Introduction
Given the ongoing complexity of the healthcare environment and the growing need for evidence-based nursing, there is a clear demand for nurses with a Doctor of Philosophy (PhD) degree or a Doctor of Nursing Practice (DNP) degree [1]. Integrating clinical and academic work in nursing enhances patient outcomes and improves the quality, safety, and efficiency of patient care through the application of research evidence. Consequently, PhD or DNP nurses can effectively lead advanced research, spearhead quality improvement initiatives, and provide high-level education [2]. This study focuses on PhD nurses, as the DNP degree is not available in some countries, such as Iran.
Nurse managers play a crucial role in ensuring safe, high-quality care, yet a gap often exists between established care standards and actual delivery, posing risks to patient safety [3]. Prioritizing evidence-based practice (EBP), which integrates research, clinical expertise, and patient values, is essential to mitigate these risks [4]. While facilitators and barriers to EBP implementation exist [5], nurse managers must understand EBP to enhance care quality and patient safety [6]. Integrating doctoral-educated nurses into clinical settings is a key step, as graduate-educated nurses are more likely to apply research in practice [7]. An increased nursing skill mix correlates with improved outcomes, such as lower mortality rates and shorter hospital stays [8].
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PhD nurses involved in direct patient care possess several advantages. They play a pivotal role in advancing nursing care within complex healthcare settings, especially considering the challenges posed by aging populations, increasing chronic conditions, and staffing shortages. Additionally, they can establish collaborative networks across disciplines, fostering the generation of innovative, evidence-based knowledge. This knowledge can be effectively applied in clinical practice, staff education, policy development, and the professional growth of nursing professionals [9‐11].
Although PhD nurses are mainly expected to contribute to research and education in academic settings, they also play a critical role in fostering and delivering the advancement of EBP. Their expertise and knowledge are invaluable in promoting the integration of research findings into clinical practice. By actively engaging in EBP initiatives, they could enhance the quality of care and contribute to improved patient outcomes [12].
Despite the critical role of doctoral-educated nurses in providing high-quality care and leadership in clinical settings [13], there is a global reluctance among PhD nurses to work directly with patients [9, 14]. Although PhD nurses are primarily expected to contribute to research and education within academic institutions, their potential contributions to clinical settings remain underexplored. In academic roles, PhD nurses engage in research, curriculum development, and mentorship, shaping the next generation of nurses [10]. However, in clinical environments, their presence can bridge the gap between evidence-based research and direct patient care, promoting improved patient outcomes through advanced knowledge translation [12].
Despite their potential to enhance clinical practice, there is limited knowledge regarding their formal integration into clinical roles. Existing literature primarily focuses on the academic and research contributions of PhD nurses, leaving a significant gap in understanding how they navigate clinical settings, what challenges they encounter, and how their expertise is utilized [9, 14]. Studies have indicated that PhD nurses often face role ambiguity, resistance from colleagues, and limited recognition of their clinical expertise, which may hinder their full contribution in patient care settings [12, 15]. Furthermore, their specific positions, rights, and responsibilities in clinical environments remain unclear [14]. Some studies suggest that the duties of PhD nurses in clinical care, as well as their contributions to healthcare delivery, have not been clearly defined [16]. A recent scoping review identified the primary roles of doctoral-educated nurses, including both PhD and DNP holders, highlighting their influence on practice development, clinical leadership, and clinical teaching for students [9]. However, little is known about the experiences of PhD-prepared nursing faculty in clinical settings, emphasizing the need for further research on their integration into clinical practice.
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In the Iranian context, where the DNP degree program is not available, nurses with PhD degrees represent the sole doctoral-level nursing professionals engaged in clinical practice settings. Though the majority of PhD nurses in Iran are employed within academic institutions and may not maintain active clinical roles, some PhD-holding nursing faculty members do supplement their university responsibilities by taking on additional clinical work hours separate from their primary academic duties [17]. The reasons behind their limited presence in clinical settings have not been extensively studied, highlighting the need for further research to gain a deeper understanding of these experiences.
As mentioned, given the increasing complexity of healthcare systems and the necessity for evidence-based nursing, the critical role of PhD nurses extends beyond academia to clinical settings. These nurses are pivotal in advancing patient care, research integration, and interprofessional collaboration [9, 12]. Despite their potential, there is a noticeable gap in the literature detailing their experiences and the challenges they face in clinical environments [14]. Studies have emphasized that unclear clinical roles and underutilization of their expertise often restrict their full impact [15, 18].
This issue is particularly relevant in contexts like Iran, where doctoral-level nurses face unique challenges due to the absence of DNP programs, leaving PhD nurses as the sole doctoral-level nursing professionals in clinical settings [17]. By exploring these experiences, this research aims to elucidate both the barriers impeding their participation and the facilitators supporting their engagement, ultimately contributing to strategies for improved role integration and utilization in clinical settings.
Methods
Study design
This study employed a qualitative content analysis approach, grounded in the naturalistic paradigm, which posits that reality is subjective and constructed through individual experiences and interactions [19]. The philosophical foundation aligns with the interpretivist perspective, emphasizing the exploration of participants’ experiences to derive contextually rich insights [20].
Qualitative content analysis was chosen because it allows for an in-depth exploration of nursing PhD faculty members’ experiences in clinical settings. This approach is particularly well-suited for studying complex and underexplored phenomena, such as the facilitators and barriers influencing their dual roles in academia and clinical practice. By systematically analyzing textual data, this method enables the identification of patterns and themes that reflect participants’ perspectives without being constrained by pre-existing theoretical frameworks [21]. Given the lack of prior research on this topic, using an inductive approach ensures that findings emerge directly from the data, capturing the nuances of participants’ experiences in an unbiased manner.
The research adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist (Supplementary File 1) [22] to ensure rigorous methodology and comprehensive reporting.
Participants
PhD nursing faculties were recruited using a purposeful sampling method. To ensure a comprehensive range of perspectives, we employed maximum variation sampling, which enabled us to include a diverse array of hospitals, such as university and regional hospitals, as well as individuals in different roles, including nursing managers, supervisors, bedside care providers, and those responsible for specific wards. Moreover, we took into account participants with varying years of clinical experience, thereby further enriching the breadth of viewpoints within our study.
The study enrolled nursing faculties who possessed a PhD degree and were affiliated with universities operating under the oversight of the Minister of Health. Specifically, the participants were individuals working in clinical settings and actively involved in overtime work. To be eligible for participation, willingness to engage in the study was required. However, individuals who expressed hesitancy or declined to proceed with the interview were excluded from the study.
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Data collection
The data collection for this study occurred between July and September 2023 in Tehran, Iran. Faculty members were initially contacted via email, and subsequently, follow-up phone calls were made to them. All faculty members expressed their willingness to participate in the interviews. The participants were interviewed in person in their respective office spaces using a semi-structured interview approach. The semi-structured interview guide, developed specifically for this study, was designed to explore the experiences of PhD nursing faculty members in hospital settings. The guide included ten open-ended questions (Supplementary File 1) and was reviewed by experts for content validity prior to use. The interviews were conducted by the two authors, A.M. and S.H., who were assistant professors in nursing with over 10 years of experience in qualitative research. During each interview, only one interviewer was present, and a senior researcher, M.J.O., provided continuous supervision [23]. A semi-structured interview guide was utilized to gather data, which was recorded using a tape recorder. The duration of each interview ranged from 45 to 90 min, with the primary focus on exploring the participants’ experiences, barriers, and facilitators related to clinical work (Table 1). To gain deeper insights, additional exploratory questions such as “What do you mean?” and “Can you provide examples and further elaboration?” were asked during the interviews. The data analysis was conducted concurrently, and once the theme was identified and data saturation was achieved, the interviews were concluded. To ensure data saturation and capture a maximum variation of perspectives, feedback on the findings was sought from the participants. In addition, two additional interviews were conducted, but no new data emerged from these interviews.
Table 1
Semi-structure interview questions
1. Can you describe your overall experience working in hospital settings as a PhD nursing faculty member? |
2. What specific roles or responsibilities do you have in the hospital setting? |
3. How do you perceive the impact of your hospital experience on your teaching and research activities? |
4. Can you share any significant challenges or barriers you have encountered while working in hospitals? |
5. What factors or resources have facilitated your hospital experience and contributed to your professional growth? |
6. How do you navigate the balance between your academic responsibilities and your involvement in clinical work? |
7. Can you provide examples of memorable experiences or situations you have encountered in hospitals that have influenced your professional development? |
8. In your opinion, what changes or improvements could be made in the hospital environment to enhance the experience of nursing faculties? |
9. How do you perceive the collaboration and interaction between nursing faculties and other healthcare professionals in the hospital setting? |
10. Can you share any personal strategies or approaches that have helped you overcome challenges or maintain a positive experience in the hospital setting as a nursing faculty member? |
Data analysis
The analysis process was conducted concurrently with data collection, utilizing a constant comparison approach. The data were analyzed using the conventional content analysis method developed by Graneheim and Lundman (2004) [24]. This method involved iterative readings of the interviews to develop a holistic understanding of the dataset. Subsequently, a coding system was devised to label the identified meaning units, and these codes were systematically sorted into subcategories, categories, and overarching themes.
To ensure reliability and consistency, two researchers (M.J.O. and H.S.) independently coded the transcripts. After the initial coding, they compared their coding structures, and discrepancies were discussed and resolved through consensus. In cases where disagreements persisted, a third researcher (S.H.) was consulted to reach a final decision. This collaborative process ensured that the coding was systematic, reproducible, and free from individual biases. The final coding framework was established through team discussions, ensuring alignment with the study objectives and the integrity of the emerging themes.
The MAXQDA software version 10 was employed for data analysis [24]. Both authors, M.J.O. and M.D., coded the data, and the final analysis was confirmed through discussion.
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Rigor
The COREQ checklist was used to guide the study [22] (Supplementary File 1). We implemented Lincoln and Guba’s recommendations [25] to enhance trustworthiness in our study. To ensure rigor in this study, credibility was established through member checking, where participants reviewed and validated the interpretations of their responses during a three-week process; for example, Participant 10 confirmed and elaborated on their statement about challenges in integrating academic knowledge into clinical practice. Peer debriefing sessions with independent researchers further ensured unbiased findings. Transferability was promoted through maximum variation sampling, which included participants from diverse roles such as bedside care providers and nursing managers, and by using rich descriptions and direct quotes, such as detailing how financial constraints impacted dual academic and clinical roles. Dependability was enhanced by maintaining an audit trail documenting methodological decisions, such as categorizing “limited mentorship” under the personal domain, and holding team discussions for coding consistency. Reflexive journaling was employed to enhance confirmability, ensuring that the researchers’ biases and assumptions did not influence the findings. For instance, during peer debriefing, the interpretation of the theme “limited clinical expertise” was refined based on feedback from two independent qualitative researchers.
Findings
Participants characteristics
The study comprised 16 participants who were nursing faculties with prior experience in clinical practice. The majority of participants were male, and their ages ranged from 33 to 53 years. The participants had varying lengths of experience as nursing faculties. In terms of their clinical experience, they had been engaged in clinical activities for different durations, ranging from 1 to 10 years (Table 2).
Table 2
Characteristics of the study participants
Participants | Gender | Age (years) | Years as a faculty | Years of clinical work during the faculty tenure | Clinical role |
|---|---|---|---|---|---|
P1 | Male | 40 | 8 | 3 | Nurse |
P2 | Male | 43 | 5 | 4 | Nurse |
P3 | Female | 41 | 6 | 4 | Nurse |
P4 | Male | 48 | 9 | 5 | Nurse |
P5 | Male | 53 | 12 | 6 | Nurse |
P6 | Male | 48 | 11 | 3 | Nurse |
P7 | Male | 49 | 9 | 4 | Nurse |
P8 | Male | 48 | 13 | 10 | Nurse |
P9 | Female | 35 | 3 | 3 | Nurse |
P10 | Male | 38 | 5 | 2 | Nurse |
P11 | Male | 38 | 3 | 1 | Nurse |
P12 | Male | 55 | 14 | 9 | Nurse |
P13 | Male | 39 | 2 | 1 | Nurse |
P14 | Male | 35 | 1 | 1 | Nurse |
P15 | Male | 40 | 4 | 2 | Nurse |
P16 | Male | 45 | 8 | 5 | Nurse |
The analysis identified facilitators and barriers experienced by nursing PhD faculty members while working in clinical settings. These findings were organized into 13 subcategories, which were further grouped into five overarching domains: personal domain, School of Nursing domain, hospital domain, professional domain, and social domain (Table 3).
Table 3
Trial code, codes, subcategories, categories and theme
Theme | Category | Subcategory | Codes | Trial code | ||
|---|---|---|---|---|---|---|
Example code | Meaning Unit | Example Quote | ||||
Under-acknowledged expertise | Personal Domain | Limited clinical expertise | Lack of mentorship, lack of fellowship course after PhD, belief of low competency | Belief in low competency | Feeling of inadequacy or lack of preparation in clinical practice due to low confidence. | “I felt ill-prepared for clinical responsibilities” (P13) |
Compensation for insufficient academic salary | The high cost of living in the capital, the inappropriate economic situation of society, the low salaries of faculty members | the low salaries of faculty members | insufficient salaries lead to overtime work | “Low faculty salaries make it difficult to make ends meet and demotivate efforts to improve income.” (P. 6) | ||
School of Nursing Domain | Enhancing the quality of clinical education | Training nursing students with concrete clinical case examples, being up to date, improving nursing skills | being up to date | The importance of staying current with clinical knowledge and practices through active hospital engagement. | “Staying in hospitals keeps me updated on evidence-based practices and advancements, essential for delivering quality clinical education.” (P. 8) | |
Impeding academic growth | Excessive Workload (research, educational, and executive tasks alone with overtime nursing responsibilities) | Excessive Workload | The negative effect of excessive academic and clinical duties on professional development and growth. | “The demanding workload of research, teaching, executive tasks, and overtime nursing hinders academic growth.” (P. 11) | ||
Hospital Domain | Resistance from other staff members | Resistance by nurses and executive members implicitly | Resistance by nurses | Nurse skepticism towards the expertise and role of PhD faculty in clinical settings. | “The nurses often question the expertise and knowledge of nursing PhD faculty members.” (P. 15) | |
Insufficient financial resource | Research credit allocation, low overtime payment, equality of payment among faculties and other nursing staff | Research credit allocation | Lack of acknowledgment for research contributions within academic and clinical environments. | “we receive inadequate recognition and credit for our research efforts.” (P.8) | ||
Ambiguity in clinical positions and roles | Mostly as ordinary bedside caregivers, with Limited leadership opportunities, Scarcity of research-oriented positions, and lack of staff training positions | Mostly as ordinary bedside caregivers | Being relegated to routine clinical tasks, limiting opportunities for teaching and research involvement. | “most of us were assigned to do routine bedside caregiving tasks, while we could be efficient in teaching and research.” (P.1) | ||
Enhanced hospital Leadership | Staff satisfaction, authorities satisfaction, staff payment growth | Staff satisfaction | Increased staff satisfaction, particularly regarding improvements in salary and management. | “Since Dr. X became Matron, most things, especially salary, have improved and been satisfying.” (P.2) | ||
Professional Domain | Development of nursing professional identity | Role modeling and mentorship, Recognition and validation of nursing expertise, Professional collaboration and interdisciplinary teamwork, Advocacy and leadership in nursing practice | Role modeling and mentorship | Demonstrating how to blend research and patient care to guide students and nurses in clinical practice. | “My presence at the bedside allows me to model the integration of research, knowledge, and compassionate care in real-world practice for students and other nurses.” (P.4) | |
Advancement of patient care | Evidence-based practice implementation, Innovative patient care interventions, Patient education and empowerment | Patient education and empowerment | Empowering patients through education to actively engage in their own care and decision-making. | “Through patient interactions, I have educated and empowered them to participate in their care and make informed decisions, advancing overall patient care.” (P.5) | ||
Social Domain | Deterioration of dignity | The stigma associated with working as a nurse under physician authority, undermining of nurses’ contributions in patient care, Perceived undervaluation of nursing expertise and contributions, Overcoming stereotypes and societal misconceptions about nursing roles and capabilities | The stigma associated with working as a nurse under physician authority | The stigma and hierarchical barriers that limit nursing faculty’s ability to engage in clinical settings. | “Working as a nurse under physician authority is often stigmatized, creating barriers for nursing faculties to fully engage at the bedside.” (P.6) | |
Social disparity between being a faculty member and being a nurse | Cultural biases towards academic roles over nursing roles, challenging the perception that nursing is a less prestigious field, Societal hierarchy favoring faculties over nurses, Lack of recognition for the expertise and contributions of nurses, Limited social prestige associated with being a nurse | Cultural biases towards academic roles over nursing roles | Social bias that elevates academic roles over nursing roles, creating a disparity in recognition and respect. | “A cultural bias values academic roles, like faculty positions, over nursing roles, creating a social disparity between them.” (P.15) | ||
The rationale for this categorization was based on the distinct contextual influences shaping the experiences of nursing PhD faculty members in clinical practice. The personal domain includes factors related to individual capabilities and motivations, such as clinical expertise and financial concerns. The School of Nursing domain captures how academic responsibilities influence their clinical work, either by enhancing clinical education or limiting professional growth due to workload. The hospital domain encompasses organizational and systemic factors affecting their clinical integration, including staff resistance, unclear roles, and financial constraints. The professional domain highlights facilitators related to professional identity and contributions to patient care, emphasizing the potential impact of PhD nurses on clinical practice. Lastly, the social domain addresses societal perceptions and the stigma associated with bedside work, which can affect job satisfaction and professional dignity.
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Personal domain
Nursing faculties’ decision to work overtime in clinical settings was primarily influenced by factors within the personal domain. Two specific subcategories, namely limited clinical expertise, and compensation of insufficient academic salary, were identified as having an impact on their willingness to assume additional clinical responsibilities.
Limited clinical expertise
The theme of limited clinical expertise reflects the challenges participants faced in bridging the gap between academic preparation and clinical practice. This was primarily attributed to the absence of structured mentorship programs and fellowship opportunities post-PhD, which are crucial for building confidence and competence in clinical roles. For example, one participant emphasized the need for mentorship, stating,
“I struggled to find a mentor who could guide me in developing my clinical skills.” (P5)
Another participant noted feeling unprepared for clinical responsibilities after completing their PhD, explaining,
“After completing my PhD, I felt ill-prepared to handle the clinical aspects of my role.” (P10)
Participant 13 expressed their belief in low competency, saying,
“I often doubted my clinical expertise due to limited opportunities for skill development and continuous learning.” (P.13)
These narratives underline the systemic gap in post-PhD training, highlighting the necessity for initiatives that support skill development and clinical integration for doctoral nursing faculty. However, it is worth noting that some participants, particularly those specializing in critical care fields, expressed confidence in their expertise and even expressed readiness to compete with physicians in their respective fields. They highlighted their proactive efforts to share their knowledge by conducting numerous workshops for healthcare workers, including medical students and doctors. Participant 1 emphasized their expertise and willingness to compete with physicians, stating,
“As a critical care specialist, I have developed skills to confidently compete with physicians and have conducted workshops to educate healthcare workers, including medical students and doctors, on critical care practices.” (P.1)
Compensation for insufficient academic salary
The challenging economic conditions in Iran have had a significant impact on various individuals, including nursing faculties, particularly those residing in the capital city, where the cost of living is exceptionally high. In response to the financial constraints imposed by their low salaries, some faculty members need to undertake overtime work or pursue second jobs as a means to partially alleviate their financial burdens. Participants highlighted the challenges of coping with the high cost of living in the capital city, emphasizing the additional financial strain it places on PhD nursing faculties. One participant stated,
“Living in the capital is extremely expensive, and it becomes increasingly difficult to meet our financial needs with the current salary.” (P. 2)
The inappropriate economic situation of society was also identified as a significant factor affecting monthly salary compensation. Participants expressed concerns about the overall economic situation, which creates barriers to improving their financial circumstances. A participant remarked,
“Unfavorable economic conditions limit our ability to negotiate better compensation.” (P. 3)
Furthermore, the low salaries of faculty members emerged as a central code within the subtheme. Participants discussed the issue of insufficient compensation among PhD nursing faculties, highlighting the impact it has on their efforts to improve their monthly salary. One participant shared,
“Low faculty salaries make it difficult to make ends meet and demotivate efforts to improve income.” (P. 6)
School of nursing domain
School of the Nursing domain had both facilitator and barrier impact on the working of nursing faculties in clinical settings. This theme is divided into two subcategories: enhancing the quality of clinical education and impeding academic growth, which were explored below:
Enhancing the quality of clinical education
Engaging in direct patient care and working at patient bedsides had a significant impact on nursing faculties, ensuring their up-to-date knowledge and enhanced quality of education. Enhancing the quality of clinical education acts as a facilitator in this context. In the study, participants recognized several benefits associated with this approach, including the utilization of concrete clinical case examples during training nursing students, staying up-to-date with best practices, and ongoing improvement of nursing skills to deliver high-quality clinical education.
One participant emphasized the influence of continuous engagement in patient care, stating, “Working at patient bedsides inspired me to use clinical cases in training, enhancing nursing students’ understanding and application of theory in practice.” (P. 7).
Regarding the importance of staying up to date, another participant highlighted the value of remaining within the hospital setting, stating,
“Staying in hospitals keeps me updated on evidence-based practices and advancements, essential for delivering quality clinical education.” (P. 8)
Furthermore, participants emphasized the significance of direct patient care in improving nursing skills. One informant remarked,
“Providing patient care and engaging in caregiving tasks enhance my practical skills essential for professional growth.” (P. 10)
Impeding academic growth
Working overtime in clinical settings can pose a significant barrier for nursing faculties. The participants emphasized the challenges they encountered in managing their workload, which encompassed research, educational responsibilities, administrative tasks, and additional nursing duties beyond their regular schedules. The inability to fulfill these numerous and demanding responsibilities was seen as a potential hindrance to their academic growth. One participant specifically mentioned the heavy workload faced by nursing faculties, stating,
“The demanding workload of research, teaching, executive tasks, and overtime nursing hinders academic growth.” (P. 11)
Another participant elaborated on the struggle to balance responsibilities, saying,
“Juggling clinical and academic obligations leaves me with little time to focus on publishing or advancing my own research projects, which directly affects my professional development” (P7).
These accounts highlight how excessive demands on time and energy detract from academic productivity, limiting opportunities for growth and advancement within their dual roles.
Hospital domain
The hospital environment had various impacts on the work of PhD nursing faculties in clinical settings. The influencing factors were grouped into the following subcategories: resistance from other staff, low payment and compensation, insufficient clinical positions, tasks, and responsibility, and enhanced hospital leadership.
Resistance from other staff
Resistance from staff emerged as a significant barrier within the hospital domain, reflecting the tension between doctoral nursing faculty and their colleagues. This resistance often stemmed from misconceptions about the expertise and relevance of PhD nurses in clinical settings. As one participant (P15) noted,
“The nurses often question the expertise and knowledge of nursing PhD faculty members.” (P. 15).
Or another said:
“Some staff view nursing faculty as disconnected from clinical practice, leading to skepticism and resistance to their guidance.” (P.9).
Such perceptions can undermine the collaborative potential of doctoral-prepared nurses, limiting their ability to contribute effectively to evidence-based practices and interdisciplinary teamwork.
Resistance by executive members
Resistance by executive members refers to the challenges faced by nursing PhD faculty members in their interactions with higher-level administrators and decision-makers within the hospital. These executive members often prioritize administrative and managerial aspects over the academic contributions of nursing faculty. As a result, there is a lack of recognition and support for the research endeavors of nursing faculties. The perceived disconnect between nursing faculty and executive members can lead to limited involvement in decision-making processes and a diminished influence on organizational policies. The resistance from executive members may manifest as a lack of engagement, exclusion from key discussions, and limited opportunities for nursing faculties to contribute their expertise. This resistance hampers their ability to effectively shape the direction of the organization and fully utilize their academic and research capabilities within the clinical setting. In this respect, some participants emphasized:
“Executive members prioritize administrative and managerial aspects over academic contributions.” (P.1)
“There is a lack of recognition and support from executive members for nursing faculty’s research endeavors.” (P.3)
“Executive members do not actively involve nursing faculty in decision-making processes.” (P.4)
Insufficient financial resource
Insufficient financial resources presented significant challenges for nursing PhD faculty members working in clinical settings. The lack of adequate financial support encompassed various aspects, including the unfair allocation of research credit and inadequate overtime payment, which often amounted to less than what other caregivers received. Nursing faculties expressed difficulties in obtaining the recognition and credit they deserved for their research endeavors, which in turn resulted in a lack of motivation to pursue scholarly activities. The limited financial resources not only jeopardized the financial stability of nursing faculties but also had the potential to negatively affect their job satisfaction, motivation, and overall retention in clinical settings. Regarding this subtheme, some participants remarked:
“we receive inadequate recognition and credit for our research efforts.” (P.8)
“Overtime work is often expected but not fairly compensated in terms of payment or time off.” (P.1)
“The salary structure does not adequately reflect the expertise and responsibilities of nursing faculties.” (P.6)
Ambiguity in clinical positions and roles
Ambiguity in clinical positions and roles emerged as a significant concern among the participants, highlighting the limited opportunities for nursing PhD faculty members to engage in meaningful and impactful clinical responsibilities. Instead, they were predominantly assigned routine bedside caregiving tasks, which hindered their opportunity to take on leadership roles, engage in research-oriented positions, or participate in staff training. These limitations severely restricted the faculty’s capacity to contribute effectively to teaching, research, and mentorship activities, thereby impeding their professional growth and diminishing their potential impact within the clinical setting. Some participants shared their experience as follow:
“most of us were assigned to do routine bedside caregiving tasks, while we could be efficient in teaching and research.” (P.1)
“Clinical positions for nursing faculty are predominantly focused on direct patient care rather than academic responsibilities.” (P.3)
“Administrative positions are typically occupied by non-faculty members, hindering the career progression of nursing faculties.” (P.7)
“There is a lack of dedicated positions for nursing faculties to focus primarily on research.” (P.8)
Enhanced hospital leadership
The experiences of the participants underscored the positive outcomes associated with assigning a nursing PhD faculty member to a leadership role as a nurse manager within the hospital. This transition resulted in several notable advantages, such as improved payment satisfaction, increased satisfaction among staff and authorities, and enhanced integration of EBP. Importantly, some participants shared valuable insights regarding this matter.
“Since Dr. X became Matron, most things, especially salary, have improved and been satisfying.” (P.2)
“A nursing faculty member in an administrative role enhances staff satisfaction by promoting professional growth, mentorship, and support.” (P.5)
“A nursing faculty member in leadership fosters staff satisfaction by prioritizing development, recognizing achievements, and addressing concerns.” (P.12)
“Having a nursing faculty member in leadership ensures the integration of expertise and evidence-based practices, improving outcomes and satisfaction.” (P.15)
Professional domain
Participant’s experiences demonstrated that being a nursing PhD faculty member and serving as an academic instructor while actively engaging in bedside work has proven to be instrumental in fostering a stronger professional identity and advancing patient care. These two subcategories are intricately intertwined within the broader theme.
Development of nursing professional identity
Participants emphasized the importance of integrating their academic and clinical roles in shaping their future responsibilities. One participant shared their perspective on this matter,
“Working at the patient bedside while teaching and mentoring future nurses has shaped my professional identity, bridging the gap between theory and practice and highlighting evidence-based care.” (P.1)
This subtheme also emphasized the importance of role modeling and mentorship. Another participant expressed,
“My presence at the bedside allows me to model the integration of research, knowledge, and compassionate care in real-world practice for students and other nurses.” (P.4)
Advancement of patient care
Participants mentioned their commitment to applying up-to-date evidence in providing patient care, which ultimately led to the delivery of high-quality patient care. For instance, one participant stated,
“As a nursing PhD faculty member in clinical practice, I integrate the latest research into care, ensuring patients receive the best evidence-based treatments.” (P.1)
Participants also highlighted the significance of innovative patient care interventions. One participant shared,
“Active involvement in patient care allows me to implement innovative approaches that improve outcomes and contribute to the development of nursing practice.” (P.4)
Additionally, participants emphasized the value of patient education and empowerment. One participant stated,
“Through patient interactions, I have educated and empowered them to participate in their care and make informed decisions, advancing overall patient care.” (P.5)
Social domain
The social domain highlights the negative emotions experienced by many nursing PhD faculty members when they are required to perform basic primary and routine bedside tasks under the authority of physicians, particularly in the presence of the public. This theme encompasses two subcategories including the “deterioration of dignity” and the “social disparity between being a faculty member and being a nurse.”
Deterioration of dignity
This subtheme addresses the stigma associated with working under the authority and orders of physicians, without having defined bedside authority for nursing PhD faculty members. This situation can lead to the undermining of their dignity, the perpetuation of stereotypes, and societal misconceptions about the roles and capabilities of nursing professionals. With this respect, some informants mentioned:
“Working as a nurse under physician authority is often stigmatized, creating barriers for nursing faculties to fully engage at the bedside.” (P.6)
“Nursing faculties work to challenge stereotypes and misconceptions about nursing roles, seeking recognition as integral members of the healthcare team.” (P.10)
Social disparity between being a faculty member and being a nurse
This sub-theme focuses on the social disparity that exists between being a faculty member and being a nurse. It encompasses several codes, including cultural biases towards academic roles over nursing roles, the challenge of changing the perception that nursing is a less prestigious field, societal hierarchy favoring faculties over nurses, lack of recognition for the expertise and contributions of nurses, and the limited social prestige associated with being a nurse. Participants noted:
“A cultural bias values academic roles, like faculty positions, over nursing roles, creating a social disparity between them.” (P.15)
“The societal hierarchy often favors faculties over nurses, reinforcing the perception that academic roles have greater value.” (P.12)
Comprehensive understanding and concluding theme; under-acknowledged expertise
The overarching theme represents that nursing faculties possess valuable abilities and expertise in research and education, but they may have limited clinical experience. As a result, they are primarily engaged in routine bedside work to provide direct patient care. Unfortunately, their skills in research and education are often overlooked or undervalued. This situation leads to dissatisfaction among nursing faculties. It is important to address this issue by implementing a fellowship program after PhD graduation, which would provide additional training in clinical work. Such a program would offer nursing faculties more opportunities to engage in professional tasks rather than routine and basic tasks, ultimately promoting clinical authority, dignity, job satisfaction, and professional nursing growth.
Discussion
The present study explored the experiences of nursing PhD faculty members working in clinical settings, identifying key facilitators and barriers to their integration. The findings align with previous research highlighting the challenges doctoral-prepared nurses face in balancing academic and clinical responsibilities while also showcasing their potential contributions to evidence-based practice [9, 12].
In the personal domain, our study discussed factors such as limited clinical expertise and the need to compensate for low academic salaries. We found that participants lacked mentorship and a fellowship program after obtaining their PhD degrees, which resulted in their lower competency in clinical work. This is consistent with findings from McKenna et al. [26], who reported that doctoral nursing curricula primarily emphasize research and education while providing minimal training in clinical practice. Similarly, Moghadam et al. [15] emphasized that PhD nurses often experience competency gaps, making it difficult for them to assert their role in clinical environments. The financial burden reported by participants, which compels them to take on additional clinical work, also mirrors findings by Nademi and Hassanvand [25], who discussed how economic constraints impact Iranian nursing professionals. This issue can be traced back to the nursing doctoral curriculum in Iran, where there is a lack of consistency between the curriculum of PhD programs and the nursing profession, its goals, and its obligations. In other words, the curriculum of PhD programs primarily focuses on research, education, and leadership, while lacking in clinical training and patient management [27].
The participants also expressed that their income is insufficient to cover their living expenses, necessitating them to work overtime in hospitals. Over the past three decades, Iran’s economy has faced various economic sanctions, including oil embargoes and other financial, banking, and commercial restrictions. The imposition of sanctions has had a profound impact on multiple economic indicators in Iran, including the livelihoods of its people [25]. The nursing profession and its faculty members have not been exempt from these effects.
The domain of the school of nursing encompassed both facilitators and barriers to the work of nursing PhD faculty members in clinical settings. Improving the quality of academic and clinical education served as a facilitator. Faculty members actively involved in patient care and clinical work were able to apply the principles of care science to their clinical practice, creating a reciprocal relationship. Research has shown that one of the advantages of working in clinical settings is the ability to bridge the gap between theory and practice. Nursing PhD professionals contribute their scientific knowledge to the planning and implementation of patient care, while also utilizing their clinical expertise in their academic endeavors within the university [16]. Furthermore, an active presence within the clinical setting was seen as providing enhanced opportunities for the successful implementation of pertinent research and the improvement of education in areas directly related to clinical practice [12]. On the contrary, the additional responsibility and extended working hours resulting from overtime work alongside academic obligations may hinder academic growth. Moreover, it is believed that engaging in bedside patient care undermines the social dignity of faculty members, which in turn limits their opportunities for academic advancement. The career prospects for PhD nurses who are involved in clinical care are largely constrained, and the absence of such opportunities has been identified as a significant factor contributing to the reluctance of PhD faculties to pursue a combination of clinical and academic roles [18]. From the authors’ view, a potential solution would be to implement supportive policies and structures that recognize and value the contributions of PhD faculties in clinical and academic settings. This could involve establishing flexible work arrangements, dedicated time for research and scholarly activities, competitive compensation packages, and fostering a collaborative and interdisciplinary culture.
Within the hospital domain, resistance from colleagues and hospital executives emerged as a significant barrier, with some staff questioning the relevance of PhD nurses in clinical practice. Similar tensions were reported by Andreassen and Christensen [14], who found that PhD-prepared nurses often face skepticism from clinical staff due to unclear role expectations. Additionally, another study highlighted that PhD nurses actively involved in clinical care are often perceived as potential threats by specific individuals, especially nurse managers, administrators, and physicians [12]. In the authors’ opinion, a potential solution could involve implementing strategies to foster better communication and collaboration between nursing PhD faculties and other healthcare professionals. This may include promoting mutual understanding, establishing clear roles and responsibilities, and fostering a supportive and inclusive work environment that values the contributions of all team members. The limited financial support experienced by participants, with overtime payment not commensurate with their advanced degrees, presents a barrier. The solution should involve fair and equitable compensation that aligns with the participants’ qualifications and recognizes their expertise [12]. The ambiguous clinical position was another challenge experienced by nursing PhD faculties. Similar studies revealed that the responsibilities and duties of PhD professionals working in clinical settings were ambiguous, with their clinical assignments often overlapping with those of colleagues lacking a PhD. A primary contributing factor proposed was the managers’ incomplete understanding of their expertise, resulting in an underutilization of their capabilities [15]. The role of providing direct patient care has been a priority for PhD faculties, which can potentially have a negative impact. Consequently, a potential consequence of this situation is the underutilization of the expertise possessed by PhD nurses [18]. In contrast, our study revealed that appointing a nursing faculty member as a matron yields favorable outcomes for both staff and patients. This can be attributed to the profound influence that PhD nurses have on leadership advancement within the nursing field. The possible reason may be that, the curriculum for a PhD in nursing, exemplified by the Iranian Curriculum of PhD in Nursing (2017), provides a comprehensive framework comprising eight to ten specific leadership responsibilities explicitly designed for PhD graduates PhD [17].
Our findings demonstrated that the involvement of nursing PhD faculties in clinical settings yields substantial benefits in terms of professional growth and improved patient care. These findings align with previous studies, which consistently highlight the proactive efforts of PhD nurses in integrating evidence-based nursing practices into various aspects of their work settings [14]. Additionally, numerous studies underscore the significant role of PhD nurses in clinical care as valuable role models for their colleagues [28]. PhD nurses educate their colleagues, particularly in bedside research projects, leading to enhanced evidence-based care provided by their peers. Additionally, Studies by Beeber et al. (2019) and Ball et al. (2018) demonstrated that doctoral-prepared nurses play a key role in translating research into practice, improving patient outcomes, and fostering interdisciplinary collaboration [8, 13].
Finally, in the social domain, participants reported experiencing a loss of professional dignity when working as bedside nurses under physician authority. This aligns with research by Andreassen and Christensen [14], who described the hierarchical challenges PhD nurses face when attempting to integrate into hospital settings. Moreover, the societal perception that academic roles hold greater prestige than clinical roles further complicates their integration, an issue also raised by Wilkes and Mohan [28], who discussed how PhD nurses often struggle with recognition and acceptance in direct patient care settings.
To address the identified barriers and leverage facilitators, it is essential to implement several targeted strategies. First, establishing structured mentorship initiatives and post-PhD fellowship programs can bridge the gap between academic expertise and clinical practice, ensuring PhD nurses are confident and well-prepared for their roles. Second, developing clear policies to define their roles and responsibilities, including leadership opportunities and research-focused positions, can enhance their contributions. Financial incentives, such as competitive salaries and fair overtime compensation, are crucial for improving job satisfaction and encouraging sustained clinical engagement. Additionally, cultural change initiatives, including awareness campaigns and workshops, can reduce stigma and promote the value of PhD nurses among healthcare teams. Leadership integration is another critical step, advocating for PhD nurses to hold decision-making roles, thereby ensuring evidence-based practices are effectively implemented. Lastly, creating supportive research environments with dedicated positions allows PhD nurses to actively contribute to evidence generation and implementation. Collectively, these measures, supported by institutional commitment, can significantly enhance the professional integration and impact of PhD nurses in clinical settings.
Limitation
One limitation of the study is that due to the absence of a DNP program in Iran, we were only able to interview PhD faculty members. This may have introduced a bias in our sample, as the perspectives and experiences of DNP-prepared professionals were not included. Additionally, another limitation of the study is the gender imbalance among the participants, with a majority of the participants being male. This gender disparity may have implications for the generalizability of the study’s findings, as the experiences and perspectives of female participants may differ from those of male participants. Future research should strive for a more balanced gender representation to ensure a comprehensive understanding of the topic. It is worth noting that despite these limitations, the study still provides valuable insights into the perspectives of PhD faculty members in Iran.
Conclusion
In conclusion, this study highlights the challenges and facilitators faced by nursing PhD faculties in clinical settings, including personal, nursing school, hospital, and social factors. To encourage increased engagement in clinical settings, it is crucial to enhance the reported facilitators while effectively managing the barriers. Strategies such as establishing a fellowship program, recognizing clinical work hours, fostering constructive communication, defining specific clinical roles, and increasing payment can address these challenges and promote social respect and dignity for nursing PhD faculties. By creating a supportive environment that aligns academic and clinical responsibilities, we can ensure a sustainable and fulfilling career path for nursing PhD faculties in clinical practice.
Acknowledgements
The authors would like to express their appreciation to the nursing PhD faculties who generously shared their valuable experience in this study. Further, we would like to express our gratitude for the guidance and advice provided by the Clinical Research Development Unit of Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Tehran, Iran.
Declarations
Ethics approval and consent to participate
The research project obtained ethical approval from Baqiyatallah University of Medical Sciences (BUMS) with the following identification number: IR.BMSU.BAQ.REC.1402.047. All procedures involving human participants were conducted in full accordance with the ethical guidelines and regulations outlined by the Declaration of Helsinki. Informed consent was obtained from all participants after they were provided with detailed information about the study’s objectives, methods, and confidentiality measures. Participation was entirely voluntary, and participants retained the right to withdraw from the study at any time without consequences. To ensure confidentiality, participants’ identities were anonymized and coded (e.g., P1, P2, etc.), and no personally identifiable information was recorded.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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