Scientific collaboration of educators and service providers is increasing. Collaboration between groups always involves organizations as systems, and individuals as members of systems. When academic and service agency nurses are the collaborators, organizational and systems theory can be used to identify potential problems in advance; however, experience in nursing settings is essential for designing the most appropriate preventive solutions. This article addresses research collaboration between nursing educators and nursing services providers. Using organizational theand two case experiences, we will show the importance of identifying the systems nvolved and will suggest principles and echniques to optimize system interactions.
According to organizational theory, both health care agencies and universities are systems seeking stability, a goal often translated into resistance to change (Simon, 1960; March, 1965; Pfeffer, 1985). Collaboration between them is made difficult by the complex interdependence inside each system and by each persons drive to fulfill needs.
According to Thompson ( 1967), the greatest problem - both for the organization as a whole and for individual employees - is uncertainty, because uncertainty keeps people from knowing cause-effect relationships. If unable to predict whether action A will lead to outcome B, employees will have trouble proposing solutions to perceived problems, claiming credit, and establishing security in their formal roles. Uncertainty, as a threat to individuals and to organizations, produces psychological stress and anxiety. These, in turn, are managed by a variety of cognitive, affective, and behavioral responses (Staw, Sandelands, & Dutton, 1981), such as reliance on prior expectations and entrenched patterns of behavior. These responses to a threat may be either adaptive or maladaptive. For instance, unofficial group norms and controls, and informal communication patterns are all adaptive responses from the individual's point of view, not random error or unexplainable behavior (Bennis, Benne, Chin, & Corey, 1976).
Collaboration between two organizations can threaten individuals and organizations by the introduction of new tasks, new roles, and substantial uncertainty. As individuals take on new assignments, both uncertainty and role pressure increase. The nursing director who becomes a coinvestigator on a research project may experience overload and ambiguity about the nature of the new role. Faculty may be uncertain about how to act within clinics or how to administer a newly funded research project.
In order to promote and guide change, organizations need: (1) formal structures that reduce the inherent uncertainty; (2) ways to meet the short- and long-term needs of individual employees; and (3) leaders who understand the contextual, organizational, and individual variables that can lead to variations in responses by different organizations. In nursing research, there have been only scattered descriptive reports of collaborative organizational experiences (Engstrom, 1984; Lancaster, 1985; Loomis & Krone, 1980; Oakley, Marcy, Swanson, & Swenson, 1989; Singleton, Edmunds, Rapson, & Steele, 1982; Sweeney, Gulino, Lora, & Small, 1987).
The analytic principles presented here have been derived from organizational theory and management literature. These principles will be used to interpret two case experiences of collaboration between a university school of nursing and community health nursing programs in two local departments of public health in separate states.
* There are multiple identifiable organizational subsystems when universities and health care agencies collaborate.
* Collaboration produces both benefits and costs for each system.
* Because collaboration requires change, each system resists collaboration through the behavior of individuals who use formal and informal power to maintain the status quo.
* The benefits of collaboration can be enhanced by reducing uncertainty.
* Collaboration can be enhanced by meeting the formal needs of each system and the informal needs of affected individuals.
Two separate projects at a large public university were funded by the National Center for Nursing Research, part of the National Institutes of Health. The study sites were large urban health departments in two different mid western states. One project was a study of child health care use (Study 1); the other was an intervention study designed to improve contraceptive use (Study 2).
Study 1. This project was a 22-month longitudinal descriptive study of the use of well-baby services. Clients were interviewed and clinic records were reviewed. The project staff included the principal investigator from the university and a research coordinator and data collectors at three health department clinics. The data collectors had varying nonhealth backgrounds (social worker, substitute school teacher, business consultant, receptionist, homemaker); one was an experienced public health nurse with a masters degree. The data collectors interviewed subjects in the clinics, by telephone, and in the subjects' homes. The data collectors' daily activities were coordinated by an experienced public health nurse who was also a doctoral candidate with research experience. This research coordinator was needed because the principal investigator was in a different state from the health department clinics.
Study 2. This was a 36-month quasiexperimental study that involved selfadministered questionnaires and, for certain treatment groups, special nursing care delivered either face-to-face at the clinic or by telephone. Study staff included four study nurses who were part-time mothers/homemakers with no previous experience in gathering or generating data; five graduate nursing students who worked part-time for the project in addition to their multiple other roles; and a nurse project-coordinator. The health department staff of about 24 in the family planning clinic were all part-time, except for the program administrators and one nurse-practitioner. Throughout the project, they continued to provide routine care. The project was initiated by a university researcher and agreed to by the middle management echelon of nurses in the health department. The family planning program administrator agreed to the study after it was funded.
Seven separate subsystems were identified as collaborators in these projects:
* service agency administrators,
* service agency staff
* nurse faculty,
* their university,
* funding agency or sponsor,
* clients/respondents, and
* research project staff
Each subsystem, and its individuals, had compatible and conflicting goals. However, subsystems associated with the research project had primarily scientific goals; those associated with clinical services had primarily clinical goals. This subsystem approach is a useful framework for understanding typical forms of resistance and uncertainty.
A service agency is very concerned about all aspects of research that directly or indirectly involve clients. Therefore, most organizations have a formal or specific process for screening requests, such as review by a research committee or by a designated staff supervisor. Persons outside the organization may misinterpret this commitment to safeguard the rights of the client, and an agency's caution in granting permission may be mistakenly considered a barrier to implementing the research plans. However, institutions vary widely in their requirements and time for review, and some situations may truly be formal, if not intentional, barriers.
Administrators of service agencies are not the only ones who protect the clients. Individual staff members may fear that the research efforts will take unwarranted client time, disrupt the flow of health service delivery to clients, and potentially harm clients by breaching confidentiality. Service agency staff can also suppose that their own nursing care is being judged and monitored by outsiders. No matter how carefully prepared and implemented, the research project is a new element in the work environment. Uncertainty among all parties can be heightened by imagination, by previous unpleasant experiences with research projects, and by personal insecurities about the ability to conduct a research project successfully.
Nurse faculty collaborators are also entering into unknown arenas. Their assumptions and behaviors have been shaped to fit the university setting, not the service agency setting. They can resist changing their own patterns by insisting on maintaining schedules, not listening, placing too much responsibility on their research staff for communicating with the service agency, or fading to plan comprehensively to meet service agency needs.
Universities involved in collaborative research can also demonstrate resistance to change. They may, for example, be inflexible as to transfers of money and appointment titles for service agency collaborators. While formally encouraging collaboration with community agencies, some universities provide little substantive help for community-based research.
Relatively little client resistance is typical. Refusal rates are usually low (approximately 5%) and a majority express an interest in receiving results (80% to 90%). But some respondents may be hard to find for follow-up or to clarify needed data.
Research project staff are not immune to resistance. Nurses who are accustomed to working as clinicians typically feel inadequate when they enter their research roles. They also typically worry about fulfilling clinical obligations for direct care that may not be appropriate for the particular research protocol.
Researchers are usually the initiators in proposing collaborative research projects. Collaboration brings benefits and costs to both major systems - the university and the service agency. Clinical agencies often have goals to participate in nursing research, while universities want to be relevant to their communities; but both have to devote time to collaboration rather than to other activities. Therefore, researchers must develop proactive mechanisms to enhance the productive and efficient interaction among the multiple systems and assure benefits while reducing resistance. Examples from the two studies presented here include top-level communication, on-site project staff, project staff discussions of problems, project identity packages, newsletters, birthday observances, and extra snack treats provided by research staff to health department clinic staff.
Top-level communication. Top-level communication meant that the principal investigator or a high-level staff member not lower-level staff, talked periodically tc the top nursing administrator of the health department. All problems betweenB staff of the research project and the health department were discussed between the leaders. All project staff were careful to| observe the authority structure of the health department. Due recognition, through appropriate co-authorship and attendance at national meetings, was given to health department program directors.
On-site project staff. The research coordinator in Study 1 helped the principal investigator to maintain effective communication among personnel at the three study clinics and helped with administration at the central office of the health department. She was immediately available at the site to provide feedback for questions from data collectors and health department personnel. In Study 2, a part-time health department staff person employed by the study collected all chart data. Her participation protected confidentiality of health department records and minimized office intrusions by unfamiliar personnel.
Project staff discussions of problems, Project staff discussions of abrasive interactions with the other systems allowed problems to be identified early and helped in solving them. Individuals came to understand that their experiences were often symptomatic of system issues, or of characteristics beyond their control, Successful coping or change strategies based on experience or on organizational or interpersonal theory were shared. An example was the inevitable discovery of one highly resistant or territorial staff member in the clinical setting. When research activities were impeded by such a person, project staff discussion helped the affected study nurse realize that others had had similar experiences. The health department supervisor realized the importance of reminding staff that part of their job was to facilitate the research project. Project staff felt supported, their attachment to the project increased, and the health department affirmed their interest in the project.
Project identity package. Project identity packages included such items as university-logo notebooks, portfolios, and pencils, which were competitively sought by project staff (Study 1). Special project colors and a project logo were used in Study 2. Both these mechanisms helped project staff develop a sense of attachment to the project, which enhanced their security and pride and made small irritations easier to deal with. Project identity also helped people recognize the project's boundaries, so that project materials were easier to retrieve if they got mixed in with clinic records.
Newsletters, birthday observances, and treats. Newsletters were used in Study 2 to reduce uncertainty about the project by bringing information to health department personnel as well as to study staff Health department staff profiles were published, and other useful news (for example, the latest research results concerning specific birth control methods) was provided as a "benefit." Birthday cards were sent to health department and study staff members. When joint staff meetings were held, the research project provided food, and study staff occasionally brought snacks for the health department staff during data collection sessions.
People in all the systems involved in a collaborative study have the same needs: respect, recognition, safety, growth, and resources. When individual and system needs are met, collaboration works well. If either the project or the health department system is not functioning well internally, and staff members' needs are not being met, problems in collaboration will increase. Primary responsibility for meeting staff and organizational needs lies with the employing unit (health department or research project). But the two units can also help each other by consulting about needs for supervision, information, and system changes.
Successful collaboration does not happen by chance. An understanding of organizations and systems, and planned preventive and corrective actions are needed. These two different experiences with health departments in two different states have helped elucidate the relevant principles and provided examples that may be useful to others in building collaborative research relationships.
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