Research for academic credit in the healthcare workplace

Abstract

FigureEmployees in hospitals and other healthcare settings are increasingly returning to school to obtain advanced degrees. In addition to course papers, graduate programs often require a thesis or major paper; not surprisingly, students often look for projects where they can collect needed data quickly and easily. They may even desire to have a project address a job requirement and an academic requirement at the same time. This article reviews the potential advantages and pitfalls of conducting a school project in one's own workplace and offers suggestions for students, faculty, and managers when this occurs (see Suggestions for students, faculty, and managers). When a student is also an employee Students taking advanced courses may be assigned to a specific project on a unit or in a practice setting other than where they normally work. The matchmaking of students with settings can happen in two ways: Healthcare managers may reach out to professors with a project for which they need assistance or managers may be approached by professors or students asking about potential projects. The student who's either not employed or employed at another institution gets to try out the role of consultant, and there's “free labor” on both sides. The setting receives hours of student time, and the students and their programs receive free supervision—the trade-off is often well worth it on both sides. Managers don't have to pay for a staff member's time or an external consultant to work on a project; however, they'll often spend extra time explaining exactly what's expected and may need to follow the work closely. Students can try out new skills under supervision where stakes are relatively low and without needing to spend a lot of time establishing their credibility. But there are drawbacks, such as when the student's time in a course or on a placement runs out before a project is finished. Situations get more complicated when the student is also an employee on the unit or within the setting that he or she is writing about. The convenience of not having to find (or travel to) another site beyond school and work to complete a project can be appealing. From the manager's perspective, a student who's also an employee may have insider knowledge, connections, or permissions that may make a project run more smoothly and it may be easier to hold him or her accountable for project outcomes. But there can be complications. The student wants to be a good employee, but also needs to be a successful student. If the employer evaluates or is in some way a grader of the project, there's a dual role that can create problems for everyone. And if the project somehow doesn't live up to the manager's expectations, the student may feel special pressures and worry that both a grade and his or her standing in the organization are at stake. There are four basic scenarios for students in an advanced course or graduate program completing projects in their work settings for academic credit. The first, and simplest, is when the student writes a course paper to describe and analyze a clinical case or ongoing situation from his or her workplace. The primary concern here is making sure that the student doesn't openly name the institution and/or specific unit, or specific patients and staff members. Usually using pseudonyms and changing identifying details are sufficient. In most cases, the manager's interest in the paper is typically minimal and he or she may not even know about it. Things get blurrier when students are involved in a quality improvement (QI) project within their normal work setting that they write up for academic credit; for instance, for a course on healthcare quality. Almost by definition, a QI project is one where there's some level of manager or leader agreement. QI projects mostly involve analyzing data that are normally gathered in the course of delivering care and managing operations and service quality. If any new or additional data gathering, interviews, or questionnaires are involved, they need to fall within the scope of what the manager can reasonably ask of others. On the other hand, a research project aims at original knowledge discovery for potential applications beyond the management of a particular setting and often does ask more of patients and staff. Students, faculty, and managers need a sense of QI project boundaries, which normally don't require research ethics clearance; exceeding these limits and purposes can cause problems for everyone involved. (On a side note, it's sometimes recommended that Institutional Review Board [IRB] clearance be sought for QI projects that a student or team hopes to publish.) Action research—a specific kind of scholarship in graduate programs emphasizing leadership—is the third type of academic project that can be done in one's own workplace. In some fields, a dissertation or thesis can take the form of a detailed review of a work situation and efforts to change it. The scholar-leader analyzes a situation, but also usually intervenes and evaluates the workplace's responses to interventions or programs. Action researchers understand that complete objectivity as a participant and leader in a change project is impossible; coming to terms with this is a key part of the method. As appealing as action research may sound, not all academic programs allow this type of thesis or dissertation. There are many layers of planning and a whole vocabulary and toolkit of data gathering and analysis skills that must be mastered. Action research also demands political skills, including securing the permission of one's superior to engage in the project (and to use it as the basis for an academic paper), obtaining agreement of major workplace stakeholders affected by the project, and working closely with university faculty to ensure that the project and its write-up meet program requirements. Depending on the nature of interviews and other forms of information gathering, research ethics clearance can be necessary for some or all of the data collection. Such projects can be, and often are, very rewarding, but they must be a good fit for the overall program of study and approached with recognition that they involve considerable effort beyond just doing one's job within the work setting. The fourth, and most complicated, situation occurs when the student embarks on original data collection for a research project in a clinical setting. Normally, confidential information is sought or the needed time and effort of patients and/or staff is above and beyond what's typically required for clinical care, monitoring, or QI. This is often considerably beyond the information use in the student's role as an employee. In many clinical settings, staff members are encouraged to get involved in research and even run small team projects as part of their roles. Sometimes these projects involve replicating earlier clinical findings or testing an instrument to see if it applies or how a local setting compares with a sample in the literature. The motivations for doing local clinical research include a general desire for on-site research activity or unit staff members' particular interest in a specific clinical topic. Unit-based research is above and beyond the scope of this article; however, in most cases, it's done out of intellectual curiosity and for professional development rather than academic reasons or advancement as researchers. Just as in the case of QI projects, there can be a special appeal to employees and managers for running a local research project as an academic study. The ideas for the study can come from the student/employee or the organization. Prominent among the advantages of students collecting data in their work settings is time saved in finding an appropriate site and obtaining an entrée into a setting. Employers may find it attractive to have a degree-seeking employee working on a project that's an organizational priority because it's assumed that he or she will want to follow through in a timely manner and at a high level of performance. However, there are some potential complications. Research is nearly always examined and approved by some kind of ethics or IRB before data collection. For students in degree programs, this often occurs at both the educational institution and clinical facility. Whereas being known as a staff member may help obtain permissions to perform a study in a clinical facility (and some agencies actually require that at least one staff member be an investigator on any project taking place in the organization), being on staff at an institution can also add wrinkles to a project being cleared. Today, most clinical agencies and ethics review boards see a clinician or manager approaching his or her own patients or coworkers directly to ask them to participate in a research project as a conflict of interest. Subjects are likely to feel pressure to sign up for a study out of duty or obligation, or even a concern that they'll somehow disadvantage themselves if they opt out. Even when there are no special surveys, interviews, blood draws, or instrument readings involved, as in the case of secondary analysis (a form of research reusing data originally collected for other purposes), researchers typically need to have arms-length contact with any identifiable data they don't have a job-related reason to access (as in the case of patients for whom they aren't personally caring or data they don't need to carry out their jobs). Dealing with these ethics issues in a manner acceptable to all parties can lead to projects needing extra personnel or other costs. Challenges of note One of the main challenges of embarking on a research project as a student is that studies for academic credit are often extensively planned, involve careful literature reviews, and require regular consultation with a committee of research faculty advisors. Because the thesis or dissertation is the proof that the student has mastered research skills in the relevant discipline at the level required for the degree, the professor(s) involved usually pays very close attention to detail in relation to how research principles are reflected in the project and how it's written up. To the student and/or manager, having the student graduate and fulfilling a functional purpose for the organization are likely to be much more important. Between ethics issues and disagreements about project direction from academic versus practical standpoints, without careful planning, the supposed time savings of “easy access” to a setting and its patients or staff can quickly be erased and the student-employee may find him- or herself in conflicts between academic and work supervisors. It's also important to remember that actually carrying out research projects can be very unpredictable. The ethics clearance process alone can take months (being known to the institution or the IRB as an institutional employee may or may not accelerate getting approval) and subject recruitment and having subjects complete all necessary data collection tends to have a number of twists and turns. Coming to work in a clinical setting where one's managers and colleagues are well aware of slow or no progress on a study can be challenging, and may be doubly challenging when managers have a special stake in seeing the project finished. Some final cautionary notes about doing research in the workplace for degree credit relate to publishing and dissemination. Reporting results when findings aren't flattering to patients, clinicians, or care quality can be challenging under any circumstances; this is even truer when researching in one's own work setting. Keep in mind that even if the workplace's identity can be camouflaged in a written report, it often doesn't take much sleuthing to figure out identities of institutions, units, and even managers, staff members, or patients, especially because institutional affiliations are often part of the author's byline or acknowledgments. Also, depending on the student's career goals and the needs and preferences of colleagues, managers, and professors, authorship considerations, such as who becomes a named author on any publications resulting from a dissertation or thesis, may become complicated if not worked out up front. Careful consideration needed It's indeed possible for nurses to do academic research that counts for credit toward an advanced degree in the clinical settings where they work. However, this kind of involvement has to be thought through carefully on all sides. Understanding common pitfalls can be helpful in starting productive dialogues between students, faculty members, and managers. Suggestions for students, faculty, and managers Tips for students Recognize the trade-offs involved in doing research for academic credit on the job and be cautious about accepting compromises that may jeopardize your future at the organization or your ability to complete projects or courses and earn your degree. Understand the difference between QI and research in terms of the types of clearance required. Be extremely careful about naming patients, staff, or practice settings in any notes or drafts of papers and assignments, and about making unflattering comments/analyses about any setting (whether you work in it or not), particularly if you present or publish your work. Tips for educators Make sure that confidentiality issues are addressed if students are asked to write about or discuss clinical or management situations from their own workplaces. These include not only the obvious need to protect information that may lead to patients being identified, but also the privacy of care settings and those who work in and manage them. Think carefully before asking or encouraging students to do a large-scale project in their workplace and be ready to steer them to other settings. Tips for managers Recognize the risks of double roles (being both a researcher trainee or student and employee in a setting or being both a work supervisor and a preceptor/project advisor/evaluator). Pressures, stresses, and possible ethical conflicts can result. Staff members must be careful about mingling their schoolwork and paid work too closely and neglecting their job duties. Be understanding if employees and their professors decide that projects are best done in settings other than the student's own workplace. Help students from local colleges and universities, your own employees, and students employed by other local organizations network to find appropriate clinical settings for their academic work when necessary.