Available online at www.sciencedirect.com

Applied Nursing Research 25 (2012) 205–211www.elsevier.com/locate/apnr

Clinical Methods

Balancing interests of hospitals and nurse researchers:Lessons learned

June Marshall, DNP, RN⁎, Cole Edmonson, DNP, RN,Gretchen Gemeinhardt, PhD, MBA, Patti Hamilton, PhD, RN

Received 25 October 2010; revised 2 February 2011; accepted 14 March 2011

Abstract While nurse researchers and administrators in health care organizations need to collaborate to

The authors acknoRobert Wood JohnsResearch Initiative.

⁎ Corresponding a75231, USA. Tel.: +1

E-mail addresses:JuneMarshall@texash

0897-1897/$ – see frodoi:10.1016/j.apnr.201

understand the variables that affect nursing practice environments and patient care outcomes, thereare inherent risks associated with these collaborations that require careful consideration. A team ofacademic and hospital researchers found that in studying the off-peak (nights and weekends) nursingenvironment using institutional ethnography, which involved interviews of nurses and adminis-trators, the subject of the research was frequently the hospitals where these individuals worked.Although the individuals who participated in the research consented to be interviewed about theirwork, it was less clear how and to what extent the anonymity of their organizations could bemaintained. The risks and benefits encountered suggest the need for a decision-making process to beundertaken by collaborative research teams. This decision process and analysis can help ensure afruitful research relationship that protects sensitive concerns of hospital entities while advancing ourunderstanding of nursing practice environments and patient care outcomes. Important strategiesinclude having all leaders and research team members discuss the agendas of all entities andindividuals involved, including clearly delineating the roles, responsibilities, and contributions of allparties. In addition, any constraints or expectations of first right of review of publications needs to benegotiated from the outset. Collaborators need to review their agreements throughout the researchprocess to avoid pitfalls that could adversely impact the relationships as well as the dissemination ofknowledge gained.

© 2012 Elsevier Inc. All rights reserved.

1. Introduction

Researchers and administrators in health care organiza-tions seek to better understand complex variables that affectnursing practice environments and patient care outcomes.Recognizing that 64% of inpatient hospital care takes placeduring nights and weekends, an academic and hospital-basedresearch team used institutional ethnography to investigatethese off-peak nursing work environments. For the purposeof this article, a case study methodology was used toexamine important considerations for forging collaborative

wledge the support of this research by a grant from theon Foundation, Interdisciplinary Nursing Quality

uthor. Texas Health Presbyterian Dallas, Dallas, TX214 345 6392.june.marshall@sbcglobal.net,ealth.org (J. Marshall).

nt matter © 2012 Elsevier Inc. All rights reserved.1.03.001

relationships between academic and hospital entities toimprove our knowledge of patient care delivery systems andnursing work environments. This research experiencesurfaced important factors to consider when formingcollaborative relationships between academic and hospitalentities for implementing research in hospital settings.

Collaborative relationships between academic institutionsand health care organizations in nursing and allied healthcreate opportunities for learning, professional role develop-ment, clinical research, and translation of new knowledgeand current evidence into “real-world” practice environments(Brown, White, & Leibbrandt, 2006; Newhouse, 2007).Despite the well-described benefits of these relationshipsbetween hospital settings and their academic partners, thereare associated risks that require careful consideration andevaluation when establishing and sustaining collaborativepartnerships between/among hospital settings and academicentities. A collaborative research effort aimed at studying

206 J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

off-peak nursing work environments in hospital settings ledone collaborative research team to uncover some of thechallenges, risks, and rewards involved in these oftendichotomous relationships. The challenges, risks, andbenefits encountered provide a rich experiential perspectiveto analyze lessons learned and forge pathways for futuredecision making related to collaborative interagency andinterprofessional research relationships.

2. Background

Curry, Nembhard, and Bradley (2009) compare andcontrast quantitative, qualitative, and mixed-method re-search methodologies, reporting the important contributionsof qualitative and mixed methods in outcomes research.Modern patient care environments are complex in nature,and traditional quantitative methods often leave burningquestions only partially answered or unanswered. Qualitativemethodologies offer another way of exploring theseunanswered questions. Institutional ethnography is oneform of field research that seeks to understand social andcultural norms from a particular perspective to explain healthcare environments and provide broader, deeper explanationsfor these environments and associated health care outcomes(Savage, 2000; Savage, 2006).

One important consideration in conducting field re-search using ethnography as a methodology in a healthcare setting relates to the ethical implications involved inthe research process and uncovered in the researchfindings. Emanuel et al. (2000) describe seven necessarycomponents for evaluating clinical research ethics, includ-ing (a) value derived from the study, (b) scientific rigorinvolved, (c) fair selection of subjects and setting, (d)positive risk–benefit ratios, (e) independent nonpartisanreview, (f) informed subject consent and voluntaryparticipation, and (g) respectful treatment of study subjects.

Of course, in qualitative health systems research, the“subject” is often a particular hospital or health care system.This role of hospital as subject carries a specific set ofconsiderations about informed consent and anonymity in thecollection of qualitative data. While staff members may haveconsented to be interviewed about their work and are promisedthat their individual remarks will not be identifiable as they talkabout their experiences in the organizationswhere theywork, itis less clear how and to what extent the anonymity of theorganization can be maintained, particularly when a largenumber of individuals participate from one institution.

Ethnographic research methods pose potential risks toorganizations by uncovering information that, if presentedpublicly, could be perceived as damaging to an organiza-tion's image by its leaders and the public. Despiteethnographers' best attempts, this method may also placethe participants at risk of losing their anonymity whendeidentified excerpts of interviews are used as illustrations inpublications of study findings.

Institutional ethnographers studying nurses in their workenvironments try to make sense of the “work of nursing”through also uncovering and understanding the “rulingrelations” that structure and support nurses' work in complexhealth care settings (DeVault & McCoy, 2006). Campbell(2006) describes that institutional ethnographer's sensemaking is “disciplined by the relations that organize orcoordinate what actually happens among those involved” inthe delivery of care and the practice of nursing. Sharing thoseprivate perspectives with these researchers and allowingthem to actively observe practice environments and gainaccess to these structural documents and organizationalprocesses that guide nursing practice require a high level oftrust between organizational leaders and researchers andadherence to the highest ethical standards by institutionalethnographers, research participants, and health care leaders.The benefit derived from collaborative relationships in-volved in institutional ethnography rests in the idea that theissues uncovered by institutional ethnographers provideimportant clues that assist researchers, health care leaders,and direct care nurses to better understand organizationalcultures and nursing work environments.

Successfully implementing research efforts to studynursing work environments, analyzing qualitative datafrom institutional ethnography, and disseminating results(while protecting the rights of participants and health caresettings) require careful relationship building, ongoingdialogue and transparency throughout each stage of theresearch process, and high levels of trust between/among allparties involved. One method for achieving success is to usestrategies from scientific decision-making or risk-analysismodels to guide research development, implementation, anddissemination processes.

3. Methods to support decision making

Decision analysis is a systematic means of determining acourse of action to take. Decision analysis has been appliedin a wide range of fields such as engineering, finance,manufacturing, health care, or any time making a choice canresult in loss of money or resources and risk to humanbeings. Two vital elements of decision analysis are value anduncertainty. When making a decision, we must decide howour decision might increase or decrease the likelihood of anoutcome we value. The difficulty in making decisions ariseslargely from our uncertainty about the outcome and, thus, thechallenge in predicting the result of any single decision. Ofcourse, another difficulty arises when those factors we valueare in conflict (e.g., leisure and income).

In a situation in which a researcher is seeking to conductresearch within a hospital setting, the values of the partiesinvolved are not identical. The researcher is seeking newknowledge, access to all necessary information relating tothat knowledge, a good working relationship with thehospital and its staff and decision makers, academic freedom

207J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

to submit results for peer review and publication, andprofessional recognition for their work. Staff nurses at thehospital value professionalism and the opportunity to sharetheir experiences and participate in finding answers to theproblems they encounter daily. However, they also valueprotecting their patients' identities and supporting theiremployers and may be unwilling to give up time off toparticipate in a research study. Nurse leaders and otheradministrators value access to useful new information abouttheir setting, improvements in patient care, and theirpositions of authority, accountability, and commitment tothe organization.

Alemi and Gustafson (2007) describe a decision analysismodel that provides a useful theoretical structure forresearchers and nurse leaders to use in avoiding problemswhen using qualitative research methods such as institutionalethnography to study nurses and health care environments.They refer to the challenges in this type of decision as“potential conflicts.” By this, Alemi and Gustafson mean thatthe outcomes valued by the two parties may seem to be inconflict. They state, “The members of a decision-makingteam may prefer different reasonable actions based on theirlimited perspectives of the issue. In this prototype, theproblem needs to be structured so the decision makersunderstand all of the various considerations involved in thedecision” (p. 5). In situations where researchers seek accessto hospital settings for research, differences in preferredactions can be addressed systematically. Special emphasis ison understanding considerations not only from one's ownperspective but also from the perspective of the other partiesinvolved. First, members of the research team would meetand speak with key decision makers and constituents, learnabout their perspectives, and establish timeframes for theresearch and dissemination process. Second, the researchersand nurse/organizational leaders must agree among them-selves about the importance of the various outcomes thatmight occur based on each decision and determine whowould be affected by the outcome and what will be achievedby studying and/or solving the research problem. Theresearchers and nurse/organizational leaders should worktogether to analyze study components and weigh their valueswhile also quantifying potential “uncertainties” that may beencountered during the research process. Finally, the “data”(meaning the conversations and estimations of likelihood ofvarious outcomes) should be analyzed; a course of action,recommended; and the decisions, disseminated to stake-holders. In Fig. 1, the steps of the decision analysis processare illustrated using the example of our own research.

4. Collaboration between nurse researchersand hospitals

Academic and service organizations have long-estab-lished collaborative efforts centered on educating andpreparing nurses to enter clinical, advanced practice, and

leadership arenas. Similarly, academic institutions and healthcare organizations have engaged in collaborative researchefforts because nurse researchers from academic settingsseeking to answer clinical questions need access to researchparticipants and clinical information readily available inhealth care practice settings. Newberger (1976) theorizedthat the basic differences between disciplines, and the lack ofunderstanding of those differences on a conceptual basis,create barriers to collaboration, including trust issues andlack of confidence.

Forging such collaborative relationships has risks andbenefits for both entities. Open communication andtransparency between academic and service partners pavethe way for healthy, vibrant, sustainable relationships thatcan be mutually gratifying for all team members (Mariano,1989). Carefully identifying and weighing relationship prosand cons at the outset of any project, coupled with ongoingevaluation along the way, ensure successful project out-comes and sustainability of the relationship for all thoseinvolved. Applying decision-making principles at the outsetclarifies the roles and responsibilities of each team memberand entity and minimizes unexpected surprise elements forboth parties along the way.

Nursing leaders' roles require and encourage them tooperate across multiple domains and frameworks amongclinical, professional, operational, and administrativeworlds. Bridging these domains and creating win–winsituations for the organization and the nursing profession,ultimately benefiting patients and the community served, arethe complex work of today's nurse leaders. Operating in suchcomplexity requires a solid understanding of leadershipduties, professional practice standards, competing institu-tional priorities, research, ethics, and a new understanding ofcomplex adaptive systems. Advancing the research agendain academia and service requires the stakeholders to stepoutside the Newtonian views of control and stability andaccept the nonlinear nature of the relationship and outcomesfrom the beginning of the partnership and affects itssustainability (Kinnman & Bleich, 2004).

Advancing the knowledge base of nursing whilemitigating risk to the organization and the professionoften creates ethical dilemmas for nurse leaders, who mustweigh decisions to advance nursing knowledge whileprotecting the rights of patients, nurses, and the organiza-tion. Deeply examining one's duty to patients demands thatnurse executives create space for “good” research to occurand to “mitigate” risk to the organization's reputation andfinancial status.

Collaborative negotiation can offer solutions for success-ful collegial partnerships between academic researchers andhospital environments that result in significant new knowl-edge and innovation. Schein (1972) described the need forincreasingly holistic problem solving in an era of special-ization that has driven increased disconnects and raisedconceptual boundaries. Preplanning during the developmen-tal phase of the research with clear understanding (by both

Framing Decisions to be made

Anticipating Outcomes

and Predicting their

Likelihood

Arriving at the final

Joint Decisions

Researcher and Administrators jointly

identified decisions to be made:

• What settings, individuals,

materials will be needed?

• Who will provide entre into the

setting?

• What IRB or other reviews will

be required?

• What type of controls over

dissemination will be

acceptable?

• Who will participate and be

named as authors?

• How long will it take to

complete the study?

Researchers were uncertain about:

• whether the study could be

completed as planned;

• how ethical obligations to

hospitals and nurses can be

balanced with pursuit of new

knowledge; and

• whether expectations of editors

and peer reviewers will conflict

with assurances to hospitals.

Administrators were uncertain

about:

• whether benefits of learning

more about their organization

would outweigh risks of

uncovering unflattering

information about the

organization; and

• whether patient information and

sensitive proprietary and/or

operational information will be

kept confidential.

Researchers and administrators jointly

decided:

• The research coordinator (a

nurse) at one hospital and

education department

employees at 2 hospitals would

coordinate research activities.

• IRB reviews would be required at all 3 hospitals and at the PI’s

university.

• Administrators at one hospital

would require review of

manuscripts to assure

confidentiality of their site in

publications.

• All study hospitals would provide

open access to settings and

materials needed.

• Authorship would go only to the

researchers

• All nurses at the study hospitals

would be offered continuing

education on the findings

Fig. 1. Research collaboration: decision analysis processes for researchers and hospitals.

208 J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

parties) of the design, implementation, risk, and publicationof results can be hardwired into the agreement. Agreementsmust honor and not comprise the tenets of research, theorganization's mission, and the ethics of both the researcherand the nurse leader. Health care, in general, is risk averse,and for good reason. Morally courageous nurse leaders, whooperate from a solid ethical foundation, understand research,their obligations to the organization, duty to patients, andduty to the profession find creative ways to partner withresearchers to advance all agendas while safeguardingpatient care and the nursing profession.

5. Off-Peak nursing work environments as a casefor collaboration

The following case study is used to illuminate keyelements that accompany decision-making and evaluationefforts related to collaborative academic–service researchefforts. During the course of developing and sustaining acollegial relationship, an experienced nurse researcher, her

coinvestigator, an administrator at one of the study hospitals,and a nurse leader at another hospital partnered to exploreunanswered questions regarding the impact of off-peaknursing work environments on patient outcomes. For manyyears, the nurse scientist and principal investigator for theproject sought to answer questions and uncover newknowledge related to the possible relationship between off-peak nursing work environments and patient morbidity andmortality (Hamilton, Eschiti, Hernandez, & Neill, 2007). Inthat study, Hamilton et al. (2007) moved from linearmethodologies to focus groups in attempts to solve thepuzzle regarding the differences in off-peak nursing workenvironments and possible associated influences on patientoutcomes. Findings from these focus groups with off-peaknurses scratched the surface of the issue, uncoveringimportant differences in off-peak nursing work environmentsthat might impact patients' health outcomes.

In 2007, Hamilton assembled an interprofessionalresearch team to use institutional ethnography to furtherexplore differences in off-peak nursing work environmentsthat could better explain their influences on patient

209J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

morbidity and mortality. In addition to the nurse scientist,the team included a health care administrator, aneconomist, and an institutional ethnographer. This teamcame together to forge collaborative partnerships withnurse leaders from health care organizations where theresearch would be implemented. As a result of thatcollaborative research relationship, the principal investiga-tor and the nurse leaders from one of the participatinghealth care organizations in a large urban area in thesouthwestern United States developed partnership strate-gies and uncovered key elements during the course of theproject that serve as important “lessons learned.” Thepartnership strategies, the steps involved in the process,and the lessons learned provide useful knowledge foracademicians, researchers, and nurse leaders in embarkingupon collaborative research partnership journeys.

6. Partnership strategies

Collaborative research relationships between academicsand service entities require the development of relation-ships between and among the leaders of each entity as wellas those individuals involved in the research process.These leaders and research team members must all be atthe table to hold crucial conversations about the project,clearly understand the agendas of all entities andindividuals involved, and work out the required contractualrelationships and agreements. Each entity needs to clearlyunderstand and accept the benefits and risks of thecollaborative agreement and the specific project. Theroles, responsibilities, and contributions of each entityand individual involved must be clearly delineated andagreed upon by the decision makers. To the extent that theproject will involve multiple organizations, it may beimportant for all to agree to the scope and constraints ofthe collaborative agreement for the specific project.Commitments regarding the expected length of the project,human/material/financial resource requirements, and plansfor accessing sensitive business or protected healthinformation must all be clearly addressed.

Ethical considerations are crucial to the success of theseagreements and relationships. Ensuring that human partici-pants and information are protected throughout the course ofthe study, including during dissemination of findings, isessential to the success of these relationships. These clearlyneed to be addressed through institutional review board and/or administrative review at each participating institution.When using institutional ethnography as a methodology inthis case, for example, the nurses' perspectives shared withthe ethnographer and information uncovered when followingthe trail to discover “ruling relations” that govern nurses'work environments may include some identifying languagethat would betray organizational anonymity during the courseof disseminating findings. Careful dialogue between theresearchers and nurse leaders along the way, coupled with

first right of review texts and presentations prior todissemination of findings, can avoid any ill feelings betweenthe nurse researcher and hospital(s) participating in theproject. The purpose and limits of that review should benegotiated openly until all parties are satisfied.

The goals and agendas of the nurse scientists and thenurse leaders can be both complementary and competing.While the hospital-based nurse leaders provide a supportiveenvironment for the nurse researcher to answer importantscientific questions, add to the body of knowledge, and bringinnovation and improvement to the nursing profession andpatients' outcomes, they are also responsible for protectingemployees, interprofessional colleagues, patients, and theorganization. The key to successful collaborative researchpartnerships is bringing together a team with the right mix ofskills, talents, and interests, and one that shares commongoals and with interests in studying the same practice issues/topics (McWilliam, Desai, & Greig, 1997).

Information gathered from collaborative research effortsserves the best interests of health care organization leadersto help improve the safety and quality of the careenvironment. Health care leaders have to have a sensitivityto operations that focuses on how actual work takes place.Most organizations have guidelines, policies, procedures,and other structural documents that define how workoccurs for specific care delivery processes. Frontline staffand leaders in health care organizations realize that theremay be a difference between what policy or proceduredictates and how the work actually occurs; however, theymay also have blind spots to some of the complexities ofcare delivery processes. Having independent research thatexplores these issues with nonlinear methods is one waythat organizations can learn about gaps between theorganization's structural documents and actual practice.Qualitative research helps organizations to gain knowledgerequired to handle situations that such policies, procedures,and practice guidelines cannot anticipate.

While the researcher shares the responsibility forprotecting human participants, the ethics involved intransparently presenting research findings do not involvethe same need to protect the health care organization'simage held by the chief nurse executive and other nurseleaders. Such conversations that lead to ethical decisionmaking by both parties do much to ensure continuedcollaboration if not derailed by unresolved competinginterests. Although the parties' agendas may not always beshared, both researchers and nurse leaders can come torespect the importance of considering each other's values,positions, and goals in establishing the partnership andaccomplishing research efforts.

7. Steps in the collaborative process

The steps involved in forging nurse–hospital researchrelationships are crucial to the successful implementation

210 J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

of research in health care settings and are outlined in thefollowing:

• Involve key decision makers and stakeholders fromacademic and service entities to explore collaborativeresearch opportunities.

• Establish research priorities and identify resources forimplementing specific projects.

• Develop shared agendas and determine availableresources. Weigh the risks and benefits associatedwith the partnership.

• Determine institutional review board requirements forprotection of human participants and, as appropriate,administrative review for the protection of organiza-tion interests.

• Draft, review, revise, and finalize collaborative agree-ments between the academic and service entities,including business associate agreements that addressprotected health information requirements such as theHealth Insurance Portability Privacy and Security Rules.

• Establish authorship and presentation guidelines andagreements between the entities.

• Implement the terms of the agreement throughinteragency research projects.

• Conduct periodic evaluations of collaborative agree-ments, relationships, and project outcomes. Reviseterms of the agreement as indicated.

• Establish a process to address any issues that arisefrom the changing of institutional roles for either nurseresearchers and/or nurse leaders, especially for multi-year projects.

Methodically following the steps involved in collabora-tive research partnerships between service and academicorganizations assists organizational leaders from bothentities and members of the resulting research teams tounderstand and value each others' roles, responsibilities,resources, priorities, and perspectives, avoiding manypitfalls that could adversely impact collaborative relation-ships and deter research processes.

8. Lessons learned

During the course of the 3-year period during which thisresearch project took place, a number of lessons were learnedby the principal investigator, members of the research team,and nurse leaders from the service entity where the researchtook place. First, the nurse leaders in the organization soughtto support the research team's efforts without initiallyrecognizing the complexity involved in disseminatingresearch findings that resulted from institutional ethnographyas a methodology. At the beginning of the project, when datawere only being collected in one organization, the nurseleaders had to exercise careful consideration with theprincipal investigator around protecting the anonymity of

the nurse participants and the hospital involved whileprotecting the image and integrity of the organization.

The chief nurse executive also spent much time with theexecutive team, educating them about the importance of thisstudy and justifying the rationale for participating. Concernsrelated to fears of exposing the organization to unwanted riskin terms of disseminating any potentially negative findingsthat could be tied back to the organization had to beaddressed. The chief nurse executive exercised tremendous“moral courage” in recognizing the importance of the studyand supporting the nurse researcher and this interprofes-sional team to implement the study in the organization(Kidder, 2005). Embarking on research efforts that canpotentially expose negative perceptions about a unit, adepartment, an organization, or any of the leaders or healthcare team members requires tremendous courage on the partof nurse leaders. Even positive perceptions of an organiza-tion need to be carefully vetted for perceived bias.

As the study continues and plans for disseminating findingsprogress, there are dilemmas related to continuing to protectparticipants' anonymity and organizational integrity andimage. With the importance of protecting the participantsand the health care setting, members of the research team fromservice settings may have to play silent roles as the findings aredisseminated in presentations and publications, despite theirkey involvement in the project. For example, coauthorship ofservice-based team members must be weighed againstdivulging the hospital affiliation in publications. Readersmay assume that the study took place in the hospital withwhich a team member is affiliated. Weighing these decisionsthroughout the course of collaborative relationships andspecific projects is an intricate dance among the academicand service partners and the members of the research teams.

9. Conclusions

The benefits derived from collaborative relationshipsbetween nurses in academic settings and hospitals forconducting and utilizing research far outweigh the risks.Both parties benefit from the values, knowledge, experience,expertise, and perspectives of the other. Furthermore,research needs to be conducted and reported to demonstratethe benefit of the investment in collaborative nursingresearch. Without such partnerships, academic researchefforts may lack sufficient real-world wisdom from clinicalenvironments and service settings, whereas service entitiesmay not have the available resources or the ability to conductscholarly research that involves discovering new knowledgeand disseminating findings in peer-reviewed journals.

Despite the risks related to disparate agendas and priorities,the rich experience and important outcomes that result fromthese academic–service research partnerships while travelingthe pathways of scientific inquiry together outweigh thechallenges and obstacles along the way. Using methodicalsteps to implement and sustain these relationships, maintaining

211J. Marshall et al. / Applied Nursing Research 25 (2012) 205–211

open lines of communication, forging trust through trans-parency, and continuously evaluating and revising theagreement to best meet both parties' goals provide a roadmapfor success. Capitalizing on the strengths of academic andservice partners strengthens relationships and serves toimprove research efforts and outcome for both academiciansand health care providers.

Acknowledgments

The investigators thank Nancy Nardelli, RN, CCRC,clinical research coordinator, Medical City Dallas Hospitaland Medical City Children's Hospital, Dallas, Texas, forher tremendous contributions to the project described in thecase study that served as the basis for these collaborativeresearch efforts.

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