The Ethics of Good Communication in a Complex Research Partnership

Abstract

The tripartite partnership among Morehouse School of Medicine, Tuskegee University, and University of Alabama at Birmingham is complex. In 2005, the three schools—with different institutional cultures, characters, and resources—agreed to collaborate in efforts to eliminate racial/ethnic disparities in cancer burdens. Pursuing this laudable aim predictably involved some miscommunication. The Bioethics Shared Resource (BSR) group foresaw such challenges and monitored interactions to prevent harm, noting that while effective communication is critical to the achievement of mutual goals, an understanding and prudent use of proven communication principles is a sine qua non for success. In this commentary, we share the undergirding moral concepts, communication approaches, and lessons learned. This experience has led us to propose an ethics of good communication for others to consider.

In response to a National Cancer Institute (NCI) sponsored initiative to promote cancer research and education at minority-serving institutions (MSIs), investigators from NCI-designated Comprehensive Cancer Centers (CCCs) and MSIs attended a cancer informational workshop hosted by the NCI in March 2001. The purpose of the workshop was to have investigators from both types of institutions meet and determine how they could form mutually beneficial collaborative partnerships, while also informing investigators about three of its new initiatives (the P20, U56, and U54). Each initiative was directed at increasing the cancer research presence and infrastructure at MSIs, and enhancing the ability of CCCs to better conduct cancer health disparity research through the development of mutually beneficial collaborative partnerships.

At this particular workshop, from our viewpoint as MSI representatives, there appeared to be feelings of distrust experienced by participating institutions during what we might call the feeling-out and shopping-around stages designed to find prospective partners. It seemed the main goal of partnering set out by the NCI was not primary for some of the institutions; for the most part, it was secondary to their desire to secure a new funding source. Institutions would literally be in the process of setting up a potential collaboration one day, and the next day, one of the institutions would be in new negotiations with a different institution. Often there would not be a word of explanation given for the disintegration of the relationship, leaving some institutions with a feeling of being used and disrespected. On the last day—when all partnership negotiations involving our institution seemed fruitless—our fortune changed at a working lunch breakout session. Here, the Tuskegee University representatives (Drs. Roberta Troy and Timothy Turner) met with the representatives from the University of Alabama at Birmingham [UAB] (Dr. Ed Partridge and Mr. Earl Sanders) and had constructive dialogue about the formation of a P20 partnership. The P20’s focus was on initiating feasibility studies for collaborative interactions between MSIs and CCCs. These discussions not only addressed the P20 partnership, but also envisioned our current U54 comprehensive three-way partnership, whose essential core elements were mapped out at this meeting on a napkin.

A tripartite partnership between Morehouse School of Medicine, Tuskegee University, and the UAB Comprehensive Cancer Center was built on an already-established collaborative partnership among these three institutions. Although the partnership was initially functioning under two separate mechanisms (a P20 grant between Tuskegee University and the UAB Comprehensive Cancer Center and a U56 grant between Morehouse School of Medicine and the UAB Comprehensive Cancer Center) the three partners have been effectively engaged as a tripartite unit from the inception of the P20 grant in 2001. In 2005, the existing three-way partnership was formalized via a U54 grant, which was designated as the Morehouse School of Medicine/Tuskegee University/UAB Comprehensive Cancer Center (MSM/TU/UABCCC) Partnership (the Partnership). Given the unequal burden of cancer borne by African Americans and other minority populations,^1–2 the locations of MSM, TU, and the UABCCC in Alabama place the Partnership in the right geographic region to address and have a significant impact on cancer health disparities.

The Partnership has eight components: (1) Scientific Research, (2) Research Training and Career Development, (3) Cancer Education, (4) Community Outreach, (5) Recruitment, (6) Evaluation, (7) Biostatistics, and (8) Bioethics. Biostatistics and Bioethics served as shared resources within the Partnership. Going into the Partnership, the one key component that has assured its longevity and productivity, as well as allowed it to endure and progress through its growing pains, has been the Bioethics Shared Resource (BSR). This shared resource has been guided by the ethical and bioethical expertise and conscience of the Tuskegee University National Center for Bioethics in Research and Health Care (the Center). The importance of the Center was seen from the start and therefore built into the fabric holding together the Partnership itself. The Center has stressed the importance of mutual respect and open communication by all members of the three institutions in establishing and maintaining trust and open lines of communication.

The BSR group foresaw the challenges of communicating in such a complex research partnership. The group planned for and monitored interactions to enhance benefits and avoid harm, noting that while effective communication is critical to the achievement of mutual goals, an understanding and prudent use of proven communication principles is a sine qua non for success. The Partnership has employed various means to confront the difficulty of communicating the logistics of its work and have enjoyed some success in doing so. In this commentary, we share the undergirding moral concepts, communication approaches, and lessons learned. This experience has led us to propose an ethics of good communication for others to consider.

Learning Assumptions

In learning to communicate effectively with its members, the Bioethics Shared Resource (BSR) group made a number of assumptions and utilized certain moral concepts that undergird communication approaches. They include the following:

1. Justice demands that core competencies in interpersonal relationships be demonstrated by all partners.

2. Engaging majority and minority cultures and institutions (research-intensive vs. teaching-intensive) in partnership is a complex undertaking that must be informed by procedural justice,³ interactional justice,⁴ and negotiation theories and practice.^5–6

The BSR group believed that the development and application of skills in procedural and interactional justice were critical to the dialogue and transparency that the Partnership needed.

Moral Virtues

The ten virtues that guided interactions within the Partnership were:

1. Transparency,

2. Procedural Justice,

3. Interactional Justice,

4. Negotiation and Power,

5. Epistemic Credibility,

6. Respect for Partners,

7. Humility,

8. Trust-Building within Partnerships,

9. Choosing Civility over Rhetoric, and

10. Humor.

Transparency

Transparency is a tool of good governance used within partnerships. It has an impact on how individual members will conduct their day-to-day activities.^7–9 Transparency pertains to openness in communication for the purpose of building trust within relationships. When this is done, partners are showing that they have nothing to hide, and are open to constructive criticism. In our case, such transparency has sometimes led to modification of modes of operation to remove the obstacles blocking achievement of mutual goals. An example of this was seen in what took place at our 2007 Partnership Retreat. On the agenda at this retreat, we purposely included what were called Partnership-Strengthening Working-Group Meetings to address areas of concern. We had to make a conscious decision whether to continue the Partnership as we had been doing and not express our true feelings about the relationship, or begin to be more transparent in our interactions and make the Partnership better. So under the guidance and impartiality of the BSR, we had a frank airing of our grievances, big and small, that we believed were keeping us from reaching the level of greatness for which we all strove. The complaints or concerns expressed were digested and incorporated into positive changes in the way we conducted all aspects of the Partnership’s business and viewed the worth of our partners. One of the outcomes from this meeting was the equitable distribution of power and accountability within the Partnership in terms of rotating the responsibilities for conducting meetings and symposia, and the submission of annual reports. In this manner, the transparency demonstrated by the Partnership members has led to a strong sense of trust and cohesion.

Procedural Justice

Procedural justice has been defined as the fairness of the procedures used to determine outcome distributions or allocations.¹⁰ In order for procedures involving partnerships to be considered fair, they should be applied consistently across people and time, be free from bias, ensure that accurate information is collected and used to make decisions, have some way of correcting flaws or incorrect decisions, conform to personal or prevailing standards of ethics or morality, and ensure opinions of various groups affected by the decision have been taken into account.^11–12 Principal investigators and co-leaders from the three institutions understood these concepts and brought them to life by practicing them. They modeled team spirit and the desirable behaviors consistent with fairness in procedures and perceived fairness in interactions. They embraced the notion of leadership as coordination and empowerment of partners rather than management of subordinates. For instance, face-to-face meetings were rotated between the institutions and leadership or chairing of joint meetings shared equitably. Delicate budgetary issues were also handled with tact as they arose.

Interactional Justice

According to reports in the literature, interactional justice is the variety of procedural justice that is concerned with the perceived fairness of interpersonal relationships.^4,13 This is important to consider in work relationships because unfair interpersonal treatment may lead to aggressive and retaliatory behavior.¹⁴ For instance, when fairness in critical appraisal of work in progress in our group became a question, the issue was addressed swiftly, but tactfully and forcefully with the members concerned.

Negotiation and Power

Lewicki and Litterer maintain that negotiation becomes necessary when a conflict of interest arises between parties in which there is no protocol for determining the outcome.⁶ This may sometimes be reducible to power dispute. According to Marcus and Dorn, there are three types of people when it comes to power: (1) those who do not have power and want to get it, (2) those with power who want to keep it, and (3) those who realize that if power is the only bargaining chip, then options and actions are limited.¹⁵ These researchers have observed that, “With so much energy invested in getting power and maintaining the power base, good options and decisions are rejected not because they are wrong; rather, they are rejected because they do not fortify the base of power for those in charge.”^15[p.61] In order for a partnership to be successful, the value placed on power must be minimized so it does not create a barrier to successful negotiating and compromising between group members. The BSR group maintained that in order to achieve success in collaborations, a shift from obtaining power to empowering each partner had to take place; therefore, it devoted one partnership learning experience to the issue of transparency and power-sharing discussions. Skills gained enabled members to take advantage of opportunities to negotiate issues of mutual interest germane to the success of the Partnership.

Epistemic Credibility

Epistemic injustice can prevent conferring credibility upon knowledgeable claimants in partnerships, particularly when research-intensive university partners may not count teaching-intensive university partners as credible intellectuals even when there is enough evidence to believe that they deserve to be regarded as such. In order to address this problem of recognition, the BSR group introduced the notion of epistemic credibility. Epistemic credibility accords importance to the fact that each partner is endowed with credible, specific, indeed unique knowledge and interest that should be respected and brought to bear on interactions within the Partnership.^16–18 This moral essential was exemplified within the BSR group and fostered by having representatives from each institution serve as members; treating them as co-leaders; and seeking, acknowledging, and respecting their input as bona fide in planning and providing services to Partnership members.

Respect for Partners

Immanuel Kant believed that we should treat others as ends in themselves and not merely as means to our own ends.¹⁹ This view is especially important within partnerships and implies that each partner deserves respect. Successful development and implementation of partnership activities depends on relationships based on mutual respect and requires significant time commitment and sensitivity.²⁰ For instance, by according respect and regard to all Partnership members anywhere and everywhere, and as often as it is required, any feeling of disrespect or marginalization was debunked.

Humility

In thinking of humility, it is important to understand its Latin root humilis which means humus or ground, and its application to human relationships. To be humble is to be close to the ground, “not proud, not arrogant, ranking low in a hierarchy of scale, unpretentious.”²¹ Humility was once associated with low self-esteem and low opinion of one’s merits leading individuals to dismiss what strengths they possess.^22–23 Current interpretations suggest a total detachment from strengths and weaknesses, in recognition of the fact that they should not be used to assert dominance or submissiveness in relation to others. Each individual has equal moral worth in terms of human existence. Thus, while humility does mean the tendency not to overestimate one’s merits, it does not mean permissiveness of contemptuous treatment at the hands of others, nor does it represent an attitude of passivity toward human wrongs.²⁴ “Humility reveals who we are—our self identity—and the profound connection and interdependence of our being with earth and nature.”^25[p.280] The BSR group understood the importance of this moral imperative to the success of the Partnership and provided a workshop on how to develop humility within research partnerships.

Trust-Building within Partnerships

Trust has been identified as a critical factor that facilitates the development, effectiveness, and sustainability of community-academic partnerships.²⁶ Factors affecting trust within partnerships include individual expectations, interpersonal relationships, and ethical principles.²⁷ Individuals are faced with both positive and negative feelings, which may include skepticism about working with partners, hopefulness of what can be accomplished through the partnership, and neutral or optimistic expectations.²⁸ Rather than take for granted any trust from previous collaborations between the institutions, the BSR group participated in and observed the building of trust by encouraging the sharing of expectations among partners and fostering positive interpersonal relationships via social engagements in appropriate retreat settings.

Choosing Civility over Rhetoric

Recent literature in methods of communication has suggested a shift from traditional views of rhetoric and persuasion to invitational rhetoric. Invitational rhetoric has been defined as “an invitation to understanding as a means to create a relationship rooted in equality, immanent value, and self-determination.”^29[p.5] This concept opens the door for more inviting and constructive arguments³⁰ and moves toward civility³¹ and a willingness to communicate with others. The Partnership not only encouraged civility, but swiftly corrected behaviors that fell short of this expectation, and acknowledged and celebrated appropriate behaviors.

Humor

Humor has been shown to improve effective communication within groups, development of group goals and objectives, and management of emotions. Humor leads to beneficial group outcomes which include productivity, viability, and development of its individual members.³² The use of humor and laughter between team leaders and members has been shown to reduce tension and leads to a good working environment.³³ Partnership meetings, whether formal or informal, were usually spiced with humor to lighten things up when discussions grew tense.

Communication Approaches

Taken together, the assumptions and the moral virtues previously enunciated enabled the BSR group to create a reflective space with the notion that communications do not fail, communicators do. With outstanding support from the principal investigators and co-leaders from the three institutions, this fundamental understanding allowed the Partnership to concentrate on the following approaches to ensure successful communication. Communications such as meeting notices, agendas, and requests for reports were kept real and simple. This made it easier for those receiving the message to listen and hear the message that the communicator was trying to convey. Furthermore, seeking clarification without penalty was permitted, and response was in most cases thorough.

Listening and hearing

Listening is important to the development and maintenance of relationships,³⁴ and partnership success depends on how well members listen and communicate with each other.³⁵ Individuals typically identify listening and communication as elements of a good relationship.³⁶ Leaders and members made it a point to listen to each other, and when necessary, sought clarification when something was not understood. The Partnership took the ability to listen and to understand one another seriously, and counted it as one element of the successful communication and collaboration.

Multiple tools or forums

As with many contemporary partnerships, coordination becomes a major issue. To reduce problems associated with coordination, email was a preferred method of communication. The use of email has been shown to reduce coordination problems associated with size, distance, interdependence, and scientific competition within organizations.³⁷ Evidence also shows that email is helpful for forming ties within associations.³⁸ Our experience supports these assertions. Although email has proven invaluable, evidence shows that its use is not associated with maintaining ties on an ongoing basis.³⁸ For this, other communication tools were also utilized by the Partnership when appropriate. In certain situations such as the relaying of negative messages or complicated policy changes, email was used with caution³⁹ and often replaced with face-to-face communication. The Partnership has also used instant messaging, a new form of communication that has proven useful for more rapid responses.⁴⁰

Opportunities for interactive skills enhancement

Interactive workshops have been found to improve professional practice of individuals in the health care setting.⁴¹ Workshops that focused on Respect in Research Partnerships, Humility in Research Partnerships, and Ethics in Research were made available to members of the Partnership by the BSR group.

Dealing with mistakes safely by example

Within complex partnerships, we reasoned that mistakes could not be avoided. In order to deal with these mistakes effectively, leaders and members reframed errors as effective learning experiences.⁴² Reframing enabled Partnership members to understand that it is okay to make mistakes when it cannot be avoided. Instead of punishing individuals for these mistakes, we explored what could be learned from them.

Leading by example

In partnerships, leaders must understand the concepts of role-making and vertical development,⁴³ as well as the functional interdependence between a person in a leadership position and a follower position.³⁴ The leaders within our Partnership chose to lead by example. One cannot expect members of any partnership to practice effective communication if the leaders communicate poorly.

Using appropriate language and addressing inconsistencies

Inappropriately used words can hurt, and they often do. More importantly, if words are perceived as intentionally hurtful, it may have a distancing effect on the relationship of the persons involved.⁴⁴ Condescension can harm partnerships. Partnership leaders and members were, for the most part, mindful of their choice of words and how those words may be perceived by the recipient. When inconsistencies were spotted, they were dealt with explicitly, but graciously and vigorously.

Lessons Learned

We described elsewhere in this commentary ten moral virtues that guided interactions within the Partnership. These ethical underpinnings were, in fact, the civilizing force of our relationship. In our attempt to confront the difficulty of communication in our complex research partnership, we have learned the following lessons: (1) Partners can create and maintain a reflective and safe space for listening to and hearing communications; (2) Partners can understand, take into account, and respect the undergirding moral particularities of all parties in communications; (3) Partners can affirm and enact desirable messages, images, and learning outcomes of the Partnership; (4) Partners can courageously make corrections when good intentions in communications lead to undesirable consequences; and (5) Partners can communicate with humor appropriately to lighten things up when discussing a difficult subject.

Normative Considerations and Challenges

Following Immanuel Kant’s principle—ought implies can⁴⁵—we suggest that our experience with what works in the Partnership is not impossible for any willing partner to accomplish, therefore it can be done, and because it can be done and will make a difference, it becomes an obligation to do it. The obligation should not be just a matter of etiquette or implied contract, it constitutes in our judgment the right thing to do. Therefore, based on our experience, we propose a set of normative considerations for partnerships by replacing the can in the lessons learned with ought to. This way, the set of learned outcomes become normative, and an obligation for partners wishing to settle the difficulty of communicating in a complex research partnership like ours.

We want to call attention to the fact that some masterful discussions in the literature for and against the ought implies can principle exist.^46–49 In our case, the framework of considerations stems not from the logical or conceptual necessity of the principle, but because the principle is plausible and supports a logical relationship between justice as fairness and autonomy: A person ought to perform a certain action only if he can do so or has the power and the opportunity. Our view is that people in partnerships are rational agents who can embrace the guiding virtues and are capable of acting rightly: action follows from character. But, because what one wants to do sometimes conflicts with what one ought to do, one can sometimes do something other than one ought to do. This is called the Principle of Alternate Possibilities. This principle has led some commentators to insist that can does not imply ought.^{46,48,50–52} We agree that in certain instances this may be so.

Nevertheless, we offer the normative considerations with the ethical underpinnings as a moral call to foster the development of an environment conducive to healthy partnership communications. This is particularly important when minority institutions must work with majority, research-intensive ones. We believe that choice of proper actions will bring about improvement in partnership communications and successful relationships. Furthermore, we must note that we are continuing with the process. We expect further progress to be laced with the challenges of bringing to par members that are at various stages of development. New members must be immersed in the sensibilities behind the Partnership.