One might ask why another discussion of collaboration is introduced in the literature at this time. Many articles and books in the health care business, education, and research literature have been written about collaboration. Principles proposed to guide collaboration and strategies to address barriers are found in current literature. Collaboration has also been highlighted in the form of examples, challenges, and case studies related to many different areas, such as interdisciplinary education, research, and practice. Unfortunately, little in the literature provides practical guidance to leaders trying to facilitate collaboration and change in a global, technological context.

Increasingly, the responsibility of leaders is to guide needed change in both organizational culture and technology, with attention to individual and collective needs, and an eye on cost-effectiveness. The purpose of this article is to guide leaders as they facilitate changes which will enable organizational members to collaborate in new ways. Insight into changing the organizational language and culture and shaping the implementation of new technologies, along with a summary of technological tools available to support collaborative efforts, is provided. Relevance to current health care issues such as patient safety, distance education, and research will be highlighted.

Background and Context

According to The American Heritage Dictionary (2000, online version), collaboration is defined as "to work together, especially in a joint intellectual effort." Similarly, the definition of collaboration in the Merriam-Webster Online Dictionary (n.d.) is "to work jointly together with others, especially in an intellectual endeavor." Gray (1989), described collaboration as "a process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their differences and...their own limited vision of what is possible" (p.5).

...building and maintaining relationships...is an active process requiring attention and effort...

According to Hinton Walker, Botelho, and Suchman (1998), three collaborative principles guide/undergird collaborative partnerships: (a) building and maintaining relationships (the medium of partnerships) is an active process requiring attention and effort, (b) one must strive to understand the perspective of others (and one’s own) to be an effective partner, and (c) shared decision making is the ultimate hallmark of partnership, enhancing motivation and consolidating mutual commitment. These principles are consistent with Weaver and Farrell’s (1997) use of the acronym TARGET to describe the characteristics of collaboration and partnerships. These characteristics include: Truth, Accountability, Respect, Growth, Empowerment, and Trust. TARGET components can be used to measure the effectiveness of collaborative relationships, regardless of whether these relationships are between individuals and groups, patients and providers, teachers and learners, administrators and em ployees, and/or interdisciplinary colleagues.

In a global environment rapidly changed by the expansion of boundaries and use of technology, new perspectives are needed. Gadman (1997) wrote about use of the Internet as a place for collaborative dialogue. He stated, "We are free to move around, explore possibilities, see connections, and follow diverse linkages. We can anchor ourselves in our own creative home page as a basis for building our unique and energizing dialogues with others" (p. xvii). Gadman further explained how microcomputers and advanced electronic technology enhance and create new wealth by applying knowledge in new and innovative ways. Kirsner (2000-01) noted the collaborative journey, whether being initiated or sustained, is one of excitement peppered with stress. The approach he described uses new technological advances to achieve collaboration in a global environment. Kirsner contended that the biggest challenge of getting employees to work together online is cultural and organizational rather than technological in scope.

Role of Leadership: Facilitating Collaboration

These new, collaborative organizations are needed in what many authors have called a new knowledge economy.

Two important challenges are inherent in the cultural and organizational changes needed to facilitate collaboration in this new environment. The first challenge is setting the stage in the organization and facilitating both a new language of work and a new approach to working together. Leaders must work to create this new environment which encourages the people within their organization to share aspirations and interests with each other in a variety of new ways. This sharing creates not only a vision but also a subsequent approach to implement that vision. This creation/invention results from the group’s collective and diverse aspirations, experience, expertise, and perspectives. The second challenge is shaping the implementation and integration of new technologies into the vision, processes, decisions, and outcomes of the new type(s) of collaborative organizations. These new, collaborative organizations are needed in what many authors have called a new knowledge economy, or an economy based on the spread and networking of information by technology in the new global environment. Specific approaches to both setting the stage and shaping the implementation will be presented below.

Setting the Stage

Successful leaders will embrace the challenge of setting the stage and helping frame how the organization will do business in this newer, global, technological environment. This approach starts with changing such things as the language of the organization. Gadman (1997) addressed this challenge for leaders in his book, Power Partnering: A Strategy for Business Excellence in the 21st Century. His basic premise is that leaders should assist their organizational culture to move beyond traditional approaches. Rather than trying to analyze situations by taking them apart and coming to certain conclusions based primarily on the logical, scientific method, he advocates a "new logic, based on values of interrelatedness, and free access to information where ambiguity, confusion, and anxiety were primary initiators of new learning, awareness and action" (p.60). Gadman further indicated that keys to success are measured by dynamically networking new insights together and dislodging routine patterns of thinking, thereby creating a powerful synergy and new worlds of ideas and exciting possibilities. In order to change one's approach, Gadman suggested that one of the first steps is to change the form of discourse to that of dialogue – rather than debate. Use of dialogue provides opportunities for individuals and groups to avoid arguing about being right or wrong. Instead, use of dialogue encourages individuals/groups to explore differing perspectives.

Gray (1989) described this process of collaboration as transforming "adversarial interaction into a mutual search for information and for solutions that allow all those participating to insure that their interests are represented" (p. 7). Gray added that collaboration enhances joint ownership resulting in collaborative agreements. Through joint ownership, people impose their own collaborative agreements on themselves instead of relying on regulation, litigation, or intermediaries such as courts, regulatory agencies, and legislators. Joint ownership (not in the legal or structural context) can also be interpreted as a form of participative decision making and shared governance. Such issues are of growing importance in academic and health care organizations today.

Beyond fostering the dialogue versus debate previously mentioned, the leader needs to guide the organization in changing other aspects of their language. For example, shifting language from other dichotomies such as: either/ors to both/ands is desirable (Gadman, 1997). Debates and arguments about who is right and who is wrong frequently polarize people and may keep an organization from moving forward in constructive and innovative ways to stay competitive in the new global economy. Gadman further indicated that, "the ease and rapidity of world-wide communication means that every one of us is aware of multiple realities, multiple contexts or backgrounds out of which people speak and act" (p.48). Changing one's language within the culture of the organization is an important way to foster the valuing of diversity. Healthy and competitive organizations in this new global environment must learn to value difference with deference. The approach of recognizing and valuing different knowledge, different skills, and different perspectives using a both/and rather than either/or leads to a creative process that transcends any dominant group’s way of thinking.

The key is for leaders to know when to get out of the way...[and allow] the excitement of growth and new insights to take its own course.

Another important language dichotomy is that of doing/not doing (Gadman, 1997). Ziegler, Ziegler, & Rosenzweig, (1992) described this dichotomy as allowing change to happen by itself rather than attempting to control, and also working to remove obstacles that are keeping it from happening. Many times in organizations today, too much effort is exerted to control the growth and change of a culture. The key is for leaders to know when to get out of the way. Getting out of the way allows the excitement of growth and new insights to take its own course. Frequently, getting out of the way is helpful not only in altering processes but also in enhancing outputs/products of the organization by increasing creativity. According to Kirsner (2000-01), trying these new approaches is a "long leap for many companies where individuals are rewarded for controlling knowledge and highlighting their own achievements, not for sharing knowledge and focusing on team accomplishments" (paragraph 6).

It is also important for leaders to bridge the stability versus agility dichotomy. Gadman (1997) advocated creating organizations that are "stagile" – sufficiently stable enough to "provide excellent products and services, while maintaining the agility to seize rich opportunities as they emerge" (p.46).

New strategies, such as these recommended changes in logic and language, are a first step for leaders who want powerful collaboration to transform their organizations. The key is to build organizations made up of diverse people and groups, embracing "difference with deference" (Gadman, 1997, pp. 60-61). This diversity might mean different skills, different access to information, and different elements of knowledge, as well as different genders, races, creeds, ages, and histories. All are designed to contribute to the creative process. Fostering a culture of valuing differences, and valuing discourse and dialogue versus debate is critical to the collaborative organization. Next, collaborative members need to be able to get together whenever and wherever necessary. Gadman (1997) indicated that this does not have to be "face to face interaction...conversations can take place using the myriad of electronic communicating technologies currently available" (p. 60).

Shaping the Implementation of New Environment

Leaders also need to address the challenge of shaping the implementation of a new environment. Identifying ways of integrating technology into the organization for the purposes of collaboration is important. Kirsner (2000-01) provided a number of steps that are crucial to making integration of technology for collaboration happen. First, he recommended that leaders start small. Train managers and employees in small groups, subsequently allowing employees to become familiar with the software by making it available at their home workstation. Secondly, similar to other change strategies in organizations, one should find a champion. Kirsner recommends a visionary or small group or initial team to test, use, and advocate for the use of the tool in the environment. The third step is to pick a real problem, which allows the champion or small group to test the collaborative software by using it in a real situation to solve or address a real problem. The fourth step recommended by Kirsner is to fill the space by having select members plant information in the online environment so that the rest of the team can see how the collaborative software can be used. Step five is to prod employees to participate by encouraging and recognizing those who do. The sixth step is to promote the benefits by emphasizing the convenience, availability, and problem-solving power of the use of the collaborative software. Celebrating the experts is step number seven and can be accomplished through incentives and the variety of forms of recognition available within the organization. According to the Kirsner, the best incentives include verbal praise. When verbal praise is used, a sense of contribution is felt, productive group work is achieved, and ideas presented are appreciated.

Allowing controversy, new ideas, and challenges of the way software is being used and/or implemented is important.

Consistent with new, transformational leadership approaches mentioned in the previous section is the thought of "don’t be safe." Allowing controversy, new ideas, and challenges of the way the software is being used and/or implemented is important. Letting the users rule is a very important ninth step, which means that, again, the leaders get out of the way and let the users take the collaborative software to its maximum creative use. In keeping with all change processes, one must measure the effect, or impact. This measure is done not only from a cost-effective perspective, but also from a savings of time, energy, convenience, and satisfaction perspective.

By using this step-wise process, the leader has a systematic approach to introducing technology that can change the way certain processes and activities within the organization are accomplished. Thus, the leader can frequently change the nature, productivity, and employee satisfaction within an organization.

New Tools of the Trade for Collaboration

Almost any tool that supports information sharing inside and outside a company's walls has the potential to deliver value...the danger for many is overspending...without making the necessary cultural and organizational adjustments.

Historically, after grease pencils, presenters used colored ink pens on their plastic sheets. From these meager but invaluable resources presenters made "presentations" or "briefings." Then businesses with more expensive resources provided text slide services with colorful backgrounds and eye-catching fonts, followed soon with simple clip art graphics. Computer applications were then developed so presenters could create slideshows to get their points across. Subsequently, short video clips were introduced. As technology advanced and computers were networked (connected) and were running sophisticated presentation software, the ability to communicate to others in one’s group who were not even in the same room became a reality. Businesses have a need to share information within their own borders and with other businesses to facilitate the collaboration necessary to support decision making. Local or Wide Area Networks (LAN), the Internet, and/or new software that facilitate collaboration have been combined by companies that see big business opportunities to create products enhance information sharing. In fact, communication of ideas to many similarly equipped locations around the state, the country, or the world could take place simultaneously. Cost savings of time, effort, and money are evident since the software, hardware, and telecommunications systems, such as the Internet, are nowadays essentially ubiquitous and affordable within any reasonably resourced enterprise.

Almost any tool that supports information sharing inside and outside a company's walls has the potential to deliver value. Collaborative tools on the market today make it easy to coordinate large groups by enabling members to post questions, work jointly on documents, schedule meetings, and track progress toward goals. However, not every company is positioned to take advantage of the tools. Additionally, the danger for many is overspending on collaborative technologies without making the necessary cultural and organizational adjustments described above, which are needed to derive any benefit from them. Leaders need to attend to both cultural and organizational adjustments before introducing technologies which enhance collaboration. A variety of collaborative tools available today will be discussed below.

Document and File Sharing

Files (including image files) and documents may be shared over intranets or the Internet in order to facilitate the goals of groups of people. This sharing can be helpful, for instance, when individuals or groups of people who work in the same organization desire to use work, which was previously completed by others for one purpose, for a new purpose. This reusing of previous work has been facilitated in recent years by the standardization of file and document formats. Depending on the operating system and file/document and application compatibility, this sharing of files and documents can increase efficiency.

Chat and Instant Messaging

Text Chatting is analogous to a telephone call or a two-way radio except that this communication uses networked computers. Just as in multiple participant teleconferences, groups of people can chat in real-time with or without someone moderating the discussion. Chat applications enable groups to collaborate when they wish to record their discussion in a text format.

Whiteboards

Whiteboards, so named because they are used in a way similar to that of schoolroom blackboards/whiteboards, use networked computers and enable groups to almost instantaneously view and draw on, or copy and paste images onto a shared drawing board (the whiteboard). Text also can be cut/copied and pasted onto the whiteboard area. Whiteboard technology is often combined with web cam technology and sometimes with text chat and teleconference calls. The opportunities for idea and information sharing become obvious the minute one uses this technology. Whiteboards allow considerable efficiencies of time and effort over the simple, non-computer facilitated, face-to-face style of meetings.

Web Cam

Web cam technology consists of audio and video signals sent to and received by networked computers. Web cam technology can be combined into applications with text chat, whiteboard, and document and file sharing technologies, providing a very powerful collaboration toolset. If a group is in the same room with audio and video from a web cam, they can also share files and documents.

Streaming

The term streaming refers to a video stream on a computer. A video stream consists of a video clip that is sent by one networked computer to another networked computer, on which the video is displayed for the viewer. Streaming may or may not include audio.

Bulletin Boards, Discussion Groups, and Forums

Boards, groups, and forums are all email-centric, which means that email is used as a vehicle to carry the message to all other group members. Questions or comments can be submitted (posted) within categories of interest by each member to all other members. Members with answers or follow-on comments can reply. In so doing, the member’s reply is sent to all other members. The system automatically associates the original message with their associated (threaded) comments. Consequently, threaded discussions can be retrieved for later use by members with a similar or identical question. Threads can be categorized for easy key word search of content and retrieval. These applications are useful to manage non-time sensitive discussions or information sharing.

Distance Learning

Distance learning software applications support the synchronous (simultaneous use by members) or asynchronous (members access and edit the document at different times) presentation and delivery of educational or training material. In the case of portable disk-based (compact disk or mini hard drive or chip drive) systems, networked computers are not necessarily required. However, the more sophisticated, higher education-focused distance learning systems require networked computers. The features described above are normally found in higher education distance learning systems. Additionally, course schedules, teacher notes, testing, course management, and/or project tracking can be incorporated into distance learning applications.

Document Collaboration

Document collaboration software (at its simplest implementation, a set of features integrated within a quality word processing application) allows members of a group to participate in the creation or editing and development of a document. The software can normally carry out the following tasks in either a synchronous or asynchronous fashion:

• recognize a document that has had multiple contributors
• highlight changes made and who made them (by text colors)
• print out the original passage and the changed passage
• compare versions of the document
• allow the owner/originator to accept/reject individual contributors

Documentation collaboration does not necessarily require a networked computer.

Interdisciplinary Collaboration. What is at Stake?

Interdisciplinary research is needed to address a number of our pressing, health-related problems to find the best and most comprehensive solutions to these issues. These problems include issues related to patient safety, homeland security, and research. The following paragraphs will discuss how interdisciplinary collaboration can help to solve these problems.

Issues with continuity, collaboration, and coordination of care have contributed to many patient safety issues within and between health care providers and health care systems.

The Institute of Medicine report, Crossing the Quality Chasm (Committee on Quality of Healthcare in America, 2001), highlighted the need for collaboration across disciplines and other groups within the health care system to address patient safety needs. Issues with continuity, collaboration, and coordination of care have contributed to many patient safety issues within and between health care providers and health care systems. Improved collaboration in the face-to-face communication encounters, as well as those that require use of technology for collaboration, must be addressed in order for problems having an impact on patient safety to be resolved. The need for improved collaboration between physicians, pharmacists, nurses, social workers, and a wide variety of heath care providers will be a primary agenda in the future.

Another area where community partnerships and interdisciplinary collaboration will be critical for the future is in the area of health-related homeland security. Collaboration is key to facilitate the use of appropriate communication technology among provider groups, government, and private agencies in a terrorist attack, and also to address the increasing need for dissemination of information to providers, patient, families, and communities. Global technology can facilitate the sharing of strategies and lessons learned form our international, interdisciplinary colleagues, such as those from Israel, Ireland, and Spain, who have been living with terrorism for some time now.

Interdisciplinary collaboration in research and scholarship is yet another area that will benefit from more attention in the future. The true value of interdisciplinary research is hard to measure in dollars because its value goes beyond cost to the possibility of revolutionizing care and health care delivery systems. Morreale and Howery (2002-2003) have, however, described a variety of benefits accruing from interdisciplinary research which occurs as collaborators enter what the authors call an academic "trading zone." In these trading zones they exchange ideas, learn from one another, and then return to their disciplines. These benefits, resulting from the synergy and creativity of working together, include:

• improved research
• improved products and clinical interventions
• greater legitimacy when presented to the world
• improved teaching practices
• deeper sense of collegiality and future networking opportunities

Morreale and Howery have added that when disciplinary representatives meet and work collaboratively on common projects and initiatives, the ‘many hands make light work’ rule is bound to apply.

...even wise leaders who have a global. technological vision need to say that "we have only just begun!"

Miller (1994) has identified the need for "conversations at the wall" which allow different disciplines to come together and move beyond multidisciplinary and interdisciplinary collaboration toward transdisciplinary collaboration (p. xi-xiii). Miller proposed a new form of collaboration, in which he contended one can go beyond the wall into a new common space where a new shared language is created. Could the development of this new language be referring the reader back to the earlier section of this article describing leaders’ responsibility to change the language from dichotomies of debate to dialogue, from either/or to both/and, and allow both doing and not doing to foster new developments in collaborative research and scholarship?

Conclusion

Mitchell and Crittendon (2000) highlighted best the challenge of the future, using the words "interdisciplinary survival." They wrote:

Interdisciplinary collaboration must expand beyond the acute care, individual health arena to achieve our national goals of improved public health. Why now? Health care is too complex for any solo practitioner to handle it all; the determinants of health are beyond the capacity of any one practitioner or discipline to manage; information is overwhelming and is beyond the management ability of any one practitioner or discipline. One must collaborate to survivor, as disciplines and as professionals attempting to help our communities and each other to achieve better health now and in the future (p. 3).

Global health care providers now have the opportunity to address health care issues, make provider connections, educate and share lessons learned through distance learning, and extend/exchange health care practice through telemedicine/telehealth. However, even wise leaders who have a global, technological vision need to say that "we have only just begun!"

Authors

Patricia Hinton Walker, PhD, RN, FAAN
E-mail: phintonwalker@usuhs.mil

Patricia Hinton Walker, PhD, RN, FAAN is a graduate of the University of Kansas (BSN), and the University of Mississippi (MN and PhD). She is Professor and Dean of the Graduate School of Nursing at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Walker has extensive experience in academic administration and has provided leadership for innovative intensive/online distributive learning and competency-based teaching/learning. Her research and scholarship areas of expertise include: cost and quality outcomes; informatics; managed care; evaluation of community-based faculty practice through practice-based research; and interdisciplinary teaching, research and practice, and managed care. She is a former American Academy of Nursing (AAN) Senior Scholar in Residence at the Agency for Healthcare Research and Quality (AHRQ) and currently serves as a member of the Strategic Medical Advisory Group (SMAG) to Veteran's Administration leadership. In addition to her administrative role, she currently teaches courses in philosophy of science and health policy in the PhD program and leadership/management in the Master's curriculum.

Karen L. Elberson, PhD, RN
E-mail: kelberson@usuhs.mil

Dr. Elberson is a graduate of The Jewish Hospital School of Nursing in Cincinnati, OH. She received her BSN and MSN from the University of Alabama at Birmingham and her PhD in Educational Administration and Supervision from Georgia State University in Atlanta. She is Associate Dean, Director of the PhD in Nursing Science program and Associate Professor at Uniformed Services University of the Health Sciences in Bethesda, Maryland. Recently, she served as Director of Instructional Technology Services at East Carolina University School of Nursing. She has taught both undergraduate and graduate level online courses in nursing research. Currently, she is teaching courses in nursing science and ethics at the PhD level and spearheading an effort to offer many of the PhD courses online.

---