Introduction

Randomised controlled trials (RCTs) have provided much-needed evidence for the effectiveness of interventions in healthcare. However, the absence of contextual information and the inability to adapt interventions during the implementation of RCTs limit the application of their findings in community settings (Wensing 2021).

Implementation science and the principles of ‘real-world effectiveness’ provide a solid foundation for balancing rigorous research with the requirements of real-world settings, in which the role of the research nurse has transformed – Stolley et al (2000) argued that the culture of nursing research has evolved to consider not only how research is conducted but also its application to and sustainability in clinical settings.

This article examines how a nurse’s dual role as research nurse and care coordinator affected the implementation in a real-world setting of an intervention called Reorganizing the Approach to Diabetes through the Application of Registries (RADAR).

Background

Research nurses typically only document and collect data, providing limited input into studies’ design and implementation, and having minimal overall impact on the research (Xing et al 2024). A recent scoping review (Xing et al 2024) found that the research nurse’s duties typically involve administration and managing interventions. However, research nurses want to be regarded as collaborators in research, and to make contributions to the design and ownership of studies as well as facilitate effective intervention delivery (Ballintine and Potter 2023).

Methodologies for conducting research in real-world settings provide research nurses with opportunities for leadership, expanding their role to include engagement and implementation activities alongside intervention delivery (Nelson-Brantley and Chipps 2021). For example, research nurses can actively collaborate with partners including healthcare providers, administrators, policymakers and community leaders (Grol and Grimshaw 2003); conduct training sessions, monitor the implementation’s progress, identify barriers and facilitate solutions (Damschroder et al 2009); and share feedback within the research team and with community partners to make iterative improvements to the implementation (Glasgow and Emmons 2007).

This coproduction of research evidence prepares the ground for the implementation of evidence-based practice, and is important to the adoption and sustainability of effective interventions (Cassidy et al 2021). This collaborative generation of evidence is particularly useful in delivering care to First Nations communities, who are among Canada’s Indigenous Peoples (Bharadwaj 2014).

Nurses are well-positioned to champion interventions to implement research successfully. This ensures the research is rigorous, successful and meaningful to all partners, not just the researchers. Interventions are more likely to be implemented as intended if the foundational research has the right design, adaptations are well-documented, and the right people support them. This approach creates valuable real-world evidence across diverse populations and settings, as well as more opportunities for nursing leadership (Nelson-Brantley and Chipps 2021).

The RADAR intervention

These principles led the RADAR intervention to make the research nurse instrumental to its implementation. RADAR was designed to support the delivery of high-quality diabetes care in First Nations communities in Alberta. Its primary objective was to implement and assess the effectiveness of an integrated, population-based, culturally tailored electronic health record (EHR) and diabetes registry system designed for First Nations communities. The system, which also includes an analytics platform, is designed to address the limitations of traditional EHR systems, such as misalignment with local programmes and lack of population-based registries. It facilitates coordinated care by integrating patient data across various health programmes and providing real-time capabilities for patient follow-up. It also leverages technology to enable systematic patient reviews, case conferencing and continuous education, thereby addressing the unique healthcare challenges faced by remote First Nations communities.

This is coupled with dedicated support from a centralised care coordinator – who is also the research nurse – to systematically organise proactive diabetes-related outcomes. The care coordinator is crucial to support local healthcare workers, bridge gaps between communities and external service providers, and promote proactive diabetes management. Specifically, this role guides the use of the registry to facilitate population-level care and is performed alongside data collection and other research team activities.

RADAR was proven to improve or maintain at target-level both patient outcomes and the organisation of diabetes care in seven First Nations communities in Alberta, Canada (Eurich et al 2023). Its primary outcome was a 10% improvement in HbA_1c, blood pressure or cholesterol measures over the control’s baseline.

The original participating First Nations communities were involved in the conceptualisation and development of RADAR, which was modelled on the learnings from a similar initiative addressing poor immunisation rates with community collaboration (Eurich et al 2017). The First Nations’ chiefs, councils and health directors were engaged early and provided letters of support as part of the application for a Canadian Institutes of Health Research (CIHR) grant:

‘With limited human and technical resources and limited access to primary care and specialist services at the community level, we believe this is an important project with the potential to significantly improve outcomes for diabetic individuals and First Nations diabetes programmes. Furthermore, the model is one that is sustainable and scalable if it can achieve its targets and prove benefit.’ (First Nations nurse manager)

RADAR’s steering committees met several times with community representatives before its implementation to adapt the model to meet local needs, hoping this would increase the chance it would succeed. Our examination of its adoption and implementation found that a strong contributor to its success was the community’s awareness of RADAR and its value, especially given that there was frequent turnover of community staff (Wozniak et al 2021). RADAR would therefore rely on the support and engagement of the communities, healthcare providers and patients – and a well-engaged research nurse would act as a champion to facilitate its implementation in these hard-to-reach communities.

The research nurse

Nursing leadership encompasses critical thinking, action and advocacy, and is present across all domains of nursing practice including research (Canadian Nurses Association 2009). It manifests in formal and informal roles that nurses naturally assume (Canadian Nurses Association 2009). Integrating these leadership qualities into research teams enables nurses to drive innovative practices, enhance patient care and contribute to the advancement of healthcare (Wagner 2018).

The RADAR research nurse was a central member of the research team: she participated in engagement and implementation activities, as a champion of the intervention delivery; she provided leadership through her expertise in the areas of research, nursing skills specific to diabetes management, and experience working with and in First Nations communities; and she trained clinic staff and acted as a mentor in regard to research protocols and diabetes care.

She performed a crucial dual role, documenting and guiding the collection of primary data points as well as acting as a centralised care coordinator, providing dedicated support to systematically organise proactive, diabetes-related outcomes. As both research nurse and remote care coordinator, she was vital in incorporating and balancing the realities of nursing and communities’ needs and perspectives into the research process. She advocated on communities’ behalf in the research team’s meetings, ensuring local context and needs were represented, which is an important strategy to champion the implementation of the intervention (Ploeg et al 2010).

The research nurse led and facilitated thoughtful adaptions to suit each community’s needs and wants, to promote the uptake of RADAR without changing the core functions of the model. Many of these engagement and implementation activities can be organised by the Expert Recommendations for Implementing Change (ERIC) framework (Powell et al 2015) (see Table 1). ERIC implementation strategies provide a structured, evidence-based approach to overcoming barriers in healthcare settings, ensuring that interventions are effectively integrated into practice and lead to improved patient outcomes (Powell et al 2015). For example, the frequencies of telehealth meetings in RADAR were tailored to each community to balance the needs of the intervention and the effectiveness study with the competing priorities and limited resources of local healthcare providers receiving the intervention.

In addition, the research nurse performed the usual tasks of collecting and managing data, including ensuring the quality of the data collected for primary and secondary outcomes, which was essential to the effectiveness study. To have the research nurse closely connected with the research team protected the integrity of the model’s evaluation – the research nurse understood the pressures of documentation and the need for consistent methodologies within the parameters of the community setting. Frequent informal meetings provided a platform for ongoing conversations about the consistency, validity and reliability of the model. Overall, very little pushback was received due to the clear and frequent communication of rationales and model fidelity among all the members of the research team. This was critical to maintain the relationships with the communities.

Furthermore, the research nurse was necessary in providing meaningful interpretation and presentation of the study’s results through her in-depth knowledge of the cultural and professional context of healthcare delivery in First Nations communities. She codeveloped plain language summaries, informal training sessions and community gatherings, and presented findings at conferences for practitioners and academics including professional conferences of the national association, Diabetes Canada.

Discussion

The dual role described in this article was essential to the effectiveness of the study, resulting in rigorous, meaningful, appropriate research that may be of value for diverse communities (Ploeg et al 2007). Combining such elements of effectiveness and implementation in research can also enhance its impact (Curran et al 2012).

Nurses are well placed to fill this dual role in research settings, thereby contributing to innovative nursing leadership. Nurses remain integral to the systematic needs of data collection, alongside performing engagement activities and intervention delivery. Communication, circumstance assessment and triage, adaptability and other holistic skills of nursing practice can provide the foundation for balancing the needs of researchers and communities.

Nurses foster empathy among patients, fellow healthcare workers, communities and researchers. This core skill gives them the ability to understand and experience other people’s feelings, thoughts and wishes (Moudatsou et al 2020), which supports their role as advocates. Although sometimes outside the domain of direct patient care and formal research, these skills affect the generation of new knowledge and the sustainability of effective interventions for First Nations communities (Wali et al 2021) – although to the authors’ knowledge, few research designs have integrated these types of enhanced nursing leadership skills into working towards better implementation of research for First Nations communities.

In many settings, the role of research nurse depends on their personal and professional qualities and their rapport with the communities being served. Traditionally trained nurses may lack the specific skills and knowledge required for this type of role; it is therefore necessary to invest in research nurses, finding, training and supporting people who will fulfil research duties and maintain relationships with the communities.

Future nursing programmes should include certifications and continuous education opportunities focused on research methodologies, project management and engagement activities. Having these opportunities available would create more awareness of implementation science and enhance nurses’ career advancement prospects. However, the difficulty of balancing clinical responsibilities with research duties could lead to burnout and job dissatisfaction, especially in the context of First Nations communities (Minore et al 2005). It may be possible to alleviate this stress by implementing workload management strategies, such as dedicated time for research activities, hiring additional support staff and offering flexible schedules (Ballintine and Potter 2023).

RADAR’s effectiveness supports both nurses in this role and communities in advocating for additional funding and the allocation of resources to the RADAR model. Indeed, the RADAR research nurse continued in her role, showing that involvement in research and engagement activities could help to retain nurses in this field.

Conclusion

As we have shown here, nurse leaders are integral members of research teams, providing the skills and knowledge to understand and anticipate population needs and trends. The RADAR nurse was a leader to both the communities and the research team, while maintaining relationships and the integrity of the intervention as well as indirectly improving patient care. Indeed, the RADAR nurse changed working practices by using emerging research, creating knowledge and adapting new technology, as well as fostering sustainable relationships within communities.

By actively participating in research teams and implementation strategies, nurses not only enhance the quality and relevance of healthcare interventions but also build trust and collaboration with community members. This sustained engagement ensures that initiatives are not only successfully implemented but also continuously supported and adapted to meet the evolving needs of the community. This ultimately leads to long-term health improvements and strengthened community bonds. As such, we believe it was the novel, dual role of the nurse as both research nurse and care coordinator that facilitated the successful partnership between the researchers and communities, leading to the successful implementation and comprehensive evaluation of the effectiveness of RADAR.