research and politics to varying degrees. Clinical professorial nursing appointments can contribute to addressing perceived gaps in the links between academia and clinicians.

15

The role of PhD- prepared hospital- based nurses: an

Nordic

study

The purpose was to investigate and compare the prevalence of PhD- prepared nurses employed at university hospitals in the Nordic countries, to investigate what functions they fulfil and what research activities they undertake and to document how they describe their ideal work life.

A descriptive

sectional study.

An electronic questionnaire was sent to RNs with a PhD working at a university hospital in one of six Nordic countries.

Descriptive analyses were performed using SPSS Statistics. Purposive sampling. 166 RNs with a PhD working at a university hospital in one of six Nordic countries.

prepared nurses employed in hospitals were, on average, spending nearly half of their time on supervision, teaching and administration. At least 70% of respondents reported they were engaged in research, teaching, supervision and research utilisation activities.

Relatively few of the

prepared nurses

worked in a clinical setting: 46% in Sweden and fewer than 35% in the rest of the countries.

29

The Clinical Nurse

Researcher: New Perspectives The aim was to create a basis for a national survey of clinical nurse researchers (CNRs). Literature review Telephone interviews

four CNRs and their respective

chief nurse executives (CNEs) were interviewed.

Purposive sampling.

four clinical nurse

researchers: 12 had a doctorate in nursing, 16 had a doctorate in another field, 6 were enrolled in a doctoral program.

The results of the survey were compared with the issues identified in the literature. Congruity existed between survey data and published reports. Both sources agreed a doctorate is a necessity for CNRs. Some disagreement existed regarding an emphasis on clinical experience or a solid background in research and statistics.

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Author, country, year Title Aim Study design/method Participants/context Main findings 28

Integrating nurse researchers in clinical

practice—

a

challenging, but necessary task for nurse leaders To create awareness among nurse leaders, of what they may need to consider, when integrating nurse researchers as advanced nurse practitioners (ANP) at

level among their

staff.

Qualitative study. A collective case study design (cases written in third person describing own profile and function in clinical context). Purposive sampling. Three ANPs with a PhD employed at a large regional hospital in Denmark.

The results showed that regardless of same position, formal level of research expertise and overall responsibility, different approaches related to each ANPs professional profile, interest, academic ambitions and personality were seen. Therefore, an important task for nurse leaders is to clarify and adapt the role and content of the role to the context and to the RNs individual condition.

16

Description of nurse scientists in a large healthcare system To describe the role, activities, and outcomes of nurse scientists employed in a national healthcare organisation

(replicate

study of Sawin, see below)

A

sectional descriptive survey

design was used.

Descriptive statistics were used to summarise the data. Purposive sampling.

three nurse scientists,

most holding a PhD in nursing, though some with a Master's degree.

The study was conducted in a large healthcare system and its hospital affiliates in the United States. The primary job responsibilities of the nurse scientists were to facilitate the research of others, provide staff development related to research and EBP, participate in EBP projects, and administration. Only 26% of the nurse scientists ran their own research program and few nurse scientists had published the results of their work within the past year.

25

The

Prepared

Nurse in the Clinical Setting To investigate how PhD- prepared nurses describe and define their role within the clinical setting. A descriptive qualitative study. Methods: Interviews were conducted with the PhD nurses and analysed using qualitative data analysis. Purposive sampling.

Five PhD nurses, all

time

employees in the clinical setting.

Two main themes were identified: • bridging the research/practice gap • serving as a healthcare leader. • All participants cited their role in leading, encouraging, or participating in clinical nursing research.

17

Nursing management

matters for registered nurses with a PhD working in clinical practice To investigate what registered nurses (RNs) with a PhD working in clinical practice experience in terms of their role, function and work context.

Qualitative design, with

structured

interviews and inductive content analysis.

Snowball sampling.

Thirteen RNs with a PhD employed at three university hospitals in Sweden.

The main areas of responsibilities were related to practice development and implementation of research results. In their work, they experienced barriers to the full use of their expertise; the expectations and prerequisites of the organisation were not clearly defined, and they often lacked a mandate to create conditions for improving quality of nursing care.

TABLE 2

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Author, country, year Title Aim Study design/method Participants/context Main findings 27

Nurse researchers in children's hospitals

The aim of the study was to describe the role, activities, and outcomes of nurse scientists employed in children's hospitals in the United States.

A

sectional descriptive survey

design. Descriptive statistics were used to summarise the data. Content analysis was used to identify themes in the narrative data generated by

ended

questions.

Purposive sampling.

three nurse scientists, most

holding a PhD in nursing, some with a Master's degree.

The study was conducted in children's hospitals in the United States. Data suggest that the NR role has both commonalities and unique components when compared with the previous studies of NRs in adult hospitals. Conducting research, staff development related to research, and facilitating evidence- based practice or research were common responsibilities.

26

Clinical Practice of Doctorally Prepared Nurses ‘To describe the clinical experiences of doctorally prepared nurses whose primary professional role is providing nursing care’. Qualitative descriptive design with a phenomenological approach. Snowball and purposive sampling. Telephone interviews were conducted.

articipants with a doctoral degree (PhD, DNSc, DNS/DSN, EdD) from 13 states in the United States. Practice settings included inpatient acute care and various outpatient/community health settings. Differences in nursing practice that could relate to doctoral education were found, both in direct

on care and in skills that

helped care delivery.

Positive changes in image and status were reported. Problems related to having a doctorate in clinical care were identified.

11

Combining clinical practice and academic work in nursing

‘To obtain

depth insight

into the perceptions of nurse academics and other

holders

regarding

the importance, facilitators and barriers for nurses combining clinical and academic work in university hospitals’. A qualitative study using semi- structured interviews as well as focus groups. Purposive sampling. Individual interviews and two focus groups with 14 participants.

24 individual interviews and two focus groups with 14 participants. The participants were physicians, managers and nurses, including 7 RNs with a PhD, They came from two Dutch university hospitals and affiliated universities. Three themes were identified: Culture:

Current nursing culture emphasises

direct patient care, which is perceived as an academic misfit.

Leadership:

Leadership is lacking at all

levels, resulting in the underuse of nurse academics.

Infrastructure:

Absence of support structures

for nurses who combine clinical and academic work.

12

Nurses in the clinical

area: Relevance of a PhD To explore the application and relevance of a PhD to nurses working in the clinical area. Mixed method, surveys and interviews. Purposive and snowball sampling. Participants 19 nurses with a PhD working/ having worked in a clinical area after obtaining their PhD.

The majority of the 19 nurses: • retained their clinical positions after obtaining their doctoral degree • believed that the degree helped them to obtain better jobs/promotions • acknowledged the value of the PhD for patient care, improving research and shaping healthcare policy.

TABLE 2

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Search results

A total of 385 published articles were identified after searching in selected databases (PubMed and Cinahl), sup-plemented by a manual search based on the reference lists in the selected articles (see Figure 1). After sorting out dupli-cates, 287 abstracts remained to be assessed as to whether these studies met the set requirements. This culminated in 50 articles that were subsequently read in full to determine compliance with the inclusion criteria. After repeated scru-tiny of the selected articles, 12 studies meeting the eligibil-ity criteria remained and were included in the systematic review. Examples of common reasons to exclude studies included those limited to addressing the education and roles of RN/PhDs, or those in which RN participants did not hold a PhD. Included studies are presented in Table 2.

Description of studies

Of the 12 studies that were judged to meet the inclusion criteria, ten were conducted using a qualitative design (11,15– 17,23– 28) and two using a mixed methods design (12,29). Six of the studies were interview studies (11,17,23– 26), three (15,16,27) obtained data from surveys, one was a case study (28) with written cases and two studies used mixed methods design, one (12) of which combined inter-views with questionnaires, while the other (29) combined in-terviews with a literature review. Five studies were conducted in the US (16,25,26,27,29), two in Australia (12,24), two in Denmark (23,28), one in Sweden (17), one in the Netherlands (11) and one in a combination of Nordic countries (15). All studies included RN/PhDs as participants; seven exclusively targeted RN/PhDs (12,15,17,24,25,26,28), while two also in-cluded nurses without a PhD (11,23). Two studies inin-cluded nurses with a master's degree (16,27), two included nurse managers/leaders (11,23,29), one included nurses enrolled in a PhD program (29) and also included physicians (11).

Half the studies (n = 6) were published in the past 5 years (2015– 2019) (11,15,16,17,23,28), five between 1999 and 2010 (12,24– 27) and one in 1986 (29).

Given the limited number of RN/PhDs currently work-ing in clinical care, both the size of the groups in terms of informants and the strategy for selection of participants are deemed be relevant and the study results to be reliable, re-flecting the current state of knowledge.

RESULTS

Two different roles/types of employment were found among RN/PhDs working in the clinical care setting: nurse research-ers and specialist RNs (e.g. advanced practitionresearch-ers).

Three categories emerged from the analysis: (1) bridge between theory and practice, (2) leadership and (3) profes-sional tradition. The first category, bridge between theory and practice, includes three subcategories: (a) evidence- based practice (EBP), (b) clinical nursing research and ed-ucation, and (c) knowledge support. The second category, leadership, also includes three subcategories: (a) doctoral de-gree promotes leadership role, (b) role model and (c) failure of managers to recognise RN/PhD skills. Finally, the third category, professional tradition, also includes three subcate-gories: (a) importance of clinical presence, (b) new roles and (c) organisational position.

Bridge between theory and practice

All included articles contained all subcategories within

Bridge between theory and practice. In the role as a bridge

between theory and practice, the RN/PhD contributes scien-tific knowledge to the design and implementation of patient care, while also applying clinical expertise to university- based pursuits.

All of the studies emphasised the importance of the lead-ership and support roles played by RN/PhDs for work on EBP and implementation of scientific knowledge in nurs-ing care (11,12,15– 17,23– 29). EBP was appreciated to be the key factor for improving quality of care, where decisive importance was ascribed to RN/PhDs according to their in-dividual knowledge of scientific theory and methodology (16,17,27).

Research was also cited as an important function of RN/ PhDs and as being integral to their ability to lead and sup-port the improvement of clinical care (11,23,25). Although some of the RN/PhDs were allocated time to conduct their own research, many were mainly tasked with supporting the research of colleagues.

An active presence in, or close contact with, clinical care was considered important for identifying relevant research issues. An active presence in the clinical setting was also considered to provide better opportunities for successful im-plementation of relevant research and for improving educa-tion in clinically related areas (11,17,23,26).

An important task for RN/PhDs was to support col-leagues and managers in their work on EBP and to apply their academic knowledge in areas such as methodol-ogy in order to critically examine and improve practical nursing care (11,17,23,25). RN/PhDs served as a clinical resource for other nurses and professionals, as well as for patients and relatives. They were consulted both for-mally and inforfor-mally regarding various issues, including searching for, interpreting and discussing scientific arti-cles, as well as matters relating to complex patient care (17,25).

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Leadership

The leadership role was cited as an important function for all RN/PhDs (11,17,24– 26), especially concerning profi-ciency to lead improvement of practical nursing skills to improve quality of care. Research training provided RN/ PhDs with insight into the various needs to be found within the organisation, thereby solidifying their leadership roles (11,12,17,25).

Several studies emphasise that RN/PhDs in clinical care can serve as an important role model for colleagues (11,12,17,23). The doctoral degree was described as benefi-cial for both self- image and professional status as an RN (26). The presence of RN/PhDs was considered to increase job sat-isfaction and promote professional development among other nurses (23). Professional development refers to continuing education and training aimed at maintaining and enhanc-ing professional knowledge among RNs. Clinical/academic

FIGURE 1 Flow chart diagram: Number of articles found and number of selected relevant articles

Articles identified through database

search.

(PubMed: 141, Cinahl: 232)

(n = 373)

Articles identified via references.

(n = 12)

Articles remaining after removing

duplicates.

(n = 287)

Articles screened

(n = 287)

Articles excluded

(n = 237)

Full-text articles assessed

for eligibility

(n = 50)

Full text articles excluded,

including reasons.

(n = 38)

Studies included in

qualitative synthesis

(n = 12)

Duplicates removed.

(n = 98)

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career opportunities were felt to improve hospital image and to attract talented and highly motivated nurses (11).

Nevertheless, nurse managers still fail to understand the extent to which RN/PhD contributions can improve quality of care (11). In the current situation, direct patient care is the top priority, both for RNs and nurse managers, which may negatively impact RNs who must also allocate time for academic pursuits (11). A possible consequence may there-fore be underutilisation of the expertise of the RN/PhD.

Professional tradition

In order to influence and improve patient care, it is impor-tant for RN/PhDs to combine clinical and academic work (11,17,23). Although the extent of direct patient work var-ied, the study emphasised how important the presence and visibility of RN/PhDs in the clinical care setting is to their credibility. Clinical presence was cited as important to stay-ing accessible to colleagues in order to answer their questions and thereby improve patient care (17,23). Such a presence was also considered important to highlight their new and un-familiar role as RN/PhDs in the clinic and to promote their visibility (11,17).

Professional tradition is a belief or behaviour, originating in the past, which is conveyed within a group and having a special meaning within the group. RNs and physicians do not share the same professional tradition. Combining clinical and academic work is not as well established for RNs as for physi-cians (11,17,31). The role of RN/PhDs in clinical care has not yet been clearly defined, which creates ambiguity in terms of both the role and scope of practice for RN/PhDs.

One problem cited for RN/PhDs involved in clinical care was being perceived as a threat to others, especially nurse managers, administrators and physicians (17,26). A strong focus on direct patient care duties alone may have a negative impact on RN/physician cooperation, sustaining the hierar-chy of physicians in the decision- making role and RNs in a subordinate position (11).

To a large extent, career opportunities for RN/PhDs who work in clinical care are quite limited and the lack of such opportunities was cited as an important reason to explain why RNs do not combine clinical and academic work. Clearly defined positions are needed to attract these RNs to clin-ical work. The need for ‘champions’ among line managers to create combined clinical- academic job opportunities was perceived as a possible pathway forward (11).

Methodological considerations and limitations

We chose to conduct a systematic literature review by search-ing relevant articles, followed by systematic selection and

quality assessment (20,21). The search strategy was based on the research questions at hand and focused on gathering data from scientific studies in order to gain a deeper understand-ing by compilunderstand-ing knowledge on the current state in this field. In addition to ‘MeSH terms’ (PubMed) and ‘subject terms’ (Cinahl), the terms that appeared in titles and abstracts were examined to identify relevant studies and to note how they were indexed. Identification of relevant keywords in quali-tative articles was more difficult due to lack of indexing in databases and article abstracts (21), which may explain the difficulty in finding relevant hits when using MeSH terms and subject terms alone. Therefore, free text searches (terms selected to match words that appear in database descriptions of each specific study) were also used. Another limitation in obtaining relevant hits is the time required for articles to be indexed in a database.

The search results produced relatively few (12) relevant studies for inclusion. A lack of informants in some studies was also problematic, probably because the number of RN/ PhDs in clinical care is still relatively few, which suggests this remains an underexplored area of research. However, certain limitations are specific to this review. First, be-cause search criteria were restricted to studies published only in English, cultural bias could result. Second, even when examining included studies for additional references, no search of grey literature was otherwise conducted. Therefore, the search, which was restricted to primary re-search in peer- reviewed journals, may have missed unpub-lished research.

DISCUSSION

To date, there is no established tradition for RN/PhDs to work in clinical care; few RNs currently fill such roles in Sweden, although their numbers are slowly increasing. Such roles represent a new job description and few posi-tions have been adjusted to take advantage of the special skills of RN/PhDs. The results describe a plethora of posi-tions, titles and responsibilities, which means that the job descriptions are often, either wholly or partially, inconsist-ent with the American Association of Colleges of Nursing (AACN) description of advanced nursing practice. This is one reason why they are often unable to contribute to care to the full extent of their ability. Advanced nursing practice, as defined by the AACN (32), includes direct care of individual patients, management of care for individuals and administration of nursing care.

The highest attainable degree within any given academic dis-cipline is known as a terminal degree. Today, in the United States and some other countries, there are at least two terminal doctorate degrees in the field of nursing: Doctor of Nursing Practice (DNP) and Doctor of Philosophy (PhD). The DNP degree focuses on

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advanced clinical practice and builds on the traditional master's programs with a focus on evidence- based practice, quality im-provement and systems leadership (32). The PhD in Nursing is a research and science- focused degree aimed at advanced nursing science and patient care. According to the AACN (32), RNs with a doctoral degree, in addition to their academic role, are also ex-pected to serve in leadership roles within the discipline, as well as serving as role models and mentors. This level of education enables RN/PhDs to bridge the gap between clinical practice and academia. Research questions often arise in response to chal-lenges and queries emerging from clinical practice (33). Taken together, this indicates that RN/PhDs can better serve the goals of their profession when given the opportunity to continue working in the same clinical area after earning a PhD. In Sweden, this has often been the case for physicians with a PhD (31) but is not yet common practice among RN/PhDs.

A leadership role in developing nursing practices that contribute to improved quality of care is an important func-tion as suggested by the data (11,12,15,17,23– 29). Providing leadership while supporting colleagues and managers with implementation of EBP and scientific advances in the clin-ical setting were also considered to be important. Two pub-lications cited a problem concerning a lack of understanding among nurse managers in regard to the enhanced contribu-tions that RNs with an advanced degree could bring to clini-cal practice (11,17). Consequently, nurse managers may not appreciate or utilise such expertise, failing to recognise the value of a postgraduate research degree for improving nurs-ing practices as well as clinical outcomes. An important issue that healthcare managers should address is how to provide adequate opportunities for RN/PhDs to combine research and clinical practice with the aim of improving nursing practices.

To assess the importance of the contributions made by RN/PhDs to clinical care, their impact on patient outcome must be better understood. Due to the limited number of RN/ PhDs working in clinical care, conclusive results regarding outcome may be difficult to obtain. Thus, insufficient data somewhat hampered the aim of this review with respect to limited materials. It has been shown that level of education among RNs (bachelor's degree or higher) (4,5) and clinical expertise (6) are important for patient healthcare outcomes. To reach the clinical expert level, as defined by Benner (34), clinical experience is necessary, in addition to formal educa-tion (34). However, theoretical knowledge guides clinicians and enables them to ask the right questions. Clinical practice generates clinical research, which requires clinical expertise to formulate the right questions for scientific testing and the-ory building. To this end, RN/PhDs engaged in clinical care have an important role to play as clinical specialists in the patient care setting.

Additionally, the educational level of RNs has been reported as significant for healthcare outcome. Notably, a positive asso-ciation has been observed between the educational level of RNs

and utilisation of research; RNs with a graduate degree (mas-ters/PhD) are more likely to apply research findings to their clinical work than RNs with lesser degrees (7). Furthermore, the presence of clinicians who are actively involved in research improves quality of care (8). Overall, these findings may lead to the conclusion that RN/PhDs contribute to safer care.

The advancement of nursing as a practical discipline re-quires RNs with expertise in both clinical practice and scien-tific research (35). Today, in the United States the DNP degree is gaining ground compared to the PhD (36), raising concerns that it may displace the PhD with untoward consequences as a result (36). To help resolve this potential dilemma, a partner-ship has been suggested between RNs with DNPs and those with PhDs, for the purpose of both generating and imple-menting evidence- based findings in nursing care (35). Some schools now also offer a dual DNP/PhD degree.

In summary, to advance improvement of nursing practices, there is a need for clearly defined clinical positions in which RN/PhDs can take full advantage of their expertise and allocate sufficient time for both supporting colleagues and students to improve clinical practice, and to conduct relevant research.

Although the current literature provides some good exam-ples of how active leadership is improving the situation, con-tinued robust efforts are required to make further progress.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHOR CONTRIBUTION

MLO and YW designed the study. MLO and YW conducted the searches, with NNF and PD as critical peers. MLO and NNF drafted the manuscript, which YW and PD revised. Thus, all authors have participated sufficiently in the pub-lication process to guarantee its content and take full public responsibility for the reported study, including its findings and conclusions. The final version has been approved by all authors.

ETHICAL STATEMENT

This study is a systematic literature review and therefore did not require an ethical permit. No research subjects or ethical problem areas are included in the study.

ORCID

Marie- Louise Orton  https://orcid. org/0000-0001-9600-7474

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How to cite this article: Orton M-L, Nelson Follin N,

Dannapfel P, Wengström Y. Roles and functions in clinical care for registered nurses with a PhD— A systematic literature review. Scand J Caring Sci. 2021;00:1–11. https://doi.org/10.1111/scs.12979

References

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