Karen

Karen has combined research with clinical practice throughout her career as a physiotherapist. She is now a clinical director in a large teaching hospital and she oversees a number of staff undertaking research.

Throughout her career as a physiotherapist, Karen has combined research with clinical practice. Initially, before she was contracted to do research, she found time to follow her interests in research on the side by working long hours. Karen’s managers were generally supportive of her research, as long as you were doing the job you were paid to do they were quite happy to tolerate you doing this on the side. She also found guidance through more senior researchers in the field by attending a monthly research group, and support from a professor and a practitioner she worked with. Acting as mentors, they offered advice and comments on research ideas through to the writing-up of findings. Some of the early research that Karen undertook included a randomised controlled trial looking at outcomes of a TENS treatment on patients with unexplained abdominal pain. Karen’s first formal post involving research was a trial on spine stabilisation, where she was asked to recruit and follow-up patients.

Over the years, Karen’s involvement in research has shifted from aiding with recruitment and data collection, to developing and initiating research. In her current post, Karen is a clinical director in a hospital where she employs 65 staff, eight of whom do research. Karen supervises several researchers, encouraging them to gain experience in clinical practice as well as research, with the aim that they will eventually work in a hybrid role. She says that continuing to develop clinical skills is also important so that they are not unemployable in the wider NHS. Karen feels a sense of duty to promote career opportunities for her staff. Nonetheless, she acknowledges that maintaining a career in both clinical practice and research has its challenges. Karen describes there being a number of changes since she initially conducted research. For example, the amount of paperwork and emphasis on information governance has increased drastically. This can be time-consuming and Karen feels it should be more proportionate to the level of risk of what the trial is.

Karen thinks research is absolutely complementary and symbiotic with clinical practice, and that this is necessary to ensure that the two inform one another. This includes to generate clinically relevant questions, but also for research to improve the care that patients receive: the whole point for me of doing research is that it improves clinical practice and clinical pathways. However, she feels it is important that patients understand the differences between the two when they are offered various treatments and interventions. Karen describes the need for research physiotherapists to make sure patients understand what participating in a study involves and what it means, you’ve got to be careful you’re not coercing them because, particularly in this sort of setting, patients tend to be so grateful that you are helping with their clinical problem that they feel an element of obligation to help with the research.

Karen encourages physiotherapists interested in taking on a research role to try it. She highlights that physiotherapists have important skills and knowledge to bring to studies. Karen suggests that an ideal career for a research physiotherapist would combine both research and clinical practice, to explore research questions that can make a difference. She feels there is a need for a much clearer clinical academic pathway for research physiotherapists.

Karen had seen increases and changes in the research governance structures across her career. Going through ethics processes could be paralysingly slow and bureaucratic.

Age at interview 55

Gender Female

Well I mean now if it’s a biggish study and you want it supported by one of the clinical trials unit, you are following acres of paperwork, of SOP’s [Standard Operating Procedures] and this, and that and the other, and you know there’s no avoiding it, you’ve just got to suck it up and do it really. I don’t think it’s actually made the research any better than what we did before when we had so much less, but you know it’s, things are different nowadays, I mean governance matters, you’ve just got to follow it.

You know it is, it is paralysingly slow sometimes, and ethics, well actually if you get, if you ever get to an ethics committee it’s fine, it’s getting it through R&D [Research & Development], checking it, changing it, changing it, and it’s very much sometimes about one person’s slant on things versus another. I mean it drives me demented when you have to put things to R&D, and they’ve changed the wording of your letter. You know, you know, for god’s sake, you know, I’ve been doing this for 30 years, I know how to write a letter to a patient. You may have phrased it differently, but what I did was not unintelligible. But, but yeah, it’s just one of the irritants of doing research.

It is quite, quite bureaucratic.

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In her own career, Karen had always coupled research and clinical work. She felt a duty to think about the long term career prospects of your staff.

Age at interview 55

Gender Female

Yeah, I think that-, given that I believe that the best questions come from clinical staff, I think if you work in research as somebody who is newly qualified, you haven’t got a lot of clinical yards under your belt. And it’s good that you understand all the research process to work on a few trials, you know, they, even when they’re doing that they work an afternoon a week on, you know, or you know probably the equivalent of a day clinically. But there’s a point if they’re going to develop their careers so that they are not unemployable in the wider NHS, where you can stay too long in a research post, and you become so narrow that it is very hard, so if you moved, you know, to a different town you would really struggle to get a, a post. So, I think it’s you know as an employer you’ve got a duty to guide their career in total, and for the newly qualifieds yes, a year, 18 months in research, but then they do need to get their clinical skills up. Yeah hopefully come back or go into a hybrid role.

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Karen felt research governance could be excessive in relation to relatively low-risk studies, and encouraged this to be changed.

Age at interview 55

Gender Female

I think the, you know you’ve got so much money to pay for all of the activity, I think that the, the level of paperwork is not always proportionate to the element of risk within any one trial, so you will have to go through almost the same amount of paperwork and forms, if you are doing a trial that is about surgery that could potentially harm you, and lead to a really serious adverse event, or to some of the other interventionist trials, than you do for an intervention that is really about one method of giving exercise to another method of giving exercise. So, whatever happens the level of any clinical risk is really low, you know with the worst you’re going to do is waste somebody’s time really. And yet the paperwork you go through is as, you know you’ve got to fill in every form, even if it’s to say that it’s not applicable, you know, I don’t, I think that time was better spent on doing more towards the research, and I think that you know research governance needs to be more, more nuanced and more proportionate to the level of risk of what the trial is, rather than having this blanket very heavy handed approach for everything.

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Across her thirty year career as a physiotherapist, Karen found ways to carry out research within her clinical job.

Age at interview 55

Gender Female

And then yes so, every clinical job I’ve been in since there’s always something you’re doing where you’re thinking well, why do we do this?’ Or why is it these patients do that? or, you know, I’ve got a fairly low boredom threshold and I don’t mind hard work and, you know, in the early days you just got on and did it, and you didn’t really need to ask too much permission, I mean most of my, my line managers were, as long as you were doing the job you were paid to do they were quite happy to tolerate you doing this on the side so to speak.

I’ve had people who’ve been supportive just in that almost they’ve turned a blind eye and let me do it, and haven’t interfered, and that is great support, cos the worst thing you need is somebody who’s going to be constantly trying to put you back in your box. So, I’ve been, I had, you know, my early career, several physiotherapy managers who, they knew I was doing this sort of thing, but they didn’t do anything to stop you. I wouldn’t say they did anything particularly to encourage me, but they let you get on and do it, as long as you were doing the rest of your job as well.

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Karen described there being different power dynamics with patients/participants in research.

Age at interview 55

Gender Female

It’s about, you know, if somebody is new in, so particularly if it’s somebody who’s been a clinician only, then they have to understand that the power relationship is very different. So when you’re treating a patient the power all sits with you really, and patients have come to you for your help and you are, you know, near enough telling them what it is you can offer and, you know. Whereas when it’s a research patient, you know, you are desperate to do anything to get them to help in the first place, and to stay involved, and you’re very aware that they are putting themselves out to help you. And so, it’s, there’s often quite a bit of training for people, and particularly for people who work in both roles because you’re almost having to swap at lunchtime from, you know, being very conciliatory to people and really wooing them and, you know, thanking them and nothing is too much trouble, you know, yes, you know, If you want me to come out to your home and do this on a-, you know, sort of, We will do it cos we’re so keen. To the next moment going, Our opening hours are this to this, and, you know, No, that’s not reasonable to expect the NHS to do that, so that’s a, you know, a difficult balance to cope with sometimes.

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In the physiotherapy research that Karen leads, there can be Adverse Events (AEs) which need to be reported as per the study documentation.

Age at interview 55

Gender Female

Yeah, I mean it happens. And usually there’s a very clear protocol for what you do to, you know, so you just follow the protocol. They, they’re not catastrophic, it’s not like drug trials where you could, we’re not talking sort of a Northwick Park [a drug trial scandal in 2006] type of event, they’re usually increased pain or people who’ve fallen or, you know, that type of thing. But I mean I think there’s always a very, very clear protocol for how they are reported, managed, it’s usually like getting the patient back in to see one of the clinical team, and, you know, and mostly they are-, they’re not directly related to something that you’ve been doing [as part of the research]. So, I mean it’s rare that you get an adverse event because they’ve been doing-, I don’t know, baseline assessment and they’ve tripped up while they’ve been doing it and broken their leg or something. So, I think they’re fairly, but I think, I think they’re, if your protocol is right and your SOP’s [Standard Operating Procedures] are right, I think they’re easy to deal with.

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Karen highlighted that, in very research-active environments, it was important to stagger studies.

Age at interview 55

Gender Female

I mean we have to phase them, so we would have to look at both the number of studies that the department can support at any one time, whether they’re the same pool of patients, and it may well be that you’re going yes well we, we can do this study, but we won’t be able to start recruiting until, you know, for six months, because we are currently recruiting for this study, and we can’t do both at once’, or, and that maybe cos there aren’t enough patients, or it may just be sheer resource, that it, and there is a limit to how many different protocols you can expect a clinical team to keep in their head, and to deliver and, and it is harder to treat patients to a clinical protocol as well, you know, so you don’t want to over burden the clinical team. So yeah, I think we have to be mindful of not over burdening the same group of people.

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