Public Health Nursing Vol. 9 No. 4, pp. 218-222 0131-I209/92/$6.00 0 1992 Blackwell Scientific Publications, Inc.
Collaboration: Integrating Practice and Research in Public Health Nursing Vonna Henry, M.P.H., Kathleen Schmitz, M.P.H., LuAnn Reif, M.P.H., and Patricia Rudie, B.S.N.
Abstract The need to integrate clinical practice and research has been stressed for many years in both public health and nursing. This article describes such a collaborative project between two rural upper Midwest public health nursing agencies and public health nursing faculty from a small, liberal arts. baccalaureate nursing program. The high-risk prenatal research project provided an opportunity for nursing staff and faculty research consultants to work together on a clinical study. A model for collaborative research is illustrated, and advantages and disadvantages for practice. administration, and research are discussed.
Public health nursing practice must be based on research to achieve scientific accountability. The demands of the practice make it difficult for staff to conduct research, relate it to practice, or discern its impact on the profession. Little connection has been made between the selection of topics for investigation and the needs nurses have for answers to practice questions (Reis, Bainbridge, & Dumbro, 1988). The need to integrate clinical practice and research has been stressed for many years in both public health and nursing. Recently, the National Institute of Medicine (1988) report recommended that “schools of public health establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake responsibilities in these
agencies, conduct research there, and train students in such practice situations.” Hinshaw (1988) stated, “One of the most effective strategies for ensuring that research findings will influence the practice and administration decisions of our professional policy makers is to collaborate on research with such individuals” (p. 22). Many authors (Reis et al., 1988; Denyes et al., 1989; Keefe, Pepper, & Stoner, 1988) contend that collaboration in nursing research has historically meant that planning and coordination of the project are managed by nurse researchers in large university settings. The practicing nurse is involved only at selected data-collection points. This structure has perpetuated myths about the difficulty of conducting nursing research and has limited the credit attributed to the staff nurse in research projects (Reis et al., 1988; Denyes et al., 1989; Keefe et al., 1988). A collaborative approach to clinical research, incorporating the strengths of administrators, staff nurses, and researchers, can be an effective method of ameliorating these problems. Lancaster (1985) described six elements for effective collaboration in nursing research studies: contribution, communication, commitment, consensus, compatibility, and credit. Using these elements, two small, rural public health agencies and two research consultants based in a small, liberal arts, baccalaureate nursing program conducted a collaborative research project.
HIGH-RISK PRENATAL PROJECT Vonnu Henry is a,ffiliated with Sherburrre County Community Heulth Services. Kathleen Schniirz and LitAnn Reif are affiliated with the Depurttnent of Nursitrg, College 0.f Saint Benedict, and Patricia Ritdie is with Benton County Health Services. Address correspondence to Vonna i i e n r y , Director, Slierhrirtie County Health Servires. Box 311, Elk Rivrr, M N 55330.
218
The high-risk prenatal project was designed primarily as a service project with a small research component embedded in it. The following description highlights only the research component. Relatively high numbers of high-risk births in two
Henry et al.: Collaboration: PHN Practice and Research 219
rural, upper Midwest counties stimulated an interest among the nursing staff and administration to address the particular needs of low-income pregnant clients. An extensive case-finding effort resulted in referrals from Women, Infants, and Children (WIC) clinics, social service agencies, schools, public health nurses from other counties, and a few from physicians. The 105 subjects received public health nursing care in the home during their pregnancy, followed by standard postpartum care. A comprehensive high-risk prenatal data base instrument was developed to assess and score prenatal risk level in an attempt to quantify risk for poor birth outcomes (Schmitz & Reif, 1991). Risk was assessed when the client was first admitted to the agency and again in the last eight weeks of pregnancy. The initial assessment most typically required at least two home appointments to gather a complete data base. This information was then used to generate a plan of care. Teaching and assessment guides were developed in an attempt to provide a minimum standard of care. As most of the subjects were admitted to the program in the second (42.9%) and third trimester (37.1%), nursing interventions had to be flexible so as to meet the anticipated as well as specific needs of each client. Consequently, a standardized care plan was not developed. Nurses made an average of six home appointments per subject (range 2-16 appointments). In the first two years the appointments lasted an average of 2 hours. As the nurses became more knowledgeable of and comfortable assessing the prenatal client, the length decreased to about an hour. Typically, nursing interventions included teaching, preparation for labor and delivery, nutrition counseling, and psychosocial support. After the delivery, additional data were collected from hospital records for evidence of complications in either the mother or the baby. In keeping with ethical guidelines for research, a written release of information was obtained from each client. Findings, of this study are available elsewhere (Schmitz & Reif, 1991). COLLABORATION IN THE HIGH-RISK PRENATAL PROJECT Contribution
Since numerous perspectives and skills must be brought to bear in understanding a nursing problem, the research team is ideally composed of individuals with diverse yet complementary gifts (Lancaster, 1985). As a service-research program undertaken jointly by two rural counties, the project team required individuals with expertise in practice, research, and management. The community health agencies instigating the grant proposal employed persons with expertise in practice and
management. However, it was realized early that neither agency had the time or ability to conduct a sound research study. Consequently, the administrators structured the proposal to include hiring external research consultants. Existing clinical relationships with nursing faculty from the area liberal arts college facilitated the search for such individuals. Thus the research team consisted of the two county community health nursing directors, staff nurses from each agency with experience in prenatal care, and two nursing faculty competent in nursing research. The contributions of agency administrators to the project were both tangible and intangible. The directors generated the idea for the study, wrote the grant proposal, and were responsible for public relations and fiscal control. The joint nature of the project required the directors to negotiate with two government bodies for approval of the grant proposal and follow-up reports. The staff nurses provided valuable input in developing and refining data-collection tools and procedures. They were flexible in making the necessary minor adjustments in their work patterns and nursing care priorities. As the staff nurses were the only members of the team actually meeting with the clients, and because they were thoroughly knowledgeable about the research study, enrollment of subjects was facilitated. The nurses obtained the consent to participate from each client, the prenatal risk data, and the release of information to view delivery records. The prenatal risk data served a dual practice-research function. Contributions of the research consultants included design of the assessment and research instruments and procedures, retrieval of prenatal and birth outcome data from agency and hospital records, and data analysis and interpretation. As faculty members, they had access to a wide range of library and computer services necessary to facilitate the research project. The consultants also provided training to all staff members involved in providing care to prenatal clients. The first training session was videotaped to provide a mechanism for orienting additional nursing staff. The specialized knowledge and experience in nursing research methods and analysis possessed by the consultants augmented the gifts of other team members. Communication
As in any team endeavor, communication among researchers is essential. Face-to-face, telephone, and written interactions among all members provided opportunities to clarify issues regarding the project and to form new collegial relationships. Team meetings were held on a regular basis to discuss the project and clarify questions. In addition, the consultants gave their home and work telephone numbers to the staff nurses so that
220 Public Health Nursing
Volume 9 Number 4 December 1992
unanticipated questions might be answered in a timely manner. Study findings were presented to the staff prior to public release.
Compatibility
Compatibility among members is important in any work group and no less so among members of a research team. Recognition and appreciation of each person’s Commitment contributions facilitates the accomplishment of the task Both physical and emotional commitment are charac- (Lancaster, 1985). Collaborative research projects usuteristic of effective collaboration (Lancaster, 1985). ally require at least a year to complete, and harmonious Interagency collaboration requires negotiation for com- relationships are necessary throughout. mitment of scarce resources to the project. Even within Building a compatible team was critical to the sucthe same agency, collaboration among researchers from cess of the prenatal project. The nursing directors apvarious levels or departments of the organization re- proached the two consultants because they had experiquires that time, energy, and material resources be com- ence in public health nursing, held similar philosophies mitted to the investigation. Contingency plans should regarding nursing and public health, and were known to be discussed in the event of an unexpected change in the staff. Effective working relationships existed among commitment from an agency or individual. all participants prior to the initiation of the project. AlIn the research proposal, the administrators re- though there was some staff turnover during the study quested funds to design and conduct the study. The period, new members quickly became acquainted with granting agency required matching funds, which were both the project and the consultants, minimizing relacommitted by each county board of commissioners. tionship difficulties. The nursing administrators willingly presented strong cases before their respective board members supporting Consensus involvement in such a project. Staff development costs and consultant fees were built into the funding proposal Adequate levels of compatibility and communication and these monies were used as allocated. The value provide the basis for arriving at team consensus. Nuplaced on participation in clinical nursing research was merous decisions are required in designing and impleoperationalized in administrative support. Time was al- menting a research study. Negotiation and compromise lotted to staff for attendance at team meetings. Manage- are integral to making decisions through consensus. Hindsight has demonstrated the critical nature of ment flexibility allowed the nurses to make the time and maintaining a balance between the needs and demands priority adjustments required when taking on high-risk of nursing practice and those of the research process. clientele. Most important, staff input was solicited at Compromise was essential in designing data-collection every phase. instruments and procedures. The research methodology Total agency commitment to the project was evident was fashioned to interfere as little as possible with nursin various ways. The nursing director changed in one ing assessment. Indeed, the intent was to develop an agency, with no loss of support. During a student nurse instrument and protocols that would ease and enhance orientation, a new supervisor described the prenatal the assessment process, make practice and research project with pride. Because the research was initiated data more easily retrievable, and focus subsequent by the community health agencies and not the outside nursing interventions. Since the instrument also had to investigators, ownership of the project was clearly sitserve a research purpose, the items were quantified, uated in the agencies. Research consultants were conmaking statistical manipulation more feasible. tracted to assist, not to control, the investigation. Staff nurses and administrators alike were well versed in the Credit research procedures and findings, and could enthusiastically discuss the project with colleagues from other Attributing credit is the final component of effective agencies. collaborative relationships among the members of a reResearch consultants also committed time, energy, search team. Ownership and control of various research and material resources. Computer services were avail- products (measurement tools, data-analysis methods, able at the college as a faculty benefit. Additional assis- findings, etc.) must be established. Authorship of mantance and consultation were secured from personal and uscripts and assignment of paper presentations must be professional networks both at the college and around discussed in advance (Lancaster, 1985). the state. Commitment to the project and to the imporEarly in the project numerous requests for copies of tance of the findings are evident in the continued in- the research tool were received by the public health volvement of the same consultants over the four-year agencies. This forced the team to discuss and come to period. agreement about the ownership and control of the tool.
Henry et al.: Collaboration: PHN Practice and Research 221
Since the instrument had been developed with public monies, it was thought necessary to make it available once testing had been completed. Credit has been given to research team members in all project presentations, whether written or oral. In addition, at the end of each year a celebration was scheduled to summarize the year’s work, forecast the upcoming year, and convey appreciation to all team members. Staff nurses, administrators, and consultants have all been involved in disseminating study findings in workshops, paper and poster presentations, and manuscripts. As future articles are prepared and submitted for publication, the contributions of all participants will be acknowledged. ADVANTAGES AND DISADVANTAGES OF COLLABORATION
The advantages of collaborative research for nursing staff, institutions, and researchers are described elsewhere (Lyons et al., 1990). This discussion focuses on the advantages and disadvantages for public health nursing practice, administration, and the quality of nursing research. Public Health Nursing Practice
The benefits for public health nursing practice resulting from the collaborative effort in this project are noteworthy. This profession is now recognized as having a legitimate role in providing home health services to lowincome pregnant women. Clients perceive nursing services as more credible because of the involvement in a collaborative research venture. As a result of the project, prenatal public health nursing practice is more clearly based on scientific research rather than tradition. As the research instrument was developed, staff raised questions about the inclusion of certain factors erroneously thought to contribute to prenatal risk. The subsequent discussion and review of the literature helped to dispel these fallacies. Staff are now more likely to pursue scientific justification for their practice. A new, more comprehensive prenatal nursing assessment tool has been developed and tested in clinical practice. This instrument has been shared locally, statewide, and nationally, making it available to practitioners of both public health and prenatal nursing. One of its special features is the inclusion of psychosocial risk factors, an area inadequately addressed in other prenatal assessments. In addition to emphasizing the importance of prenatal assessment, the value of a structured appraisal has facilitated assessments of other client populations. Finally, quantification of the instrument has as-
sisted the nurse to set case load priorities based on degree of risk. Disadvantages of collaborative nursing research to clinical practice include added time commitments and the need to redefine roles. Staff had set aside more time in order to participate in team meetings. The size and depth of the assessment instrument also required staff to reorganize time frames and priorities in the early stages of the nurse-client relationship. Most of the staff did not consider themselves to be nurse researchers at the beginning of this project. They had little experience or knowledge of research beyond their undergraduate nursing education. For some, the idea of defining themselves as a researcher was frightening, and resistance was evident. Eventually, they were able to realize the value of their practice perspective in all phases of the clinical study. Administration
A variety of administrative advantages were experienced in the collaborative approach. In these days of fiscal constraint, costs incurred in the study were shared by three agencies. Credibility of the project was enhanced through the involvement of external consultants. This provided a check on agency self-interest that was appealing to county commissioners. Finally, collaboration facilitated the process of change in both public health agencies. Staff, administrators, and consultants were all involved in creating new practice approaches that incorporgted clinical research. A collaborative project requires additional administrative coordination. A communication system crossing agency boundaries required some time and perseverance to establish and maintain. Administrators experienced an increase in the amount of one-to-one time spent with staff in providing reassurance about their capabilities to make the necessary personal and professional adjustments. Research
The collaborative model for clinical research places constraints on the classic research approach, yet has some advantages that may outweigh this risk. Subjects are clearly more available to nurses in practice than to those in administration or educational settings. Thus collaboration can simplify subject enrollment. In the prenatal project, research data collection was occurring simultaneously with clinical data collection. This increased the difficulty (from both ethical and logistic standpoints) of establishing reliability among data collectors. The number and personal traits of collectors and individuality of each subject precluded some control of data collection.
222 Public Health Nursing
Volume 9 Number 4 December 1992
Since the ultimate goal of clinical nursing research is to improve client care, it seems futile to attempt to explore clinical problems without involving front line providers of nursing. Prior to this study, few guidelines were available for the care of high-risk prenatal women in the home. Involvement of the staff in this project provided a research-based approach to the assessment and identification of risk in this population.
SUMMARY The development and implementation of nursing research ventures between practitioners and researchers has certain impediments in isolated rural areas. Budgets in small facilities are more constrained, and access to persons with research expertise and computer facilities may be correspondingly limited. Similarly, research opportunities for nursing faculty in small, rural liberal arts colleges are restricted. This collaborative project offset these hindrances to nursing research by employing Lancaster’s (1985) collaborative research model. Cooperation was required among three sets of participants, all of whom were critical to the project. County public health nursing administrators, county public health nursing staff, and research consultants from the nursing program worked together to design and implement the high-risk prenatal research project. It is hoped that collaborative experiences in clinical nursing research will make future encounters with the process less intimidating. Such experiences have the
potential for participants to view themselves as having less confining roles. The staff nurse can be clinicianresearcher; the director, administrator-researcher; and the faculty, educator-researcher. Thus no one group bears the entire responsibility.
REFERENCES Denyes, M . , O’Conner, N., Oakley, D., & Ferguson, S. (1989). Integrating nursing theory, practice and research through collaborative research. Journal of Advanced Nursing, 14, 141-145. Hinshaw, A. (1988). Using research to shape health policy. Nursing Outlook, 36(1), 21-24. Keefe, M., Pepper, G.. &Stoner, M. (1988). Toward researchbased nursing practice: The Denver collaborative research network. Applied Nursing Research, 1(3), 109-1 15. Lancaster, J. (1985, September/October). The perils and joys of collaborative research. Nursing Outlook, 5 , 23 1-232, 238. Lyons, N., Stein, M., Blackburn, S., Tribotti, S., &Withers, J. (1990, March/April). Too busy for research? Collaboration: The answer. Maternal Child Nursing, 15,67-68,70,72. National Institute of Medicine. (1988). The future of public health. Washington, DC: National Academy Press. Reis, D., Bainbridge, E., & Dumbro, M. (1988). Education and service collaborate: First steps to clinical nursing research. Nursing Connections, 1(4), 73-78. Schmitz, K., & Reif, L. (1991). Prenatal risk and subsequent birth outcomes: A public health nursing approach. Unpublished manuscript.
Collaboration: Integrating Practice and Research in Public Health Nursing Vonna Henry, M.P.H., Kathleen Schmitz, M.P.H., LuAnn Reif, M.P.H., and Patricia Rudie, B.S.N.
Abstract The need to integrate clinical practice and research has been stressed for many years in both public health and nursing. This article describes such a collaborative project between two rural upper Midwest public health nursing agencies and public health nursing faculty from a small, liberal arts. baccalaureate nursing program. The high-risk prenatal research project provided an opportunity for nursing staff and faculty research consultants to work together on a clinical study. A model for collaborative research is illustrated, and advantages and disadvantages for practice. administration, and research are discussed.
Public health nursing practice must be based on research to achieve scientific accountability. The demands of the practice make it difficult for staff to conduct research, relate it to practice, or discern its impact on the profession. Little connection has been made between the selection of topics for investigation and the needs nurses have for answers to practice questions (Reis, Bainbridge, & Dumbro, 1988). The need to integrate clinical practice and research has been stressed for many years in both public health and nursing. Recently, the National Institute of Medicine (1988) report recommended that “schools of public health establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake responsibilities in these
agencies, conduct research there, and train students in such practice situations.” Hinshaw (1988) stated, “One of the most effective strategies for ensuring that research findings will influence the practice and administration decisions of our professional policy makers is to collaborate on research with such individuals” (p. 22). Many authors (Reis et al., 1988; Denyes et al., 1989; Keefe, Pepper, & Stoner, 1988) contend that collaboration in nursing research has historically meant that planning and coordination of the project are managed by nurse researchers in large university settings. The practicing nurse is involved only at selected data-collection points. This structure has perpetuated myths about the difficulty of conducting nursing research and has limited the credit attributed to the staff nurse in research projects (Reis et al., 1988; Denyes et al., 1989; Keefe et al., 1988). A collaborative approach to clinical research, incorporating the strengths of administrators, staff nurses, and researchers, can be an effective method of ameliorating these problems. Lancaster (1985) described six elements for effective collaboration in nursing research studies: contribution, communication, commitment, consensus, compatibility, and credit. Using these elements, two small, rural public health agencies and two research consultants based in a small, liberal arts, baccalaureate nursing program conducted a collaborative research project.
HIGH-RISK PRENATAL PROJECT Vonnu Henry is a,ffiliated with Sherburrre County Community Heulth Services. Kathleen Schniirz and LitAnn Reif are affiliated with the Depurttnent of Nursitrg, College 0.f Saint Benedict, and Patricia Ritdie is with Benton County Health Services. Address correspondence to Vonna i i e n r y , Director, Slierhrirtie County Health Servires. Box 311, Elk Rivrr, M N 55330.
218
The high-risk prenatal project was designed primarily as a service project with a small research component embedded in it. The following description highlights only the research component. Relatively high numbers of high-risk births in two
Henry et al.: Collaboration: PHN Practice and Research 219
rural, upper Midwest counties stimulated an interest among the nursing staff and administration to address the particular needs of low-income pregnant clients. An extensive case-finding effort resulted in referrals from Women, Infants, and Children (WIC) clinics, social service agencies, schools, public health nurses from other counties, and a few from physicians. The 105 subjects received public health nursing care in the home during their pregnancy, followed by standard postpartum care. A comprehensive high-risk prenatal data base instrument was developed to assess and score prenatal risk level in an attempt to quantify risk for poor birth outcomes (Schmitz & Reif, 1991). Risk was assessed when the client was first admitted to the agency and again in the last eight weeks of pregnancy. The initial assessment most typically required at least two home appointments to gather a complete data base. This information was then used to generate a plan of care. Teaching and assessment guides were developed in an attempt to provide a minimum standard of care. As most of the subjects were admitted to the program in the second (42.9%) and third trimester (37.1%), nursing interventions had to be flexible so as to meet the anticipated as well as specific needs of each client. Consequently, a standardized care plan was not developed. Nurses made an average of six home appointments per subject (range 2-16 appointments). In the first two years the appointments lasted an average of 2 hours. As the nurses became more knowledgeable of and comfortable assessing the prenatal client, the length decreased to about an hour. Typically, nursing interventions included teaching, preparation for labor and delivery, nutrition counseling, and psychosocial support. After the delivery, additional data were collected from hospital records for evidence of complications in either the mother or the baby. In keeping with ethical guidelines for research, a written release of information was obtained from each client. Findings, of this study are available elsewhere (Schmitz & Reif, 1991). COLLABORATION IN THE HIGH-RISK PRENATAL PROJECT Contribution
Since numerous perspectives and skills must be brought to bear in understanding a nursing problem, the research team is ideally composed of individuals with diverse yet complementary gifts (Lancaster, 1985). As a service-research program undertaken jointly by two rural counties, the project team required individuals with expertise in practice, research, and management. The community health agencies instigating the grant proposal employed persons with expertise in practice and
management. However, it was realized early that neither agency had the time or ability to conduct a sound research study. Consequently, the administrators structured the proposal to include hiring external research consultants. Existing clinical relationships with nursing faculty from the area liberal arts college facilitated the search for such individuals. Thus the research team consisted of the two county community health nursing directors, staff nurses from each agency with experience in prenatal care, and two nursing faculty competent in nursing research. The contributions of agency administrators to the project were both tangible and intangible. The directors generated the idea for the study, wrote the grant proposal, and were responsible for public relations and fiscal control. The joint nature of the project required the directors to negotiate with two government bodies for approval of the grant proposal and follow-up reports. The staff nurses provided valuable input in developing and refining data-collection tools and procedures. They were flexible in making the necessary minor adjustments in their work patterns and nursing care priorities. As the staff nurses were the only members of the team actually meeting with the clients, and because they were thoroughly knowledgeable about the research study, enrollment of subjects was facilitated. The nurses obtained the consent to participate from each client, the prenatal risk data, and the release of information to view delivery records. The prenatal risk data served a dual practice-research function. Contributions of the research consultants included design of the assessment and research instruments and procedures, retrieval of prenatal and birth outcome data from agency and hospital records, and data analysis and interpretation. As faculty members, they had access to a wide range of library and computer services necessary to facilitate the research project. The consultants also provided training to all staff members involved in providing care to prenatal clients. The first training session was videotaped to provide a mechanism for orienting additional nursing staff. The specialized knowledge and experience in nursing research methods and analysis possessed by the consultants augmented the gifts of other team members. Communication
As in any team endeavor, communication among researchers is essential. Face-to-face, telephone, and written interactions among all members provided opportunities to clarify issues regarding the project and to form new collegial relationships. Team meetings were held on a regular basis to discuss the project and clarify questions. In addition, the consultants gave their home and work telephone numbers to the staff nurses so that
220 Public Health Nursing
Volume 9 Number 4 December 1992
unanticipated questions might be answered in a timely manner. Study findings were presented to the staff prior to public release.
Compatibility
Compatibility among members is important in any work group and no less so among members of a research team. Recognition and appreciation of each person’s Commitment contributions facilitates the accomplishment of the task Both physical and emotional commitment are charac- (Lancaster, 1985). Collaborative research projects usuteristic of effective collaboration (Lancaster, 1985). ally require at least a year to complete, and harmonious Interagency collaboration requires negotiation for com- relationships are necessary throughout. mitment of scarce resources to the project. Even within Building a compatible team was critical to the sucthe same agency, collaboration among researchers from cess of the prenatal project. The nursing directors apvarious levels or departments of the organization re- proached the two consultants because they had experiquires that time, energy, and material resources be com- ence in public health nursing, held similar philosophies mitted to the investigation. Contingency plans should regarding nursing and public health, and were known to be discussed in the event of an unexpected change in the staff. Effective working relationships existed among commitment from an agency or individual. all participants prior to the initiation of the project. AlIn the research proposal, the administrators re- though there was some staff turnover during the study quested funds to design and conduct the study. The period, new members quickly became acquainted with granting agency required matching funds, which were both the project and the consultants, minimizing relacommitted by each county board of commissioners. tionship difficulties. The nursing administrators willingly presented strong cases before their respective board members supporting Consensus involvement in such a project. Staff development costs and consultant fees were built into the funding proposal Adequate levels of compatibility and communication and these monies were used as allocated. The value provide the basis for arriving at team consensus. Nuplaced on participation in clinical nursing research was merous decisions are required in designing and impleoperationalized in administrative support. Time was al- menting a research study. Negotiation and compromise lotted to staff for attendance at team meetings. Manage- are integral to making decisions through consensus. Hindsight has demonstrated the critical nature of ment flexibility allowed the nurses to make the time and maintaining a balance between the needs and demands priority adjustments required when taking on high-risk of nursing practice and those of the research process. clientele. Most important, staff input was solicited at Compromise was essential in designing data-collection every phase. instruments and procedures. The research methodology Total agency commitment to the project was evident was fashioned to interfere as little as possible with nursin various ways. The nursing director changed in one ing assessment. Indeed, the intent was to develop an agency, with no loss of support. During a student nurse instrument and protocols that would ease and enhance orientation, a new supervisor described the prenatal the assessment process, make practice and research project with pride. Because the research was initiated data more easily retrievable, and focus subsequent by the community health agencies and not the outside nursing interventions. Since the instrument also had to investigators, ownership of the project was clearly sitserve a research purpose, the items were quantified, uated in the agencies. Research consultants were conmaking statistical manipulation more feasible. tracted to assist, not to control, the investigation. Staff nurses and administrators alike were well versed in the Credit research procedures and findings, and could enthusiastically discuss the project with colleagues from other Attributing credit is the final component of effective agencies. collaborative relationships among the members of a reResearch consultants also committed time, energy, search team. Ownership and control of various research and material resources. Computer services were avail- products (measurement tools, data-analysis methods, able at the college as a faculty benefit. Additional assis- findings, etc.) must be established. Authorship of mantance and consultation were secured from personal and uscripts and assignment of paper presentations must be professional networks both at the college and around discussed in advance (Lancaster, 1985). the state. Commitment to the project and to the imporEarly in the project numerous requests for copies of tance of the findings are evident in the continued in- the research tool were received by the public health volvement of the same consultants over the four-year agencies. This forced the team to discuss and come to period. agreement about the ownership and control of the tool.
Henry et al.: Collaboration: PHN Practice and Research 221
Since the instrument had been developed with public monies, it was thought necessary to make it available once testing had been completed. Credit has been given to research team members in all project presentations, whether written or oral. In addition, at the end of each year a celebration was scheduled to summarize the year’s work, forecast the upcoming year, and convey appreciation to all team members. Staff nurses, administrators, and consultants have all been involved in disseminating study findings in workshops, paper and poster presentations, and manuscripts. As future articles are prepared and submitted for publication, the contributions of all participants will be acknowledged. ADVANTAGES AND DISADVANTAGES OF COLLABORATION
The advantages of collaborative research for nursing staff, institutions, and researchers are described elsewhere (Lyons et al., 1990). This discussion focuses on the advantages and disadvantages for public health nursing practice, administration, and the quality of nursing research. Public Health Nursing Practice
The benefits for public health nursing practice resulting from the collaborative effort in this project are noteworthy. This profession is now recognized as having a legitimate role in providing home health services to lowincome pregnant women. Clients perceive nursing services as more credible because of the involvement in a collaborative research venture. As a result of the project, prenatal public health nursing practice is more clearly based on scientific research rather than tradition. As the research instrument was developed, staff raised questions about the inclusion of certain factors erroneously thought to contribute to prenatal risk. The subsequent discussion and review of the literature helped to dispel these fallacies. Staff are now more likely to pursue scientific justification for their practice. A new, more comprehensive prenatal nursing assessment tool has been developed and tested in clinical practice. This instrument has been shared locally, statewide, and nationally, making it available to practitioners of both public health and prenatal nursing. One of its special features is the inclusion of psychosocial risk factors, an area inadequately addressed in other prenatal assessments. In addition to emphasizing the importance of prenatal assessment, the value of a structured appraisal has facilitated assessments of other client populations. Finally, quantification of the instrument has as-
sisted the nurse to set case load priorities based on degree of risk. Disadvantages of collaborative nursing research to clinical practice include added time commitments and the need to redefine roles. Staff had set aside more time in order to participate in team meetings. The size and depth of the assessment instrument also required staff to reorganize time frames and priorities in the early stages of the nurse-client relationship. Most of the staff did not consider themselves to be nurse researchers at the beginning of this project. They had little experience or knowledge of research beyond their undergraduate nursing education. For some, the idea of defining themselves as a researcher was frightening, and resistance was evident. Eventually, they were able to realize the value of their practice perspective in all phases of the clinical study. Administration
A variety of administrative advantages were experienced in the collaborative approach. In these days of fiscal constraint, costs incurred in the study were shared by three agencies. Credibility of the project was enhanced through the involvement of external consultants. This provided a check on agency self-interest that was appealing to county commissioners. Finally, collaboration facilitated the process of change in both public health agencies. Staff, administrators, and consultants were all involved in creating new practice approaches that incorporgted clinical research. A collaborative project requires additional administrative coordination. A communication system crossing agency boundaries required some time and perseverance to establish and maintain. Administrators experienced an increase in the amount of one-to-one time spent with staff in providing reassurance about their capabilities to make the necessary personal and professional adjustments. Research
The collaborative model for clinical research places constraints on the classic research approach, yet has some advantages that may outweigh this risk. Subjects are clearly more available to nurses in practice than to those in administration or educational settings. Thus collaboration can simplify subject enrollment. In the prenatal project, research data collection was occurring simultaneously with clinical data collection. This increased the difficulty (from both ethical and logistic standpoints) of establishing reliability among data collectors. The number and personal traits of collectors and individuality of each subject precluded some control of data collection.
222 Public Health Nursing
Volume 9 Number 4 December 1992
Since the ultimate goal of clinical nursing research is to improve client care, it seems futile to attempt to explore clinical problems without involving front line providers of nursing. Prior to this study, few guidelines were available for the care of high-risk prenatal women in the home. Involvement of the staff in this project provided a research-based approach to the assessment and identification of risk in this population.
SUMMARY The development and implementation of nursing research ventures between practitioners and researchers has certain impediments in isolated rural areas. Budgets in small facilities are more constrained, and access to persons with research expertise and computer facilities may be correspondingly limited. Similarly, research opportunities for nursing faculty in small, rural liberal arts colleges are restricted. This collaborative project offset these hindrances to nursing research by employing Lancaster’s (1985) collaborative research model. Cooperation was required among three sets of participants, all of whom were critical to the project. County public health nursing administrators, county public health nursing staff, and research consultants from the nursing program worked together to design and implement the high-risk prenatal research project. It is hoped that collaborative experiences in clinical nursing research will make future encounters with the process less intimidating. Such experiences have the
potential for participants to view themselves as having less confining roles. The staff nurse can be clinicianresearcher; the director, administrator-researcher; and the faculty, educator-researcher. Thus no one group bears the entire responsibility.
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