BACKGROUND AND OBJECTIVE

For health services research findings to shape clinical practice, it takes engagement from many collaborators such as health care administrators, frontline clinicians, and patients. Involving these collaborators early in the research process can lead to scientific advancements that are more widely implemented.1 Furthermore, research arising from the community of concern is more likely to generate findings that take less time to become practice.2 Community-engaged research is gaining traction among American health care researchers.3 Nevertheless, we do not know how best to engage with busy frontline clinicians to assure that their valuable perspectives are used to inform research questions, shape methodological approaches, and contextualize findings.

Engaging various collaborators, including clinicians, is an important part of any research study and is considered best practice.4,5 Yet, engaging with clinicians on how to conduct research is rarely seen.6 Exploring how clinicians can inform clinical relevance and improve researchers’ ability to recruit for, and disseminate, research can enhance the sustainment of the program or practice.5 Indeed, investing in clinicians as research collaborators is beneficial to clinicians themselves, the health systems who employ them, and those for which they care. Clinician engagement in research endeavors stands to positively impact the generalizability of study findings and adoption into clinical practice thus improving patient care.7

We undertook a quality improvement study within one Veteran Affairs (VA) Healthcare System to determine the barriers, facilitators, and solutions to optimal clinician engagement in the research enterprise. The purpose of this QI initiative was to form the foundation of our frontline clinician engagement efforts at our research center. Thus, this QI study was an extension of our other engagement efforts at our research center that, to date, had been centered on patients and operations leaders. We seek to gain a broad set of stakeholder collaborator input on the research we conduct to better align our work with the needs, preferences, and values of frontline clinicians. The goal of this project was to gauge frontline clinicians’ interest in being involved in research and to inform ways in which researchers can partner with frontline clinicians in a mutually beneficial and sustainable way.

METHODS

This quality improvement study (“study” going forward) is formative work to optimize how VA research units can engage more effectively with frontline clinicians to inform and execute clinically relevant research. We conducted semi-structured interviews with clinicians whose primary role was patient care at a VA Health Care System. The Durham VA IRB reviewed and designated this study as a quality improvement study.

Participants

We purposively recruited clinicians by collaborating with key clinical leaders who provided a list of clinicians. We specifically aimed to recruit across multiple types of clinicians including physicians, physician assistants, nurse practitioners, social workers, psychologists, physical therapists, occupational therapists, and nurse professionals. We also aimed to include clinicians from different practice concentrations (i.e., primary care, geriatrics, women’s health, hospitalists, mental health, subspecialties). Additionally, we want to include rehabilitation practitioners such as physical therapists.

Inclusion criteria included being employed as full-time clinical staff at the Durham VA Health Care System for (minimum length of time) and having less than 5 peer-reviewed publications and no publications as the first or senior author. The goal of this publication threshold criteria was to develop a screening measure to assess if the potential participants were more clinically or research focused. Yet, we also believed that some research exposure could be beneficial in our pursuit of information on research engagement. Some limited prior research may afford the interview participant a richer source of past experiences to explore during interviews. Clinician participants completed a phone screening to confirm eligibility. We then scheduled participants for a virtual video interview following an explanation of the study and verbal agreement to participate. Enrolled participants were not compensated for their time in the interview.

Measurements

The multidisciplinary research team created a semi-structured interview guide (see Supplemental) complete with open-ended interview questions and probes. The interview guide was developed using the Consolidated Framework for Implementation Research,8 with a focus on barriers and facilitators to research engagement and a review of the literature on frontline clinician engagement in research. The guide was additionally reviewed and informed by our research center’s qualitative methods core and was piloted with two clinicians who provided feedback on the draft guide. Along with demographic questions, domains included clinician role, impression of research, description of daily workflow, typical communication channels for sharing ideas with clinical peers and supervisors, desired type of research involvement (if any), and description of “perfect” engagement scenarios between clinicians and researchers. Other questions included how can barriers to research be addressed, what is the feasibility of participating as a research informant, what should an engagement process look like, and what are potential benefits to research engagement for clinicians.

We defined the term “research” in the interview guide as “research on human health, including research that finds ways to detect, diagnose, treat, and prevent disease, including health care delivery.” We also asked what impact (if any) does clinicians’ racial and ethnic identity have on research involvement; our research center has an explicit focus on dismantling racism and other forms of oppression in our workplace by promoting equity in our environment and research activities. In our exploration of the literature to inform the interview guide, the racial and ethnic identity of researchers and the impact this has on the production of knowledge do not appear well understood. Thus, we explored frontline clinician participants’ perception of their identities and the potential impact this may have on research engagement.

Interviews were between one interviewer and one clinician participant, with an additional researcher present to take detailed notes. Neither audio recording nor additional transcription processes were approved given the quality improvement framework of the study. As we have demonstrated in our prior work and as others have also noted, interview notetaking can be comparable to audio recording and transcription.9,10 The research team shared the detailed notes with respective interviewees to determine accuracy (i.e., participant checking) and revised notes based on their feedback.11

Analysis

When further observations and analysis were no longer yielding new or discrete themes we discontinued interviews.12,13 Two coders (NAB, MCT) analyzed the data using descriptive content analysis with an inductive approach with input from other investigators (JMG, BE, JWW, BSW, MD) to develop the codebook.14 Coders used NVivo 12 Pro (QSR International Pty Ltd. 2018) to manage data and develop codes to segment clinicians’ narratives into conceptual categories (e.g., incorporating text describing a similar concept). We identified content-driven codes and applied them to the text for each of the conceptual categories (e.g., potential themes related to responsibilities as care partners). Coders selected three interview transcripts, and two coders separately identified themes. After reconciling emergent themes and revising the codebook, coders separately coded the next three interviews. We discussed the application of coding for those three interviews. Confirmation coding was used thereafter (coded by one, confirmed, or disputed by the second). Coding disagreements were resolved through meetings with the larger research team. One coder (MCT) then completed coding on the remaining transcripts. We examined code frequencies across transcripts to identify salient factors for participants.

The research team collected data, identified themes, and then shared initial data analysis with interview participants and a larger group of researchers to check the team’s understanding and observations. Next, the team shared findings and initial interpretation with health system leaders to gain contextual information and aid in further interpretation. To conclude the analysis, we used direct quotes to demonstrate common themes.

RESULTS

The sample was comprised of 21 participants (out of 131 approached to participate via email; 16% response rate). Participants were majority white females (Table 1). We found two main themes with subthemes most relevant to the discussion of front-line clinician engagement with the VA research enterprise. The first theme, “Perceptions of Research,” encompassed subthemes of (a) prior research experience; (b) desired degree of engagement; (c) benefits to clinicians engaging in research. The second, “Characterizing Effective Engagement,” has subthemes of (a) engagement barriers; (b) engagement facilitators; and (c) impact of clinician’s racial identity.

Table 1 Sample Characteristics

Perceptions of Research

Prior Research Experience

Nearly all participants had favorable views of research. Yet, only three participants noted exposure to research methods during their clinical training. Almost all participants indicated they were consumers of published research and were applying that knowledge to clinical practice in some way. As one primary care nurse stated, “I am forever looking at clinical research to help guide my patients’ treatment plans, I use research very much in my clinical practice.” None noted experience as a participant in a research study.

Desired Degree of Engagement

As full-time clinicians, participants discussed their desired level of engagement with research as not generally a part of their job role. Given the following definitions, adapted from Goldstein et al.,7 participants discussed where they were willing to engage: supportive, recognizing that research is important to the VA mission and you allow access to your patients; informant, recognizing potential research topics in your service and report on them; Involved, acting on information generated by a study; collaborator, actively involved in the research process and share your thoughts and ideas with leaders; and leader, leading a research investigation. Supportive, informant, involved, and collaborator were endorsed widely across the sample while only two (both social workers) chose Leader. One internal medicine MD stated, “I think I’m reasonably comfortable with disseminating information to a larger audience if I’m familiar with the information. Probably much less comfortable with analyzing data. I might be able to make contribution to some areas like figuring out what topics or the design of a particular study. I think some of my colleagues would be more comfortable with many of these items.” Participants indicated experience as research collaborators (e.g., informing a research topic, helping collect data) and less frequently as leaders of research studies. Participants also focused on the importance of the patient as they relate to the research being conducted. A mental health social worker stated, “Having the perspective of being practical to the people doing the work, making sure it works within the practice, making sure we are matched to who we are serving, making sure the research is relevant.” Early-stage research involvements—defining the problem, designing the approach, and recruiting of study participants—were areas in which participants thought frontline clinicians could contribute. A mental health psychologist said, “I would always be an informant where I could help inform research projects.” Additionally, most indicated they would be willing to disseminate the findings to their colleagues.

Benefits to Clinicians Engaging in Research

Participants readily noted benefits to front-line clinicians who engage in research. This included professional development—learning new skills, putting trained skills to use, and improving patient care with new knowledge. One physical therapist working in a community-based clinic said, “I feel like the VA is nice because we do have the research opportunities, the opportunity to have a change of pace.” Another RN in an ENT setting said, “We are the ones working with the results, sharing with patients or colleagues, job satisfaction, breaking the monotony of clinic, changing pace, get a glimpse of the other side and what we are not doing.” Additionally, engaging in research was seen to create a diversity of job tasks which was noted to be a way to prevent clinician burnout. Participants also saw an additional benefit of being able to have a greater awareness of research opportunities for their own patients to participate with one mental health psychologist saying that the “primary benefit is the VA being a system with limited resources, limited providers, limited treatment options, know research that can provide more treatment options, an additional resource.”

Characterizing Effective Engagement

Barriers to Effective Engagement

Frontline clinicians highlighted multiple barriers that impeded their ability to meaningfully engage in shaping research. One major barrier was the general lack of awareness of what research was being conducted at their facility and a lack of awareness on how to get connected with a researcher who was working on areas of interest to their clinical context. As one mental health clinical social worker stated, “Yes, that speaks to being compartmentalized, being super impressed at NEO [new employee orientation] about hearing about research [being done at this healthcare system] and then that was it, there is not a lot of research dissemination.”

Another barrier stated by frontline clinicians was a lack of formal training in research methods. Many clinicians stated that they were too busy with their clinical duties to find time to be involved in research. While innovation in their clinical units was often discussed, there was a lack of time and knowledge to implement these investigations. One physical medicine and rehabilitation physician voiced his frustration about such an instance recently in his work, “Just today, I talked with the group and said we should track outcomes to see how we’re doing and what needs to be changed or tracked… And I noted that I need to look back at it, but that might die right there. Everyone is busy, and once the meeting time is gone, they don’t have time to think about these [research] things.”

Most frontline clinicians discussed a lack of compensation for research time while employed primarily as a clinician. Additionally, participants indicated they had no “protected” time to do research either as a collaborator or to lead their own research. Some clinicians indicated that a lack of compensation or protected time conflicted with the research mission of the VA learning healthcare system and signified to them that research involvement was not a priority for clinicians. Additionally, due to the way that clinical and research funding is appropriated within the VA healthcare system, there was an expressed concern that research engagement may negatively impact a provider’s ability to meet their patients’ needs or that clinical colleagues would need to take additional clinical duties should a clinician decide to devote any time to research. This comment by a registered dietician sums up these complexities about competing priorities and lack of protected time for research: “My [barriers] for my staff are that we are understaffed, uncertainty of the unknown, fear of what they might be getting into, time and effort, priorities. If you could demonstrate how it [time spent engaging in research] would be beneficial for a clinician’s job it would be worth it for them.”

Engagement Facilitators

Despite multiple barriers to engaging in research, frontline clinicians noted multiple factors that could foster bi-directional engagement with health services researchers. Participants noted that regular contact with researchers would aid them in keeping abreast of current studies in planning or being implemented at their worksite, help build bridges between clinical leadership and health research leadership, and foster better engagement about how they might be able to be involved. As one internal medicine physician informant stated, “There has to be some kind of introduction first of the 2 big parties [researchers and clinicians] and the development of some sort of relationship. I have very little knowledge of the group you are working with that already exists. Some kind of information sharing like who you are and what you do. Relationships are needed between the groups maybe some regular meetings and focused discussion on topics would be helpful in clinicians learning about research endeavors you all are a part of.”

Front-line clinicians discussed ways in which research communications and activities could fit into the workflow of the clinical day, including researchers reporting at clinical team meetings to maintain a presence in clinical settings in addition to regular email and other virtual contacts to share the latest initiatives. Others suggested a liaison—from among the clinicians—to act as a conduit between researchers and clinicians. Additionally, VA leadership buy-in to research as a priority would help their departments and local managers appreciate and prioritize research as part of their organizational mission and as part of employee work hours.

Impact of Clinician’s Racial Identity (See Table 1)

We also asked about the potential impacts of clinician race and ethnicity on their interest in research engagement. Most participants did not indicate race or ethnicity played a role in their interest in collaborating with researchers. Some participants hypothesized that frontline clinician race or ethnicity could have two impacts on research engagement. The first was that differing cultural backgrounds can, at times, pose some barriers (e.g., difficultly communicating if not a native English speaker). The second was that racially concordant research teams mirroring the study population could enhance study participant recruitment. Lastly, some clinicians noted that having racially diverse perspectives on research teams could provide different cultural insights into the research making research more feasible and acceptable for underrepresented racial and ethnic groups and bringing these cultural perspectives into the production of new knowledge creation via research. As on mental health clinical social worker stated, “I think it’s maybe the same thing that would impact a potential participant, as Black and brown people we all have that historical context of the Tuskegee studies…I think culturally Black or brown clinicians might believe more in lived experiences…if there aren’t a lot of African American marine biologists you won’t have a Black perspective in marine biology.” Another clinician of color spoke to their newfound willingness to talk about their experiences as a person of color, “I think we used to hold on to a lot of those challenges to not be labeled as difficult to work with but now are more comfortable talking about our experiences.”

Solutions to Engagement Barriers

Figure 1 shows a summary of our findings as presented to study participants in a post-interview listening session and reviewed by our local VA research unit and health system leaders, also in separate listening sessions. We sought both their interpretation as well as the beginnings of solutions to engage frontline clinicians.

Figure 1
figure 1

Findings reviewed by clinicians, researchers, and administrators to generate workable solutions.

Possible solutions to improve clinician engagement in research follow from our findings and review of those findings in the listening sessions. These include (a) offering “How to get involved in research” sessions at staff meetings; (b) conducting annual surveys of frontline clinicians to determine clinical challenges needing research; (c) restructuring Return-of-Results forums for clinicians to learn about their contributions; (d) encouraging research participation in quality improvement efforts; (e) establishing a Research Review Committee (with evolving and rotating membership), with clinician membership, to check the relevance of planned studies; and f) tailoring approaches to individual disciplines (e.g., nursing, social work) to increase relevance and expert input.

DISCUSSION

In this project, we queried frontline clinicians’ views of engagement in research at one VA medical center. The abundance of roles clinicians can take in research lead to a robust conversation about the degree to which clinicians desire to engage in research. Prior research training or exposure may influence clinicians’ desired degree of engagement with the research enterprise.15 This is reflected by our data in which perceived ability and confidence appear to follow from prior research experience, though we lack statistical evidence for this due to our study design. Even among participants with prior research experience, it is not surprising that research leadership was not seen as a viable choice by most of our sample as a prospective role given the time and dedication to tasks required for that role. Still, it was heartening to see a general desire to help define the research, recruit for studies, and apply research findings into practice. It should also be noted that since all of our participants wanted to be involved in research in some capacity, researchers can expand their pool of potential frontline partners by coming to them with their research, instead of waiting for more eager participants to come to them. It is established that clinicians are effective framers of potential research.2,4,16 Clinicians are also consumers of completed research through institutional practices derived from the evidence base.17,18 Clinicians identified suitable roles that range across the spectrum of research involvement, which points towards many potential points of collaboration.

Benefits to clinicians involved in research were readily noted by participants in this sample. With other studies describing clinicians’ view that research has value for both patient care and contribution to clinical evidence19, our study adds data specific to the VA where clinicians are salaried and may have limited options to “buy out” their patient care duties with paid research effort. However, many VA centers share clinical faculty between the VA and a neighboring academic medical center. It is helpful to know what motivates research participation for clinicians in these settings. Our data suggest there is a value among clinicians in offering patients opportunities to contribute to the evidence base as study participants, and that research itself allows clinicians to keep current with science and apply new knowledge to patient care. Our frontline clinical participants’ description of potential opportunities to use acquired skills and learn new skills within the VA research enterprise to vary job duties and possibly mitigate burnout mirrors some literature showing research as satisfying intellectual curiosity for clinicians.19,20,21 Additionally, clinician retention may benefit from the protective effect of clinician engagement in research.

Several barriers to doing research exist for clinicians. Lack of protected time or compensation to conduct research continues to be a perennial barrier according to our data and other study findings over recent years.22,23 A 2016 survey of 647 clinicians from multiple professions indicated “time” as a barrier to doing research (65%) along with “support” (34%) and “getting started” (32%). According to some in our sample, formal support from researchers and center leadership to do research was lacking. Indeed, commitment and deliberate support from system leadership and departmental management may be key.24 Furthermore, some clinicians in our sample expressed not knowing where to begin with research, echoing the “getting started” barrier from the 2016 survey above as well as other research.23

Regarding engagement facilitators, prior research demonstrates clinicians see better alignment of clinical and research goals, research mentoring, and opening doors to collaboration as key to increasing clinician-researcher engagement.22 Our data indicate some adjacent findings with regard to the importance of fitting research tasks with clinical task workflow, increasing connections to VA researchers who can offer guidance as well as engagement opportunities, and the necessary shift of health systems leadership priorities to include clinician-involved research.

While we attempted to explore clinician race/ethnicity and its impact on research engagement, the lack of racial or ethnic diversity in our sample made the data somewhat conjectural. However, it was the start of an important conversation and needs to be highlighted here. Diversity in race, ethnicity, and gender has the potential to produce stronger research interpretation and implementation.25 Indeed, research designs uninformed by a diverse research team could ultimately limit the generalizability of study findings.26 Diversity in research study recruitment—a critical and growing effort—can benefit from diversity on the research team doing the recruitment.27 Racial and ethnic diversity on the research team itself is underexplored and in need of further research.

Regarding limitations, recruitment for this study was difficult. Those frontline clinicians able to take the time with us to discuss research engagement had the time and flexibility to do so. Thus, we may have enriched our sample with clinicians who may be more amenable to taking on additional opportunities, such as research engagement. Frontline clinicians appeared to be very busy with clinical care in the context of COVID-19 and few were able to take the time to participate as our response rate indicates. Another limitation was the lack of diversity in the sample—despite a goal of recruiting a diverse sample—leading to less rich data regarding the race/ethnicity inquiry and our findings overall. There was a conspicuous lack of opinion on the topic as many of our White informants did not have particular insights into how their own race may influence their values and behaviors, and how others may perceive them. A third limitation is that our research took place in the VA system where clinicians work on salary rather than through insurance reimbursement; the applicability of our findings may be unique to the VA system. Lastly, the quality improvement frame of our study—without research dollar funding—limited options for recording and transcription as underwriting of study staff time.

Our study is unique as it rigorously queries the viewpoints of a multidisciplinary sample of frontline clinicians on how to engage them in research collaborations setting the pace and form of future engagement within the VA, a learning health system.28 The multidisciplinary nature of our inquiry is important as limited prior research shows physicians are the profession that most readily views research participation as key to job requirements and career progression.19,22 Highlighting other professions is key to strengthening team-based science in learning health systems.

CONCLUSION

A concerted effort to involve frontline clinicians—likely in their clinical settings and on their terms—stands to strengthen the fields of health services research and clinical research but requires system-level prioritization of the research enterprise and clinicians’ roles therein. The VA health care system—or any large, integrated health care system, for that matter—could align incentives for research between researchers and clinicians, for example by building “research participation” into clinicians’ annual performance evaluation and creating research funding that motivates researchers to collaborate with clinicians. This action is justified with the reasoning that clinician-engaged research can lead to better care and outcomes for patients.