Rethinking Health Professionals’ Motivation to Do Research: A Systematic Review

Introduction

Health professionals (HPs), including doctors, nurses, midwives, and allied health professionals (AHPs) who undertake research have been referred to in the literature under various titles including, clinician researcher¹ clinician investigator² and physician-researcher.³ This group of HPs spend time as both active clinicians and researchers and they engage in translational health and medical research (HMR) to address the issues they see in clinical practice.⁴ HP led research is important because it fosters evidence-based clinical practice and improved health outcomes for patients.⁵ For example, research on chronic diseases has significantly contributed to better health outcomes and improved quality of life for people across Australia and globally.⁶ In addition to the patient health benefits, employment of those engaged in HMR has resulted in continued productivity due to better health outcomes and financial benefits from new medicines and technology. HMR has helped Australia become a leading economy of the 21st century returning an increasing net benefit of $8.2 billion, returning $3.90 for every dollar invested⁶ and from 2000 to 2015, National Health and Medical Research Council (NHMRC)-funded research saved the Australian health system $23.4 billion.⁶ Despite the benefits of research to the economy and health benefits to patients there still exists a dearth of HP researchers.

There has been an ongoing global concern that the number of HPs undertaking research is declining.⁷ The seminal paper by Wyngaarden,⁸ “The clinical investigator as an endangered species” addressed this concern over 40 years ago.^9,10 Recent international trends from the USA,^7,11,12 Canada,¹³ UK,¹⁴ Sweden,¹⁵ Africa,¹⁶ Singapore,¹⁷ Pakistan¹⁸ and Saudi Arabia¹⁹ still indicate a decline in the number of young researchers replacing an aging workforce. For example, in the US, the fraction of physician-researchers has reduced from 4.7% in the 1980s to approximately 1.5% currently.²⁰ In New Zealand (NZ) and Australia there exists a similar scenario, with the number of individuals training in medical research decreasing or stagnating over the past few decades.^21–23 The Australian Institute of Health and Welfare (AIHW) reported a decline in the proportion of employed Australian doctors who identified primarily as researchers from 2.1% in 2002 to 1.5% in 2010.^24,25 The 2018 Medical Deans of Australia and New Zealand (MDANZ) report indicated a further 3.9% drop in the number of physician-researchers between 2013 and 2017.²⁶ Comparatively, of the 1346 registered doctors who self-reported as physician-researchers in 2017, 59% were males and 39% were 55 years and above.²⁶

Decline in the number of HP researchers has largely been attributed to significant factors including lack of dedicated research time, research expertise, awareness and skills.^10,27 Additionally, there has been lack of effective succession planning.¹² Furthermore, younger generations of HP graduates, particularly females, are wanting more work-life balance; and this generates situations where undertaking research competes with other goals, values and career pathways.^3,7,28 Reduced accessibility to research positions, particularly in rural areas has also been highlighted as a major challenge.²⁹ Building the capacity of HPs to undertake research is considered to be an international priority in view of the increasing predominance of chronic diseases and aging world populations.³⁰ Health organisations with strong research culture have been associated with greater service efficiencies and reduced patient mortality and morbidity, indicating that involvement in research extends beyond individual HPs’ professional development.³¹

Motivation to undertake or stay in HMR is a key factor in addressing the shortage of HP researchers currently being experienced.³² Motivation has largely been attributed to the opportunities and barriers HPs have experienced or expect to experience in their research journey.³² However, the number of HPs engaging in research has still not improved. Applying a theoretically informed approach to examining existing literature findings can point the way to more effective strategies to motivate HPs to do research. The Expectancy-Value-Cost (EVC) motivation theory postulates that achievement-related choices are motivated by a combination of people’s expectations for success and subjective task value in particular domains.^33,34 For example, individuals are more likely to pursue an activity if they expect to do well and value the activity. The model further differentiates task value into three components: attainment value (ie, importance of doing well), intrinsic value (ie, personal enjoyment) and utility value (ie, perceived usefulness for future goals). However, motivation can be limited by potential barriers which are referred to as cost (ie, competition with other goals). According to the EVC model, expectations for success and task value are shaped by a combination of factors. These include individual characteristics (abilities, previous experiences, goals, self-concepts, beliefs, expectations, interpretations) and environmental influences (cultural milieu, socializers’ beliefs, and behaviours).³⁵

A recurrent theme in the literature is that motivation to undertake research has largely been extrinsic, that is, to improve CVs,³⁶ career progression³⁷ or for academic improvement. This indicates a need for further exploration into the underlying concepts of motivational theory and its relevance to research uptake and retention by HPs. It is not surprising, therefore, that motivation is increasingly becoming a major area of interest within the field of HPs’ education³⁸ and health research orientation,³⁹ with a focus on Self-Determination Theory (SDT)^40,41 which has special implications for HMR. Evolving from research on intrinsic and extrinsic motivations, SDT is a macro theory of human motivation that has been successfully applied to healthcare education and HMR.^42,43 The focus of SDT is not on how motivation can be controlled from without, but instead on how motivation is functionally designed and experienced from within.⁴¹ SDT relates to three basic psychological needs: (1) Competence: People need to gain mastery of tasks and learn different skills. When people feel that they have the skills needed for success, they are more likely to take actions that will help them achieve their goals. (2) Connection or Relatedness: People need to experience a sense of belonging and attachment to other people. (3) Autonomy: People need to feel in control of their own behaviours and goals. This sense of being able to take direct action that will result in real change plays a major part in helping people feel self-determined.⁴⁴

Rethinking HPs’ motivation to engage in research, now has immediate and wider implications for all HPs whether medical, nursing and midwifery or allied health.⁶ The decline in number of HP researchers comes at a critical time when medical innovations are urgently needed to combat the current global COVID-19 pandemic, other communicable diseases and the aging population crisis.^2,18 The threat to individual and societal health and economic welfare requires a holistic approach to HP engagement with research and research training to ensure long-term outcomes for survival of world populations.² Research can no longer be restricted to an elite and specialized few, it needs to be appreciated as a fundamental activity for most, if not all HPs. To foster HP engagement with research, it is important to gain deep insight and understanding of what motivates or discourages them from taking up or continuing with research along the career pipeline. Hence this systematic review utilised two theoretical frameworks (EVC^33,34 and SDT^40,41) to (1) examine the facilitators and barriers to health professionals’ motivation to undertake research and (2) identify current research gaps.

Methods

The systematic review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement.

Inclusion and Exclusion Criteria

For the purpose of this review, the term HP researcher is defined as a medical graduate, nurse, midwife or AHP who works both clinically and in research – often varying the fractions throughout their career. The study population consisted of all HPs: AHPs, Medical, Nursing and Midwifery in hospital/research centres. Peer-reviewed articles written in English were considered if they related to HPs’ motivation, attitudes, and perceptions about undertaking research. There was no restriction on study design. Articles were excluded if they did not meet the inclusion criteria and/or they were review papers.

Search Strategy

Seven electronic databases comprising, CINAHL Complete, Informit, Medline Ovid, Medline (PubMed), Scopus, Web of Science and Google Scholar were searched. Peer reviewed primary articles, written in English and published between 2011 and 2021 (a decade of literature) were included in this review to reflect the current level of activity in the topic area.

Search terms used were research, health professionals (including physicians, AHPs, nurses, midwives), research, and motivation. The terms research capacity, attitudes and barriers were purposefully excluded as they would have limited a full exploration of the topic. The comprehensive search strategy used for this review is presented in Appendix 1. Reference lists from previous reviews and included studies were also screened for additional relevant articles.

Study Selection

All the identified articles were imported into Endnote X9 software (Clarivate, Australia), then titles and abstracts were screened. Two authors (LMDA and BSMA) independently screened the titles and abstracts of the retrieved articles and excluded those that did not meet the inclusion criteria. Subsequently, full-text articles categorised as potentially eligible for inclusion were screened and disagreements were resolved in a consensus meeting.

Data Synthesis and Analysis

Meta-analysis was not possible, due to the heterogeneous nature of the included articles. A data extraction form was developed and used to collect relevant information from all the included studies. Descriptive data including author, study year, title, country of study, research/study focus, setting – urban/rural/remote, study design, type of participants, participant numbers, gender and mean age were extracted from each of the selected studies. Elements of the Self-Determination Theory (SDT)⁴³ and the Expectancy-Value-Cost Model of Motivation (EVC)⁴⁶ were adopted to facilitate extraction of the key determinant factors to research motivation. The identified barriers and facilitators of HPs’ motivation to undertake research, as reported in each reviewed article were independently extracted and categorised by two authors (LMDA and BSMA). Conceptual content analysis^47,48 was used to extract and systematically code the factors as determined by the tenets of the EVC and SDT frameworks. Rules for translation of text into codes were developed by the researchers. Coding of pre-defined concepts/sets of categories was done manually and analysis of results involved quantification of coded concepts for frequency of occurrence and determination of relationships, trends and patterns.⁴⁸

Three major factors were considered namely: Research Capacity which relates to expectancy and competence; Attitude which relates to value and connection; and Barriers which relate to cost and autonomy. Research capacity was coded based on explicit/implicit statements within each reviewed article about participants’ perceived levels of confidence/ competence to participate in research. Participants’ attitude to research was underpinned by the type of value they attributed to research – attainment, intrinsic and/or utility value, as well as the connection or relatedness they expressed towards research. Participants’ attitude to research was categorised into three groups based on the frequency with which values and connections held by the study participants were openly stated or inferred. Attitude to research was coded as “very positive” if all three value types were established in a study, “positive” if only one and “negative/fear of research” if no value or connection to research was indicated. For autonomy/ cost, reported barriers in all studies were listed and grouped into categories, number of categorised barriers in each study were then quantified. LMDA and BSMA independently extracted and categorised all factors and subsequently met to check for consistency. All discrepancies were resolved through discussion.

For the purpose of this review, research capacity is defined as the ability to engage in, perform or carry out quality research.⁴⁹ The expectancy and competence of individuals to carry out research activities underpins research capacity and was viewed through the EVC (expectancy) and SDT (competence) frameworks. While it is postulated that there are two types of expectancies: ability beliefs that comprise of current/immediate beliefs about being able to complete a task and expectancy beliefs that reflect being able to do the task in the future, most investigations collapse measures of ability and expectancy beliefs into a general expectancy scale.⁴⁶

Attitude to undertaking research was viewed through the EVC (value) and SDT (connection) frameworks. Value is differentiated into three components: value of attainment is espoused in meeting a personal need; intrinsic value is gained through personal enjoyment or satisfaction and utility value is perceived usefulness for future goals and may be predictive of current and future interest.⁴⁶ Connection or relatedness is where people need to experience a sense of belonging and attachment to other people.⁴⁴

Barriers to undertaking research was also viewed through the EVC (Cost) and SDT (autonomy) frameworks where the perceived cost of undertaking research competes with other goals,⁴⁴ and autonomy is seen as the need to feel in control of one’s own behaviours and goals without undue external influences.⁴⁴ Cost and autonomy are largely seen as influences external to the individual although they may be encountered at the individual, organisational and/or system level.^43,46

Quality Assessment of Reviewed Articles

The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess the methodological consistency and quality of the included studies.⁵⁰ This tool contains 16 items and is used for examining studies with different research designs. Each of the included studies was graded on a scale of 0 to 3 for each criterion, with 0 = not at all, 1 = very slightly, 2 = moderately and 3 = complete. To assess the methodological quality of each of the included studies, the criteria scores were summed and expressed as a percentage of the maximum possible score. The percentage scores were classified into low (<50%), medium (50–80%) or high (>80%) quality evidence for easy identification. The QATSDD criteria included: (1) theoretical framework; (2) aims/objectives; (3) description of research setting; (4) sample size; (5) representative sample of target group; (6) procedure for data collection; (7) rationale for choice of data collection tool(s); (8) detailed recruitment data; (9) assessment of reliability and validity of measurement tool(s) (Quantitative only); (10) fit between research question and method of data collection (Quantitative only); (11) fit between research question and data collection method (Qualitative only); (12) fit between research question and method of analysis; (13) good justification for analytical method selected; (14) reliability of analytical process (Qualitative only); (15) evidence of user involvement in design; (16) strengths and limitations.⁵⁰

Results

Included Studies

Four thousand and twenty four (4024) articles were identified from all searched databases. Ten (10) additional articles were identified through hand searching. After screening the titles and abstracts of the identified articles and reviewing 228 full texts, 46 met the inclusion criteria for this review as shown in Figure 1.

Figure 1 Flow chart of the study selection protocol. PRISMA figure adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 6(7):e1000097. Creative Commons45.

Assessment of Methodological Quality

Table 1 portrays the QATSDD assessment with scores ranging from 33% to 90%. The aims and objectives, description of the research setting as well as the fit between research question and data collection method were well addressed in most studies. Strengths and limitations of the studies were also generally well addressed by most studies. Nonetheless, good justification for analytical method selected was overlooked in 14 studies and only 19 (41.3%) studies had evidence of user involvement in the design. Overall, 10 studies (22%) were rated as high quality because they were judged to be explicit in their methodology and mostly utilised theoretical frameworks. Thirty-five (76%) were medium quality studies and some of the weaknesses identified from these studies included: lack of theoretical framework, inadequate sample sizes and poor reliability. One study⁵¹ met only few quality criteria, had low rating (33%) and therefore was removed from the review.

Table 1 Quality Assessment of the Included Studies

Study Characteristics

A summary of the characteristics of the included 45 studies is presented in Table 2. The total number of participants was 11,438 and participant numbers per study ranged from 15 to 2052. Of the 33 studies that included both genders, 5620 (62.2%) of the 9039 participants were females. Only 19 studies indicated participants’ mean age which ranged from 34.5 ± 9.5 to 50 ± 7.7 years.

Table 2 Study Characteristics and Participant Demographics for Reviewed Articles

Sixteen (16) of the studies were conducted in Australia,^3,52–66 eight from USA,^32,67–73 six from UK,^74–79 four from the Middle East,^69,80–82 four from Europe,^83–86 three from Africa,^16,87,88 two from South East Asia,^89,90 one from Japan and South Korea⁹¹ and one each from Canada⁹² and New Zealand⁹³ Study settings included 13 urban,^{53,58,64–67,73,79–82,90,91} six regional^{52,55,61–63,84} and five urban and rural settings.^{54,69,76,85,86} Two studies were conducted in all three settings (urban, rural and remote)^56,59 while one was located in rural and remote settings.⁷⁸ The setting type was not specified in 18 studies. The study designs were varied with 29 quantitative, 10 qualitative and six mixed methods studies.

Five studies focused on all HPs^{56,59,65,66,92} as a heterogeneous group, two on AHPs and nurses^58,79 and one on nurses and physicians.⁸⁸ Overall, 18 studies concentrated on AHPs with 7 of those studies considering them as a homogenous group,^{52,55,60–64} five studies were solely on pharmacists,^{76,78,80–82} four on physiotherapists^75,85,86,93 and one each on psychologists⁵³ and speech language pathologists.⁵⁴ Ten studies focused on nurses^{57,67,68,71,72,74,77,83,84,90} and nine on physicians.^{3,16,32,69,70,73,87,89,91}

While HPs’ motivation to do research was investigated by all 45 reviewed studies, only eight studies utilised a theoretical framework or model in their investigation. These included Self-Determination Theory (SDT),⁸⁶ Social Cognitive Career Theory (SCCCT) and Professional Identity Formation as an integrated framework,⁶⁹ COM-B framework,⁷⁵ Vroom’s Expectancy Theory,⁷¹ Research-Active Nurse Model,⁷² Theoretical Domains Framework (TDF),⁷⁸ Social Cognitive Theory,⁸² combination of TDF and COM-B.⁶³

Factors Influencing Motivation

In relation to factors influencing motivation, all the studies in this review were appraised utilising the EVC and SDT frameworks. A summary of the findings is presented in Table 3.

Table 3 Theoretical Framework Summary of Study Outcomes

HPs’ Research Capacity

Research capacity was investigated in the studies in terms of competence/confidence and expectancy to do research. As shown in Table 3, over half 25 (56%) of the reviewed studies identified their participants as competent to undertake research, while the participants in the remaining 20 (44%) studies were identified as lacking confidence and requiring support to undertake research.

Of the 25 studies where participants were identified as competent, seven focused on physicians (medical doctors).,^{3,32,69,70,73,89,91} another seven on AHPs,^{52,55,60–64} four of which targeted pharmacists.^78,80–82 Five studies focused on nurses, four on all HP groups and one each on nurse-physician group and nurse-AHP group. Most participants who felt competent perceived that they had the required abilities, skills, and knowledge to participate in research. For example, participants in one study reported high competence levels ranging from 3.14 to 4.06 on a 5-point rating scale.⁹⁰ About 60–90% of participants who were identified as competent reported having prior research experience, with 66–75% confirming that they had formal training during their undergraduate education.^{3,58,65,66,70,75,80,82,88,90} Between 20% and 65% of this group of participants indicated that they had either completed or were undertaking a postgraduate qualification which had enhanced their research capacity.^{59,60,71–73,75,77,78,81,82,88}

Eleven studies that targeted AHPs reported that the participants lacked competence/confidence to undertake research. Similar results were obtained for five studies focused on nurses, two on physicians and one each on all HP groups and nurse-AHP group. Common features for these studies were overwhelming poor research capacity, very little or no prior research training/experience, low research culture with other work roles taking priority and need for research support. In one study, participants indicated that they had never attended research training nor spent time on research and reported mean confidence level of 38% (SD 27).⁹³

Overall, the results show that HPs’ confidence and expectancy to undertake research is largely dependent on research skills and experience gained through research training during their undergraduate/postgraduate education. The medical doctors were the most confident to undertake research as indicated in seven out of nine studies (77.8%) compared to nurses in five out of 11 (45.5%) studies; and AHPs in seven out of 18 (38.9%) studies. This may be attributed to the reported early exposure to research training and research experience by the medical doctors in comparison to nurses and AHPs. These findings highlight the impact of research training on perceived competence, confidence, and capability to participate in research.

HPs Attitude – This Relates to Value and Connection

As depicted in Table 3, participants’ attitude to research was assessed as very positive in 17 (38%) studies,^{16,32,55,56,60,65,66,68–70,72,73,75,84–87} positive in 21 (47%) studies^{3,52,57–59,61,62,64,67,71,78–83,88,90–93} and negative in four (9%)^53,74,76,89 studies.

The 17 studies in which HPs were deemed very positive included six on medical doctors,^{16,32,69,70,73,87} five on AHPs,^{55,60,75,85,86} three on nurses^{55,60,75,85,86} and three on a combination of the three groups.^56,65,66 The 21 studies that identified respondents as positive comprised nine on AHPs,^{52,61,62,64,78,80–82,93} (including four on pharmacists^78,80–82 and one on physiotherapists),⁹³ five on nurses,^{57,67,71,83,90} two on medical doctors^3,91 and five on a combination of the HP groups – two focused on all three HP groups,^59,92 two on AHPs and nurses^58,79 and one on medical doctors and nurses⁸⁸ The four studies in which HPs were identified as negative included two on AHPs – pharmacists⁷⁶ and psychologists,⁵³ one each on nurses⁷⁴ and medical doctors.⁸⁹ Another three studies reported their respondents as being afraid of research – two on AHPs^54,63 and one on nurses.⁷⁷

Generally, participants who demonstrated very positive attitude towards research were keen to contribute to clinical practice by engaging in collaborative research to advance clinical knowledge and improve patient health outcomes (utility value). Additionally, they were avidly interested in publishing, producing new knowledge, gaining grants and getting respect of colleagues (attainment value) as well as broadening personal scope of professional career and becoming knowledgeable researchers with genuine interest in research as a problem-solving tool^32,55,69,87 (intrinsic value). This group of participants had genuine curiosity and willingness to learn, were mostly satisfied with their jobs, wanted to develop research skills so they could increase knowledge and develop cutting edge research that proffer solutions to clinical problems.^{55,60,75,85,86} They also felt a strong connection to research and their profession bodies. For example, research active pharmacists reported the importance of research in uplifting the pharmacy profession and enjoyed reading articles.^80,82

Participants who demonstrated positive attitude mainly viewed research as beneficial for making a difference in clinical care with improved patient health outcomes and service delivery.^16,70,73,91 This group focused on the utility of research and mainly focused on its benefits in improving clinical care and practice. For participants who were negative, the common attitude reported included perceived benefit only for the institution in which they worked.⁸⁹ They also did not feel supported by their organisation and therefore did not consider research as part of their role. Interestingly, one study on the medical group identified its participants as negative/not involved in research and perceived the value of research as solely for the benefit of patients and the institution in which they worked.⁸⁹ Nurses were negative in one study⁷⁴ and found research frightening in another.⁷⁷ Two studies on AHPs fell under the fear of research category.^54,63 This group of participants reported minuscule⁶³ or no value⁵⁴ for research and emphasised the need for connection and relatedness. Participants in the negative/fear of research groups were of the opinion that research was a “huge undertaking” and “daunting task”.⁵⁷

Overall, most of the participants in the medical group were very positive while the AHP and nursing groups were mostly in the positive category. Intrinsic value was seen as a pre-requisite for motivation, while utility value is the trigger for research to satisfy the need in clinical practice.⁷² The results suggest that very positive attitude towards research is based on intrinsic and attainment values and these help the HPs develop strong long-term connection with research. On the other hand, negative attitude seemed to be linked to perceived low organisational support for research. Although participants with negative attitude acknowledged that research could improve clinical practice and boost professional reputation, but feelings of poor connection to research team created disillusion or fear. These findings indicate that sense of value and connection could be paramount in determining HPs’ level of motivation to engage with research.

HPs Barriers to Undertaking Research Relates to Cost and Autonomy

Table 4 depicts the barriers identified by the participant groups. The most frequently reported barriers to undertaking research were lack of time and funding. Lack of designated time for research was reported in 32 (71%) studies^{3,32,52–57,59–66,70,72,74–76,78,80,82–85,87–89,91,92} while lack of funding (including incentives and failed grants) was identified as a significant barrier to conducting research in 18 (40%) studies, mostly by the medical doctors,^{3,32,59,66,69,73,88,89,91} followed by the AHPs^{53,55,60,62–64,75,80} and nurses.^72,88

Table 4 Major Types of Barriers by Participant Groups

Respondents in 15 (33%) studies reported lack of confidence, competence, skills and/or research experience,^{57,62–64,68,74–76,79,84,85,87,90,93,94} while 17 (38%) studies reported lack of organisational support as a significant barrier to research involvement^{53–57,60,64,66,71,76–79,81–83,91} Lack of research competence and organisational support were mostly flagged by the AHPs,^{52–55,60,62–64,75,76,78,79,81,82,85,93} followed by the nurses^{57,68,71,74,77,83,84,90} and only few medical doctors.^87,91

Lack of training/resources/dedicated research team was mentioned by participant groups in 15 studies (33%)^{3,16,56,57,60,62,64,66,74,77,81,84,88,89,91} Lack of knowledge was of concern in 11 studies (24%) and mostly acknowledged by the nursing group,^{67,68,72,74,83,90} followed by the AHPs^79,80,85,95 and the medical group.⁷⁰ Lack of support (including acceptance by colleagues, reward and acknowledgement) was mentioned in 13 studies (29%) and mostly indicated by AHPs,^{55,60,62,78,85} and the medical group.^16,32,91 Eight studies (18%) reported lack of supervision/mentors,^{54,56,60,66,67,83,89,91} seven studies (16%) reported lack of interest in research.^{57,64,70,76,83,84,86} Five studies each (11%) identified unrealistic workload/tedious research process^3,64,90–92 and access to literature as barriers to research, while lack of research opportunities was reported in 4 studies (9%).^65,80,82,87 Participants felt undervalued in one study⁹² while another study found barriers specific to women⁷³ as a deterrent to their participation in research.

Overall, AHPs reported more barriers than nurses and medical doctors, particularly in relation to lack of organisational support, confidence, training, and acceptance by colleagues. Major barriers for nurses were lack of knowledge, training, and confidence; while for medical doctors, it was lack of funding. The results show that the AHPs and nurses were less able to demonstrate autonomy to engage with research in comparison to the medical doctors and they were mostly limited by lack of knowledge, training, and confidence which are important pre-requisites of research capability. This finding indicates that just as research knowledge and training can foster confidence and competence, lack of them can also serve as major and costly barriers that limit HPs’ capacity to participate in research.

Integration of the Elements of the Conceptual Frameworks

Integration of the findings based on the EVC^33,34 and SDT^40,41 theories indicate strong interactions between the three components – research capacity (expectancy and competence), attitude (value and connection), and barriers (cost and autonomy). Table 5 presents the relationship between the components that influence motivation to engage in research. Generally, HPs who were reported as competent (mostly studies on medical doctors or combination of all three groups^{32,56,60,65,66,69,70,72,73,75}) had prior exposure to research training either in their undergraduate or postgraduate education. This boosted their confidence and facilitated interest and connection with research in their career paths. In addition, engagement with research was based on the type of value (utility, intrinsic and attainment) HPs attached to research. Those who were very positive demonstrated all three types of value, felt connected to other research colleagues and despite multiple barriers, they had genuine interest which fostered their capacity for on-going, long-term research. They viewed research as highly beneficial in advancing clinical knowledge, improving patient health outcomes (utility value), producing new knowledge, gaining recognition (attainment value) as well as broadening personal scope of professional career and building sustainable problem-solving systems to identify solutions to key clinical problems (intrinsic value). Some HPs (mostly AHPs and nurses) were competent and positive in their attitude, but they exhibited only utility value^{3,58,59,67,71,78,80–82,88,90,91} because connection with professional organisation was lacking.^3,59 Interestingly, another group of HPs reported high confidence/competence levels, but they were negative and feared research.^53,77,89 The reason for this attitude was the perception that research was not part of their job roles and there was no organisational support, so they did not see the connection with the research community.⁵³ This same reason was observed for HPs who lacked confidence, had no prior exposure and had negative attitude towards research.^54,63,74,76 They perceived that it had no value and involved a lot of personal cost for limited personal gain.⁷⁶ Others lacked confidence but because of their predisposing personal qualities and exposure to research, which was facilitated by workplace research opportunities, they had positive attitude towards research.^{16,55,68,84–87}

Table 5 Integration of Theoretical Framework Elements by Participant Groups

Overall, the type of value attributed to research directly influenced the relevance of barriers and affected motivation to participate in research. As shown in Figure 2, participants who were very positive displayed an attitude inclusive of attainment, intrinsic and utility values as well as connectedness to research and were able to overcome the barriers relating to cost with a display of great autonomy. HPs who were positive but lacking confidence/requiring support, mainly subscribed to utility values and were limited by the burden of barriers. HPs who reported low expectancy and competence, exhibited total lack of value for research, had no sense of belonging or attachment to researchers in their organisations, focused on the barriers/ limitations and therefore had no interest to undertake research. These findings indicate that prior exposure to research training increases expectancy and confidence, but type of value placed on research determines the strength of connection to research, and ability to disregard the myriads of challenges/barriers. High values foster on-going intrinsic commitment and long-term motivation to engage with research.

Figure 2 Process of motivation to do research.

Discussion

Various strategies and assumptions have been made and tested regarding the reasons for the decline in the uptake/continuation of research by HPs and how to build research capacity among HPs.^{3,7,55,61,96–98} Despite these efforts, little headway has been made which necessitates taking the opportunity of examining HPs engagement in research through a different lens. This review has explored the literature with a focus on understanding HPs’ motivation to do research through the EVC^33,34 and SDT^40,41 theoretical constructs and an investigation of expectancy, research capacity, attitude and barriers as precursors to motivation to undertake/continue with research. The elements in these theories have been used to understand the interactions and sequence of occurrence of themes to allow for long-term motivation to do research.

Based on SDT with its elements of competence, connection, and autonomy, the review findings posit that competence is enhanced if there is prior exposure to research in undergraduate/postgraduate space and this then influences graduates when they come into the workspace as it helps them to get that connection and a sense of belonging with other research active members of the organisation and that makes them feel that they are in control and they are able to keep going.^41,44 However, if HPs have not had prior exposure to research and there is no perceived organisational support, they see the barriers or limitations more and that sometimes frightens them and stops them from engaging in research.⁴⁴

EVC follows a similar pattern as it considers HPs’ expectancy or anticipated ability to do research which is fostered by that confidence gained from prior exposure to research in their undergraduate/postgraduate years. Taking it one step further, EVC helps to unpack the importance of value that is attached to research. The findings from this review predicate that even when research training is strong, which is important for confidence building and expectancy to do well in research, what keeps HPs motivated and helps them to overlook or disregard the myriads of barriers is the kind of value they attach to research.

Factors which motivate and facilitate research by HPs are dependent on both extrinsic and intrinsic variables.⁴⁹ These variables are dynamic in nature and are influenced at the individual, organisational and cultural level in a dynamic research ecosystem.⁹⁸ In this review, in most cases those who were competent in their research capacity, with high expectations of success and had very positive attitude towards research demonstrated all three values attributed to doing research (intrinsic – personal enjoyment, utility – future usefulness and attainment – doing well). This group of HPs were keen to take up research despite the barriers. Those who had a positive attitude were only motivated to do research because of its utility value, although they did not necessarily see it as having personal relevance for themselves.^{57,61,88,90,93} Those who were unmotivated did not see any connection or relatedness to the research experience for themselves, felt it was too difficult and had very low ability beliefs which de-valued active participation in research.^54,74,76,77 Ability beliefs have been predicted to positively impact expectancy and research capacity, while task difficulty negatively impacts expectancy.³³

The barriers to involvement in research which were identified in this review corroborate previous literature findings and centre around lack of knowledge and skills to conduct research,^94,97 lack of protected research time,^99,100 lack of funding^69,101,102 and lack of support from colleagues, and the organisation.^54,74,76,77 Clinical workloads take precedence over time available for research^17,56 and this was confirmed in a recent Australian study which reported that 55% of research active doctors spend most of their time on clinical activities.³ Studies have also shown that research careers pay lower salary than clinical careers^3,13 and offer lower job security relative to clinical careers.^3,101 These issues are compounded by the difficulty in getting research grants^13,32 and the lower funding rates available for research.^3,102 Lack of resources was also a deterrent for otherwise motivated medical professionals to engage in research.^16,32

The lack of support, acceptance by colleagues, reward and acknowledgement highlighted in this review can be attributed to lack of organisational support. Studies have shown that organisational challenges such as lack of acknowledgement and recognition of medical professionals undertaking a research role by their peers and by the organisation for which they work are significant barriers to research involvement.^32,103 Several studies found that medical professionals had difficulty finding a mentor for their research project.^102,104,105 In this review, for HPs who were negative, the emphasis was on the concept of lack of mentorship which would have offered a sense of connection to inspire an attitude of value (intrinsic, attainment, and/ or utility), boosting confidence and providing support for research participation.^106,107 Effective mentorship has been identified as vital for HPs undertaking research^70,108,109 and an important contributor to research success.¹¹⁰ Mentoring programmes that support the health researcher with resources and expertise will optimise research training and research outcomes.^60,111 Healthcare organisations in Australia,²¹ the US^108,110,111 and the UK⁹⁶ have been encouraged to include meaningful mentoring programmes into their research profile at all stages of the clinical academic training and career pathway from medical student, intern and pre-vocational doctor, vocational trainee, post-doctoral/early fellowships and definite appointment.²¹ Positive reinforcement by research active HPs is critical at all stages of the research training and career pipeline.^3,112 An effective mentorship program is integral to establishing or building a research culture within the HPs’ organisation.⁵⁶ Conducive organisational research culture enhances research capacity building, which is enhanced by developing organisational structure, processes and systems, developing appropriate links with external partners and research career pathways^16,94 to enable health researchers to conduct research in a safe, supportive and nurturing environment where research is valued and resourced.^96,113 An organisational culture that supports research and enables building research capacity through supporting research training, quarantined time for research and adequate funding espouses the value of research which engenders connection. Overall, barriers impact on attitude to conduct research^{66,70,80,82–84,87–89,100} and by implication affect response to the cost of doing research and significantly contribute to undervaluing research.^49,65

The concept of value in research is of primary importance and is an area that needs to be focused on, particularly during training.^61,64 Emphasis should be placed on the value elements of motivation, with focus on attainment and intrinsic motivation. Explaining that value goes beyond the utility of research in clinical practice, is a useful way of introducing and developing an appreciation of attainment value which is about professional gains and fostering intrinsic value, which is about being involved in finding solutions to clinical problems as such an approach may keep HPs engaged in research. This strategy may be worthy of consideration by accrediting professional bodies, educational institutions, funding bodies and workplace organisations in their endeavours to foster uptake and retention of research activities by HPs.

Of all three HP groups, AHPs were the most lacking confidence and requiring support which may be attributed to having less research training and research experience than the other groups. Nonetheless, it is interesting to note that amongst the AHPs, the pharmacists were the most confident to undertake research. The findings of this systematic review also indicate that medical professionals, possibly due to their prior exposure to research training and research experience are in a better position than AHPs and nurses to overcome the barriers. Future studies could investigate how HPs navigate their way through barriers at different career stages – early, mid-career, late career. Future explorations could also consider whether the three HP groups (AHPs, medical doctors, nurses) follow similar or dissimilar trajectories in terms of how their research values change over their career stages.

The ability to accurately inform potential researchers regarding the attractions and barriers to health research in their careers, and to implement strategies to reverse current concerning trends in the decline of health professionals engaging in research will help to ensure HPs’ leadership in HMR into the foreseeable future. Furthermore, utilisation of theoretical frameworks that inform processes and facilitate a culture of HP research would enable optimisation of health workforce research capability and high-quality care.

Strengths and Limitations

The major strength of this review is the integration of the EVC and SDT theories which offer an overarching construct that provide in-depth understanding into HPs’ motivation to do research. Additionally, the quality appraisal of the reviewed articles provides evidence for the methodological rigour of the reviewed articles and strengthens the interpretation of the findings because all the articles were assessed as medium to high-quality studies. However, interpretation of the results must be applied cautiously due to some inherent limitations of the review. Generalisation of the findings may be limited by the authors’ interpretation of the investigated research elements/domains in the reviewed papers. Other limitations of this review include the heterogeneity of the included studies and the possible exclusion of relevant studies due to the pre-set inclusion criteria.

Conclusion

Overall, this review provides good evidence for the practicality of EVC and SDT in understanding HPs’ motivation to do research. In line with SDT elements, competence is enhanced by prior exposure to research training, and this enhances autonomy and connection with other research active members of the organisation. Similarly, EVC considers HPs’ expectancy or anticipated ability to do research which is fostered by confidence gained from prior exposure to research. EVC further emphasises the impactful effect of the type of value attributed to research on the relevance HPs attach to the myriads of barriers they face and their motivation to engage in research. The findings from this systematic review indicate priority facilitators to research participation revolve around the themes of allocated time for research, funding, research training, strong organisational research culture and mentorship program. The importance of confidence building and the expectation to succeed leading to competency through research education and training is accentuated. Nonetheless, autonomy and on-going motivation to actively engage in research are mostly influenced by HPs’ attitude vis-A-vis the three value components – intrinsic attainment and utility. Therefore, emphasis on the value attributes of research may be worthy of note by accrediting professional bodies, educational institutions, funding bodies and workplace organisations as critical to the research pipeline and the motivation of HPs to undertake research.