Rehabilitation Nurses Working as Collaborative Research Teams

132 Rehabilitation Nursing • Vol. 30, No. 4 • Jul/Aug 2005

Rehabilitation NURSING

Rehabilitation Nurses Working as Collaborative Research TeamsLinda L. Pierce, PhD RN CNS CRRN FAHA

Rehabilitation nurses conducting research would benefit from working within collaborative research teams. The develop-ment of intradisciplinary (one discipline) and interdisciplinary (many disciplines) research teams is described in this article. A research team is defined as more than a single person in the role of the researcher while studying the same topic of interest in a joint or collaborative manner. Strategies to ensure successful research team collaboration are described. Exemplars of developing and maintaining a team at one site, which consists of members of the same discipline, as well as another team that consists of multiple professional disciplines, are shared. Collaboration among research team members in practice, administration, and education settings transcends degrees and roles to make substantial contributions to professional practice.

Rehabilitation nurses conducting research as solo investigators may assume a sense of freedom to be creative. However, numerous unforeseen challenges can arise during the research process that can chal-lenge this freedom. Support from colleagues can pro-vide guidance through these challenges (Norwood, 2000). Sound research rarely happens in isolation and a “good study has enough glory to share with all…and a poor study is a heavy burden to bear alone” (Martin, 1998, p. 92).

Sometimes research teams are defined as the dyad between researcher and participant or informant in qualitative studies. More broadly, the research team is defined as two or more researchers studying the same topic in a joint or collaborative manner (Gates & Hinds, 2000). Intradisciplinary (one discipline) and interdisciplinary (many disciplines) collabora-tive research is a growing trend for several reasons. Many issues in health care are so complex that they warrant a team approach to investigation as well as care delivery (Brown & McWilliam, 1993; NIH, 2003). Collaborative research can promote cooperative ap-proaches to care delivery (Sprague-McRae, 1988) and supports nursing’s philosophy of working with others to meet the needs of individuals and families (Norwood, 2000).

Strategies for Successful Collaboration

Schlotfeldt (1974) identified several individual characteristics necessary for research success: intel-lectual curiosity, conceptual ability, competency, cre-ativity, and caution. One researcher may not possess all of these needed characteristics. Collaborative pro-cesses among discipline-specific individuals, as well as people from multiple disciplines, help to ensure that these essential characteristics are incorporated

into the project. Building on Schlotfeld’s earlier work, Lancaster (1985) described six Cs of collaborative re-search (contribution, communication, commitment, compatibility, consensus, and credit) and Govoni and Pierce (1997) added a seventh C—cohesion. Contribution

Seasoned researchers contribute knowledge of re-search methodology as initiators and facilitators of research. Other members of the research team may or may not have this knowledge, but they bring enthusi-asm and energy to the project that helps to motivate the team. The work of the project is divided according to each person’s skill and ability (Lancaster, 1985). Collaborative research promotes mutual professional respect and fosters positive working relationships. In addition, it enables all members of the team to pool talent and resources to meet mutual goals that may affect care, validate practice, and hone research skills. The background that each member of the research team brings to a research problem provides a unique filter for critically evaluating issues from a number of perspectives that ensures a more sound and credible study with more comprehensive and possibly more widely applicable findings (Norwood, 2000). Communication

Throughout the research process, communication is crucial for successful collaboration and outcomes to occur. The team members must accept one another enough to work together. Group dynamics influence communication throughout the project (Lancaster, 1985). For example, the principal investigator has skill in overall research design. However, different leaders may emerge as the project moves from design to data collection. A software engineer is the expert in design-ing Internet-based forms of data collection, while the statistical manipulation of data often requires a spe-cialist in data analysis techniques. Individual team

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KEY WORDS

collaborative research

collaborative teams

Rehabilitation Nursing • Vol. 30, No. 4 • Jul/Aug 2005 133

members must feel comfortable with one another so that control can be relinquished by one person and established or reestablished by another team member as the project moves through the various phases of the research process. Commitment

Physical and emotional commitment of time, energy, and resources to the project from all team members is needed. Such commitment may be dif-ficult to realize as many individuals struggle to di-vide their time and energy among many activities, such as practice, administration, education, and re-search endeavors. Managing time and dealing with scheduling constraints, as well as administrative sup-port, are issues that must be resolved if the research project is to come to fruition. Commitment often is influenced by factors outside the researchers’ con-trol (Lancaster, 1985). For example, increased client workload for any researcher can adversely affect any project. When unexpected occurrences happen, re-search responsibilities usually can be temporarily or permanently renegotiated, reducing tension among the team members.Compatibility

Research teams need to fit together to make an effective whole. Development of trust, mutual under-standing, and respect among members is important, along with development of confidence in team mem-bers’ abilities (Brown & McWilliam, 1993; Sangster & Grace, 1993). Team members need to find ways to recognize and appreciate one another’s differences and similarities. The team needs to find ways to harmonize different members’ styles so that mutual respect is maintained and optimal performance is en-couraged. In this way, potential liabilities are turned into assets (Lancaster, 1985). Consensus

As team members evaluate their degree of com-patibility, they will also recognize whether consen-sus is possible. Consensus is an unending process of communication, compromise, and negotiation. Col-laborative research guards against vested interests. As team members with different values, beliefs, and backgrounds collaborate, biases may be countered by making vested interests known and negotiating until a middle ground is found (Lancaster, 1985). Ground rules need to be established for attending meetings, adhering to deadlines, and handling disagreements, as well as authorship issues, before the study commences (Brown & McWilliam, 1993; Sangster & Grace, 1993).Credit

Credit may become an issue. The research team must agree upon ownership of group efforts. To de-crease sources of disagreement, decisions such as order author names in publications and presenta-tions are best made at the beginning of the project when all members of the team are present. Decisions

should be put in writing either in meeting minutes or in a separate written agreement (Lancaster, 1985). All those involved need to be given recognition for their work on a project. Sometimes team members receive publication authorship when they participate in writing reports; nonauthor team members often are given an acknowledgment in the publication for their contributions to the work.Cohesion

Like and unlike individuals develop cohesion when they are united in working together toward a common goal. The size of the team is central to ef-fective cohesion. Usually six to eight core members are best to ensure project completion. Larger groups may place high demands on the principal investiga-tor, lessen group participation, and decrease group unity. If additional research expertise is needed, con-sultants or ad hoc members can be added to the team (Govoni & Pierce, 1997). Cohesion can be built and maintained by celebrating small successes through-out the project.

Intradisciplinary Research Team: A Case Study

For advanced practice nurses in clinical practice at a large metropolitan teaching hospital and rehabilita-tion center in northeastern Ohio, teamwork became a way of life, and inherent in that life were multiple research endeavors. A research component was part of all nurses’ job descriptions and one of the steps in the clinical advancement program for staff nurses. Administrators sanctioned these research projects as being important to the institution and the profes-sion, and work time was committed to them. This arrangement was a win-win situation for all involved, because the findings of these projects affected clinical practice decisions and care outcomes. Exemplar

Clinical nursing judgment related to reducing the incidence of falls by elderly clients (Turkoski et al., 1997) was a collaborative qualitative study based on a body of nursing research suggesting that expert clini-cal judgment is the guide for discretionary nursing behaviors that result in quality nursing care (Benner, 1984; Corcoran, 1986; del Bueno, 1983). Interviews were completed with 14 female nurses between the ages of 24 and 55 years working on a geriatric reha-bilitation unit in northeastern Ohio. Staff nurses iden-tified variables as influencing their clinical decision-making and the nursing behaviors associated with preventing client falls. Four themes emerged from these data: (a) the reasons for client falls, (b) identifi-cation of clients who are likely to fall, (c) prevention of falls, and (d) nurses’ feelings when clients fall.

This collaborative research team involved a staff nurse, two nursing managers, three clinical nurse spe-cialists (CNSs), and a doctoral-prepared university


Rehabilitation Nurses Working as Collaborative Research Teams

nursing professor. These seven rehabilitation nurse collaborators became a cohesive group in which all members could make their unique contributions.

The original problem was identified by the staff nurse and the nursing managers, and they worked with the CNSs to design the research project. The CNSs found the nursing professor in the Association of Rehabilitation Nurses (ARN) membership direc-tory. She had expertise not only in rehabilitation nurs-ing but also in qualitative research methods and data analyses. The nursing professor joined the team and took part in the participant interview processes and data analyses.

Communication was enhanced by weekly or monthly meetings with all members of the team dur-ing which the researchers got to know one another and divided up the work of the project. Because the six members of the research team had varying levels of experience with data content analysis, the entire team spent time over a 4-month period in informal classes led by the nursing professor. These sessions included the rationale for content analysis, different approaches to content analysis and coding, and sev-eral hours of practice with data analysis. These ses-sions represented a large commitment of time and energy by the entire team, but desire to complete the project kept the members motivated.

The members were compatible; they worked well together and brought out the best in each other. Con-sensus was obtained throughout the project. For ex-ample, as the four themes emerged from these data during data analysis, consensus not only helped establish the themes but also determined how the data could be used in practice. The aspects of clinical decision-making found to be successful in prevent-ing falls were incorporated into staff orientation and education programs by the managers and CNS and into falls-prevention protocols by the staff nurse and CNSs.

Several presentations at local and national meet-ings and two publications resulted from this project. Credit was divided among the researchers. The nurs-ing professor took the lead in writing the results of the project (Turkoski et al., 1997) and a nurse man-ager (see Table 1) took first-author responsibility for writing the manuscript that precipitated this research (Brady et al., 1993). All members of the team are listed in the authorship of both manuscripts, because all participated in writing sections of the papers.

Interdisciplinary Research Team: A Case Study

In 1999, a colleague at a medical college in north-western Ohio brought together two doctoral-prepared researchers, one a rehabilitation nurse and the other a

developmental psychologist with similar interests in caregivers and caregiving outcomes. The nurse had a strong background in caring, stroke, and caregivers, and had facilitated a face-to-face support group for caregivers of persons with stroke and their families for several years (Pierce & Salter, 1988). The psycholo-gist had worked with geriatric populations, complet-ed research in health behaviors and with caregivers of persons with dementia, and is considered an expert in Intranet applications. Both researchers used Internet-based applications in their teaching assignments. As they began to work together on a research project, each made their own contributions based on their past experiences and current ability. Roles intrinsic in university life are research and scholarship, as well as teaching and service. Working with individuals from different disciplines within the university setting is important and fosters research processes.Exemplar

A cohesive bond was formed between these two researchers. Together, they developed an Internet-based intervention of education and support for caregivers of persons with stroke called Caring~Web© (Steiner & Pierce, 2002). Once caregivers gain access to Caring~Web©, they can link to and/or participate in: a customized educational caregiving tip that changes on a monthly basis; a consultation with a nurse specialist and rehabilitation team called Ask the Nurse; an e-mail discussion group, Caretalk, with other caregivers and the nurse specialist; and links to educational information from reliable sources (Steiner & Pierce).

This Web site was designed in consultation with software engineer and student Web-page designers at the college. The need for the caregiving tips was iden-tified and much of the content was written by two graduate students as their scholarly projects (Pierce, Finn, & Steiner, 2004; Pierce, Rupp, Hicks, & Steiner, 2003). Another graduate student’s project evalu-ated the quality of the Caring~Web© design (Steiner, Pierce, & Herceg, 2004). A coinvestigator and nurs-ing professor from another university in northeastern Ohio who is a CNS with a solid background in home care as well as psychiatric and rehabilitative experi-ence manages the Ask the Nurse component of the intervention. As a back-up for this nurse specialist, a multidisciplinary rehabilitation team helps her an-swer caregivers’ questions. This rehabilitation team is composed of a physician, occupational and physi-cal therapists, dietitian, pharmacist, speech therapist, and social worker (Govoni, Pierce, & Steiner, 2003; Pierce, Steiner & Govoni, 2002; Pierce et al., 2004).

This intervention is used in research endeavors with caregivers of persons with stroke; the medical college is the primary performance site. Caring~Web©


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Table 1. Summary of Collaborative Research Projects

Title/Journal Authors (Date)Purpose or Research Question

Method/Sample and Setting

Analysis of Data Results

4) “Frequently Selected Nursing Diagnoses for the Rehabilitation Client with Stroke”/Rehabilitation Nursing

Pierce, Rodrigues-Fisher, Buettner, Bulcroft, Camp, & Bourguignon (1995)

The purposes of this study were to identify the most frequently cho-sen nursing diagnoses for rehabilitation clients with stroke and to deter-mine if the consistently addressed nursing diag-noses are defined by objective clinical charac-teristics.

Retrospective chart audit examined 100 randomly selected stroke clients (51 male and 49 female with a mean age of 66 years) at a large rehabilitation center in northern Ohio.

Descriptive statis-tics, including χ2

• At admission and discharge, impaired physical mobility (99%) and self-care defi-cit (91%) were the most frequently occur-ring diagnoses.

• Impaired physical mobility was usually related to neuromuscular impairment and self-care deficit was usually related to neu-romuscular dysfunction.

5) “Rehabilitation Nursing Approaches to Cerebro-vascular Accident: A Comparison of Two Approaches”/Rehabilitation Nursing”

Salter, Camp, Pierce, & Mion (1991)

The purpose of this study was to com-pare clients receiving neurodevelopmental therapy (NDT) to clients receiving a traditional approach.

Retrospective chart review at a rehabilitation center in northern Ohio on 2 separate medical units, each using one treatment approach. Forty-three clients with the traditional treatment approach and 37 clients (51–72 years of age) with NDT were audited.

t-test for interval data, Mann-Whitney U test for ordinal level data, and χ2 for nominal level data.

• No significant differences between the groups were found at admission, except the NDT group had higher scores in dress-ing and toileting.

• At discharge, the NDT group had higher scores on toileting.

• Length of stay was almost identical between the groups.

• Eighty-six percent of the NDT sample were discharged home compared to 78% of the traditional sample, but this was not statisti-cal significant.

• One approach to treatment was not appar-ently superior.

6) “The Lived Experience of Aloneness for Older Women Currently Being Treated for Depression”/Issues in Mental Health Nursing

Wilkinson, & Pierce (1997)

What is the lived experi-ence of aloneness for older women being treated for depression?

Phenomenology/Interviews with 8 women from north-ern Ohio.

Same as 2) Aloneness in depression and aloneness in reco-very with five paired, somewhat dichotomous themes defined the essence of aloneness:• Vulnerability versus self-reliance• Fear versus hope

Helplessness versus resourcefulness• Loss of self-control versus self-

determination• Identity confusion versus self-reflection.

(continued)


has been tested in pilot studies and found easy to use and valuable by the caregiver participants (Govoni et al., 2003; Pierce et al., 2002; Pierce et al., 2004). Cur-rent research with the Caring~Web© intervention is underway [National Institutes of Health/National Institute of Nursing Research RO1 NR07650] by a collaborative research team that (a) examines care-givers’ well-being and use of healthcare services between Web users and non-users and (b) examines the caregivers’ experience of caring by identifying problems and successes in caring.

In addition to the initial three investigators and graduate students, a larger collaborative team of researchers came together to participate in these accomplishments. Less-seasoned members were enthusiastic and motivated to participate, while the more experienced researchers spearheaded the project. Individuals contributed in their own way. The team consisted of nurses in the role of recruiters; medical care workers, nurses, and social workers in the role of interviewers; a computer technician that connected caregivers’ equipment to the Internet and trained them in the use of the intervention; a software engineer that maintained the Web site; and several consultants for qualitative and quantitative analyses of data and overseeing the theoretical components of the project.

Communication among team members was crit-ical with such a large collaborative group and oc-curred in three formal ways. First, monthly meetings were held. One meeting was held for the interview-ers, the software engineer, and the investigators to talk specifically about their issues with data collec-tion. Another monthly meeting was held with the in-vestigators, recruiters, the computer technician, and software engineer to discuss recruitment and subject maintenance. All members could attend both meet-ings, if desired, and oftentimes they did, as issues cut across all members of the team. At times, they could not attend any of the monthly meetings, and e-mail served as the vehicle to keep all team members up-to-date.

Another communication method involved semi-annual 2-day meetings between the consultants and the team. The qualitative data and the theoretical consultants were nursing professors from Michigan and Florida, respectively. Agendas for all meetings were essential to keep focused and move the work forward. The meeting days were long and filled with content items that often extended into the evening. E-mail communication occurred throughout the year on a weekly basis, depending upon the needs of the team members. For example, the researchers and the nursing consultants discussed how the data and the theory were connected as they continued to work on a coding rubric for these data. Each consultant

contributed expertise in the form of content analysis, theoretical framework, and overall knowledge of the research process.

The third communication method involved bi-annual meetings between the researchers and the seven discipline-specific rehabilitation team mem-bers, including the nurse specialist that ran the Ask the Nurse portion of the intervention. Each of these members contributed their professional expertise in answering e-mail questions the subjects asked. Reha-bilitation team members demonstrated compatibility in their e-mail messages to one another. For example, therapists might not know the answer to caregivers’ questions about diabetes, but the nurse specialist, physician, and dietitian did. Each respected the oth-er and said so in their e-mails to one another; they learned from one another. Meeting in person brought the group together and increased their unity. They came together in other ways, too. Many rehabilita-tion team members wrote and reviewed educational tips for the Web pages. They also wrote descriptions of the rehabilitation team for posting on the Web site intervention. In addition, the social worker took the lead as first author in a publication effort, with consensus on credit for authorship of the team mem-bers. Together, most members wrote and submitted a manuscript for publication on the role of the reha-bilitation team with the investigators. All in all, the entire collaborative team members were committed, both physically and emotionally, to this project, and open communication helped all members become comfortable with each other and the activities of the project.

Discussion and ImplicationsMeshing research into professional roles contin-

ues to elude many individuals. Networking with oth-ers at meetings or conferences is one way for staff and advanced practice rehabilitation nurses to begin to identify other professionals with similar interests and initiatives for collaboration. Another way that rehabilitation nurses can find research partners is to contact doctoral-prepared university professors to discuss similar interests. While this access may be easier for advanced practice nurses because these professors may be their former advisors, anyone can contact a university’s research department for information about collaborative research endeavors. However, it also is not uncommon for university pro-fessors to contact nurses in daily practice for assis-tance and collaboration with research projects.

Collaborative projects result in relevant research that not only increases the scientific knowledge base for professions that may improve professional prac-tice, but also makes research work manageable and attainable. In different phases of these projects, distinct


Rehabilitation Nurses Working as Collaborative Research Teams

team members took the lead. No matter what the team members’ roles were, commitment and clear commu-nication was essential in ensuring successful working relationships, as well as favorable outcomes for the projects. Differing levels of commitment and poor communication can hinder any team. Communication was the responsibility of all research team members. Open discussion and feedback contributed to team cohesion and compatibility, and facilitated consensus in decision-making processes. Using these strategies prevented power struggles from occurring. Everyone contributed his or her expertise to the projects. For example, when one member wanted to push ahead without thinking through all aspects of the process, another was cautious and insisted that the collabo-rators look at alternatives, allowing all research col-laborators to come to consensus on the major aspects of the projects. Order and credit for publications and presentations were established early in the projects. In describing entire projects, it was either the principal or coprincipal investigators who took responsibility and first authorship for manuscripts. Other times, different members of the team took first authorship responsibilities in publications and presentations de-pending upon manuscript content and presentation audience.

SummaryThis article discussed researcher characteristics

and explored issues for successful research team collaboration among rehabilitation nurses at all levels of practice and in several settings. In today’s complex world of healthcare practice, research team collaboration is a necessity. Team members came to-gether through professional networking opportuni-ties and mutual research interests. Through regular opportunities to discuss and revise their own and other team members’ ideas, rehabilitation nurses as researchers working in collaborative teams formed personal friendships, developed a mutual mindset, and grew in ability to function interdependently and learn from one another. As a result, team members provided mentoring and support to each other. Mem-bers also benefited from shared labor. Similar to other teams, members of collaborative research teams have an enlarged information system and expanded con-tacts for research and other scholarly activities. With highly motivated and committed members, research teams can make substantial contributions to health-care initiatives in practice and education settings.

AcknowledgmentsThe author acknowledges the collaborative re-

search work of many colleagues. Victoria Steiner, PhD, assistant professor at the Medical College of Ohio, and Amy Govoni, MSN RN CS, associate professor

at Cleveland State University, are thanked for their review of this manuscript.

The research undertaken in the exemplar of the interdiscipline collaborative research team is sup-ported by grant RO1 NR07650, National Institutes of Health/National Institute of Nursing Research.

About the Author

Linda L. Pierce, PhD RN CNS CRRN FAHA, is a professor at the Medical College of Ohio School of Nursing in Toledo, Toledo, OH. Address correspondence to her at 3015 Arlington Ave., Toledo, OH 43614, or by e-mail to [email protected].

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Earn nursing contact hoursRehabilitation Nursing is pleased to offer

readers the opportunity to earn nursing con-tact hours for its continuing education articles by tak-ing a posttest through the ARN Web site. The posttest consists of questions based on this article, plus several assessment questions (e.g., how long did it take you to read the article and complete the posttest?). A passing score of 88% on the posttest and completion of the assessment questions yield one nursing contact hour for each article.

To earn contact hours, go to www.rehabnurse.org, and select “Continuing Education.” There you can read the article again, or go directly to the post-test assessment. The cost for credit is $9 per article. You will be asked for a credit card or online payment service number.

The Association of Rehabilitation Nurses is accred-ited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC COA).

to another. Increased emphasis on developing more minority professional relationships also may be a priority.

Although these initial steps may appear over-whelming, the articles in this issue will assist in their realization. Readers will be reminded of the linkage of learning styles to patient outcomes, pivotal elements in developing cultural competency, and how collabo-ration between research teams maximizes the collec-tive skills of individuals to advance nursing knowl-edge development. Another article acknowledges the recurring role effective communication plays in the referral process while an additional author ex-plores the importance of periodically reframing old concepts such as “pain” within a new context. One study reports findings pertaining to the challenge of caring for an adult patient who fails to thrive in spite of all efforts, and another describes how evidence-based interventions can be bundled to improve the care of a mechanically ventilated patient.

Despite focused efforts to address health dispari-ties of patients, solutions will not be simple or imme-diate. By becoming increasingly mindful that health disparities exist, rehabilitation nurses can serve as leaders in targeting strategies that dramatically affect primary and secondary disease prevention, health maintenance, and restoration of maximal function

now and in the future for those with overt and covert health disparities.

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Embracing Diversitycontinued from page 122

Documents

Rehabilitation Nurses Working as Collaborative Research Teams