Abstract
Registered nurses (RNs) with a PhD constitute a resource for other healthcare professionals, patients and relatives, and may contribute to the advancement of nursing research and nursing science in education. Nevertheless, they seem to lack clear descriptions of career pathways or prerequisites for developing a career. Therefore, the aim was to explore existing and desired prerequisites for career development after earning a PhD, as described by RNs. Thirty-six individual, semi-structured interviews were conducted digitally with RNs who had earned a PhD degree between 2016 and 2022. The data analysis was guided by conventional qualitative content analysis. The results showed that prerequisites described as essential for careers formed two categories: Structural and Dynamic, with five subcategories: Employment, Finances, Research culture, Supportive engagement and Personal investments. The described prerequisites for career trajectory planning for PhD-prepared RNs may serve as a guide for the development of national career structures.
Introduction
In view of the need to respond to the future challenges faced by health care, there is an ascertained lack of doctorally prepared registered nurses (henceforth RNs with a PhD). 1 No exact numbers are accessible, but estimations show a rate of below 1% of RNs holding a PhD internationally1,2 and nationally. 3 PhD-prepared RNs are able to create, translate and communicate new knowledge within the discipline in both academic and clinical contexts, 4 thus being crucial to the advancement and implementation of evidence-based nursing care. However, pursuing a career within nursing research seems to come with challenges, with PhD-prepared nurses’ different roles in various contexts having been described as hard to balance. 5 Therefore, an identification of common challenges and opportunities may help to inform nursing research careers and better prepare nursing research doctoral students for a research career across contexts.
Exposure to nursing research and familiarity with the research process have a positive influence on how research is experienced among nurses, in addition to inspiring professional development. 6 Thus, in the clinical context, RNs with a PhD are valuable resources as mentors to colleagues, contributing scientific knowledge and evidence-based nursing and implementing new routines.7,8 University-based nurses with a PhD bring competence to nursing education at an undergraduate level, as well as at an advanced and research level, providing new research and supporting competence development within the clinical context.9,10 Thus, RNs with a PhD are needed in both clinical and the academic contexts, but there are great differences and inconsistencies regarding where in the organizational structure they are employed and what work functions they have. 11
Internationally, there seems to be a disparity regarding the opportunities for continuing a research career as a RN with a PhD. A recent review 5 concluded that there was a dearth of data on described career paths, with most studies reporting from employments within academia. However, working in academia, the RNs with PhD still reported desiring a combination of both a clinical and an academic context. 5 The same tendency was reported in a Swedish national study, charting the career paths of RNs with a PhD. That study showed that there was a significant change in employment – from clinical towards academic positions – when earning a PhD, although a desire to stay close to the clinical context was expressed. 3
No clear national structure for career paths for RNs with a PhD exists across contexts in Sweden. In Swedish academia, academic positions are consistent with the European Union framework, 12 with employments such as assistant senior lecturer, senior lecturer and professor. In the clinical context, a variety of career descriptions has been developed across regions, which is a problem previously described internationally as creating confusion and ambiguity in role expectations. 13 Prerequisites (i.e., conditions needed) for career opportunities within the clinical context have been described as ambiguous, 14 with a lack of suitable positions 5 due to RNs with a PhD breaking new ground. 14 So-called shared positions (i.e., where there is a division of time and responsibilities between clinical and academic settings) exist and have been reported as desirable among RNs with a PhD.3,5 Shared positions are also an important bridge between the clinical and the academic context, generating beneficial effects on both sides. 15 However, this demands a collaboration and a common vision between contexts, which is challenging, 16 although it has been argued for with the aim of strengthening the profession. 17 A lack of understanding from the management, especially in the clinical context, has been reported previously, 18 despite the benefits of having RNs with a PhD. 19 Thus, no clearly described career development seems to exist for PhD-prepared RNs compared to medical doctors and dentists who have clinical academic trajectories that are well established, with research embedded in their career development. 15
In conclusion, for RNs with a PhD in Sweden, there is a described lack of national consensus for career paths, 3 regardless of what context they are working in. It is a lack that seems to be shared within the research community internationally, where the promotion of scientific careers in nursing has been advocated for with the aim of shaping trajectories for nursing researchers. 20 Thus, it can be argued that the need for structure and consensus regarding nurses’ career opportunities is a general phenomenon, internationally and nationally, and this raises the question of existing prerequisites for such careers. Identifying career conditions for RNs with a PhD across contexts, could provide information on common challenges and opportunities and thereby guide future improvements of, and a clear structure for, career paths and nursing research education.
Aim
The aim of this study was to explore existing and desired prerequisites for career development after earning a PhD, as described by RNs.
Methods
Design
An explorative qualitative design with individual interviews was used to meet the aim of the study.
Participants and recruitment process
The participation criteria were RNs with a PhD degree earned between 2016 and 2022 from Swedish universities, whose dissertations were listed in the national register provided by the Swedish Society of Nursing (www.swenurse.se). This is a convenience sampling based on a previously performed cross-sectional study, 3 where participants were also invited to indicate whether they were interested in participating in an interview study. Interested participants were subsequently contacted and provided with further information regarding the present study. In total, 55 emails were sent with detailed information about the study and available time slots for interviews. Forty RNs replied and expressed interest in participating, and a confirmation email with a time slot and an online link was sent to those RNs. Two of the participants missed the time for the interviews and two replied that they were interested in participating but had difficulties during the suggested time slots. Thus, a total of 36 interviews were conducted. The participants had a mean of 24 years of experience as RNs, with the shortest experience being 13 years and the longest 39 years, and 75% had a specialist nursing degree, which, in Sweden, includes a 1-year master degree and in-depth subject knowledge. There was also a geographical national distribution, with the location of participants ranging from the north to the south of Sweden.
Data collection
Data were collected through digital interviews using Zoom Video Communication® (https://www.zoom.com) between November 2022 and January 2023. The interviews followed a semi-structured interview guide, with questions covering the participants’ previous and present working conditions, their duties, their wished prerequisites, and their career prerequisites so far. During the interviews, probes were identified and asked, examples of probes being “How do you think this impacted your decision?” and “Why do you think it was like this?”. The participants were also asked to give further examples or describe their replies in further detail. The interviews lasted between 25 and 50 min with a mean time of 36 min.
Data analysis
The analysis was conducted based on a conventional qualitative content analysis, which is used for analysing empirical data of an explorative nature. 21 All of the individual interviews were transcribed verbatim soon after the interview. The whole research team became familiar with the data by reading it line by line. Thereafter, chunks related to the aim of the study were highlighted independently by two of the researchers (AE and MH). NVivo 14 (https://lumivero.com/products/nvivo) was used to organize and visualize the transcripts and the generated code lists. To ensure that no essential content was missed related to the aim, the researchers went continuously back and forth between the transcribed data and labelled chunks during the analysis process. The coded chunks were compared and discussed between the two aforementioned researchers until they reached agreement. To support the analysis process, related codes were charted in a mind map to create an overview of the process. Labelled chunks were subsequently compared with each other, and those with a similar meaning and a connection were grouped together to create subcategories and categories. The analysis process and identified categories and subcategories were discussed within the whole research team until all researchers were in agreement.
Ethical considerations
Information about the study was given to the participants in the invitation email. Before the interviews started, the participants gave verbal consent to participate in the study and were informed that the interviews would be digitally recorded. They were further informed that they could withdraw from the study at any time without having to give a reason. An ethical advisory opinion was granted from the Swedish Ethical Review Authority (Reg. No. 2022-02251-01).
Results
The resultd are described in two main categories, representing different kinds of prerequisites: Structural and Dynamic.
Structural prerequisites
This category describes the prerequisites for career paths from an organizational aspect and depicts how careers can be influenced by structures within a variety of organizations. Three subcategories were identified: (a) Employment, (b) Finances and (c) Research culture.
Employment
A range of employments in different organizations were reported among the participants; for example, in universities, clinics and national authorities. Some reported shared positions with various employment arrangements. The type of employment was emphasized as being important, comprising attributes such as organizational position, time for research and title.
An employment where you have an academic title such as assistant senior lecturer, or a post doc position, provided clarity and confirmation with regard to the career. The participants described these positions as enablers to continue their research, as they often include time designated for research and competency development. Research time that was incorporated within the employment description generated clarity and mandate as a researcher. … An employment now with 50% allocated time for research and where I can feel that I’m able to have time for my present research studies and I can create new contacts … (Participant no 8)
This type of academic employment could also have a negative aspect, according to the participants, as it was associated with high demands or combined with many educational assignments. Moreover, the participants, regardless of their current employment (they all had a clinical background), reported that schedules within hospital-based positions were more rigid and therefore not possible to combine with a PhD career including research for nurses. In the clinical context, the personnel are seen as more replaceable, which strained the loyalty of many research nurses, contributing to making clinical work schedules and research impossible to combine. Sometimes there's a lack of understanding from the closest managers and, like, the persons responsible for the rota. They don’t understand how much I work when I’m not there. I mean, they can send a text like “Can you work this evening?”. No, like, I can’t. I haven’t had a free afternoon in two weeks because I’ve got so many meetings and it's so busy all the time … They don’t understand that I’m not able to manage an extra shift at short notice. (Participant no 27)
Moreover, the burden of administration created a feeling of being torn between assignments, removing the focus from the research. Participants from all contexts reported that this could bring the career to a standstill.
The ambiguity of roles within the clinical context was further compared to the situation of physicians, who have predetermined career paths within their employment after earning their PhD. This enables them to remain in clinical work and do research at the same time, something which was regarded as lacking for nurses. Well, the physicians have their research groups, they have administrators who are used to organizing this, which we don’t have. We have no career paths at all. (Participant no 4)
Finances
Financial prerequisites, that is, funding and salary, were reported on both a professional and a personal level. On a professional level, the importance of getting grants to finance the research was mentioned. On a personal level, an increased salary was described as a beneficial and expected part of the career. Thus, a secure financial situation was reported as a positive indicator for the freedom and power to control your situation and career.
On a professional level, getting financial support through grants implied the opportunity for the participants to elaborate their specific research area, which was regarded as important for the career. Money equalled time. Applying for grants was an important strategic advancement for the career, and to be awarded grants was viewed by the participants as a considerable step in their career. … yes, it's very luxurious [to get a grant] and I understand that … and now we have applied for and received yet another one, so I have a job for another 3 years … So I acknowledge having a luxurious job situation, and it's rare. (Participant no 17)
However, the possibility of getting grants was reported as limited for a junior researcher and this was regarded as a barrier by the participants. With higher academic ranking the possibility for grants also increases, something mentioned as a prerequisite for career development.
On a personal level, there was a difference in prioritization among the participants, regarding salary. Some mentioned the increasing salary as an important drive for advancement in their career, especially within the university setting. It would perhaps increase my salary. As a lecturer you don’t earn that much money and within the university … It's known for, well, being a bit stingy. (Participant no 5)
Others chose differently and prioritized time for their own research, accepting a possibly lower salary when funding was less successful.
Research culture
When organizations have an embedded culture of a positive attitude towards research and its contribution, this is experienced as invigorating by the RNs with a PhD. The positive attitude is visible in the structures built into the organization, structures that promote and facilitate researchers’ career development. Conversely, a negative attitude towards and ignorance about research within organizations were reported as obstacles. This was described as resulting in participants feeling questioned in what they did and regarding what purpose their research would serve in the organization.
Formal structural investments in research growth, such as academic seminars, lunch symposiums and access to supervisors or mentors, were reported as beneficial for researchers’ knowledge sharing with their colleagues. However, the informal meeting structures were also important, for example, being able to discuss methodological questions over lunch or a coffee, all representing natural meeting points for researchers within an organization. A difference between clinic and university was identified, with the clinical context reported as lacking in that type of meeting. We have to create our own infrastructure at the clinic. At universities it's easier, there's nothing strange about having a research lunch, there's nothing strange about talking about a manuscript over lunch, but at the clinic it becomes super strange. And we maybe don’t even have any food, sort of, perhaps a twenty-minute lunch break and then there's no space at all. (Participant no 17)
Dynamic prerequisites
This category highlights dynamic prerequisites for career paths and illustrates how careers can be affected by more flexible variations within different organizations. The category includes two subcategories: (a) Supportive engagement and (b) Personal investments.
Supportive engagement
External support, mainly from the participants’ immediate heads or managers and from networking with other researchers, was described as a helpful prerequisite for the participants’ careers. Sometimes, the heads had a personal engagement in the participants’ careers, despite there being no formal requirements or obligations for this from the working organization. And there I’m actually lucky now, in that I have precisely that clinic manager. If I’d had another individual, things would likely have looked different. So, it depends on the individual person, and it's of course a bit sad that it should be like that. (Participant no 27)
Supportive engagement included a positive approach from the heads towards their employees’ research progress and their research topic. The supportive heads were also described as having the ability to see the benefits and the value of research within the working context. As a result, there were heads that tried to construct and modify positions for nurses with a PhD since they realized the value of their competency. The participants understood the importance of the heads’ commitment and expressed their gratitude for that.
However, the opposite was also mentioned during the interviews, that is, having heads without any understanding of or interest in the value of research and research competency. Having such heads was described as a barrier to the participants’ careers.
Another aspect of the supportive engagement was the opportunities to be invited to work with more senior researchers, which increased the participants’ knowledge about research and opened for important creations of networks. Getting the possibility to be part of networks both nationally and internationally and spread our research. That I find mega interesting and important. But also the opportunity to attend conferences, for example. (Participant no 13)
Furthermore, networking was considered to be positive as it kept the participants updated within a specific research area. Therefore, opportunities to collaborate, along with the engagement of senior researchers in the networks, were welcomed by the junior researchers, even if the collaborations could result in a heavy workload and stress. The participants were wary of declining any offer of collaboration since they were afraid not get new chances of networking, which could give rise to a sense of constraint.
Personal investments
The participants were aware of the need to take responsibility for creating prerequisites for a desirable career, through personal investments and efforts. A huge amount of flexibility, energy and personal motivation was required in order to invest the time and the work effort needed, and this might even include the need to relocate.
Regardless of where the participants had their employments, they expressed that they had periods of heavy workloads. To handle these periods and the concomitant requirements, the participants needed to invest a great deal of time and often utilize their spare time, which was not always appreciated, even though it was their own decision. … over the years […] freedom becomes very valuable too, one doesn’t have the same … I personally think, and one doesn’t have the same, like, hunger to work all day and night, I’ve had enough of that in my job, you know. I’ve done that, after all. (Participant no 15)
A common motivator mentioned for coping with the periodically heavy workload, was to be able to have an impact on changing conditions for others, especially for patients. This motivator was often driven by the participants’ curiosity with respect to research and finding answers to unanswered questions.
The participants further mentioned that they needed to take responsibility themselves for their career and its progress. Thus, they had to be open and flexible to seize chances when they occurred, something which they said required a measure of courage. Furthermore, they felt a responsibility to invest time in applying for their own research funds.
Discussion
The overall result of this study, which aimed to explore prerequisites for a career among RNs with a PhD in Sweden, showed two types of prerequisites: structural and dynamic. Within both, a lack of established structures was described, sometimes leading to an increased responsibility for the participants to create their careers themselves.
The need for national regulations has previously been expressed, 3 and the present study illuminates that, although some structural prerequisites for careers for RNs with a PhD do exist, they are not sufficient. The participants reported a need for a high degree of individual solutions and personal investments to enable the pursuit of a career. Academic titles, such as post doc and assistant senior lecturer, were regarded as positive since they provided clarity and a confirmation of career advancement. Still, there is an ambiguity within the nursing profession worldwide as to defining the roles for RNs with a PhD, 22 which is something that can also be seen in Sweden. Previous research has shown that RNs with a PhD find themselves unprepared when confronting the existing challenges in health care included in clinical positions. 15 Also, a lack of standardization of nursing position titles has been shown to generate confusion regarding role expectations, which could potentially compromise the delivery of evidence-based care 13 and result in inequity across regions. Creating a national career structure for RNs with a PhD could bring clarity with regard to their possible career paths and thus avoid the previously reported confusion in role expectations, 13 as well as avoiding possible differences, career wise, between regions. The results of this study could therefore provide guidance in forming a national structure because both existing and functional prerequisites and the absence of such prerequisites in different contexts are highlighted.
Different aspects of finances were reported in this study, both on a professional and a personal level. Getting grants was described as an important prerequisite for conducting research and, implicitly, for the career, which has been reported previously for both nurses and physicians with a PhD. 23 However, obtaining grants was described as very difficult by the participants, who pointed out that not getting grants considerably reduces the possibility of conducting research. A personal level was also revealed, with the participants describing the raise in salary that comes with a career development as desirable. On the other hand, some reported accepting a decrease in salary to be able to continue to conduct research. Here, age could be a factor for the financial aspect on a personal level. In the previous cross-sectional study, 3 on which the present study is based, the mean age of the participating RNs with a PhD was 51 years, indicating that RNs start their PhD studies quite late in their career. This is also supported by other studies, where the RNs with a PhD reported having a mean age above 50 years.11,23 The fact that it may be more difficult later in life (when you have perhaps started a family) to have an insecure employment relying on funding or to have to reduce one's salary could be an impeding factor with regard to initiating and continuing a career within research. 24 Also, there is a difference regarding at which stage of the professional and educational development research is introduced, that is, late or early during the RN career, and, for some, perhaps even during the bachelor education. Physicians, for example, have a professional tradition of becoming introduced to research early in their careers, as well as having post-PhD trajectories supporting them to stay in clinic, which is something that is reported as lacking for nurses. 23
This study has generated new insights into the prerequisites for RNs with a PhD who want to advance career-wise. It shows that careers for PhD-prepared RNs depend on high personal investments and initiatives along with external support. The external support from heads or managers was mentioned as being important on a personal level, combined with the managers’ engagement and the ability to acknowledge the positive outcomes of nursing research. Managers have previously been recognized for their influence in enabling a research culture within organizations,25,26 but, in the present study, their personal investment was highlighted as something beyond the organizational assignments, going that extra mile – something that should not be needed if a national career structure was created. However, exploring managers’ conceptions of the role of RNs with a PhD, especially in the clinical context where the structures for research culture are reported as lacking the most, might increase the understanding of the present organizational barriers.
Finally, the present study has performed a general exploration of prerequisites among RNs with a PhD across organizations and employments in Sweden, with the intention of showing common aspects regardless of work conditions. Although there are general similarities across the results, a tendency towards a difference is noticed on the organizational level (in both a clinical and an academic context), which could be affecting career choices and development. Therefore, to be able to continue towards the development of national career structures for employments, there remains a need to summarize and compare experiences among nurses with PhDs from different working organizations.
Methodological considerations
All of the reseachers are RNs and, additionally, five of us have a PhD degree and one is a PhD candidate. All of us have working experiences from a Swedish context. Reflexivity is essential in qualitative research, as there is a risk that the researchers’ pre-understanding influences the data collection and the analysis. 27 However, in the present study, the reseachers’ pre-understanding may also have helped to achieve a deeper understanding of the participants’ experiences. A continuous reflection upon the pre-understanding was present in the group during the analysis and when writing the result.
To achieve congruity, all the digital interviews were conducted by one of the reseachers (AE), who wrote notes shortly after the interviews. Throughout the study process, efforts were made to enhance trustworthiness related to the central terms of Lincoln and Guba. 28 Dependability was ensured by the analysis mainly being conducted by two of the reseachers (MH and AE), one of whom (MH) needed to rely on the transcribed text, which enhanced the dependability. To further confirm the dependability of the study, the whole research team discussed the analysis process until agreement was reached.
It is voluntary to report the PhD graduation in the register of the Swedish Society of Nursing, and no other national registers are available, which is a limitation for reaching potential participants. This made a complete invitation for participation in the study, that is, to all nurses who earned a PhD within the chosen timeframe, difficult. However, there was a great interest in participating in this study among the participants in the previous cross-sectional study, 3 and, out of the 55 RNs that showed interest to participate, 36 were conclusively interviewed, which was regarded as high and increasing the transferability. Furthermore, the demographic variation among the participants also augmented the transferability. Digital interviews have been criticized for not providing the same rich data as face-to-face interviews. 29 Digital interviews were, however, considered applicable in this study because the cohort was used to digital work and because they enabled a geographical variation, which further enhanced the transferability. Moreover, a detailed description of the design and method process will allow the readers to determine the transferability into similar contexts.
To ensure credibility, an interview guide was used that covered the topic related to the aim of the study. Probes were also used during the interviews to obtain more detailed information, with such information being confirmed in the course of the long interviews (mean time 36 min). Furthermore, to enhance the credibility, quotations from the interviews are included in the results. The number of interviews was considered to be sufficient because no new information was identified during the analysis, which also confirms the credibility.
Conclusions
In general, there is a lack of established career trajectories for RNs with a PhD, which has induced this group to create their own working solutions in forming careers. It is essential to develop guidelines towards a clarified role and an established career trajectory for this group, as well as further inspiring the development of national career structures. Furthermore, employments including allocated time for research, along with research grants specifically directed towards nursing research, are needed for RNs with a PhD.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
