Conducting research in the clinical arena is a challenging endeavor, both because the researchers have limited control over the environment and because of the high level of collaboration needed between the researchers and the clinical staff in the research setting. It becomes even more complex when the research involves an interdisciplinary research team whose members’ primary responsibility is their teaching and teaching-related activities. Yet involvement of both faculty and students in research is important. This article describes some of the challenges related to the collaboration needed by an interdisciplinary research team consisting of faculty members, students, and health care agency staff. Being aware of these challenges in planning interdisciplinary clinical research, and making plans early on to meet these challenges, can minimize the untoward effects of these challenges on a study’s outcomes. These challenges include finding an appropriate clinical site, gaining entrée to the site, establishing staff-researcher relationships, recruiting participants, involving students in the study, finding the time needed for the study, collecting the data, and obtaining adequate funding. The authors conclude that the funding challenge has the most significant impact on the ability of a faculty research team to collaborate on a research study in a clinical setting. Suggestions for meeting these challenges and enhancing the collaboration between the research team and clinical site are included.
Key words: barriers, bridging barriers, clinician participation in research, collaboration, collaborative research, collaborative partnerships, communication, faculty research, interdisciplinary, multidisciplinary, student participation in research, research teams
The educational mission of the academy identifies three role expectations of faculty in higher education: teaching, scholarship (including research), and service. Yet the relative emphasis given to each of these roles varies by institution. Some institutions place high value on scholarship development and require that faculty conduct research; and for faculty in a practice discipline, this research is often clinically based. Other institutions place a relatively higher value on teaching. The ability of these faculty members to perform clinical research while employed in a non-research-focused institution creates unique challenges.
Although a few researchers have begun to describe these challenges (Miller, Johnson, Mackay, & Budz, 1997; Pellino, 2002), greater depth in addressing these challenges and offering solutions is needed to guide future researchers and strengthen their research endeavors. One way to facilitate research for faculty teaching in settings where research is encouraged yet teaching remains the primary focus is to initiate research studies involving faculty from different disciplines and different institutions. Involving faculty from different disciplines and institutions increases the number and variety of resources for the study and provides the differing perspectives needed so often in today’s research programs. The authors describe the challenges they faced as faculty from a non-research-focused university who conducted a clinical, interdisciplinary, multi-university study and offer suggestions for meeting these challenges through collaboration. They present the solutions they devised to overcome the challenges they encountered and suggest other strategies which could be considered in similar situations.
Our interdisciplinary study, “Oral assessment and oropharyngeal bacterial colonization in intubated patients,” involved a collaborative effort between faculties from two universities, and included a nurse, dental hygienist, and microbiologist. This study also included students representing both educational institutions. The purpose of this descriptive study was to identify the changing status of oral microorganisms in the mouth over the period of intubation. We anticipated the routine mouth care that promotes healthy gingival and periodontal tissues would reduce the number of organisms potentially aspirated by the intubated patient, and in turn decrease the incidence of ventilator associated pneumonia (VAP) in intubated critically ill patients.
The specific research questions of the study were: (a) Is there a relationship between the frequency of oral care and the growth of microorganisms in the mouth? (b) How does the oral tissue of intubated patients change over the period of intubation? (c) How does the oral flora change over the period of intubation? and (d) What demographic data may be identified that correlate with the development of VAP?
The nurse researcher contacted the clinical site and coordinated the project. The setting was a 15 bed, critical care unit in a 125 bed community hospital. Although the desired sample size was 10-15 patients, the final sample included only three patients. Funding in the amount of $5,000 was received as a faculty development grant from one of the universities. Additional funding from an external agency was requested, but not granted. IRB approval was obtained prior to implementing the study.
The following protocol was used in the study. After a participant was enrolled into the study, the volunteer site coordinator nurse, a Clinical Nurse Specialist (CNS), contacted the dental hygiene department. The dental hygiene student then completed an oral assessment and collected plaque samples within 24 hours of intubation and again on days 3 and 6. The dental hygiene student also began the oral assessment using the Plaque Index (Loe & Silness, 1967) and the Gingival Bleeding Index (Carter & Barnes, 1974). A student nurse collected participant demographic data. For edentulous patients, a culture of the endotracheal tube was to be obtained by swabbing as close to the base of the tongue as possible. Upon collection, the dental plaque samples were transported to the medical sciences laboratory at one of the universities, whereupon medical laboratory staff grew the cultures from dental plaque and collected and identified organisms.
Challenges which occurred during the course of this study included finding an appropriate clinical site, gaining entrée to the site, establishing staff-researcher relationships, recruiting participants, involving students in the study, finding the time needed for the study, collecting the data, and obtaining adequate funding. Each of these challenges is discussed below along with suggestions for meeting each challenge.
Finding an Appropriate Clinical Site
Selection of the clinical site best suited for the study is of utmost importance. The researchers in this study considered potential site proximity to the universities, size of the unit, and anticipated support. Since the research team anticipated greater support would come from a unit already acquainted with at least one team member, the clinical setting selected was one in which the nurse researcher had previously been employed. As will be noted below, adequate support from the unit was often not provided even with the unit’s acquaintance with one of the researchers, thus decreasing the success of the study. Other factors to consider when selecting a clinical site would include: (a) having current or former students working in the setting who can assist with gaining entrée and developing trust by advocating for the research project; (b) involving a nurse faculty member who is presently teaching or has previously taught clinical rotations in the unit and who would be known to the staff; (c) identifying geographical ease of access to the agency, and (d) professional networking with and among staff so as to increase staff commitment to the project.
Gaining entrée to the clinical facility and specific unit is another step necessary to the success of the project. In this study entrée was facilitated by selecting a site in which one of the team members had been previously employed and by frequent collaboration with the facility during the entrée period. Written approval and support from nursing administration and the medical staff may also be required. It was important to recognize that completion of the required administrative forms and review processes may take up to six months; this time period needs to be considered in developing the timeline for the research project.
Establishing a Staff-Researcher Relationship
Because the research team members were not current employees of the clinical facility, they knew staff “buy-in” and the development of a trusting, collaborative relationship between the researchers and staff throughout the study would be essentialBecause the research team members were not current employees... staff “buy-in” and the development of a trusting, collaborative relationship...would be essential; and they took steps to develop this relationship. The nurse researcher began coordinating the project with the nurse manager six months prior to the start of the project. One month before the project was to begin, the nurse researcher initiated involvement with the staff by presenting information about the project at staff meetings; hanging a poster about the study in the staff lounge; and recruiting the volunteer site coordinator, who was the unit CNS, with the assistance of the nurse manager.
It was important to work to develop a relationship with all staff members, even though most staff members were not directly involved in this research study, because all staff members were invited to identify their patients who might be participants in the study. The challenges in obtaining staff involvement were related to a very high staff workload. Unfortunately, inadequate staffing led to loss of interest in the project by the staff; and the nurse manager resigned during the study, diminishing support for the project.
The challenges in obtaining staff involvement were related to a very high staff workload. Maintaining communication between the research team and staff in the clinical setting was also identified as a challenge by Fitzgerald et al. (2003). Although the volunteer site coordinator, the CNS, was recruited to facilitate communication so as to increase collaboration and staff member acceptance of the project, and to help integrate the project into the clinical routines of the unit, she, too resigned during the course of the study. Having a presence in the unit was most difficult for the research team members who already had full-time commitments to their faculty positions.
Although a research team cannot influence staffing in the unit, nor be present continuously, there are strategies which can help to bridge the buy-in challenge and enhance staff–researcher collaboration. These strategies include increasing interaction between the research team and staff, clarifying responsibilities between researchers and clinicians (Crow, 2005), providing frequent updates about the project to help maintain staff involvement, offering snacks and/or lunches at specific times during the study to maintain morale related to the study, giving small thank you gifts, and supplying letters of appreciation that can be included in the staff members annual performance appraisal. For those staff members actively involved in the study, authorship in the final paper can be offered.
The initial research plan called for the CNS volunteer site coordinator to review charts of potential participants for inclusion criteria and obtain informed consent. However, the CNS would frequently be needed for staffing support, eliminating her opportunity to recruit participants or interact with staff who could suggest their patients as possible participants. When the site coordinator worked as a staff nurse, she worked a 12-hour shift and hence often was not available on days when potential subjects were admitted to the unit. In such cases no one was available to recruit participants into the study. Because the site coordinator did not know ahead of time when she would be required to provide patient care, the research team did not receive adequate advance notice of her inability to review charts. Due to their teaching commitments and other faculty responsibilities, they did not have time to travel to the unit to recruit participants themselves or to get there at a time when family/significant others were visiting and could give consent. As a result a number of potential participants were lost to the study sample.
Another factor contributing to difficulty with recruitment was the resignation of the CNS with no one to replace her. This loss of support for the staff resulted in strained relationships with research team and difficulty in recruiting participants, and extended the planned time frame for data collection. These same challenges have been identified by Chouliara, Kearney, Worth, and Stott (2004), as well as Hancock, Chenoworth, and Chang (2003).
Rosenthal (2005) discussed the recruitment challenge and described the need for a “well developed mechanism and key personnel for subject recruitment” (p. 989) in order to obtain an adequate number of participants for a study. The following options could be used to bridge the recruitment challenge. One option would be to have several site coordinators for recruitment on a 24-hour basis. With several coordinators, if one has the day off, another will be there to maintain continuity in the recruitment process. Another option would be to “buy-out” a portion of the site coordinators’ time, thereby providing the site coordinator with a specific number of hours each week that would be dedicated to the project. Additionally, developing a collaborative relationship with a variety of professionals willing to assist in recruiting participants could be helpful. The best action, however, may be to hire a full-time research assistant who would be present at the clinical facility to recruit participants and enhance collaboration between the staff and research team. This action would alleviate the need for and dependence on volunteer recruiters.
Involving Students in the Study
The research team worked well together from a collaborative perspective. The ideas, knowledge, and expertise they each provided contributed to the ease of planning the research study. There were no obstacles that arose among the researchers or between the academic institutions.
As faculty, however, one of the goals of the project was to provide students with the opportunity for involvement on the research team. one of the goals of the project was to provide students with the opportunity for involvement on the research team. While the initial research budget included two students as research assistants, we, like Moore (2005) found that hiring and keeping these students was challenging. In our study one student was hired, then subsequently left for another more lucrative position. A replacement student was hired but due to health reasons could not continue on the project. The third student left school at the beginning of the project.
Actions to address the challenge of obtaining student members for the research team could include strong mentoring of these students, providing credit as an elective course or substituting course assignments for research activities, and providing sufficient funds to attract and motivate students to stay with the project. Mentoring students is an important aspect of student recruitment on research projects and requires student and faculty collaboration. Although many students will be motivated to join a research project as a learning experience, it is still best to offer the extrinsic monetary compensation along with the intrinsic learning reward.
Finding Time for the Research
As full-time teaching faculty, our primary focus was on our teaching and other academic commitments. While every faculty member has time constraints, the eight-hour clinical lab responsibilities several days a week, along with administrative and teaching responsibilities on the other days, limited the participation of the nurse and dental hygienist in this research project, a project which took them away physically from their university setting. Adding to a heavy teaching load was the time needed to travel between the Universities and the clinical setting which often took one to two hours due to traffic flow and geographical constraints. Campbell, Weissman, Moy, and Blumenthal (2001); Moore (2005); Webster, Parker, Moore, and Johnson (2003); and Yates et al. (2002) also described the time-related challenges encountered in conducting research in a clinical setting.
It is our belief that release time from selected faculty responsibilities is necessary for involvement in clinical research at an off-campus site. This release could be obtained by negotiating with the department chair to teach a heavier assignment one semester and a lighter assignment in the semester in which the research will be conducted, providing blocks of time for conducting research, or modifying teaching assignments through collaboration with faculty members within a department. Although these options may be feasible in some settings, a small department allows for little flexibility in negotiating teaching assignments. One other consideration is to plan the research for a clinical agency in which the nurse researcher will be conducting student clinical experiences. Using this setting would provide a presence of the nurse researcher to the staff one or two days per week. However, funding for release time, when it is available, may do the most to strengthen a research study.
Collecting the Data
The original research protocol called for collecting biologic specimens upon patient entry into the study and then at days 3 and 6. However, during the study, the clinical practice in the facility was modified in that faster weaning and shorter intubation times became the standard, necessitating adjustment of the study protocol for this change in practice. There is no specific action to bridge this clinical practice challenge, since changes in practice occur unexpectedly. Yet a strong collaborative relationship and clear communication with the nursing staff and middle management will keep researchers informed of any pending clinical changes and provide adequate time to make these needed adjustments.
Obtaining Adequate Funding
One means of facilitating clinical research is to increase the size of the research team and include clinical staff on the team. Although funding was obtained to cover the cost of supplies and the student research assistants, lack of additional funds made this project difficult to maintain. The need for adequate funding has been identified as a challenge by many researchers (Moore, 2005; Webster et al., 2003; Yates et al., 2002). It is estimated that twice the amount of funding received for this study was actually needed. One reason for the need for greater funding of this study was the distance between the universities and the nearest appropriate medical center in which to conduct the research. This lack of adequate funding required greater dependence on volunteer staff assistants, who as noted above, were often unable to perform the duties to which they originally committed.
To overcome this funding challenge, sufficient funding based on a realistic budget which plans for incidentals is needed. While plans were in place for staff members to identify potential participants and obtain informed consent, working with volunteers who have other priorities put completion of the study in jeopardy. A full-time, paid staff person at the clinical facility, or at least someone paid to be at the clinical facility enough time to recruit and obtain needed data, would have eliminated the difficulties associated with depending on staff volunteers, facilitated communication with the staff, and potentially improved staff-researcher collaboration. Sufficient funding would also provide for faculty release time, allowing the research team members to have more of a presence at the clinical site and enhance collaboration.
Both academic and health care institutions are financially challenged to support research. New and creative solutions to the challenges described in this article are needed. One means of facilitating clinical research is to increase the size of the research team and include clinical staff on the team. With collaboration of members from both the academic and practice institutions, the workload of a research study could be managed more easily, despite lack of compensation. Another benefit of collaborative research is the broadening of the potential funding sources. While nursing research focused on oral care may consider funding from nursing resources, broadening the research team to include dental hygiene increases the size of the funding source pool to include those funds accessible to dental hygienists. The inclusion of respiratory therapy would also have expanded the funding source pool.
We encourage future researchers to seek adequate funding before initiating a collaborative research study. Health care providers are accountable for their practice, and this practice is now being based on evidence from clinical research. Evidence-based practice to identify best practices and improve patient outcomes is needed. Mentoring students in collaborative research contributes to their career development and prepares more researchers for the future, researchers who can provide a base of evidence for our practice. Although difficult, clinical research must continue and increase to provide the best care possible for our patients.
The research team members for this study have examined the challenges that arose during their study. They have shared their solutions to these challenges, and suggested other strategies which could be considered.
In summary, the authors offer the following recommendations to enhance collaboration between researchers and clinicians:
- commit to carrying out the study, regardless of compensation
- select a supportive and committed clinical site
- allow adequate time for the entrée process
- develop trusting, effective relationships between researchers and clinicians
- establish firm plans for participant recruitment
- identify adequate incentives for student researchers
- find release time for faculty
- anticipate change in clinical practices
- assure adequate funding before beginning the study
While the planning and development stages of a research project allow the research team to anticipate numerous contingencies, unanticipated events can have an impact on a well-designed study and strain the collaborative relationship. Of all of these challenges, we believe the funding challenge is the one that can have the most significant impact in the ability of an interdisciplinary faculty research team from non-research-focused colleges and universities to conduct clinical research. We encourage future researchers to seek adequate funding before initiating a collaborative research study.
Sharon K. Broscious, DSN, RN, CCRN
Sharon K. Broscious, a faculty member at the School of Nursing, Troy University/Atlantic Region, was a member of the interdisciplinary research team conducting this research. Her teaching focus is adult medical-surgical nursing and critical care. Her background as a critical care nurse and her many years of clinical experience led to the idea of examining mouth care in intubated patients using an interdisciplinary research team to do so. Sharon received her DSN from the University of Alabama at Birmingham and was on the faculty of Christopher Newport University when this project was conducted. Her professional activities include program consultation, providing expert witness, and serving on the Advisory Council for the Dental Hygiene Research Center at Old Dominion University. She has made numerous presentations at local, regional, national, and international nursing meetings.
Michele Darby, BSDH, MSDH
Michele Darby has been a faculty member at Old Dominion University since 1974 where she has served for seven years as chairperson and over 20 years as graduate program director. From 1972-1974, she was an Instructor of Dental Hygiene at Columbia University. Michele has published three books on dental hygiene. In addition to an active publication record, Michele has served as Editor of Educational Directions, Journal of the American Dental Hygienists’ Association Foundation, and as Editor of Dental Hygiene, Journal of the American Dental Hygienists’ Association. She is a long-time member of the Editorial Advisory Board of the Journal of Dental Hygiene, and currently serves as associate editor of the International Journal of Dental Hygiene, and editorial advisory board member of Dimensions of Dental Hygiene. She has served on several collaborative research teams focusing on the clinical evaluation of various oral care interventions, products, and devices. She has made numerous presentations at national and international meetings.
Karin C. Loftin, PhD
Karin C. Loftin graduated from the University of Texas Health Science Center at Houston, Graduate School of Biomedical Sciences, during which time she studied the inflammatory response to dental plaque in non-human primates. She has served as a research associate both at the Texas Medical Center in Houston and University of Texas Medical Branch in Galveston. From 1989-2000 she worked as a senior research scientist in medical and environmental sciences for Wyle Life Sciences, a NASA contractor at the Johnson Space Center in Houston. In 2000 she became a visiting assistant professor in microbiology and in 2002 adjunct assistant professor at Old Dominion University, Norfolk, VA. In 2002 she also joined the Norfolk Department of Public Health as a microbiologist supporting their arbovirus environmental surveillance program and working in their biosafety level 3 laboratories. Her numerous peer-reviewed articles are published in a variety of research areas and her presentations have been at national and international meetings. She has participated on many multidisciplinary research teams throughout her career. She is currently a trainer in Biological and Chemical Safety at the University of Texas Medical Branch in Galveston, Texas.
Article published November 30, 2007
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