Breaking barriers and perceptions: a path towards the increase of health professionals research participation
Abstract
Ao longo dos últimos anos, a comunidade de profissionais de saúde envolvidos na investigação em Portugal e na Europa tem sido uma preocupação recorrente. A participação ativa dos profissionais de saúde em projetos de investigação traz uma perspetiva prática e clínica para a investigação básica. Apesar das evidências claras que destacam os benefícios de ter profissionais de saúde a liderar e contribuir para projetos de investigação clínica nas instituições e organizações de saúde onde trabalham, a sua participação permanece aquém do ideal. Temos o objetivo de compreender melhor os desafios que os profissionais de saúde enfrentam ou o apoio que encontram para se envolverem com sucesso em investigação, como percecionam o apoio organizacional e como esta perceção afeta o envolvimento em investigação. Neste projeto, procuramos proporcionar uma compreensão mais aprofundada do impacto que o apoio organizacional tem no envolvimento dos profissionais de saúde em investigação. Além disso, desejamos compreender como apoiá-los de forma eficaz, dentro do seu contexto clínico, no sentido de os incentivar ‡ participação e/ou liderança em projetos de investigação. A metodologia deste estudo avançou com uma integração sistemática de dados quantitativos e qualitativos, através de entrevistas e de um questionário, aplicado para compreender a experiência dos profissionais de saúde portugueses que participam em projetos de investigação, no ‚âmbito das suas organizações de saúde. Os resultados mostraram que os principais facilitadores destacados pelos profissionais de saúde estão predominantemente relacionados com o domínio pessoal, e as barreiras estão predominante focadas nos domínios organizacionais. Contudo, e considerando o baixo nível de apoio organizacional percebido, os profissionais de saúde em Portugal parecem possuir a resiliência necessária para superar obstáculos. Acreditamos que existe potencial para um grupo mais alargado de profissionais de saúde se envolver em investigação, se as condições apropriadas na organização forem consideradas.
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i DIREITOS DE AUTOR E CONDIÇÕES DE UTILIZAÇÃO DO TRABALHO POR TERCEIROS Este é um trabalho académico que pode ser acedido por terceiros desde que respeitadas as regras e boas práticas internacionalmente aceites, no que concerne aos direitos de autor e direitos conexos. Assim, o presente trabalho pode ser utilizado nos termos previstos na licença abaixo indicada. Caso o utilizador necessite de permissão para poder fazer uso do trabalho em condições não previstas no licenciamento indicado, deverá contactar o autor, através do RepositóriUM da Universidade do Minho. Atribuição-NãoComercial-SemDerivações CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/ [Esta é a mais restritiva das nossas seis licenças principais, só permitindo que outros façam download dos seus trabalhos e os compartilhem desde que lhe sejam atribuídos a si os devidos créditos, mas sem que possam alterá-los de nenhuma forma ou utilizá-los para fins comerciais.]
ii FINANCIAL SUPPORT This study was supported by Fundação para a Ciência e a Tecnologia (FCT) through a PhD grant (SFRH/BD/144911/2019) financed by Programa Operacional and União Europeia.
iii Supervisor Doctor Ana Carvalho, PhD, Associate Professor Escola de Economia e Gestão (EEG) da Universidade do Minho, Braga, Portugal Núcleo de Investigação em Políticas Económicas e Empresariais (NIPE), Braga, Portugal Co-supervisor Doctor Carla Oliveira, PhD, Affiliated Professor Instituto de Investigação e Inovação em Saúde da Universidade do Porto (i3S), Porto, Portugal Instituto de Patologia e Imunologia Molecular da Universidade do Porto (IPATIMUP), Porto, Portugal Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
iv ACKNOWLEDGMENTS/ AGRADECIMENTOS Gostaria de expressar os meus sinceros agradecimentos a todos aqueles que, com o seu apoio, orientação e colaboração, contribuíram de forma decisiva para a realização desta tese de doutoramento. Sem o vosso envolvimento e dedicação, este trabalho não teria sido possível. À Ana Carvalho, minha orientadora de tese, pela orientação dedicada, apoio inestimável e comprometimento ao longo deste percurso académico. A sua expertise, incentivo e orientação foram fundamentais para o sucesso desta investigação. À Carla Oliveira, minha co-orientadora, agradeço profundamente pela inspiração constante e pelo ambiente de aprendizagem colaborativo que me proporciona desde sempre. Foi, e é, uma honra e um privilégio ser orientada por alguém tão exemplar e dedicada, que tanto contribuiu para o meu crescimento profissional e pessoal. A Carla é uma verdadeira força da natureza e inspiração para todos nós. Quero expressar o meu agradecimento ao grupo ERiC por todo o apoio e pela troca de ideias ao longo desta jornada. Trabalhar lado a lado com cada membro do grupo tem sido verdadeiramente enriquecedor. Por fim, quero expressar a minha profunda gratidão a todos os profissionais de saúde que participaram neste estudo, pela sua colaboração essencial e dedicação incansável. O vosso compromisso em melhorar a qualidade dos cuidados de saúde, aliado ao vosso envolvimento na investigação, é uma fonte de inspiração. A todos os que procuram constantemente aprimorar o seu trabalho através da ciência e inovação, o meu reconhecimento sincero.
v DEDICATION/ DEDICATÓRIA Dedico esta tese à minha família e amigos, cuja presença e apoio incondicional me deram força ao longo deste percurso. A todos vocês, que me inspiraram e estiveram ao meu lado em cada passo, esta conquista também vos pertence. À Celina, Silvana e Marta, quero agradecer a amizade e companheirismo ao longo destes anos. Apesar de não compartilharmos a mesma área académica, o apoio constante que recebi de cada uma de vocês foi verdadeiramente valioso. Nos momentos de desafio no mundo académico e além, a vossa amizade e apoio foram insubstituíveis. À minha Filó, um agradecimento especial por estar sempre na linha da frente. O teu apoio e amizade significam o mundo para mim. Agradeço do fundo do coração por estares presente em todas as fases da minha vida. Gostaria de expressar a minha gratidão à Ana Sofia, Filipa e Luzia. A vossa amizade e companheirismo e alegria são fundamentais para o meu sucesso. Quero dedicar um agradecimento especial aos meus pais e irmão. Sem eles, eu jamais teria alcançado este patamar. Todo o meu percurso é profundamente marcado pela vossa presença, apoio e amor incondicional. Cada desafio superado, cada conquista alcançada é, em grande parte, resultado do suporte incrível que recebi da minha família. À Cátia, minha cunhada, obrigada por toda a paciência e apoio em todo este processo. Ao Nelson, meu melhor amigo e companheiro nesta incrível aventura que é a vida. Agradeço por suportares todos os altos e baixos que esta jornada implicou, por permaneceres sempre ao meu lado e por nunca duvidares de mim, mesmo quando eu própria duvidava. O teu apoio constante é um inestimável, e agradeço por seres a rocha que sustenta a minha jornada. (A nossa aventura está só a começar, e em breve a três). E ao Eddie, o nosso companheiro de 4 patas, por me obrigar a levantar da secretaria e atirar umas bolas ao ar livre.
vi STATEMENT OF INTEGRITY I hereby declare having conducted this academic work with integrity. I confirm that I have not used plagiarism or any form of undue use of information or falsification of results along the process leading to its elaboration. I further declare that I have fully acknowledged the Code of Ethical Conduct of the University of Minho. University of Minho School of Economics and Management Ph.D. in Business Administration September 2024 Name: Liliana Filipa de Carvalho Sousa Signature: Assinado por: LILIANA FILIPA DE CARVALHO SOUSA Num. de Identificação: 14176371 Data: 2024.09.23 14:53:06+01'00'
xiii TABLE INDEX Table 1Search terms used in the systematic literature review ...................................................... 15 Table 2Inclusion and exclusion criteria for studies screening. Legend: HP=health professionals .... 16 Table 3Interviewee's demographics ............................................................................................. 43 Table 4Distribution of Health Professionals according to sociodemographic characteristics........... 49 Table 5Distribution of health professionals according to professional category .............................. 50 Table 6Distribution of health professionals according to educational qualification ......................... 50 Table 7Distribution of health professionals according to the organization's context. ...................... 51 Table 8. Evaluation of the enablers for health professionals’ engagement in research through a likert scale from 1 to 5 .......................................................................................................................... 52 Table 9Evaluation of the barriers for health professionals’ engagement in research through a likert scale from 1 to 5 .......................................................................................................................... 54 Table 10Perception of Organizational Support of health professionals in the organization where they perform their clinical activity ......................................................................................................... 55 Table 11Research participation at current health organization ..................................................... 56 Table 12Scope of the research .................................................................................................... 56 Table 13Role that HP represented in research activities ............................................................... 57 Table 14Types of organizations that funded research projects...................................................... 57 Table 15Participation in research projects by health professional category ................................... 58 Table 16Relationship between the roles that HP represented in research and the different health professional categories ................................................................................................................. 59 Table 17Distribution of funding sources across diverse health professionals’ categories ............... 62 Table 18Relationship between individuals' marital status and allocated time for a research .......... 63 Table 19Regression analysis to predict the influence of different enablers and barriers with the factor research participation in the organization ...................................................................................... 63 Table 20Path coefficients to predict the influence of perceived organizational support with the factor research participation ................................................................................................................... 69 Table 21Average Variance Extracted and correlations of latent constructs .................................... 70 Table 22Path coefficients from the model Enabler > POS > RE .................................................... 71 Table 23Path coefficients from the model Barriers > POS > RE.................................................... 73
xiv FIGURES INDEX Figure 1PRISMA flow diagram characterizing the literature review process for the main barriers and enablers for HP research participation........................................................................................... 17 Figure 2Frequency of articles published between 2000 and April 2023 ........................................ 18 Figure 3Cohort studied distribution by country ............................................................................. 18 Figure 4Conceptual model regarding the main barriers and enablers that health professionals face to engage in research ....................................................................................................................... 19 Figure 5Study design conceptual framework ................................................................................ 31 Figure 6Interviews data structure process.................................................................................... 37 Figure 7Results of statistical analysis of mediating effect of POS between enablers and research participation ................................................................................................................................. 71 Figure 8Results of statistical analysis of mediating effect of POS between barriers and research participation ................................................................................................................................. 72 Figure 9Glasziou’s triangle: different levels of research participation (Adapted from Del Mar, 2004) .................................................................................................................................................... 76
xv ACRONYMS AND ABBREVIATIONS ACA - Affordable Care Act ACSS - Administração Central do Sistema de Saúde DGEEC - Private Non-Profit Institutions DGS - Direção Geral de Saúde FCT - Fundação para a Ciência e a Tecnologia HP - Health Professionals HRM - Human Resources Management IPCTN - National Scientific and Technological Potential Survey ME-MCTES - General Directorate of Statistics for Education and Science OB-HMR - Organizational Behaviour and Human Resource Management OE - Ordem dos Enfermeiros OM - Portuguese Medical Association POS - Perceived Organizational Support SEM - Structural Equation Modeling SET - Social Exchange Theory SNS - National Health Service ( Serviço Nacional de Saúde ) SPSS - Statistical Package for Social Science TSDT - Sindicato dos Técnicos Superiores de Diagnóstico e Terapêutica
xvi “ We’re at risk of having two separate worlds that don’t interact - the research world and the clinical world ” - Robert Alpern
1 CHAPTER 1 – INTRODUCTION 1.1. Contextualization and justification of the topic Scientific research in areas such as healthcare is nowadays integrated into a complex panorama, requiring and prioritizing the direct involvement of health professionals. Health professionals, including medical doctors, nurses, allied health professionals, and other health professionals, have a critical role to play in conducting clinical research, in advancing medical knowledge and improving patient care (Hanney et al, 2013). Health professionals, with their expertise and experience in patient care, are well-positioned to identify research questions that are relevant to their patients' needs and can help to design studies that are practical and feasible to conduct in a clinical setting (Pager et al, 2012; Hanney et al, 2013). The benefits at individual, organizational and societal levels for health professionals that participate or lead research projects, has been shown in previous studies (Wenke et al, 2021). Indeed, this type of practice is directly linked to reduced staff turnover among health professionals, increased productivity and efficiency in patient care, treatment, and diagnosis (Lizarondo et al, 2011; Williams et al, 2015; Boaz et al, 2015). By participating in research, health professionals can also gain experience in research design, data analysis, and scientific communication. This experience can be valuable for career advancement, as well as for improving the quality of patient care (Babiker et al, 2014; Wenke et al, 2021). Health professionals who engage in clinical research can help to bridge the gap between research and practice. They can serve as a link between researchers and clinicians, helping to ensure that new knowledge generated from research is translated into clinical practice in a timely and effective manner (Smee, 2002; Nass et al, 2009). Finally, health professionals who conduct clinical research can contribute to the development of evidence-based guidelines and policies that can improve patient care and outcomes, by generating high-quality evidence (Pager et al, 2012; Hanney et al, 2013; Sashka et al, 2020). More benefits of health professional’s participation in research projects are mentioned regarding impact on research studies, wider research system, clinical practice and at a personal level (Sashka et al, 2020).
2 Despite the obvious advantages listed above, health professionals’ participation in research projects remains sub-optimal (Lander et al, 2010; Deligiannidis, 2015; Traill et al, 2016; Windsor et al, 2017). In previous studies, concerns have been raised about the fluctuating levels of health professionals engaging in research activities. James Wyngaarden highlighted the issue 40 years ago in his article “The Clinical Investigator as an Endangered Species” (1979), emphasizing the need for ongoing attention to this matter. While the situation may vary across regions, recent data from countries such as the United States show that the percentage of medical researchers decreased from 4.7% in 1980 to 1.5% in 2019 (Jain et al, 2019). Similar trends have been reported in countries like Canada, Australia, and New Zealand (Lander et al, 2010; Windsor et al, 2017; Al-Busaidi & Tarr, 2018; AlBusaidi & Wells, 2017). Although the decline may not be as pronounced or verifiable in every context, including Portugal, it remains crucial to explore strategies aimed at fostering greater participation of health professionals in research. By identifying potential barriers and opportunities, stakeholders can design targeted interventions and policies to encourage a culture of research within the healthcare community. This, in turn, will help advance healthcare research and improve patient care quality, ultimately benefiting society as a whole Several limitations of previous studies regarding health professionals’ involvement in research projects, are listed below: o Most previous studies were performed by health professionals interested in their colleagues' involvement in research, and rarely by Organizational Behaviour and Human Resource Management (OB-HMR) scholars, therefore lacking their perspective (Wenke et al, 2020); o Most previous studies focused exclusively on research careers for medical doctors or nurses, disregarding other categories of health professionals, who perform clinical or non-clinical activities (Borges et al 2010); o Recent studies on this topic rely on small samples, since they are developed with a low number of clinicians from a single organization, making it inadequate to generalize the results to the health professional’s community (Buckley et al, 2000); o The inconstant terminology and inconsistent definitions are also mentioned as a limitation in previous studies regarding what is considered “a research active individual”; “research
3 participation” and “engagement in research" (Hanney et al, 2013; Sanders et al, 2021; Daniels et al, 2021); o Most studies have been developed in UK, USA, Canada or Australia and the specificities of other countries such as Portugal, with a unique national health system and career development system of health professionals, were never considered (Ciemins et al, 2020), to the best of our knowledge 1.2. Healthcare Organization & Healthcare Research Healthcare Organizations play a pivotal role in ensuring the delivering of high-quality medical services to the population. These organizations encompass a diverse spectrum, ranging from public hospitals and primary care centres to private clinics and specialized medical institutions. The healthcare landscape is characterized by a blend of public and private entities working in tandem to provide comprehensive healthcare services to citizens (Nunes & Ferreira, 2022). Healthcare Research stands as a dynamic and evolving field that contributes to the advancement of medical knowledge and the improvement of healthcare practices. Renowned research institutions, both academic and clinical, are dedicated to exploring various dimensions of medical science, including disease mechanisms, treatment modalities, and healthcare policies. Collaborative efforts between these institutions, healthcare professionals, and regulatory bodies foster innovation and drive progress in medical research, ultimately enhancing the overall quality of healthcare services (Institute of Medicine (US), 1994; Condell & Begley, (2007). The evolution of healthcare research is full of historical milestones and transformative developments. One pivotal moment in the medical history occurred in 1537 when the renowned surgeon Ambroise Parè inadvertently conducted the first clinical trial of a novel therapy, marking an accidental yet groundbreaking finding into evidence-based medicine (Bhatt, 2010). Fast forward to the 1960s, a period that witnessed the inception of health services research as a scientific field of inquiry. Academic leaders from a select number of institutions laid the groundwork for the systematic study of crucial questions surrounding access, cost, and quality of care. This era set the stage for a profound understanding of the intricacies of the healthcare system (Bindman, 2013). Over the ensuing decades, traditional health services research has played a pivotal role in shaping healthcare practices. Its contributions extend beyond academia, influencing innovations in healthcare organization, delivery, and policy. Notably, this
4 body of research has underpinned transformative initiatives such as the Affordable Care Act (ACA), and its enduring legacy continues to fuel the ongoing expansion of the role of health services researchers in shaping the future of healthcare (Zerhouni, 2005). Also, it is important to highlight that healthcare research in developed and developing countries exhibits notable differences due to variations in resources, infrastructure, priorities, and healthcare systems. The gap in research and development investment between developed and developing regions is substantial (UNESCO, 2005). Sanyal and Varghese (2007) explain that "all developing countries invest less than 1 per cent of their GDP in R&D activities while almost all developed countries invest more than 1 per cent, while many invest more than 2 per cent and a few invest over 3 per cent" (Sanyal & Varghese, 2007, p.10). In developed nations, the focus often revolves around advanced technologies, precision medicine, and the management of chronic diseases, reflecting the sophisticated healthcare infrastructure and resources available (Smith et al, 2019). On the other hand, developing countries struggle with challenges such as limited resources, a higher burden of infectious diseases, and the need for costeffective and scalable interventions to address pressing health issues (Shiffman & Smith, 2007). The disparities in research priorities, infrastructure, and disease profiles necessitate tailored approaches in each context. Moreover, ethical considerations and regulatory frameworks may differ, adding an additional layer of complexity to global health research endeavours (Pratt et al, 2016). In Portugal, the healthcare system operates through a combination of public, private, and social sectors. The cornerstone of the public system is the National Health Service (SNS – Serviço Nacional de Saúde), which provides accessible and comprehensive healthcare to all Portuguese citizens and legal residents. Funded primarily through taxes, the SNS offers a wide range of services, including primary care, hospital treatments, specialist consultations, medical tests, surgeries, and medications. Primary healthcare is delivered through a network of health centres and clinics, where patients can access general medical care, referrals to specialists, and prescriptions (Nunes & Ferreira, 2022). In addition to the public sector, the private healthcare sector also plays a role, although its contribution to the treatment of acute, severe, or complex conditions is relatively limited. Private hospitals, clinics, and practitioners offer services on a fee-for-service basis, often covered by private health insurance or schemes like ADSE, which is a special public-sector health insurance scheme that provides additional coverage for civil servants and public employees (Nunes & Ferreira, 2022).
5 Furthermore, various professional bodies and associations, such as the Portuguese Medical Association (OM – Ordem dos Médicos), Portuguese Nurses Association (OE – Ordem dos Enfermeiros), and the Union of Diagnostic and Therapeutic Technicians (TSDT – Sindicato dos Técnicos Superiores de Diagnóstico e Terapêutica), General Directorate of Health (DGS - Direção-Geral da Saúde), Institute of Legal Medicine and Forensic Sciences (IMLCF - Instituto da Medicina Legal e Ciências Forenses), National Health Agency (ANS - Agência Nacional de Saúde), play a critical role in regulating medical practice and ensuring the quality of healthcare delivery. These organizations, along with others, contribute to the oversight and continuous improvement of healthcare standards across the country. It is also important to acknowledge the role of the social sector, which includes charitable and nonprofit organizations that complement the SNS by providing healthcare services, particularly in areas like longterm care and support for vulnerable populations. In summary, while the SNS remains the central pillar of healthcare in Portugal, the private and social sectors, alongside various regulatory and professional bodies, contribute to the overall provision of health services in the country (Nunes, 2016). As mentioned before, healthcare research carried out by health professionals has unique characteristics. And in the last decades, there has been remarkable progress in biomedical sciences in the country, with a significant growth in highly qualified human resources, although most of them are non-medical scientists (FCT, 2019). The National Scientific and Technological Potential Survey (IPCTN) of 2022, shows that the human resources allocated to Research & Development activities in Portugal in 2022 totalled 74.025, of which 59.051 performed researcher functions, values that reflect a growth of 6% and 5%, respectively, compared to the previous year. This survey also reveals that researchers continue to focus on the Higher Education sector 29.763 (50%), and on Companies, 26.456 (45%) (IPCTN, 2022). However, when we check the expenditure on research and development (€3.236.212 thousand) by execution sector and thematic area, we see that the health theme allocated a total of 580.492 thousand euros, 33% in the Business sector, 48% in Higher Education, 10% in the Government and 9% in the Private non-profit Institutions (DGEEC, 2023). This, aligned with the creation of laboratories of excellence focused on researching crucial topics for Medicine, shows that currently Portuguese health professionals seem to have favourable conditions to establish productive collaborations between clinical practice and healthcare science.
6 1.3. Health Professionals As aforementioned, the central role of health professionals working within healthcare organizations to participate in research is unquestionable, due to their privileged position (Hanney et al, 2013). But it is also important to define specifically which health professionals are being considered. There are several categories within the group of health professionals, with a high number of people involved, this number being composed by medical doctors, nurses, administrators, health assistants, social workers, psychologists, nutritionists, and diagnostic and therapeutic technicians. According to their functions, these professionals perform clinical or non-clinical activities. The target group of this study are health professionals who exercise clinical activity, such as: medical doctors, nurses, and allied health professionals. As they are in direct contact to patients and clinical cases. This proximity to patients and the involvement in research gives them the possibility to objectively evaluate their practice and be involved in the advancement of their discipline. i. Medical Doctors The career of medical doctors in Portugal is structured into various categories and levels, as defined by Decree-Law No. 176/2009. The training of doctors is governed by the attainment of a medical degree and the completion of specialized training. After graduation, physicians must undergo a period of complementary training, which varies in duration depending on the chosen specialty (ACSS, n.d.; Dec-lei n.º 176/2009 de 4 de Agosto). Doctors can be classified as family doctors, specialists, or consultants, depending on their training and experience. Progression in the career is linked to merit-based criteria, professional experience, and performance evaluation, with continuous education being essential throughout their careers (DGS, n.d.). The rights and duties of doctors are detailed in the legislation and regulations governing the SNS, ensuring that professionals maintain high standards of quality in providing healthcare to the population (ACSS, n.d.). ii. Nurses The Nurse is the professional with scientific, technical and human competences to provide general nursing care to an individual or family, groups and the community, at the levels of primary, secondary and tertiary health care. In Portugal, nursing is a regulated profession that requires a specific educational pathway. Nurses must obtain a Bachelor's degree in Nursing, which typically lasts four
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14 CHAPTER 2 - THEORETICAL FRAMEWORK In order to conduct an empirically based study, it is essential to explore all the variables and mechanisms, and their theoretical synthesis to deeply understand the state of the art of the subject in study. Therefore, this chapter presents a literature review on the specificities of the main barriers and enablers that these health professionals face to successfully engage in research and other variables and theories under study. 2.1. Potential Enablers and Barriers for Health Professional Research participation (a systematic literature review) To successfully assess the path toward the increase of health professionals' research participation and to reorganize all the dimensions involved, first, it is important to understand what are the main barriers and enablers that health professionals face when engaging in research. Hence this systematic literature review to (i) examine the main barriers and enablers to health professionals engaging in research and (ii) identify current research gaps. A constant comparative technique was applied to identify dominant themes, which were integrated to create a conceptual model. This systematic literature review followed a clear and defined protocol with specific inclusion and exclusion criteria. It is a comprehensive, transparent search conducted over multiple databases and grey literature that can be replicated and reproduced by other researchers (Dewey & Drahota, 2016). The potential enablers and barriers to the involvement of health professionals in research, identified through this systematic literature review, were considered, analysed, and synthesized within three main determinants: Individual; Managerial; and Organizational and Cultural. i. Search Strategy and Selection Criteria The electronic databases Pubmed, Web of Science, and Scopus were searched for publications where the assertions were based on empirical evidence or practical experience. For the purpose of this review, the term Health Professional could be defined as doctor, nurse, diagnostic and therapeutic technician, allied health professional, or other MeSH terms considered. Other key search terms using explosions and combinations such as healthcare research, participation, barriers, and enablers were considered (table 1).
15 Table 1Search terms used in the systematic literature review Databases were searched within a specific time period starting in 2000, with a last update on April 30, 2023. Table 2 lists the inclusion and exclusion criteria for this systematic literature review that were established before the electronic databases search. Studies were included if based on empirical evidence or practical experience, with full text in the English language. Commentaries, editorials, opinion pieces without direct reference to empirical evidence or practical experience, and conference abstracts were not included. The exclusion of studies and articles conducted in developing countries was a deliberate choice aimed at fostering a nuanced comprehension of research outcomes within distinct contextual settings. This approach guarantees that the conclusions derived from the systematic literature review are pertinent, adaptable, and attuned to the distinctive challenges and opportunities encountered in developing countries. A total of 1,981 identified articles were imported into the Endnote software from Clarivate and followed the flow diagram of the different phases of the systematic search and review based on PRISMA (Fig. 1). After screening the titles/abstracts and eliminating duplicates, 1,695 articles were excluded due to duplication or irrelevance, and 286 documents remained for further evaluation to determine their eligibility. Databases: Pubmed, Scopus, and Web of Science Time Frame: 2000-2023 (Last updated April 30, 2023) MeSH terms considered Health Professional; Health Personnel; NHS Staff; Clinician; Doctor; Nurse; General Practitioner; Diagnostic Therapeutic Technicians; Allied Health Professional; Research; Healthcare Research; Health Research; Participation; Engage; Involve; Contribute; Design; Codesign; Co-Design; Conduct; Produce; Barrier; Enabler; Facilitator; Motivation; Obstacle; Challenge;
16 Table 2Inclusion and exclusion criteria for studies screening. Legend: HP=health professionals Title and abstract screening Inclusion Exclusion Topic Articles which: • Focus on methods or approaches to the participation of HP in the prioritization, design, or conduct of research studies or evaluations of healthcare or improvement interventions; • Focus on the barriers and enablers to HP research participation; • Focus on formal schemes such as research fellowship programs; • Study elaborated in developed countries; Articles which: • Focus on the involvement of HP as participants in research, but where they are not actively involved in its prioritization, design, or conduct; • Focus on the involvement of HP solely in the delivery of an intervention to be evaluated; • Focus on patient recruitment for clinical trials or academic research; • Focus on barriers and enablers of research results application in health organizations; • Study elaborated in developing countries; Language • English • Any language other than English Document type • Any type of publication where the assertions are based on empirical evidence or practical experience. • Commentaries, editorials, or opinion pieces without direct reference to empirical evidence or practical experience; • Conference abstracts. Text availability • Abstract • Full text • No abstract available • No full text available Date of publication From 2000 onwards Before 2000 The remaining process was carried out strictly following all exclusion and inclusion criteria, excluding 204 articles that did not meet the appropriate criteria, resulting in a total of 82 articles included for review. However, the reference lists of included studies and previous reviews were also selected as additional relevant articles, adding 19 more included articles to the final list for review of 101 articles (Appendix III).
17 Figure 1PRISMA flow diagram characterizing the literature review process for the main barriers and enablers for HP research participation. ii. Outcomes These results of the review of the 101 articles provide us with an overview of the studies carried out on this topic, by country, year, category of health professionals, and methodology. Also noteworthy is the analysis of the results of items with similar content and meaning, grouped by specific determinants. In the literature search, we included a time frame from 2000 onwards. The earliest result obtained in our review is from 2001, and the most recent result is from 2023. This demonstrates that the topic in
18 question has been recurrent and emerging over time (Fig. 2). Furthermore, the frequency of publications presents oscillations, with a peak (10) in the year 2022. Figure 2Frequency of articles published between 2000 and April 2023 From figure 3, it is evident that most studies have been developed in Australia (22%), UK (19%), USA (17%) and Canada (13%). The majority of studies performed in Europe are from the UK, with very few studies carried out in other European countries such as Austria, Finland, France, Italy, Switzerland, and The Netherlands (all with 1% each). These results identify 13 European countries as the producers of publications in this area, leaving out many developed countries and their respective specificities. Fourteen studies focused on all health professionals as a heterogeneous group, fifteen on allied health professionals, thirty-three on nurses, and thirty-nine on medical doctors. While enablers and barriers to health professionals engaging in research were investigated by all 101 reviewed studies, only eight studies follow a theoretical framework or model in their investigation. These 0 2 4 6 8 10 12 Number of studies Date of study publication 22% 19% 17% 13% 7% 5% 3% 3% 2% 2% 2% 1% 1% 1% 1% 1% 1% Australia UK USA Canada Germany Ireland Denmark Norway Croatia Spain Sweden Austria Finland France Italy Switzerland The Netherlands Percentage of studies Countries Figure 3Cohort studied distribution by country 18
19 included Self-Determination Theory (SDT), Social Cognitive Career Theory (SCCT) and Professional Identity Formation as an integrated framework, COM-B framework, Vroom’s Expectancy Theory, Social Cognitive Theory, combination of TDF and COM-B. A constant comparative technique was applied to identify dominant themes, which were integrated to create a conceptual model regarding the main barriers and enablers that health professionals face to engage in research, in the individual domain, organizational domain, or the environment and cultural domain. A total of 34 variables that can be defined as enablers or barriers were extracted from the 101 included studies for review. Through an interactive review process and constant comparison, the variables with similar content and meaning were grouped using the domain headings summarized in Figure 4. At the individual level, we were able to assess that health professionals encounter both barriers and enablers that significantly influence their participation in research activities. One prominent barrier is the constraint of time, often due to the demanding nature of clinical obligations. Additionally, a lack of specific training in research methodology and data analysis may hinder their confidence and ability to conduct research effectively. However, intrinsic factors such as high levels of motivation, a genuine interest in advancing medical knowledge, and strong analytical skills serve as powerful enablers. Moreover, health professionals who actively seek opportunities for collaboration with peers, academic institutions, and research organizations are more likely to overcome barriers and engage in meaningful research. Additionally, ongoing professional development and access to resources, including mentorship and funding, play a pivotal role in nurturing a research-oriented mindset among health professionals. Overall, recognizing and addressing these individual-level factors is imperative for creating a conducive environment that empowers healthcare practitioners to actively contribute to the research landscape. Figure 4Conceptual model regarding the main barriers and enablers that health professionals face to engage in research
20 At the managerial level, health professionals encounter a range of factors that either enable or hinder their involvement in research. Adequate funding emerges as a critical enabler, as it provides the necessary resources for conducting studies, procuring equipment, and supporting research personnel. A well-structured governance and management infrastructure further streamline the research process, ensuring efficient coordination and allocation of resources. Moreover, integrating research contributions into job plans, appraisal systems, and career pathways demonstrates an organizational commitment to valuing and rewarding research participation, motivating health professionals to actively participate in scholarly activities (Bench et al., 2019; Harvey et al., 2016). Leadership support can be a crucial enabler or barrier, as it fosters a culture that champions research initiatives and provides guidance to aspiring researchers, as well as establishing formal roles dedicated to research within the organization. (O'Brien et al., 2022; Elphinston & Pager, 2015).
21 Efficiently designed time-management systems can alleviate the challenge of balancing clinical duties with research commitments (French & Stavropoulou, 2016; Slade et al., 2018; Orton et al., 2021). As mentioned by Rahman et al. (2011, p. 87) “Financial incentives have been shown to be among the most important factors motivating physician involvement in research”, such as pay progression tied to research contributions, can further incentivize health professionals to invest time and effort in research activities. Additionally, implementing practices that allow headspace for professionals to engage with research, coupled with streamlined bureaucratic processes and ethical committee procedures, alleviates administrative burdens and promotes a favourable research environment (Diebolt et al., 2008; Black et al., 2015; Kunhunny et al., 2017). Clarity regarding the role of health professionals in research within the organization reinforces the importance of their contributions (Moore et al., 2012; Roberts et al., 2015). In summary, it is clear throughout this systematic analysis that a supportive organizational environment, characterized by effective governance, financial backing, and structured pathways, plays a pivotal role in enabling health professionals to actively engage in research (Fudge et al, 2016; Caldwell et al, 2017; Burkinshaw et al, 2022). At the organizational and cultural level, health professionals are influenced by a variety of factors that either impede or enable their participation in research activities. A crucial enabler is the presence of a robust organizational leadership and culture that places a premium on research (Segrott et al., 2006; Kjerholt & Hølge-Hazelton, 2018; Ajjawi et al, 2018). This fosters an environment where research is valued, encouraged, and integrated into the core mission of the healthcare practice. Recognition and awards for involvement in research further incentivize health professionals, providing tangible acknowledgment of their contributions and spurring continued participation (Evans et al., 2013; Elphinston & Pager, 2015; Gilbert et al., 2016). In addition, effective dissemination mechanisms for research findings are imperative, ensuring that valuable insights reach a wide audience and exert a meaningful impact on clinical practice (Mitchell et al, 2015). A compelling narrative about research, underlining its relevance and potential to enhance patient outcomes, acts as a motivational force, inspiring health professionals to actively participate in scholarly pursuits (Awaisu & Alsalimy, 2015). Simultaneously, a culture of feedback within the
22 organization encourages continuous improvement and provides vital support for ongoing research efforts (Albers & Sedler, 2004; Rahman et al., 2011; Roberts et al., 2015). Early exposure to research training during the formative stages of a health professional's career is mentioned as a significant enabler, equipping individuals with the skills and confidence to embark on research. Moreover, support from peers, including mentorship and collaborative opportunities, creates a network of like-minded professionals who can share insights and resources, further strengthening the research ecosystem (Rait et al., 2002; Beasley et al., 2007; Miller et al., 2020; D'Arrietta et al., 2022a). Nonetheless, certain barriers are also mentioned at this level. For example, the divergent views among stakeholders about what topics are important to research can lead to conflicting priorities and hinder collective efforts (Elphinston & Pager, 2015; Reali et al., 2021). Additionally, the perception that research is a specialized activity distinct from the domains of healthcare practice seems to discourage some professionals from engaging in research activities, as mentioned by Moore et al. (2012, p. 42) “In a discussion with the staff of all grades there was a general recognition that research was regarded as a specialized activity and in some instances, it was seen as the domain of the medical staff”. In contrast, it is recognized that establishing a strong connection between research and clinical decision-making enables health professionals to discern the immediate applicability and influence of research on patient care. This, in turn, cultivates a culture in which research is regarded as a vital and inseparable element of delivering high-quality healthcare (Jensen et al., 2013; Scarsini et al., 2022; Jensen et al., 2023). iii. Discussion The synthesis of findings from the selected studies provides valuable insights into the main variables identified as barriers or enablers of health professionals to engage in research. Numerous studies highlight the significance of the individual domain as a key factor potentially facilitating health professionals' participation in research. Constructs related to personal motivation and opportunities, such as collaboration with other organizations and individuals displaying an active research interest, are consistently mentioned in the majority of studies as enabling factors. Moreover, the nature of the health organization can significantly impact the extent which health professionals engage in research. For instance, public health organizations with direct affiliations to universities and
29 tasks that enhance health outcomes often hinges on the allocation of health professionals' time and personal resources. Antecedents of POS encompass a range of factors that influence an individual's perception of the extent to which their organization values their contributions and cares about their well-being. These antecedents can include various organizational practices and behaviours. For instance, fair treatment, supportive leadership, opportunities for skill development, effective communication, and equitable compensation are all recognized as key antecedents. Additionally, the presence of positive social interactions among colleagues, a positive work environment, and clear organizational policies can also contribute to an enhanced perception of organizational support. Moreover, the alignment of personal values and goals with those of the organization, as well as a history of positive experiences within the work environment, can further bolster an individual's sense of organizational support. Overall, understanding these antecedents provides valuable insights into the factors that shape employees' perceptions of the support they receive from their organization (Wayne et al., 2002; Ling et al., 2006; Dawley et al., 2010). The perception of organizational support among health professionals is intricately linked to a range of antecedents that shape how these individuals perceive the value attributed by the organization to their contributions and the care devoted to their well-being. Factors such as fair treatment, supportive leadership, opportunities for skill development, effective communication, and equitable compensation are recognized as key elements. Additionally, positive social interactions, a healthy work environment, and clear organizational policies contribute to an enhanced perception of support. In the context of research, identifying barriers and facilitators becomes crucial. Barriers, such as lack of resources, limited time, and a lack of organizational incentive, can undermine POS. Conversely, enablers, such as a culture of innovation, institutional recognition of research, and investment in training, have the potential to strengthen the perception of support. The association of these elements is essential when considering that engaged research can be a direct consequence of POS, where healthcare professionals, perceiving strong organizational support, are more likely to overcome barriers and actively engage in research activities. The consequences of POS are far-reaching and have profound implications for both individuals and the organization itself. When employees perceive high levels of support from their organization, they are more likely to exhibit greater job satisfaction, organizational commitment, and overall well-being.
30 This, in turn, leads to reduced turnover intentions and increased retention rates, as employees feel a stronger attachment to the organization. Additionally, individuals with a heightened sense of POS tend to demonstrate higher levels of discretionary effort, going above and beyond their formal job requirements. This extra effort positively impacts organizational performance, productivity, and effectiveness. Moreover, they are also more likely to report lower levels of stress and burnout, resulting in improved mental and physical health outcomes. Overall, the consequences of POS extend beyond individual well-being to encompass broader organizational success and effectiveness (Wayne et al, 2002; Wu, 2006; Lee et al, 2011; Yu et al., 2017). The literature posits that a heightened sense of obligation to contribute to organizational goals and an escalating anticipation of recognizing and rewarding superior performance stem from POS. These outcomes of POS are of paramount interest to research-oriented health organizations, given that active involvement in research, especially for professionals primarily engaged in clinical activities, is typically viewed as an extra-role endeavour (Eisenberger et al., 1986). Nonetheless, the participation of health professionals in research has been correlated with heightened productivity and efficiency in patient care, treatment, and diagnosis, significantly aiding health organizations in attaining their objectives (Lizarondo et al, 2011; Williams et al, 2015; Boaz et al, 2015). Hence, evaluating the POS experienced by health professionals stands as a valuable instrument in fostering their research participation within their respective organizations.
31 CHAPTER 3 - METHODOLOGY 3.1. Study Design As outlined by Freixo (2010), a comprehensive review of existing literature lays the foundation for shaping the research question and determining the suitable methodologies to be employed. The main research questions of this study are: what are the main barriers and enablers that health professionals face to engage in research in their health organization; what is the level of organizational support perceived by these health professionals; and how does this POS affect their research participation within the organization? To offer a more insightful comprehension of how factors like enablers, barriers, and POS impact the involvement of health professionals in research, and how best to facilitate their active participation, we present the conceptual framework illustrated in Figure 5. This framework posits that enablers and barriers influencing research participation among health professionals ultimately affect their level of Research participation by influencing their perception of Organizational Support. As a result, Perceived Organizational Support is suggested to act as an intermediary in the relationship between research participation facilitators and barriers, and the level of Research participation exhibited by health professionals. The following hypotheses are therefore derived: H1: The main research participation Enablers are positively related to Health Professionals' Research participation. Figure 5Study design conceptual framework
32 H2: The main research participation Barriers are negatively related to Health Professionals' Research participation. H3: The main research participation Enablers are positively related to Health Professionals' POS. H4: The main research participation Barriers are negatively related to Health Professionals' POS. H5: Health professionals' POS is positively related to Health professionals' research participation. H6: POS mediates the relationship between the main research participation Enablers and Research participation. H7: POS mediates the relationship between the main research participation Barriers and Research participation. To test the proposed hypotheses, we designed the following objectives: i. Analyse the main factors that influence health professionals to successfully engage in research projects (barriers and enablers). ii. Unravel the experience of Portuguese health professionals that may (or may not) be involved in research. iii. Understand the level of POS among Portuguese health professionals and how can this affect their research participation. iv. Design a set of HRM practices to strategically reinforce research participation in Portuguese Public Healthcare Organizations.
33 3.2. Methodological Approach Due to the increasing complexity of health management, the mixed methods approach allows us to explore different perspectives and unravel the relationships that exist between the intricate layers of our multifaceted research questions (Bowers et al, 2013). To address our objectives, we propose the following tasks: a. Assessment of the Portuguese health professionals' experience in the involvement in research and validation of the main barriers and enablers identified in the literature review, through semi-structured interviews; b. Development of a questionnaire survey to evaluate in Portuguese public health organizations the practical relevance of the: main barriers and enablers identified in the previous task; the perception of organizational support of health professionals in the organization where they perform their clinical activity; research participation. c. Design a set of recommendations to strategically reinforce research participation in the Portuguese Public Healthcare Organizations, based on the results obtained in the previous tasks. The main data collection technique used is the questionnaire survey. It is a data collection technique geared toward large-scale studies, which allows us to obtain comparable and generalizable data, that can be submitted to statistical analysis (Freixo, 2010). However, semi-structured interviews with health professionals were used to contribute to the selection of the main enablers and barriers to be included in the questionnaire survey, keeping in mind that the qualitative research interview's main goal is to “gather descriptions of the lifeworld of the interviewee with respect to interpretation of the meaning of the described phenomena” (Kvale, 1996, p. 174).
34 3.3. Qualitative Study A number of semi-structured interviews with health professionals were carried out with the goal of understanding the experience of a health professional participating in research projects in Portugal, focusing on what are the main enablers and barriers they face and the position of their organization regarding this theme. The main goal of these semi-structured interviews was to compare the results with the literature described in other countries (since this theme has never been studied in Portugal) and mainly to select the enablers and barriers - adapted to the reality of Portuguese health professionals - that were selected to integrate the survey questionnaire. We balanced the main contributions of the current literature review with a validation perspective, in order to extract an integrative and global model to evaluate and, consequently, design a set of human resource management recommendations to strategically reinforce research participation in Portuguese healthcare organizations. Hereafter, this part of the study aimed to answer the following research questions: a. What is the perceived perspective held by Portuguese health professionals regarding their participation in research activities? a) Do the barriers and enablers encountered by health professionals in conducting research, as identified in the literature, align with those perceived by health professionals in Portugal? The twenty-three interviews performed with medical doctors, nurses, and allied health professionals performing clinical activities in Portuguese health organizations (table 3) were conducted predominantly via Zoom meetings, with a few conducted over the phone. The duration of each interview varied, ranging from a minimum of fifteen minutes to a maximum of one hour. Prior consent was obtained from all participants for recording purposes, with the intention of capturing detailed notes and verbatim quotes for the study. Following this, all audio recordings underwent transcription, with particular attention paid to identifying key concepts within individual transcripts. The subsequent step involved subjecting all transcripts to a thorough comparative analysis, enabling the identification of both shared themes and contrasting responses across participants. The interview guide (appendix I) was structured with open-ended questions, providing respondents the opportunity to freely share their personal experiences. While each interview encompassed consistent
35 themes, a flexible approach to the interview schedule was adopted, allowing each participant to express their unique narratives. The areas of inquiry covered were: (i) their involvement in research; (ii) the specific scope of their involvement; (iii) reasons for not engaging, if applicable; (iv) their perspective on the importance of research participation for health professionals; (v) their assessment of leadership support; (vi) their emotions towards involvement in research projects; (vii) factors influencing their decision; (viii) the enablers and barriers they identified; and (ix) their organization's stance on this matter. 3.3.1. Sample The target population under study includes healthcare professionals (medical doctors, nurses, and allied health professionals) working in health organizations in Portugal, specifically focusing on clinically active professionals who may or may not be involved in healthcare research within their organizations. Our qualitative research employed a two-tiered sampling methodology: purposeful sampling followed by snowball sampling. Purposeful sampling allowed us to select participants based on specific criteria essential to our research objectives: all healthcare professionals currently performing clinical activities in Portuguese health organizations, regardless of their involvement in research. We aimed to include participants of any age range, from various regions across Portugal, as long as they were medical doctors, nurses, or allied health professionals. This intentional selection ensured that participants possessed characteristics and experiences directly pertinent to our exploration of health professionals' experiences regarding healthcare research. Snowball sampling complemented purposeful sampling by leveraging social networks and referrals, enabling us to identify additional participants from across the country. Informed consent was collected at the beginning of each interview, ensuring that participants were fully aware of their rights and the study's aims. Anonymity for both participants and their organizations were guaranteed throughout the research process. A total of 23 semi-structured interviews were conducted as part of this qualitative study. The decision to conclude the interview phase was guided by the principle of data saturation, which occurs when new interviews cease to yield substantially new information or insights, indicating a comprehensive understanding of the research topic has been reached within the chosen sample. 3.3.2. Data Analysis
36 The data analysis for the conducted interviews with health professionals encompassed a systematic and comprehensive approach to extract meaningful insights. Following verbatim transcription, an initial open coding process was applied to identify recurring themes across the nine key areas of inquiry. Each interview was meticulously analyzed to capture nuances related to (i) the extent of health professionals’ involvement in research, (ii) the specific focus of their participation, (iii) reasons for nonparticipation, if applicable, (iv) perceptions on the importance of research participation for health professionals, (v) their evaluation of leadership support, (vi) emotions associated with involvement in research projects, (vii) factors influencing their decision-making, (viii) enablers and barriers identified, and (ix) their organization's stance on research participation. Subsequently, these initial codes were organized into broader themes, enabling a holistic interpretation of the data (Fig. 6). Constant comparison techniques were employed to refine emerging themes, ensuring a nuanced understanding of health professionals' perspectives and experiences regarding research participation. The analysis aimed to provide rich insights into the multifaceted dynamics surrounding health professionals' involvement in research activities, shedding light on both individual and organizational factors influencing this crucial aspect of professional practice.
37 Figure 6Interviews data structure process 3.4. Quantitative Study The prominent instrument selected for data collection was a survey questionnaire (appendix II). This questionnaire was preferably distributed through the organization's computerized system. The questionnaire was structured into four parts to assess variables in the conceptual model and gather respondents' sociodemographic data: Research transformative potential Symbiotic relationship between clinical practice and research Personal fulfilment participation through research projects Not all paths require active participation in research Significance of research projects within health organizations Enablers influencing HP research participation Motivation and personal interest Career advancement Network Culture of research Administrative support Barriers influencing HP research participation Healthcare Research and Organizational Stance Funding Time Confidence and skills Organizational policies Transparency 1st Order Concepts Aggregate Dimensions
38 1. Sociodemographic Data: This section included 10 questions designed to characterize the sample by gender, age, marital status, educational qualifications, professional category, health organization location (north, center, or south), type of health organization (public, private, publicprivate), and affiliation with research institutes or universities. 2. Enablers and Barriers: Respondents assessed the main enablers and barriers identified through literature review and interviews using a Likert scale from 1 (strongly disagree) to 5 (strongly agree). 3. Perceived Organizational Support (POS): The POS of healthcare professionals was evaluated using the scale proposed by Eisenberger et al. (1986), again on a scale from 1 (strongly disagree) to 5 (strongly agree). 4. Research Participation: This final section focused on the research participation of health professionals, measured through an adapted scale addressing the number of projects they participated in, the percentage of time devoted to research, roles in projects, types of collaborations, and sources of funding. To ensure clarity and reliability, the questionnaire underwent a preparatory study with 5 individuals from various health professional categories and organizations. This pilot testing facilitated the refinement of statements related to barriers and facilitators. Following the validation of the final questionnaire, it was distributed digitally via the Qualtrics platform across nine distinct health organizations, with further outreach requests among health professionals. The survey was accessible from January to May 2023, with two dedicated follow-up periods in each organization to enhance participation. This collaborative approach aimed to create a diverse and representative participant pool. The initiative to distribute the questionnaire to healthcare organizations underwent a rigorous ethical approval process, ensuring adherence to robust data protection standards. Prior to engaging in the study, explicit informed consent was prominently featured at the outset of the questionnaire. This consent was mandatory, and participants were excluded from the study if they chose not to accept it. The careful integration of ethical considerations and the requirement of informed consent underscore the commitment to upholding ethical standards throughout the research endeavour.
45 meaningful endeavour. Emphasizing that the satisfaction arises from the belief that their contributions are part of a larger effort for the betterment of society: “Participation in research projects for me is having some type of personal fulfilment. In other words, when we believe that we are contributing to a greater good, we are satisfied. We become better professionals because we are participating in specific science-based developments for our patients.” (Allied health professional, female) “I see participation in research as a complement to my clinical activity.” (Medical doctor, female) On the other hand, not every health professional is required to be actively engaged in research. While research plays a crucial role in advancing healthcare, there are various roles within the field that don't necessitate direct involvement in research activities. It's important to recognize that each health professional contributes to the overall healthcare ecosystem in a unique way, and not all paths require active participation in research: “I do not agree that all healthcare professionals should be expected to participate in research projects. There are people who don't have this vocation or this calling, and that's okay. But conditions should be given to the few who want to participate in research”. (Medical doctor, male) Absolutely, while it's true that not every health professional needs to be directly involved in research, it's imperative that those who aspire to engage in this pursuit should have the means and opportunities to do so. Providing avenues for research involvement ensures that individuals with a passion for advancing medical knowledge can actively contribute to the progress of healthcare. As previously mentioned in the literature review, the reality is that health professionals who want to engage in research often encounter a mix of enablers and barriers. 4.1.2. Enablers influencing Health Professionals' research participation Our interviewees showed that motivation and personal interest seems to be the main enablers for the participation of health professionals in research: “Research enriches me clinically and personally, but it is mainly a personal choice because it allows me to develop my most creative side.” (Medical doctor, male)
46 The type of health organization where health professionals work is presented as an influencing factor to their research involvement. It seems that health organizations that maintain direct affiliations with universities and research institutes, or health professionals that present a personal connection with research institutes or universities are likely to foster greater participation in research: “I maintain a close contact with the University of Cambridge where I developed my PhD project and we continue to collaborate in several studies” (Medical doctor, male) Moreover, several interviewees mentioned that is easier to participate in research if other members from the service where they work are already involved in research projects, or even if they present a position of mentorship. It creates an environment where curiosity and innovation thrive, making it easier for individuals to get involved (Matus et al, 2019). This study showed that when other professionals, especially those in higher positions, were involved in research activities, it encouraged others to join and participate: “Dr. X is always careful to involve us in her research and help us with all the tasks to be carried out throughout the project.” (Nurse, female) Within the organizational framework, for health professionals to get involved in research, it seems to be helpful if their workplace provides good facilities and there is support from the administrative side. Having the right tools and spaces for research is reported as important: “Our hospital has recently created a research department to help professionals who want administrative help or even help searching for funding opportunities. Which makes life much easier for us.” (Medical doctor, female) Also, smooth administrative processes, like getting approvals and managing funding, make it easier for health professionals to focus on research. 4.1.3. Barriers influencing Health Professionals' research participation On the other hand, a notable issue arises when there's a lack of such support, particularly in crucial areas like funding. This emerges as a significant obstacle for these health professionals, which demonstrate that in many cases, if they want to publish the results obtained in their research projects, they need to use personal savings or raise money in creative ways:
47 “ Often, when we want to publish the results of our studies, we have to draw on a piggy bank to which everyone contributes a little, in order to finance it.” (Medical doctor, female) While conducting the interviews, a recurring barrier emerged, consistent with existing literature: the limitation of time. Each and every interviewee emphasized the challenge of balancing clinical duties and patient care with dedicated research efforts. The healthcare sector's overall workload further compounds this challenge, as many professionals associate involvement in research with dedicating their personal and leisure time. This highlights the considerable time constraints that health professionals encounter when seeking to engage in research: “I just don't participate in research projects anymore because I don't have time. We are overwhelmed with clinical and bureaucratic activities that our role requires.” (Medical doctor, female) “Health professionals doing research is the syndrome of the 3 F’s: vacations, holidays and weekends. [in Portuguese: férias, feriados e fins-de-semana]” (Medical doctor, male) “There is no time allocated for research in healthcare organizations. What is reported to the FCT [Foundation for Science and Technology in Portugal] is false.” (Medical doctor, male) In addition, some health professionals may refrain from engaging in research due to feelings of inadequacy or a lack of confidence in their abilities to participate effectively: “Sometimes I feel like I don't have the necessary skills.” (Nurse, female) They might perceive the research process as complex or scary, potentially leading them to doubt their own capacity to contribute meaningfully. Additionally, the unfamiliarity with research methodologies and the perception of a steep learning curve seem to possibly create apprehension. Consequently, these professionals might opt to stay on the side-lines, despite their potential interest in research. 4.1.4. Healthcare Research and Organizational Stance In our study, a notable finding emerged concerning the managerial organization and policies: regardless of their current involvement in research activities, all health professionals expressed a shared desire for changes in the research policies within health organizations.
48 A good number of health professionals we interviewed felt that their organizations didn't provide enough support. Some even mentioned that they felt the management of their organization was not fully honest about certain things: “There is an incentive for us to participate and develop research projects because it increases the prestige of the hospital, but at the same time, they don't want to spend a lot of money on it. The objective is to carry out the investigation as long as it does not bring extra expenses or trouble to the organization.” (Nurse, female) However, when asked if they have ever tried to discuss this matter with managers or service leaders regarding the potential for improvement in research support, the answer was no. The majority have never openly addressed this issue. It's important to emphasize that no differences were observed in the participation in research projects, regardless of the various categories of health professionals, their gender, age, and location of the organization. 4.2. Questionnaire Survey to Portuguese Health Professionals In this section, we present the results derived from a comprehensive questionnaire survey designed to illuminate critical aspects regarding Portuguese health professionals’ participation in research. The robust methodology, expounded upon in the previous chapter, played a pivotal role in securing a comprehensive dataset, garnering a total of 1.204 submitted responses, of which 936 were validated. The trust analysis conducted, indicating that with a confidence level of 95% and a margin of error of 5%, we would require 659 participants, further strengthens our confidence in the representativeness of the obtained sample. Notably, we surpassed this requirement with a total of 936 validated responses, affirming that our sample adequately mirrors the population under investigation. 4.2.1. Sociodemographic features of Health Professionals operating in Portugal Table 4 summarizes the sociodemographic characteristics of our sample, showing that 692 of the health professionals who participated in the study are female, representing 74% of the sample, while only 244 of the health professionals surveyed are male, representing 26% of the sample. This can be justified by the factor that in Portugal, women represent around 80% of the health professional’s workforce.
49 Regarding marital status, 297 individuals are single (32%), 492 are married (52%), 81 are divorced (9%), 8 are widowed (1%) and 58 selected the option “other” without specifying (6%). Regarding age, the majority of respondents are in the age range between 36-45 years old with a representation of 32% of the sample, followed by the age group 26-35 years with 29%, the age group 46-55 years old with 21%, the group with more than 56 years of old with 14% and, finally, the age group with less than 25 years old with a representation of 4%. Table 4Distribution of Health Professionals according to sociodemographic characteristics (N=936). Sociodemographic Variables Frequency N (n=936) % Sex Male 244 26% Female 692 74% Age ≤ 25 years old 39 4% 26 – 35 years old 272 29% 36 – 45 years old 297 32% 46 – 55 years old 194 21% ≥ 56 years old 134 14% Marital Status Single 297 32% Married 492 52% Divorced 81 9% Widowed 8 1% Other 58 6% Table 5 shows that, of the 936 individuals participating in the study, 324 are medical doctors, being the most represented category of the sample with 35%, followed by 319 individuals as allied health professionals represented with 34%, and 293 individuals are nurses with a representation of 31%. While the representation of various categories of health professionals in our sample is not precisely identical, the similarity observed across these categories suggests a balanced distribution. This ensures
50 that our sample does not exhibit a biased distribution concerning the professional categories of health professionals participating in the study. Inquiries regarding the medical specialty and/or clinical service in which participants engage in their professional activities revealed that none of the 29 specialties demonstrated a notable prominence or significance (appendix II, question 6). Table 5Distribution of health professionals according to professional category (N=936) Professional Category Frequency N (n=936) % Medical Doctor 324 35% Allied Health Professional 319 34% Nurse 293 31% Upon examination of table 6, it becomes evident that a predominant proportion of respondents hold a bachelor's degree, constituting 58% of the sample. Following this, 34% of participants possess a master's degree, while a smaller segment, comprising 8% of the respondents, holds a PhD degree. Table 6Distribution of health professionals according to educational qualification (N=936) Literary abilities Frequency N (n=936) % Bachelor degree 546 58% Master degree 317 34% PhD degree 73 8% Inquiring into organizational details during the questionnaire survey design, we probed respondents about their seniority within the organization. Table 7 reveals a breakdown of this information, indicating that 258 individuals (28%) have been affiliated with the organization for less than 5 years, 149 individuals (16%) have accumulated a tenure of 6 to 10 years, 253 individuals (27%) have a service span ranging from 11 to 20 years, and a notable 276 individuals (30%) have been part of the organization for more than 21 years.
51 In terms of the organizational context in which these health professionals operate, the predominant setting is public general hospitals, constituting 38% of the sample. Following closely, 22% of respondents are affiliated with public university hospitals, while another 22% are associated with public hospitals under private administration (E.P.E.). A smaller segment, comprising 18% of the participants, is engaged in professional roles within private hospitals. In terms of the geographic distribution of these organizations, the majority is situated in the northern region of Portugal, comprising 59% of the total. This is attributed to the significant participation of organizations from the northern part of the country in this study. Subsequently, 28% of respondents are affiliated with organizations located in the southern and island regions of Portugal, while 13% of participants work in organizations positioned in the central part of the country. Table 7Distribution of health professionals according to the organization's context (N=936). Organizational Context Frequency N (n=936) % Seniority in the Organization ≤ 5 years 258 28% 6-10 years 149 16% 11-20 years 253 27% ≥ 21 years 276 30% Type of Organization Public General Hospital 356 38% Public University Hospital 206 22% E.P.E. 206 22% Private Hospital 168 18% Organization Location North 552 59% Center 122 13% South & Islands 262 28%
52 In response to inquiries about their affiliations with research-related organizations and, if applicable, the nature of these affiliations, the majority of participants, totalling 477 individuals (51%), reported not being associated with any type of research-linked organization. Among the remaining 459 participants (49%) who affirmed their ties to such organizations, 23% indicated affiliations with universities/polytechnics, 10% with research institutes, another 10% reported dual associations with both research institutes and universities/polytechnics, while 6% mentioned other unspecified forms of research-linked organization. 4.2.2. Evaluation of the enablers for Health Professionals participation in research The paramount enabler acknowledged by health professionals for engaging in research (Table 8) is the aspiration to “improve knowledge, skills, and professional abilities through research activity” garnering agreement or strong agreement from 83% of respondents. Subsequently, “seeking intellectual fulfilment and the stimulation and development of creativity through research” is affirmed by 74% of participants. Moreover, over 63% of respondents express agreement or strong agreement with the enabler factor, “I am personally motivated for research activity”. It is noteworthy to emphasize the potential enabler with the least agreement among health professionals, as “There are time management policies at my institution that recognize research activities” encountered disagreement from 65% of participants. The questionnaire provided an opportunity for participants to identify an additional enabler and evaluate it as the tenth option. However, no significant outcomes emerged, and the introduction of other enablers yielded interpretations similar to those already considered. Table 8. Evaluation of the enablers for health professionals’ participation in research through a likert scale from 1 to 5. (Legend: 1Strongly disagree; 2Disagree; 3Neither agree nor disagree; 4Agree; 5-Strongly agree) Rank Enablers for Health Professionals research participation Strongly agree/ Agree (%) Neither agree nor disagree (%) Disagree/ Strongly disagree (%) Mean/ SD 1. “I seek to improve my knowledge, skills and professional abilities as a result of research activity.” 83% 9% 8% 4,09±0,91 2. “I seek intellectual fulfilment and the stimulation and development of my creativity through research.” 74% 14% 12% 3,84±1,06
53 3. “I am personally motivated for the research activity.” 63% 18% 19% 3,62±1,13 4. “I look for opportunities for professional progression, including learning and new opportunities, as a result of research activity.” 59% 23% 18% 3,56±1,10 5. “There are established collaborative relationships between my health institution and universities or research institutes.” 58% 25% 17% 3,51±1,09 6. “There are mechanisms on the part of my health institution for the dissemination of research opportunities.” 33% 26% 41% 2,76±1,17 7. “My institution has an appropriate organizational and operational infrastructure for research.” 32% 21% 47% 2,63±1,20 8. “I seek recognition and awards through research.” 25% 28% 47% 2,66±1,14 9. “There are time management policies at my institution that recognize research activities.” 17% 18% 65% 2,20±1,19 4.2.3. Evaluation of the barriers for Health Professionals participation in research The predominant obstacle recognized by health professionals in research participation (Table 9) is articulated as 'I lack dedicated time to engage in research,' with concurrence or strong agreement from 81% of respondents. Subsequently, the barrier “There is a lack of sufficient funding for research and/or a lack of information on access to funding” is affirmed by 80% of participants. Furthermore, over 76% of respondents express agreement or strong agreement with the barrier “Management support and strategic planning for research participation at institutional level is insufficient”. Lastly, with an agreement of more than 70%, respondents identified the barrier “The institution's work plans, evaluation systems and career plans do not properly recognize research contributions”. Regarding the barriers that health professionals disagreed upon with more than 60% of disagreement is “I have the perception that research is a specialized activity and outside the scope of my practice as a health professional”, “I feel that a health professional's priority should be clinical and not academic”, “I think it would be difficult to work with academic research teams”, and, “I have little personal interest in doing research”.
54 The questionnaire provided an opportunity for participants to identify an additional barrier and evaluate it as the tenth option. However, no significant outcomes emerged, and the introduction of other barriers yielded interpretations similar to those already considered. Table 9Evaluation of the barriers for health professionals’ participation in research through a likert scale from 1 to 5. (Legend: 1Strongly disagree; 2Disagree; 3Neither agree nor disagree; 4Agree; 5-Strongly agree) Rank Barriers for Health Professionals research participation Strongly agree/ Agree (%) Neither agree nor disagree (%) Disagree/ Strongly disagree (%) Mean/ SD 1. “I lack dedicated time to engage in research.” 81% 8% 11% 4,21±1,03 2. “There is a lack of sufficient funding for research and/or a lack of information on access to funding.” 80% 19% 1% 4,15±0,79 3. “Management support and strategic planning for research participation at institutional level is insufficient.” 76% 18% 6% 4,10±0,93 4. “The institution's work plans, evaluation systems and career plans do not properly recognize research contributions.” 74% 18% 8% 3,98±0,98 5. “I lack the knowledge and skills needed to do research.” 35% 22% 43% 2,90±1,11 6. “I have the perception that research is a specialized activity and outside the scope of my practice as a health professional.” 24% 13% 63% 2,45±1,16 7. “I feel that a health professional's priority should be clinical and not academic.” 19% 17% 64% 2,36±1,09 8. “I think it would be difficult to work with academic research teams.” 16% 21% 63% 2,33±1,03 9. “I have little personal interest in doing research.” 14% 20% 66% 2,20±1,09 4.2.4. Assessment of the Perceived Organizational Support among Health Professionals To assess the internal consistency of the POS scale by Eisenberger et al. (1986), Cronbach's Alpha was computed. Notably, this analysis encompassed the entirety of the scale, inclusive of the four additional questions pertaining to research support that were introduced beyond the original scale. The obtained result from this assessment yielded a global scale α=0.92, indicating an excellent level of
61 funding, potentially indicating a need for targeted strategies to enhance their involvement in both aspects of healthcare research.
62 Table 17Distribution of funding sources across diverse health professionals’ categories Medical Doctor Allied Health Professional Nurse Yes No Yes No Yes No N % N % N % N % N % N % Funding agency (e.g. FCT) (n=229) 110 48% 214 30% 99 43% 220 31% 20 9% 273 39% Other research grant (n=87) 48 56% 275 32% 31 36% 288 34% 7 8% 286 34% Financial support from own organization (n=33) 16 49% 308 34% 11 33% 308 34% 6 18% 287 32% Industry sponsored research (n=144) 85 59% 239 30% 39 27% 280 35% 20 14% 273 35% The research was not funded (n=425) 203 48% 121 24% 115 27% 204 40% 107 25% 186 36% The cross-tabulation table 18 delves into the relationship between individuals' marital status and the time allocation for a research activity. Among singles, a substantial 41% spend no time on research, while 36% dedicate up to 4 hours. The distribution further diminishes for higher time brackets, with 8% allocating >4 but ≤10 hours, 4% >10 but ≤20 hours, and 10% >20 hours. For married individuals, 34% report no commitment to research, while 52% allocate up to 4 hours. The percentages decline for >4 but ≤10 hours (8%), >10 but ≤20 hours (2%), and >20 hours (3%). Within divorced individuals, 48% spend no time on research and 35% allocate up to 4 hours. Smaller proportions are reported for >4 but ≤10 hours (11%), >10 but ≤20 hours (1%), and >20 hours (5%). Among Widowers, 50% invest no time and 38% allocate up to 4 hours to research. Responses for higher time brackets (>4 but ≤10 hours, >10 but ≤20 hours, >20 hours) are minimal or non-existent. In the "Other" category, 34% report 0 hours, while 47% dedicate up to 4 hours. The distribution tapers for >4 but ≤10 hours (5%), >10 but ≤20 hours (7%), and >20 hours (7%). In future investigations, it would be valuable to include information about whether these health professionals have children or not. This additional data could provide insights into potential correlations between parental responsibilities and the time allocated to research activities, offering a more comprehensive understanding of the factors influencing their research participation.
63 Table 18Relationship between individuals' marital status and allocated time for a research 0 hours >0 hours but ≤4 hours >4 hours but ≤10 hours >10 hours but ≤20 hours >20 hours TOTAL N % of row N % of row N % of row N % of row N % of row N % of row Single (n=297) 122 41% 108 36% 25 8% 11 4% 31 10% 297 100% Married (n=492) 167 34% 258 52% 40 8% 10 2% 17 3% 492 100% Divorced (n=81) 39 48% 28 35% 9 11% 1 1% 4 5% 81 100% Widower (n=8) 4 50% 3 38% 1 13% 0 0% 0 0% 8 100% Other (n=58) 20 34% 27 47% 3 5% 4 7% 4 7% 58 100% 4.2.7. Effect of enablers and Barriers on Research participation and POS In order to test Hypothesis 1 (The main research participation Enablers are positively related to Health Professionals' Research participation) and Hypothesis 2 (The main research participation Barriers are negatively related to Health Professionals' Research participation), the multiple linear regression test was applied with the factor “Research participation in the Organization” and “Perceived Organizational Support” as dependent variables and the main barriers and enablers as independent variables. It is crucial to emphasize that the variables have been appropriately coded to facilitate accurate result interpretation. Specifically, the variable "Research participation" was assigned a value of 1 for a positive response and 0 for a negative response. Table 19 illustrates the relationships between independent variables and their predictive capabilities concerning Research participation and POS. Table 19Regression analysis to predict the influence of different enablers and barriers with the factor research participation in the organization. *p≤0.05; **P≤0.01 “Research participation in the organization” “Perceived Organizational Support” Enabler 1 - “I seek to improve my knowledge, skills and professional abilities as a result of research activity.” 0.096* 0.092* Enabler 2 - “I seek intellectual fulfillment and the stimulation and development of my creativity through research.” 0.195** 0.041 Enabler 3 - “I am personally motivated for the research activity.” 0.120** -0.054 Enabler 4 - “I look for opportunities for professional progression, including learning and new opportunities, as a result of research activity.” -0.004 0.003
64 Enabler 5 - “There are established collaborative relationships between my health institution and universities or research institutes.” 0.204** 0.088** Enabler 6 - “There are mechanisms on the part of my health institution for the dissemination of research opportunities.” -0.061 0.121** Enabler 7 - “My institution has an appropriate organizational and operational infrastructure for research.” 0.059 -0.060 Enabler 8 - “I seek recognition and awards through research.” -0.094* -0.040 Enabler 9 - “There are time management policies at my institution that recognize research activities.” -0.165** 0.396** R2 0.152 0.233 R adjusted 0.143 0.226 Barrier 1 - “I lack dedicated time to engage in research.” -0.115** -0.022 Barrier 2 - “There is a lack of sufficient funding for research and/or a lack of information on access to funding.” 0.048 0.048 Barrier 3 - “Management support and strategic planning for research participation at institutional level is insufficient.” -0.233** -0.433** Barrier 4 - “The institution's work plans, evaluation systems and career plans do not properly recognize research contributions.” -0.024 -0.121** Barrier 5 - “I lack the knowledge and skills needed to do research.” -0.095** -0.125** Barrier 6 - “I have the perception that research is a specialized activity and outside the scope of my practice as a health professional.” -0.013 -0.123** Barrier 7 - “I feel that a health professional's priority should be clinical and not academic.” -0.080* -0.028 Barrier 8 - “I think it would be difficult to work with academic research teams.” -0.123** 0.108** Barrier 9 - “I have little personal interest in doing research.” -0.104** 0.014 R2 0.130 0.290 R adjusted 0.122 0.283 A meticulous examination of the table reveals that, out of the nine enablers under study, only six demonstrate explanatory power on research participation. Enabler 4, focused on seeking professional progression and learning opportunities through research activity, as well as Enablers 6 and 7, pertaining to mechanisms and organizational infrastructure for research dissemination, yielded results with p-values greater than 0.05, indicating a lack of statistical significance. Conversely, Enablers 1 (the pursuit of knowledge and skills improvement), 2 (seeking intellectual fulfilment and creativity development through research), 3 (personal motivation for research activity), and 5 (established collaborative relationships with universities or research institutes) exhibited positive explanatory power on the variable "Research participation”. These findings align with the emphasis
65 placed by Portuguese healthcare professionals on these specific enablers, as highlighted in the results of the evaluation of the enablers for health professionals’ participation in research (section 4.2.2.). Enabler 8, focused on the pursuit of recognition and awards through research, and Enabler 9, which involves time management policies recognizing research activities at the institution, surprisingly exhibit a negative impact (β=-0.094; p<0.05 and β= -0.165; p<0.01, respectively) on the variable "Research participation." Intriguingly, these specific enablers align with the areas where healthcare professionals in the study express the highest disagreement, as highlighted in the results of the evaluation of the enablers for health professionals’ participation in research (section 4.2.2.). The unexpected negative impact observed in the linear regression results suggests that, contrary to expectations, the pursuit of recognition and the existence of time management policies might be associated with decreased research participation among the participants, or It Is possible that these time management practices are not appropriate and end up constraining health professionals’ activities rather that helping. Further exploration into the nuanced dynamics of these enablers and their potential implications is warranted. Therefore, we can affirm that Hypothesis 1 has been partially verified. Specifically, the key research participation enablers exhibit a positive correlation with the research participation of health professionals. In other words, as these main enablers are confirmed, there is a tendency for an increase in the research participation levels among health professionals. Concerning the barriers under study, six of them present explanatory influence on research participation. Notably, Barrier 2, highlighting the inadequacy of funding and access information, Barrier 4, emphasizing the institutional failure to adequately acknowledge research contributions within work plans and career structures, and Barrier 6, centered on the perception of research as a specialized activity beyond the scope of health professionals' practice, produced results with p-values exceeding 0.05, signaling a lack of statistical significance. On the other hand, Barrier 1, emphasizing the constraint of insufficient dedicated time for research participation, Barrier 3, highlighting the inadequacy of management support and strategic planning at the institutional level, Barrier 5, underscoring the lack of necessary knowledge and skills for research, Barrier 7, expressing the belief that a health professional's primary focus should be clinical rather than academic, Barrier 8, indicating perceived difficulty in collaborating with academic research teams, and Barrier 9, centred on limited personal interest in research, collectively demonstrated a negative explanatory impact on the variable "Research participation".
66 Consequently, we can affirm that Hypothesis 2 has been partially verified. It is evident that their confirmation is associated with a discernible decrease in research participation levels among health professionals, thus affirming the findings in support of Hypothesis 2 (The main research participation Barriers are negatively related to Health Professionals' Research participation). In essence, the examination revealed that, as anticipated, the presence of enablers identified in the literature review and validated through interviews with Portuguese health professionals generally corresponds to elevated levels of research participation. Similarly, the identification of barriers tends to exert a negative influence on research participation levels. Contrary to initial expectations, it was surprising to find that certain enablers exhibited a negative impact on the research participation of these health professionals. This unexpected finding may be attributed to differing expectations; specifically, since these enablers were not validated by the majority of respondents in the questionnaire, individuals harboured lower expectations regarding their involvement in research. To validate this hypothesis, further interviews or additional questionnaires would be necessary. The enabler that appears to exert a more substantial influence on the research participation of health professionals is Enabler 5 - "There are established collaborative relationships between my health institution and universities or research institutes" (β=0.204; p<0.01). This finding is reinforced by various studies documented in the literature review, as evidenced in Appendix III (e.g., Rait et al., 2002; Fudge et al., 2016; Frisk et al., 2019). These studies consistently support the notion that fostering collaborative relationships between health institutions and academic or research entities positively contributes to enhancing the research participation levels of healthcare professionals. The robust support from multiple sources in the literature enhances the credibility and generalizability of this observed impact. On the other hand, among the identified barriers, Barrier 3 - "Management support and strategic planning for research participation at the institutional level is insufficient" emerges as having a more pronounced negative impact on the research participation of health professionals (β=-0.233, p<0.01). This finding is supported by multiple studies in the literature review, as presented in Appendix III (e.g., Pager et al., 2012; Elphinston and Pager, 2015; O'Brien et al., 2022). These studies consistently emphasize the critical role of management support and strategic planning at the institutional level in fostering an environment conducive to reinforced research participation among health professionals.
67 The wealth of supporting evidence from various sources strengthens the validity and reliability of this observed negative impact. Regarding the impact of main enablers and barriers on the variable "Perceived Organizational Support," our assessment reveals that only a select few exhibit statistically significant explanatory power. Enablers 5 - "There are established collaborative relationships between my health institution and universities or research institutes", 6 - "There are mechanisms on the part of my health institution for the dissemination of research opportunities", and 9 - "There are time management policies at my institution that recognize research activities" exhibit a positive effect on the "perceived organizational support" variable (β=0.088; p<0.01; β=0.121; p<0.01; β=0.396; p<0.01 respectively). This result can be justified by the nature of these enablers, all of which pertain to organizational mechanisms and policies. It is inherently logical that when such enablers are observed, they possess the inherent capacity to enhance perceived organizational support. Collaborative relationships with external institutions (Enabler 5) foster a sense of broader support and networking. Dissemination mechanisms for research opportunities (Enabler 6) demonstrate a commitment to communication and inclusivity within the organization, contributing to perceived support (Andrew et al, 2013; Bartelink et al, 2019). Additionally, time management policies recognizing research activities (Enabler 9) signal an institutional acknowledgment of the importance of research, further bolstering the perception of organizational support (Gilbert et al, 2016). Therefore, these findings align with the intuitive expectation that organizational structures and policies promoting collaboration, communication, and recognition positively influence the POS among health professionals. Regarding barriers, barrier 3 - “Management support and strategic planning for research participation at institutional level is insufficient”, barrier 4 - “The institution's work plans, evaluation systems and career plans do not properly recognize research contributions”, barrier 5 - “I lack the knowledge and skills needed to do research” and barrier 6 - “I have the perception that research is a specialized activity and outside the scope of my practice as a health professional” present a negative effect on the "perceived organizational support" variable (β= -0.433 p<0.01; β= -0.121; p<0.01; β= -0.125; p<0.01; β= -0.123; p<0.01 respectively).
68 The observed negative effects of Barriers 3 and 4 on the "perceived organizational support" variable can be attributed to specific organizational policies and mechanisms. Barrier 3, which denotes insufficient management support and strategic planning for research participation at the institutional level, implies a deficiency in organizational commitment to fostering a supportive environment for research activities. Similarly, barrier 4, highlighting the inadequacy of the institution's work plans, evaluation systems, and career plans in recognizing research contributions, indicates a critical gap in the organizational infrastructure. If the institution fails to adequately acknowledge and integrate research contributions into its evaluation and career advancement frameworks, health professionals may perceive a lack of organizational support for their research endeavours (Berthelsen & HølgeHazelton, 2018; Kunhunny et al, 2017). Considering that barrier 5 and 6, involving a perceived lack of knowledge and skills needed for research, can underscores a potential deficiency in organizational support for professional development. When health professionals feel inadequately equipped to engage in research due to a perceived lack of support for skill development, it can negatively impact their overall perception of organizational support. Also, the centred perception that research is a specialized activity outside the scope of a health professional's practice, can suggest a potential communication or cultural gap within the organization, if health professionals perceive that the institution does not recognize or integrate research as an integral part of their roles (Elphinston and Pager, 2015; Kunhunny et al, 2017). To confirm these assumptions, further investigation would be necessary, delving into the specific dynamics of organizational support for professional development, as well as exploring potential communication or cultural gaps within the organization that may impact health professionals' perceptions of research integration into their roles. Paradoxically, Barrier 8 - "I think it would be difficult to work with academic research teams" exhibits an unexpected positive effect (β= 0.108, p<0.01) on the variable "perceived organizational support". This counterintuitive result may be indicative of a unique organizational context where individuals who perceive challenges in collaborating with academic research teams also interpret such difficulties as a demonstration of the organization's commitment to maintaining high standards and expectations for collaborative efforts and/or standards of healthcare. This unexpected positive association suggests that, in this particular context, the perceived complexity of working with academic research teams may be viewed as a testament to the organization's emphasis on rigorous collaboration, which, in turn,
69 positively influences health professionals' perceptions of overall organizational support. However, to thoroughly comprehend and validate this surprising finding, further investigation is needed, exploring the nuanced perceptions and contextual factors influencing health professionals' views on collaboration and organizational support. 4.2.8. Perceived Organizational Support effect on Research participation To test Hypothesis 5 (Health professionals' POS is positively related to Health professionals' research participation), we employed a bootstrap calculation. In this analysis, the POS dimension served as the independent variable, while the research participation dimension acted as the dependent variable. This method, widely utilized across diverse fields, is particularly advantageous for handling distributions that may not be well-understood in more complex models. Its utility lies in simplifying the inference calculation process, automating the generation of inferences (Efron & Tibshirani, 1993). Table 20Path coefficients to predict the influence of perceived organizational support with the factor research participation Model Original Sample Sample Mean Standard Deviation T statistic p value POS > Research participation 0.122 0.138 0.050 2.418 0.016 Based on the presented results in table 20, there appears to be a statistically significant and positive relationship between POS and Research participation among health professionals (β= 0.122; p≤0.05). These findings suggest that higher levels of POS are associated with increased participation in research activities. 4.2.9. Mediating Effects Unveiled: Insights from structural equation modelling In order to test Hypothesis 3 (The main research participation Enablers are positively related to Health Professionals' POS), Hypothesis 4 (The main research participation Barriers are negatively related to Health Professionals' POS), Hypothesis 6 (POS mediates the relationship between the main research participation Enablers and Research participation) and Hypothesis 7 (POS mediates the relationship between the main research participation Barriers and Research participation), a structural equation modelling analysis was conducted.
70 In our study, we conducted an examination of the Average Variance Extracted (AVE) for the latent variables Perceived Organizational Support (POS ) and Enablers included in our structural equation model. The AVE serves as a crucial metric in assessing the convergent validity of these latent variables, offering insights into the extent to which the variance captured by the constructs surpasses measurement error. Convergent validity is imperative for ensuring the reliability and accuracy of our measurement model (Fornell & Larcker, 1981). Table 21Average Variance Extracted and correlations of latent constructs Average variance extracted (AVE) Enablers 0.560 Barriers 0.511 POS 0.542 As depicted in Table 21, the calculated square roots of the Average Variances Extracted for the latent constructs surpassed the threshold of 0.5, affirming satisfactory discriminant validity (Chin, 1998). Specifically, the AVE values for Enablers (0.560), Barriers (0.511) and POS (0.542) surpassed the recommended criterion, underscoring that each latent construct captures more variance from its indicators than measurement error. This finding reinforces the robustness of our measurement model, assuring that the latent constructs are distinct and reliably represent their respective underlying concepts. To test the mediating effect of "Perceived Organizational Support", it is necessary to verify the following prerequisites: the mediation model illustrates a causal sequence in which the independent variable (enablers/barriers) indirectly influences the dependent variable (research participation) through the mediator variable (perceived organizational support). It is postulated that barriers and enablers affect POS, and this effect subsequently causally propagates through research participation.
77 company); Users of research are all clinicians, but to a greater or lesser degree." (Del Mar, 2004; p. s36). At every tier, health professionals may exhibit varying degrees of participation in research, ranging from suboptimal to optimal levels. It is essential to prioritize efforts aimed at fostering and facilitating health professionals to participate at the highest possible level within each tier. This strategic focus ensures a more robust integration of research activities across all levels, maximizing the positive impact and contributions of clinicians in advancing research within their respective domains. According to the findings from the questionnaire survey, a significant majority of Portuguese health professionals appear to hold leadership roles or actively participate in research endeavors. Notably, 72% of those involved in research projects assume critical roles such as principal investigator, site principal investigator, or co-investigator, indicating a robust participation in the research process. However, a noteworthy aspect is that a substantial portion of these research initiatives (45%) operates without external funding. This duality in roles — acting as research leaders while a considerable proportion of projects lack financial support — raises important considerations. While the high level of participation and leadership roles among health professionals is commendable, the prevalence of unfunded projects may pose challenges in terms of resource availability, potential limitations in project scope, and overall sustainability. This scenario invites further theoretical inquiry into the interplay between funding structures and research engagement, suggesting that financial support mechanisms are critical for sustaining high levels of participation among health professionals. It prompts further exploration into the dynamics of research funding within the healthcare context and underscores the need for strategies to enhance financial support for research initiatives led by health professionals. Initiatives aimed at fostering collaboration, securing external funding, and promoting awareness of the value of healthcare research could contribute to optimizing the impact of health professionals in advancing research within the Portuguese healthcare system.
78 Chapter 6 - Conclusions & Future Perspectives 6.1. Conclusions In light of the considerations outlined above, the primary aim of this study was to investigate the variables that facilitate or impede the active participation and leadership of health professionals in research projects within national healthcare entities. The newly obtained data provides further depth to these findings, reinforcing existing conclusions while offering fresh perspectives on health professionals’ participation in research. Based on this information provided earlier about the main enablers and barriers for health professionals to participate in research in Portugal, several conclusions can be drawn: a. Research-Oriented Institutions: The presence of research-focused institutions and universities in Portugal creates a conducive environment for health professionals. These entities provide essential resources, infrastructure, and mentorship that support research participation. b. Collaborative Networks: National and international collaborative networks significantly facilitate research participation among health professionals. Partnerships with other researchers and organizations foster knowledge exchange and joint research initiatives. c. Availability of Research Funding: Access to research funding, including grants from government agencies and private foundations, offers crucial financial support. Such funding opportunities incentivize health professionals to initiate and sustain research projects. d. Skill Development Programs: Initiatives aimed at enhancing research skills and knowledge contribute to higher levels of participation. Ongoing education, workshops, and training empower professionals to participate effectively in research activities and bridge any confidence gaps regarding their capabilities. e. Clinical Workloads: Heavy clinical workloads and time constraints can hinder health professionals from dedicating adequate time to research. A strategic approach to balancing clinical responsibilities with research demands, particularly through optimized time management systems, is essential. f. Research Culture: The lack of a robust research culture within healthcare settings may deter health professionals from pursuing research. Limited exposure and encouragement can act
79 as barriers. Strengthening institutional research culture through targeted initiatives can help alleviate this challenge. g. Resource Limitations: Insufficient funding, inadequate research facilities, and limited access to technology can obstruct research participation. Enhancing the visibility of research outputs through effective dissemination can attract additional funding and resources. Additionally, we explored the impact of perceived organizational support (POS) on health professionals' involvement in research activities. Our study effectively achieved its objectives by providing valuable insights into the factors influencing research participation within the healthcare sector. Social Exchange Theory serves as a theoretical framework for interpreting these findings, emphasizing the role of POS in shaping research participation. Social Exchange Theory posits that individuals engage in reciprocal relationships with their organizations, where favourable treatment and support foster a sense of obligation and commitment. In this context, when health professionals perceive strong organizational support, they are more likely to reciprocate with increased involvement in research initiatives. Our findings affirm that POS plays a pivotal role in shaping the landscape of research participation. Health professionals who feel supported by their organizations are more likely to invest time and effort in research activities. This reciprocal relationship is crucial for cultivating a research-oriented culture within healthcare organizations. However, our findings reveal that the relationship between perceived organizational support and research participation runs parallel to, rather than mediating, the effects of enablers and barriers. While POS positively influences research participation, it does not act as a mediator between enablers and barriers and research participation. Instead, the presence of enablers and the mitigation of barriers independently enhance research participation, while perceived support from the organization further amplifies this participation. This underscores the need for healthcare organizations to address both individual and institutional factors concurrently to foster research involvement. This nuanced understanding provides valuable insights for healthcare organizations aiming to cultivate a research-oriented culture. While addressing specific enablers and barriers is crucial, concurrently fostering a supportive organizational environment can enhance the effectiveness of strategies designed
80 to promote research participation among healthcare professionals. The coexistence of these factors emphasizes the multifaceted nature of influences on research participation. In conclusion, facilitating health professionals' participation in research within Portuguese healthcare organizations requires a comprehensive strategy that addresses prevailing barriers while leveraging key enablers. Aligning with the principles of Social Exchange Theory, POS emerges as an important antecedent, fostering a reciprocal relationship between health professionals and their organizations. Despite facing significant barriers and challenges within the Portuguese healthcare landscape, health professionals demonstrate a commendable level of research participation, driven by their intellectual commitment and alignment with research goals. Their positive participation is further exemplified by their genuine interest in research outcomes, illustrating a reciprocal exchange where organizational support fosters sustained commitment. Our findings highlight the importance of cultivating a robust research culture and providing institutional support in line with POS principles to motivate health professionals to actively contribute to research activities. Additionally, creating funding opportunities and promoting collaborative initiatives are pivotal in cultivating an environment conducive to research participation. Addressing issues related to workload, resource availability, and administrative burdens is crucial for sustaining and enhancing health professionals' active involvement in research endeavors. Ultimately, our study reveals that intrinsic motivation emerges as a potent driver of sustained research participation among Portuguese health professionals. This intrinsic motivation can be viewed as a form of psychological reciprocity within the professional-organizational relationship, where health professionals, propelled by an inherent desire for autonomy and competence fulfilment, actively seek and participate in research initiatives. Based on the findings of our study, we posit that implementing a set of recommendations, which has demonstrated efficacy in other countries, viable and beneficial for application in Portugal. These recommendations include the following: 1. Cultivate a Research-Conducive Atmosphere in Health Organizations: Foster a research-friendly environment within hospitals by aligning the institution's strengths and
81 clinical focus with the professional interests of health professionals. This entails a top-down approach, necessitating active participation from the entire hospital hierarchy. 2. Recognize and Incentivize Health Professionals' Research Contributions: Implement measures to acknowledge and reward the active participation of health professionals in research endeavours. This involves transparently outlining how contributions are acknowledged and funded, providing regular updates on research progress and impact, promoting career development opportunities, and establishing mutual benefits for both the health professionals and the organization. 3. Optimize Time Management Systems for Research-Oriented Health Professionals: Enhance time management systems for health professionals with a keen interest in research. This includes the implementation of effective strategies and tools to assist them in efficiently allocating their time between clinical duties and research activities. 4. Establish Infrastructure for Efficient Research Time Utilization: Develop a robust infrastructure that ensures the efficient utilization of time dedicated to research. This encompasses providing appropriate physical space, as well as administrative and financial personnel support, to facilitate and streamline research activities effectively. 5. Implement Tailored Contracts for Clinician-Researchers: Introduce specific contracts designed for clinician-researchers within healthcare organizations. These contracts play a pivotal role in offering clarity and transparency to clinicians as they navigate the dual demands of clinical practice and active involvement in research. Such tailored agreements provide a structured framework to support and balance the diverse responsibilities of clinicianresearchers. In summary, these recommendations collectively aim to cultivate a thriving research culture within the healthcare landscape of Portugal, acknowledging the dual roles of health professionals as clinicians and researchers. By fostering a supportive environment, recognizing contributions, optimizing time management, establishing efficient infrastructure, and implementing tailored contracts, these measures seek to empower health professionals, enhance research participation, and ultimately contribute to the advancement of evidence-based healthcare practices in the country.
82 6.3. Main Contributions For the first time, our study pioneers an exploration of healthcare professionals' participation in research and its implications in the context of Portugal. This research is ground-breaking as it not only fills a notable gap in the existing literature but also sheds light on the unique challenges and opportunities within the Portuguese healthcare landscape. A significant contribution of our study lies in the validation and adaptation of the POS scale, incorporating specific questions related to research support. This tailored approach ensures a more nuanced understanding of the organizational dynamics that influence healthcare professionals' participation in research. We firmly believe that the potential for a broader spectrum of health professionals to actively participate in research exists, provided that the appropriate organizational conditions are established. Our findings emphasize the crucial role of organizational support in shaping healthcare professionals' involvement in research activities. The theoretical contributions stemming from the results of this study on the main barriers and enablers influencing health professionals' participation in research unveil a significant role played by POS with a direct effect on research participation. Rooted in Social Exchange Theory, theoretical insights derived from the findings of this study regarding the main barriers and enablers influencing health professionals' research participation highlight the significant and direct impact of POS on research participation. In contrast to the initial hypothesis, which proposed POS as a mediator, our results indicate that POS exerts a direct influence on the level of research participation among health professionals. The Social Exchange Theory provides a compelling framework to rationalize this direct effect. According to the Social Exchange Theory, POS becomes a vital factor in shaping the relationship between the organizational context and the active involvement of health professionals in research. This theory posits that strong organizational support establishes a foundation for positive social exchanges. In this reciprocal dynamic, health professionals, perceiving robust support, are more inclined to reciprocate with heightened commitment that surpasses mere job obligations, thereby contributing significantly to the organization's overall success. This reciprocal relationship creates a reinforcing cycle, aligning with the findings of Kurtessis et al. (2017).
83 Therefore, the study not only elucidates the main barriers and enablers influencing health professionals' research participation but also underscores the pivotal and direct role of POS in fostering a positive environment for research involvement. This direct effect underscores the importance of cultivating organizational support as a standalone factor, independent of its mediating role, in promoting and sustaining health professionals' active participation in research activities. 6.2. Limitations & Future Research Perspectives This research has delved into a particular angle of health professionals' participation in research, exploring the main barriers, enablers, and the intricate relationship with organizational supporting light of these findings, the logical progression for future research involves shifting the focus towards the perspectives of health managers and policy makers within healthcare organizations in Portugal. An insightful extension of this study would entail a collaborative examination of the results with health managers through the implementation of focused and interactive focus groups. This approach not only fosters a deeper understanding of the nuanced challenges and opportunities identified, but also facilitates a more comprehensive and collaborative exploration of strategies to enhance research involvement. By broadening the scope to include the perspectives of key decision-makers, who are often absent in traditional survey-based studies, future research endeavours can address the limitation of not having the health manager's perspective. This inclusion of diverse viewpoints can contribute valuable insights towards the development of targeted interventions and policies that support and promote a culture of active research participation within healthcare settings. Furthermore, given the apparent significance of time as a crucial variable influencing the participation of health professionals in research, it becomes imperative to investigate whether the presence of children and/or family duties may exert an influence on such involvement. The absence of an exploration into this perspective represents a notable limitation in our study. By not considering the potential influence of parenthood on research participation, we may overlook a crucial dimension that could contribute to a more comprehensive understanding of the factors influencing professionals' participation in research activities. Future research should therefore aim to address this gap by specifically examining the interplay between parental responsibilities and the time constraints experienced by health professionals in the context of research involvement.
84 Expanding the exploration of perspectives on the involvement of health professionals in research, a compelling avenue for further investigation lies in a more nuanced examination of the relationships between health professionals and academia. Unfortunately, this type of insightful analysis was not possible within the scope of our study. Understanding the dynamics and collaborations between these two realms could reveal innovative approaches to fostering a symbiotic partnership. For instance, investigating how academic institutions and healthcare professionals collaborate in the development and implementation of research initiatives could offer insights into optimizing knowledge exchange and leveraging resources effectively. Additionally, exploring the impact of emerging technologies on this partnership, such as telemedicine and digital health, could provide a futuristic dimension to the study (Butcher & Hussain, 2022). In addition, exploring future research directions to comprehensively bridge the findings from our study, it becomes imperative to delve into novel theories that can better elucidate the complex panorama of health professionals' research participation. While our initial hypothesis posited that POS might serve as a mediating variable between enablers/barriers and the involvement in research by health professionals, our results demonstrated a rejection of this assumption. Surprisingly, health professionals exhibited a capacity to overcome high barriers associated with organizational policies, showcasing resilience and an inherent motivation to participate in research. This suggests a noteworthy aspect of personal determination, possibly rooted in the overarching goal of delivering optimal patient care. To further unpack this intriguing dynamic, future research could benefit from incorporating theories that delve into the motivational aspects of health professionals. The application of the selfdetermination theory, for instance, could provide valuable insights into understanding the internal drive and personal motivations that propel health professionals to participate in research despite organizational barriers (Deci & Ryan, 1985). By unravelling the intricacies of these connections, future research activities have the potential not only to enrich our comprehension of the collaborative landscape but also to inform strategies that cultivate a robust and mutually beneficial synergy between health professionals and the academic sphere.
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94 APPENDICES Appendix I – Interview Guide 1. Qual é a sua categoria como profissional de saúde? 2. Qual o tipo de organização de saúde onde desempenha funções? 3. O que significa para si estar envolvida em projetos de investigação? 4. Acha importante que os profissionais de saúde participem em projetos de investigação no local de trabalho? 5. Está ou esteve envolvida(o) em projetos de investigação? a. Se sim, em que âmbito? Para obter algum tipo de grau académico? No âmbito de algum projeto desenvolvido na sua organização de saúde? No âmbito de alguma colaboração com universidades/institutos de investigação? b. Se não, porquê? 6. Existe algum tipo de apoio ou incentivo de outras pessoas para se envolver em investigação clínica? 7. Como se sente quando pensa em participar em projetos de investigação? 8. O que pode afetar a sua decisão ou dos seus colegas em participar em investigação? 9. Na sua opinião qual a maior barreira(s) para os profissionais de saúde envolverem-se em projetos de investigação? 10. Na sua opinião qual a maior motivação ou facilitador para os profissionais de saúde envolverem-se em projetos de investigação? 11. Participar em projetos de investigação afeta a relação com outros colegas profissionais de saúde? 12. Qual a posição da organização onde desempenha funções sobre este assunto? 13. Alguma vez falou com alguém da direção sobre este assunto? Solicitações de exemplos: Pode me falar um pouco mais sobre isto? O que quer dizer com…? Como? Porquê?
95 Appendix II – Questionnaire Survey O principal objetivo deste questionário é compreender a experiência dos Profissionais de Saúde Portugueses que participam (ou não) em Projetos de Investigação dentro das suas Organizações de Saúde. Dito isto, as suas respostas devem ser focadas na sua experiência pessoal como profissional de saúde e na sua participação em projetos de investigação, e por isso não há respostas certas ou erradas. A informação recolhida é estritamente anónima e confidencial, destinando-se exclusivamente a ser tratada estatisticamente no âmbito do projeto. > Depois de ler o texto introdutório, considero-me informado/a e aceito participar neste estudo. * □ Sim □ Não *(só avança para a Parte 1 caso a resposta seja “sim”) PARTE ICaracterização sociodemográfica da amostra 1Sexo: □ Feminino □ Masculino □ Outro 2Idade: □ ≤ 25 anos □ 26 – 35 anos □ 36 – 45 anos □ 46 – 55 anos □ ≥ 56 anos 3Estado Civil: □ Solteiro(a) □ Casado(a) □ Divorciado(a) □ Viövo(a) □ Outro 4Habilitações Literárias: □ Licenciatura □ Mestrado □ Doutoramento 5Categoria Profissional: □ Mèdico(a) □ Tècnico(a) Diagnóstico e Terapêutica □ Enfermeiro(a) 6-Especialidade(s) Médica(s) e/ou Serviço(s) Clínico(s) em que exerce a sua atividade profissional
96 □ Anatomia Patológica; □ Anestesiologia; □ Cardiologia; □ Cirurgia; □ Cuidados Paliativos e Medicina Interna; □ Dermatologia; □ Endocrinologia; □ Farmácia; □ Gastrenterologia; □ Genètica; □ Ginecologia/ Obstetrícia; □ Hematologia; □ Imagiologia; □ Imunohemoterapia; □ Medicina Nuclear; □ Neurologia/ Neurocirurgia; □Nutrição; □ Oncologia; □ Otorrinolaringologia; □ Patologia; □ Pediatria; □ Pneumologia; □ Psiquiatria; □ Psicologia; □ Radioterapia; □ Urologia; □ Outro: _________________ 7Antiguidade na Organização: □ ≤ 5 anos □ 6 – 10 anos □ 11 – 20 anos □ ≥ 21 anos 8Tipo de Organização onde desempenha funções: (selecione todas opções aplicáveis) □ Pöblico; □ Privado; □ E. P. E.; □ Hospital Universitário; □ Outro _____________________________ 9Localização da Organização: □ Norte; □ Centro; □ Sul e ilhas; 10Está associado a organizações ligadas à investigação? □ Não; □ Sim, universidades; □ Sim, institutos de investigação; □ Sim, institutos de investigação e universidades; □ Outro _____________________________
97 Parte II Qual o seu grau de concordância relativamente a cada uma das seguintes afirmações sobre facilitadores para o envolvimento de profissionais de saúde em investigação? Selecione o número associado à resposta que quer dar, usando a seguinte escala: 1Discordo Completamente; 2Discordo; 3Não Concordo Nem Discordo; 4Concordo; 5Concordo Completamente i. Procuro melhorar os meus conhecimentos, competências e capacidades profissionais, em resultado da atividade de investigação; ii. Estou pessoalmente motivado(a) para a atividade de investigação; iii. Procuro reconhecimento e prémios através da investigação; iv. Procuro oportunidades de progressão profissional, abrangendo aprendizagem e novas oportunidades, em resultado da atividade de investigação; v. Procuro realização intelectual e estimulação e desenvolvimento da minha criatividade através da investigação; vi. Existem relações colaborativas estabelecidas entre a minha instituição de saúde e universidades ou institutos de investigação; vii. Existem políticas de gestão de tempo na minha instituição, que reconhecem as atividades de investigação; viii. A minha instituição tem uma infraestrutura organizacional e operacional apropriada para a investigação; ix. Há mecanismos por parte da minha instituição de saúde para a divulgação de oportunidades em investigação; x. Se identifica outro facilitador para o seu envolvimento em investigação, por favor especifique e avalie o seu grau de concordância_____________________________; Parte IIIQual o seu grau de concordância relativamente a cada uma das seguintes afirmações sobre barreiras para o envolvimento de profissionais de saúde em investigação? Selecione o número associado à resposta que quer dar, usando a seguinte escala: 1Discordo Completamente; 2Discordo; 3Não Concordo Nem Discordo; 4Concordo; 5Concordo Completamente i. Há falta de financiamento suficiente para a investigação e/ou falta de informações sobre o acesso a financiamento;
98 ii. Os planos de trabalho, sistemas de avaliação e planos de carreira da instituição não reconhecem devidamente as contribuições ao nível da investigação; iii. Tenho falta de tempo dedicado para me envolver em investigação; iv. O apoio por parte da administração e o planeamento estratégico para o envolvimento em investigação a nível institucional é insuficiente; v. Tenho a perceção de que a investigação é uma atividade especializada e fora do domínio da minha prática como profissional de saúde; vi. Acho que seria difícil trabalhar com equipas de investigação académica; vii. Sinto falta dos conhecimentos e habilidades necessárias para fazer investigação; viii. Tenho pouco interesse pessoal em fazer investigação; ix. Sinto que a prioridade de um profissional de saúde deve ser clínica e não académica; x. Se identifica outra barreira para o seu envolvimento em investigação, por favor especifique e avalie seu grau de concordância_____________________________; Parte IVRelativamente a cada uma das afirmações que se seguem, diga qual o seu grau de concordância. Assinale o número associado à resposta que quer dar, usando a seguinte escala: 1Discordo Completamente; 2Discordo; 3Não Concordo Nem Discordo; 4Concordo; 5Concordo Completamente 1. A instituição valoriza o meu contributo para o bem-estar institucional. 2. A instituição não aprecia devidamente o meu esforço profissional. 3. A instituição ignora os meus protestos. 4. A instituição preocupa-se realmente com o meu bem-estar. 5. Mesmo que desempenhasse o meu trabalho o melhor possível, a instituição não se iria aperceber. 6. A instituição preocupa-se com a minha satisfação profissional. 7. A instituição demonstra muito pouca preocupação comigo. 8. A instituição preza a minha realização profissional. 9. A instituição aprecia o meu contributo para a investigação.
99 10. A instituição valoriza o meu esforço para conciliar as minhas atividades clínicas com as atividades de investigação. 11. A instituição não valoriza o meu trabalho de investigação. 12. A instituição não me proporciona condições para a realização de investigação. Parte VPreencha as questões abaixo relativamente ao seu envolvimento em investigação e use os campos de comentários para fornecer qualquer informação ou explicação adicional. 1. Trabalhou em algum projeto de investigação desde que está a desempenhar funções na instituição atual? a. Sim b. Não 1.1.1. Se sim, em que âmbito? (selecione todas as que se aplicam) a. no âmbito da obtenção de um grau académico (ex: mestrado, doutoramento) b. participação num ensaio clínico na instituição de saúde c. projeto de investigação desenvolvido na instituição de saúde d. projeto de investigação desenvolvido em colaboração com universidades/institutos de investigação 2. Nos últimos 5 anos, em quantos projetos de investigação participou? 3. Selecione as funções em que atuou em investigação nos últimos 5 anos (selecione todas as que se aplicam): a. Investigador Principal – envolve a captação de financiamento e a supervisão de um estudo realizado em um ou mais locais; b. Investigador Principal do Local – líder do estudo/tarefas no seu local, liderado por outra instituição ou pela indústria;
100 c. Co-investigador - membro da equipa de investigação, mas não um investigador principal ou investigador principal do local; d. Site Champion – uma pessoa designada que ajuda a garantir que um projeto de investigação seja realizado com sucesso localmente; e. Consultor - fornece conhecimentos de especialidade para a equipa de investigação; f. Recrutador - identifica e recruta pacientes da sua própria prática clínica ou de outras práticas para investigação; g. Participante - completa questionários ou entrevistas para um estudo de investigação; i. Nenhum, não participei em nenhum projeto de investigação nos últimos 5 anos; 4. Que tipos de organizações financiaram a investigação em que esteve envolvido? (selecione todas as opções aplicáveis) a. Agência de financiamento (por exemplo: FCT, Institutos Nacionais de Saúde, Agências de Investigação e Qualidade em Saúde, Centros de Inovação); b. Outra bolsa de investigação (por exemplo: associações de pacientes, donativos de organizações, universidades); c. Apoio institucional (por exemplo, uma bolsa financiada pela sua própria instituição); d. Investigação patrocinada pela indústria (ex.: indústria farmacêutica); e. O projeto de investigação não foi financiado; f. Não sei; g. Outro (por favor, especifique) __________________________________; 5. Qual é aproximadamente o tempo por semana que dedica a investigação? a. 0 horas b. >0 horas mas ≤4 horas c. >4 horas mas ≤10 horas d. >10 horas mas ≤20 horas e. >20 horas OBRIGADO POR DISPONIBILIZAR O SEU TEMPO PARA RESPONDER A ESTE QUESTIONÁRIO.
101 O fato de estar a ler esta mensagem indica que preencheu o nosso questionário sobre a sua experiência como profissional de saúde em Portugal e o envolvimento em projetos de investigação. De forma a anonimizar a sua participação, e caso queira receber os resultados do estudo, deixe um contacto de email através do link: https://eeguminho.eu.qualtrics.com/jfe/form/SV_9t04hQI6oLYPbE2 Agradecemos imensuravelmente o tempo que dedicou para auxiliar o nosso estudo e estamos comprometidos em usar todas as informações obtidas para contemplar e implementar práticas para reforçar estrategicamente o envolvimento dos profissionais de saúde em investigação.
102 Appendix III – List of studies included in the systematic literature review Reference Country Sample Type of study approach Journal Identified Enablers Identified Barriers McDonald & Smith, 2001 Australia Nurses Literature review Aust Health Rev Education programs on the research process; Lack of research literacy; Rait et al, 2002 UK Medical Doctors and Nurses Qualitative Primary Health Care Research and Development Training; Mentoring schemes; Understand the research process better; Collaborations; Training on research methods and conducting research; Mentorship schemes; Clinical commitments; Administrative work-loads; Research perceived as low priority; Fear of unfamiliar territory; Edwards et al, 2002 Australia Nurses Literature review Nursing and Health Sciences Early academic nurse education; Nurses beliefs; Perceptions, values and practices about research; Carrel, 2002 Switzerland Medical Doctors Literature review Transpl Immunol Active support; Close contact with PhDs; Poor understanding of the research process; Albers & Sedler, 2004 USA Nurses, midwives, physicians, primary health care teams, occupational therapists, or marital and family therapists Qualitative J Midwifery Women Health Interest in the topic; A responsible party to handle the logistics and deal with problems; A relationship with the lead researcher; Regular feedback and support; Minimal impact on clinical practice; Financial compensation; Time constraints; Lack of ongoing support and feedback; limited familiarity with research methods and procedures.
109 Black et al, 2015 Canada Nurses Mixedmethods Journal of Nursing Administratio n Support from their employing organizations; Presence in the clinical setting of advanced practice nurses; Research mentors, and educators knowledgeable about research, nursing research internships, and designated nurse researchers. Lack of knowledge about the research process; Lack of awareness of research; Colleagues not supportive of practice change; Insufficient time; Lack of access to research; Berthelsen et al, 2016 Denmark Nurses Mixedmethods Journal of Clinical Nursing na Lack of time; The perception that research is not a priority; Not able to see the relevance of research usage; Messner et al, 2016 USA Health professionals Qualitative Contemporar y Clinical Trials Communicati ons Motivations related to patient care; Intellectual, professional, and societal benefits; Lack of time; Increased paperwork; Disruption to workflows; Concern over practice finances; Borkowski et al, 2016 Australia Allied health professionals Literature review Australian Journal of Primary Health Skills development; Job satisfaction; Career advancement; Lack of time; Limited research skills; Other work roles taking priority; Harvey et al, 2016 Australia Allied health professionals Qualitative Aust Health Rev Quarantined research time; Funding; Research-friendly workplace culture; Positive research relationships; Personal characteristics; Rewards; Lack of supportive research relationships; Unhelpful workplace culture and systems for research; Time constraints; Lack of funding; Personal characteristics;
110 Johnson et al, 2016 Canada Dietitians Mixedmethods Can J Diet Pract Res na Lack of time; Lack of self-perceived competence; Lack of confidence; Lack of administrative support; Lack of funding; Barratt et al, 2016 UK Healthcare and public health partner organisations Quantitative BMJ Open na Lack of institutional support; Access to relevant equipment and resources; Lack of time; Liira et al, 2016 Finland Medical doctors, nurses, dentists, physiotherapis ts, and nutritionist Mixedmethods Scandinavian Journal of Primary Health Care Activating teaching methods; Encouraging focus on own research planning; Support from peers; Mentoring; Interesting research topic; General interest in research; Curiosity; na Fudge et al, 2016 UK Health professionals Mixedmethods PLoS ONE Healthy research culture; Interdisciplinary collaboration; Translational research as entrepreneurial science; Differing concepts of translational research; Research processes; The perceived cultural divide between research and clinical care; Poor relationship for interdisciplinary collaboration; Nordsteien et al, 2017 Norway Nurses Mixedmethods Nurse Education Today Collaborative library-faculty teaching interventions; na
111 Caldwell et al, 2017 UK Health Professionals Quantitative European Journal of Cancer Care Healthy research culture; Lack of the required knowledge; Lack of skills and training; Lack of support from managers; Lack of opportunity or time to be involved in research; Archibald et al, 2017 Canada Health professionals Mixedmethods Health Research Policy and Systems Program for Innovation in Medical Education (PIME): Programme in which physicians receive the funding, coaching, and supportstaff necessary to complete a 2year research project. na Eley et al, 2017 Australia Medical Doctors (interns) Mixedmethods BMC Med Educ Job prospects, career options, and professional advancement; Funding (salary increase); Clear pathway and dedicated time for research; Mentoring; Lack of life balance; Lack of funding for research and delay in paid work; Lack of time; Mckee et al, 2017 Ireland Nurses Mixedmethods BMC Nursing Top-down approach; Support of a hands-on research fellow; Peer collaboration with academics; Strong clinical ownership by the clinical nurse researcher; Experiential learning opportunities; Lack of time; Appropriate support from academics and from peers; Van Der Graaf et al, 2017 UK Public health professionals and researchers Mixedmethods BMC Public Health Collaborative models, such as the use of researchers embedded in practice; Flexible research funding schemes; Structures and challenges under which health professionals and researchers work are required;
112 Wenke et al, 2017 Australia Allied health professionals Quantitative BMC Health Services Research Develop skills; Increase job satisfaction; Career advancement; Lack of time for research; Other work roles that take priority; Lack of suitable backfill; Kunhunny et al, 2017 UK Clinical research nurses Qualitative Journal of Clinical Nursing Successful navigation through the complexity of advice; Support; Management and leadership tasks related; Lack of recognition; Lack of clarity of the role; Lack of career development opportunities; Poggenburg et al, 2017 Austria Medical Doctors Mixedmethods Wiener Klinische Wochenschrift Strengthening general practice; Improving the quality of care for patients; Personal knowledge gain; Working on research questions relevant to general practice; Learning evidence of practical relevance; Contributing to the development of the field of general practice in the coming years/decade; Lack of time; Administrative workload; Lack of assistance; McRae et al, 2018 Canada Emergency medicine researchers Qualitative Canadian Journal of Emergency Medicine Research-supportive culture; Clear communication between the research team and ED clinical staff; Optimization of data collection material and strategies; Incentives to promote staff engagement; Absence of remuneration; Lack of patient engagement; Lack of time; Berthelsen & HølgeDenmark Nurses Qualitative Journal of Clinical Nursing Low monodisciplinary interest; Lack of recognition of the Multi-dimensional research participation with physicians; Passionate management support;
113 Hazelton, 2018 nurse's research work; Lack of support; Noble et al, 2018 Australia Residents Literature review Academic Medicine Guidance on integrating research into their clinical practice;Clear completion requirements;Protected time and more long-term projects;Allowing residents to develop and conduct their own research projects; Lack of dedicated time;Lack of mentors or faculty support;Lack of guidance on integrating research into their clinical practice;Lack of interest; Fullam et al, 2018 Ireland Nurses and midwives Mixedmethods Journal of Research in Nursing A program that provides academic support and mentorship in the clinical environment; Skills development; Research capacity; Lack of support; Lack of research skills; Unertl et al, 2018 USA Health professionals Mixedmethods BMC Health Services Research Personal motivation: Potential benefits for their patients; Matching patients with relevant studies; Contribute to the greater good and the body of medical knowledge; Clear communication and established collaboration; Additional resources; Appropriate compensation for research involvement; Embed research into the existing practice workflow; Challenges of getting started in research; Consequences of time spent on research; Patient-related barriers to expanding research;
114 Kjerholt & HølgeHazelton, 2018 Denmark Nurses Mixedmethods Journal of Nursing Management Journal club; Research action learning; Supportive research culture; NA Luckson et al, 2018 UK Nurses and Allied Health Professionals Mixedmethods Journal of Clinical Nursing Time; Build capability; Resources; Communication issues; Lack of support at the middle management level; Slade et al, 2018 Australia Allied health professionals Literature review Health Research Policy and Systems Dedicated staff research positions; Time allocated to research; Mentoring; Professional education; Research infrastructure; Strong partnerships with universities and co-located research leaders; Research skills and capabilities; Motivation; Participation in research teams; NA Heard et al, 2019 European (MetabERN Reference Network) Health professionals Quantitative Orphanet Journal of Rare Diseases Personal motivation; Rotational positions for clinicians and researchers; International collaborations; Lack of time; Insufficient funding; Matus et al, 2019 Australia Allied health professionals Qualitative Asia Pacific Journal of Health Management Building on existing motivators; Linking research engagement goals to strategic plans and key performance indicators; Actively involve the whole Lack of time; Lack of incentives to prioritize research; Low level of confidence to lead or facilitate research within their teams;
115 team in the process of research; Bartelink et al, 2019 The Netherlands Health professionals Qualitative Education for Primary Care Dedicated time;Access to information, experts and peers in networks;Corresponding and compatible interests;Multiple opportunities for interaction;Recognition and appreciation;Adding value in the dual role;Setting priorities;Switching perspectives;Support from organisation;Culture of mutualrespect and trust;Responsibility for making research clinically relevant and practice evidence-based;Need for selfdevelopment;Inspiration for both clinical work and research; Time limitations;Financial constraints;No corres-pondinginterests;No support fromtheorganisation;No support frompeers;Competing priorities;Feeling invisible or not valued;Falling betweentwo camps;Inadequacy because of dua lresponsibilities; Frisk et al, 2019 Sweden Pharmacists Qualitative International Journal of Pharmacy Practice Collaboration with other local healthcare; Resources; Competition among pharmacy chains; Lack of competence; Lack of time; Lack of communication skills; Lack of research knowledge; Lack of funding;
116 Bench et al, 2019 UK Nurses Mixedmethods International Journal of Orthopaedic and Trauma Nursing Job appraisal; Designated protected and back filled time for research; Sign posting and buddy systems; Lack of confidence and competence; Lack of knowledge; Lack of research training; Lack of financial resources; Gill et al, 2019 Australia Nurses, allied health staff and doctors Quantitative Australian Journal of Rural Health Skill development; Increased job satisfaction; Brain stimulation; Lack of time; Clinical work taking priority; Lack of funding; Miller et al, 2020 UK Health professional research interns Qualitative Nurse researcher Accessible opportunities; Accessible training; Formal support from the interns’ manager and organisation; Negative, hostile and bullying attitudes from peers and managers; Lack of support; Lalloo et al, 2020 UK Occupational therapists Mixedmethods Occupational Medicine na Not interested; Lack of time; Lack of training; Lack of mentorship; Lack of opportunity; Frost & Britten, 2020 UK Research managers, clinical research staff, health professionals, and patients Qualitative Healthcare (Switzerland) Organizational culture; Healthcare performance improvement; Personal interest in the topic; Behavior of someclinical colleagues (disparaging comments; Lack of time; Ambivalent feeling in recruiting patients; Lack specialist training or leadership;
117 Wenke et al, 2020 Australia Allied health professionals Qualitative BMJ Open Motivation;Positive beliefs about the consequences of research participation;Enabling social influences;Peer support and motivation;Skill development;Inform practice; Fear of failure; Feeling overwhelmed;Lack of funding;Lack of time; Perceptions of reduced capability; Senecal et al, 2021 Canada Medical doctors, allied health professionals, and nonclinician researchers Quantitative J Transl Med na Managing competing interests; Lack of time; Lack of funding; Lack of infrastructure and networks; Lack of permanent post-graduate medical trainees; Collaborators with overlapping interests; Muhandiramg e et al, 2021 Australia Medical Doctors (interns) Quantitative BMC Medical Education Interest in academia; To determine specialty choice; Increasing employability; Skill development; Interest in a particular field; Previous negative experience; Financial constraints; Lack of interest; Impact on personal or social life; No active encouragement; Impact on length of medical training; Unsure how to get started; Time constraints; Orton et al, 2021 Sweden Registered nurses and physicians with a PhD Qualitative Worldviews Evid-Based Nurs Time allocated for research; Networking and relationship with academia; Support from strategic management; Personal interest; Work overload; Lack of financial support; Informal permission to pursue research;
118 Reali et al, 2021 Australia Pharmacists Literature review Journal of Pharmacy Practice and Research Post-graduate qualification; Positive attitude towards research; Departmental support; Designated research time; Creation of research networks and forums; Lack of time; Workplace support; Funding; Research culture; Competing priorities; Mersfelder et al, 2021 USA Doctor of pharmacy Quantitative Curr Pharm Teach Learn Mentorship; Interest in the research topic; Comfort level in working with faculty; Improvement in the profession/medical community; Pursue a position that requires research/scholarship; Lack of time; Morrison et al, 2022 UK Nurses Literature review Journal of Clinical Nursing Educational partnerships; Research-motivated clinical nurses; Access to research role mode; Lack of research knowledge; Lack of confidence; Lack of access to resources; Lack of protected time; O'Brien et al, 2022 Ireland Nurses Qualitative Journal of Nursing Management Leadership; Supportive environment; Consistent and transparent communication in the team; Shared accountability and support network; Lack of skills; Staff turnover; Lack of support from management; Lack of time; Ramón et al, 2022 Spain Nurses Quantitative Healthcare (Switzerland) Work environment; Economic incentives; Improve curriculum vitae; Lack of time; Lack of institutional support; Lack of training (especially in languages);
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