Collaborative Childcare Health Consultation:
First received
Blackwell JanuaryInc
Publishing 21, 2007; Revision received May 25, 2007; Accepted for publication August 24, 2007.
A Conceptual Model
Angela A. Crowley, PhD, APRN, BC, PNP, and Ronald M. Sabatelli, PhD
PURPOSE.
consultation between childcare providers and
nurse childcare health consultants and identified
factors that promote a collaborative relationship.
DESIGN AND METHODS.
semistructured, individual interviews of five
collaborative and five conflicted pairs of nurse
childcare health consultants and childcare center
directors. Data were analyzed following principles
of grounded theory and applying the constant
comparative method of analysis.
RESULTS.
was influenced by previous experiences and four
themes in the relationship: open and active
communication, commitment, respect, and
congruent philosophies.
PRACTICE IMPLICATIONS.
developing collaborative relationships should
be incorporated into the education of nurse
consultants and childcare directors and providers.
Search terms: Child care, collaboration,
conceptual model, health consultation
First received January 21, 2007; Revision received May 25, 2007;
Accepted for publication August 24, 2007.
JSPN Vol. 13, No. 2, April, 2008
74
This study explored the nature of Angela A. Crowley, PhD, APRN, BC, PNP, is an
Associate Professor, Yale University School of Nursing,
New Haven, CT; and Ronald M. Sabatelli, PhD,
is a Professor, Department of Human Development and
Family Studies, University of Connecticut, Storrs, CT.
A qualitative study using A pproximately 12 million preschool children spend
time in nonparental care, a large portion of which is
center- or family-based child care (Federal Interagency
Forum on Child and Family Statistics, 2006). Studies
published over the past 25 years reveal that participa-
tion in child care poses both risks, such as an increased
rate of communicable diseases and injuries (Bradely
& National Institute of Child Health and Human
Development Early Child Care Research Network,
2003; Waibel & Misra, 2003), and benefits to children’s
health and safety, such as up-to-date health visits and
immunizations (Williams & Sadler, 2001). To decrease
health and safety risks and to support health promo-
Establishing a collaborative relationship tion in these settings, the Maternal and Child Health
Bureau of the U.S. Department of Health and Human
Services funded a number of initiatives in collabora-
tion with the American Academy of Pediatrics and the
American Public Health Association to support healthy
and safe child care, including the publication, Caring
for Our Children, National Health and Safety Performance
Standards: Guidelines for Out-of-home Child Care Programs
(2002). One of the priority standards for improving
Preparation in health and safety is the utilization of childcare health
consultation services. Evidence suggests that health con-
sultation to childcare settings improves child health
outcomes, including access to health care, health screen-
ings, and up-to-date immunizations, and teacher health
knowledge, regarding health and safety practices
(Ramler, Nakatsukasa-Ono, Loe, & Harris, 2006).
However, the outcome of the consultation experi-
ence is contingent on the establishment of a positive
relationship between consultant and consultee
(Ramler et al., 2006). Professionals in health and
other disciplines report potential barriers to effective
consultation, particularly across disciplines, such as
JSPN Vol. 13, No. 2, April 2008
health and education. Differences in language, com-
munication styles, world views, goals, and orientation
to the interdisciplinary process can impose a significant
negative effect on consultation (Kendrick, 1994; McDaniel,
1995; Taras, 1994). However, no study to date has
examined the process of consultation between
childcare providers and health consultants. Thus,
the purpose of this study was to explore the nature
of consultation between childcare center directors
and health consultants and to identify those factors
that promote or inhibit a collaborative relationship.
Literature Review
Consultation is defined most often as a voluntary
and time-limited process in which the consultee seeks
assistance from a consultant regarding a problem and
seeks options for resolution (Conoley, Conoley, Ivey,
& Scheel, 1991; Wynne, Weber, & McDaniel, 1986).
Consultants are chosen based on their expertise, thus
awarding them authority within a specific focus area.
The consultant must first clarify the problem and, based
on the consultee’s goals, offer potential solutions. The
power and responsibility for enacting suggested
solutions then shifts to the consultee. The relationship
is usually terminated when both the consultant and
consultee agree that the goals have been achieved or
when one or both determine there is no further benefit
from the association (McDaniel, Weber, & Wynne, 1986).
Collaboration, unlike consultation, occurs
over time and inherently implies parity and
joint dedication to achieve a common goal.
Wynne et al. (1986) assert that establishing a col-
laborative role relationship is central to consultation.
JSPN Vol. 13, No. 2, April 2008
Unlike the traditional, hierarchical consultant–consultee
relationship, collaboration connotes “a partnership
of two providers who respect each other’s skills and
communicate in a way that enhances the care for the
target population” (McDaniel, Hepworth, & Doherty,
1992, p. 40). While consultation focuses primarily on
unidirectional knowledge sharing, collaboration con-
centrates on joint, interactive problem solving that
recognizes the complementary nature of roles (Fagin,
1992). A successful collaborative relationship requires
open, active communication, a personal relationship,
shared goals, and a commitment to work together
(Fagin; McDaniel, 1995). Consultants and consultees
often have different educational backgrounds, train-
ing, and theoretical perspectives (McDaniel, Campbell,
& Seaburn, 1989). These characteristics can interfere
with effective consultation unless both actively share
and respect each other’s frame of reference. Collabo-
ration, unlike consultation, occurs over time and
inherently implies parity and joint dedication to
achieve a common goal.
Theoretical Framework: Symbolic Interactionism
A grounded theory approach was utilized in this
study, specifically the framework developed by
Charmaz in which researchers acknowledge relevant
extant theory (2006). While early grounded theorists
advocated avoidance of preconceived ideas (Glaser,
1978), more recent scholars argue that researchers are
inevitably influenced by previous work (Henwood &
Pidgeon, 2003). Charmaz clarifies this perspective,
such that researchers should “take a critical stance
toward earlier theories . . . [which] must earn their
way into your narrative” (p. 166).
In this study, the researcher employed the theory
of symbolic interactionism, which advances an under-
standing of how social relations influence behavior
and also offers theoretical grounding for interpreting
the consultative process (LaRossa & Rietzes, 1993). The
literature on consultation and collaboration defines
the characteristics of each construct and identifies
75
Collaborative Childcare Health Consultation: A Conceptual Model
barriers, but it provides little insight into how indi-
viduals evolve a collaborative, consultative relation-
ship. Role development as a central construct of
symbolic interactionism is particularly appropriate for
studying the evolution of the consultant–consultee
relationship. Roles serve as prescriptions of expected
behavior and maintain consistency within social
interactions. For every role there is a counter-role,
which defines the complementary behavior inherent
in the role. For example, in the nurse–patient relation-
ship, there are inherent behavioral expectations in the
roles of nurse and patient.
Thornton and Nardi (1975) define four stages in the
socialization to a role. During the first two stages, the
individual takes on the role. In the anticipatory stage,
an individual learns the expectations of the role prior
to assuming the position, and during the informal
stage, the individual occupies the role and learns the
prescribed behaviors. During the latter two stages,
the individual engages in role making: learning the
informal role meanings and personalizing the role in
which the self and the role merge. In the process of
role making, individuals bring their past experiences,
including the influence of family-of-origin, culture,
religion, ethnicity, and class, to their interpretation
of a role. Socialization to a role, then, is a process of
infusing a role with self-meaning. Stryker (1981) adds
that occupants of roles are continuously assessing
themselves and others to validate their expectations
for behavior and consistency within roles. Furthermore,
role transition is facilitated when there is sufficient
anticipatory socialization and role clarity; that is,
explicit expected behaviors (Burr, 1973). Role transi-
tion is impeded when there is role conflict; that is,
incompatible expectations for a role.
Consultation and Collaboration:
A Symbolic Interactionism Perspective
Upon agreeing to consultation, individuals enter
the relationship with a view of themselves, the other,
and a perception of their respective roles. Well-defined
76
roles prescribe behavior for both participants and
ease role transition, while poorly defined roles create
ambiguity, discomfort, and limit role development.
Inevitably, due to the unique nature and experience
of each individual, the transition to a role must be
negotiated to overcome the barriers of differences.
Traditional consultation is clearly defined. The con-
sultee seeks the expertise of a consultant for a specific
purpose, accepts the power and authority of that
individual, but ultimately determines when and
whether enactment of the consultant’s recommenda-
tions will occur. The time-limited and well-prescribed
nature of this relationship require little interaction
or negotiation.
In contrast, to achieve collaboration, individuals
must communicate their perspectives and negotiate an
agreeable identity of themselves and the other, which
maximally serves both participants. Each must under-
stand and incorporate the other’s perspective into
the relationship. Although not clearly elaborated, the
literature implies that health consultation to child
care should be collaborative (Goodman, Lie, Deitch, &
Hedberg, 1986; Kendrick, 1994; Taras, 1994). For health
consultants and childcare providers to jointly work
toward the common goal of child health promotion
and quality childcare programs for children, families,
and staff, a collaborative relationship must be devel-
oped. Ultimately, the health consultant and childcare
provider must negotiate a role/counter-role that is
mutually satisfying. In order to understand the health
consultation relationship between childcare directors
and health consultants, the tenets of symbolic inter-
actionism, particularly role theory, were employed.
Methods
Design
This qualitative study explored the nature of
consultation between childcare center directors and
health consultants and identified factors that promote
or inhibit a collaborative relationship. This study was
JSPN Vol. 13, No. 2, April 2008
done in follow-up to a large quantitative study, which
included 100 pairs of randomly selected directors
and consultants who were engaged in weekly, on-site
health consultation as required by the Connecticut
Department of Public Health (Crowley, 2000). The
pairs independently completed a self-administered
questionnaire that examined perceptions of childcare
health issues, health consultant knowledge, and the
role of the health consultant.
In this study, in-depth interviews were completed
with pairs of health consultants and childcare center
directors drawn from the prior study sample. The
purposeful sample represented a wide range of demo-
graphic characteristics and experiences (Patton, 2002).
Among the pairs, half suggested a collaborative
director/health consultant relationship and half a
conflicted director/health consultant relationship.
Pairs were classified as collaborative or conflicted based
upon data from the primary study, which assessed the
degree of understanding of the director’s or health
consultant’s role. Collaborative pairs felt that the
health consultant understood the “demands” on the
director, was realistic with regard to recommendations,
and the director acted on those recommendations.
Conversely, conflicted pairs did not feel as understood
and were less optimistic about the health consultant
being realistic or the director following through on
recommendations. Other indicators of a collaborative
or conflicted relationship included the comments at
the conclusion of the self-administered questionnaires
and agreement (collaborative pairs) or disagreement
(conflicted pairs) across dyads about the importance of
health issues and assessment of the health consultant’s
knowledge in specific areas. A semistructured inter-
view guide for both the health consultants and
directors was developed for the study and included
the following domains: the role of the health con-
sultant, the evolution of the working relationship,
the perception of an ideal consultant and the extent
to which it was reflected in the current relationship,
and the value of health consultation to childcare
programs.
JSPN Vol. 13, No. 2, April 2008
Data Collection
The data collection process was iterative in nature,
guided by the principles of theoretical sampling
(Glaser & Strauss, 1967). Data were analyzed to iden-
tify categories, their properties, and interrelationships
as each interview was completed. Based on this
process, pairs with experiences relevant to the theory
emerging from the data were selected until redund-
ancy or theoretical saturation was achieved (Glaser &
Strauss). In total, 10 pairs of childcare directors and
health consultants were interviewed individually to
further explore their experiences with health consulta-
tion. The interviews occurred 9–12 months after com-
pleting the questionnaire. The location of the interview
was determined by the consultant or director with
consideration for convenience, privacy, and confid-
entiality of the participant. All of the childcare
directors were interviewed at the centers. The health
consultants were interviewed at their homes, other
places of employment, and in the community. The
interviews ranged from 45 to 90 min. All of the inter-
views were conducted by the first author. The interviews
were audio-taped and transcribed verbatim for content
by the researcher and a transcriptionist. Permission to
conduct this study was obtained from the University
of Connecticut and the Yale University School of Nursing
Human Subjects Research and Review Committees.
Analysis
The interview data of the pairs with a collaborative
relationship were analyzed first. Incidents, or examples,
were coded by category and simultaneously contrasted
and compared with similar incidents. The continuous
comparison of incidents generated theoretical pro-
perties of the category (Glaser & Strauss, 1967; Miles
& Huberman, 1994; Strauss & Corbin, 1998).
In the second stage of analysis as coding continued,
categories and their properties were compared for
greater precision. On further analysis, not only the
themes within the relationships, but the chronological
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Collaborative Childcare Health Consultation: A Conceptual Model

sequence of the relationships as well as the influence Table 1. Demographic Characteristics of Childcare
of previous experiences and attitudes contributed to Directors and Health Consultants
the evolving relationship. Theory developed during
this process of integration, and a developmental model Health
Directors consultants
of a collaborative, consultative relationship was created. (n = 10) (n = 10)
Theory was further delimited when similarities across
categories and properties were identified and condensed, Variable Mean Range Mean Range
and higher level concepts were developed. Although
Age 42.5 25–50 46 35 –70
symbolic interactionism provided a theoretical frame- Years in child care 15.9 5–30
work for approaching the interviews, the researcher Years as director 5.6 1–19
and advisors maintained a critical stance as to the use- Number of centers consulting to 4.3 1–18
fulness of the theory. During the final stage of analysis, Years consulting to this center 2.5 1–4
role theory and the concept of identity bargaining n % n %
emerged as theoretical underpinnings in the process of Some college 3 30 0 0
developing a collaborative consultative relationship. Diploma 0 0 5 50
The researcher addressed methodological rigor Associate’s degree 0 0 1 10
through several techniques designed to ensure Bachelor’s degree 1 0 3 30
credibility, fittingness, auditability, and confirmability Master’s degree 6 60 1 10
(Sandelowski, 1986). An audit trail was constructed to
document all stages of the analysis (Miles & Huberman,
1994). The researcher shared the experiences of other were White except one childcare director who was
directors and health consultants at the conclusion of African American. All of the health consultants were
individual interviews and confirmed a high degree of nurses and as a whole were less educated than the
agreement with respect to characteristics of effective childcare directors. All but one of the nurse con-
health consultation across their experiences. In addi- sultants reported some experience in maternal and
tion, the contrast between the pairs with collaborative child health. The childcare centers ranged from small
and conflicted relationships provided disconfirming (20 children) to large (130 children) and served few
evidence and further substantiated the findings. By (1%) as opposed to a large (50%) proportion of fami-
sharing and reviewing the transcriptions and results lies on public assistance. Three centers were for-profit,
with three experts, of which all had expertise in family and one of those was affiliated with a national chain of
studies, one had additional expertise in child develop- childcare programs. Of the seven nonprofit programs,
ment and qualitative methods, and another additional one was publicly funded, one was affiliated with a
expertise in social policy, the experiences and findings public high school, and one was located in a long-term
were confirmed. care facility. The centers were located in four of the
five regions in Connecticut.
Results
The Influence of Previous Experiences, Attitudes,
Demographics and the Relationship on the Role

The collaborative and conflicted pairs were com- The five pairs with a collaborative working relation-
parable in terms of demographic characteristics (see ship described the health consultant role as far more
Table 1). All of the participants were female, and all comprehensive than that which is cited in regulations.

78 JSPN Vol. 13, No. 2, April 2008

The directors considered the nurse consultants inte-
gral members of the healthcare team. The directors
and nurse consultants relayed remarkably similar
narratives during their individual interviews, spoke
with great admiration and respect for each other, and
often smiled when referring to the other. In contrast,
the conflicted pairs related a range of negative feelings
and dissimilar narratives. The directors were dissatis-
fied with some aspect of the consultant’s role; however,
some of the nurses were unaware of the tension in their
relationship. These nurse consultants had a far more
restricted role in the programs. Thus, the extent to
which the role expanded beyond minimum regulatory
requirements was influenced by two factors: (a) previous
experience and attitudes about health consultation and
(b) critical themes in the relationship.
The five pairs with a collaborative working
relationship described the health consultant
role as far more comprehensive than that
which is cited in regulations.
Role Taking
Stage 1: Beginning the role: Past experiences and
attitudes. Health consultants and directors described
the influence of previous experiences and perspectives
on new relationships, ranging from positive to
negative in nature (see Figure 1). The pairs with a col-
laborative relationship generally described a positive
previous experience with a health consultant as opposed
to only two directors in the conflicted pairs. The sea-
soned directors in the first group had very satisfying
experiences with their previous consultants and were,
therefore, better able to guide and shape the relation-
JSPN Vol. 13, No. 2, April 2008
ship. One director (D) worked with a former health
consultant (HC) who helped her develop the expanded
role within her center, and she valued that perspective.
In this case, the director was previously employed in a
Head Start program and had excellent preparation to
work with a childcare health consultant since health
coordinators are actively involved in Head Start.
D: I come from a Head Start background . . . so
when [health consultant] applied I was really glad
because not only had she had the pediatrics but she
had special needs pediatrics.
In contrast, one director among the pairs with a con-
flicted relationship admitted in the interview that she
had great difficulty with the power and influence of
the healthcare system. She initially resented the fact
that she was required by regulations to employ a
health consultant and felt it was unnecessary, as she
explained:
D: I personally have a real serious problem with
the healthcare professions . . . I’m always having to
overcome that piece that says not only do they not
need to know, but I need them out of my life.
Among most of the collaborative pairs, the directors’
previous experiences guided their selection of health
consultants, and how they shaped that role with their
consultants. In contrast, among the conflicted pairs,
they had either no experience with a health consultant
or previous experiences that were negative or of mar-
ginal value. Unless directors and consultants engaged
in an earlier constructive partnership, they typically
entered agreements with no awareness of how their
attitudes or earlier experiences or those of the other
might influence the relationship and the role.
Role Making: Identity Bargaining
Stage 2: Developing the relationship role. All of
the dyads utilized the description of health consultant
79
Collaborative Childcare Health Consultation: A Conceptual Model
Figure 1. Collaborative Childcare Health Consultation: A Developmental–Symbolic Interactionist Model
services and responsibilities as outlined in the childcare
regulations to initially guide the development of the
role within the childcare centers.
D: . . . just the very basic . . . you need to begin with,
and first you need to meet those regulations, then
you can go beyond them, but you have to meet
them first . . .
HC: When I go to a new center I start with the
paperwork . . . I know that their immunizations and
the paperwork is okay . . . if the state were to come
in tomorrow, their paperwork is okay.
80
In the simple task of maintaining records, the consult-
ant recognized that this was a serious priority for the
director, and she responded accordingly. In contrast,
the conflicted pairs described different perceptions of
the consultant’s performance of the role. One director
explained:
D: Our understanding of her job was that she was to
keep abreast of the children’s immunization records
. . . give us some direction about the whole process
. . . she came in, sometimes weekly, stayed for 5 to
10 min, sometimes took a tour of the place, sometimes
looked at the records, but she never updated them.
JSPN Vol. 13, No. 2, April 2008
 HC: I checked their medical records for their
employees and the children and made sure they
were up-to-date. Gave them a system for tracking
their infants . . . and immunizations . . .
Even in the initial descriptions of the health con-
sultant’s tasks outlined in the regulations, these two
groups presented contrasting perspectives on the
role and each other. Thus, in the absence of clear role
expectations and with little to no socialization to the
role, the relationship between the directors and health
consultants became a critical factor in defining the
scope and success of the health consultant’s role and
the director’s counter-role.
Without previous experience or orientation, some
of the directors and health consultants experienced
confusion and uncertainty during the early stages of
the role. The dyads among the collaborative pairs
were particularly sensitive to this:
D: When our nurse consultant first started, it wasn’t
that comfortable. We didn’t know her; she didn’t
know us . . . She didn’t know our purpose for being
here . . . it took time to build that relationship.
HC: The nurse before me used to run in and out,
and sign her name and leave, and have no
relationship. And when they first met me they
weren’t quite sure of me, they held back for a long
time. And then I sat down in the little chairs and
talked with the children . . . and now it’s different.
While the pairs in the first group struggled together
with how to create an effective role, the directors
among the conflicted dyads were clearly frustrated,
but they did not confront their consultants with their
uneasiness.
The development of a collaborative relationship
was contingent on four critical and interrelated themes
in these relationships: open and active communication,
comprehensive commitment, mutual respect, and con-
gruent philosophies and values.
JSPN Vol. 13, No. 2, April 2008
Open and Active Communication
Frequent, active, and open dialogue is essential
in order to define roles, particularly those that are
ambiguous. In the process of interacting, pairs not
only shared content but communicated their
perceptions of each other and the state of the rela-
tionship. Among the pairs with a collaborative
relationship, both the directors and the consultants
actively communicated with each other on a regular
basis.
D: Usually if [she] and I disagreed about a way to
handle something, we compromised . . .
HC: We were working towards the same end.
I wasn’t pushing for something that she wasn’t in
agreement with and vice versa.
In contrast, the conflicted pairs:
D: . . . she’ll call parents. . . without consulting
me . . . I feel that is something that should be dealt
with through me first, and something I talk to her a
lot about . . .
HC: I’m very concerned about allergies . . . in this
case I left messages with the mother several times
and just sent a note to the doctor . . . the mother got
extremely upset . . . [the director] may not have
thought it was such a good idea . . .
Although the nurse consultant had good intentions,
inadequate communication between the nurse and
the director created considerable stress in their rela-
tionship. From the director’s perspective, the nurse’s
failure to discuss procedures was interpreted as dis-
regard for the director’s authority. Inattention to the
process of communication and the meanings that were
unintentionally conveyed inhibited the relationship,
and the nurse’s goal of ensuring the child’s well-being
was obscured.
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Collaborative Childcare Health Consultation: A Conceptual Model
Comprehensive Commitment
All of the childcare directors were devoted to pro-
viding quality childcare programs, and they valued
health consultants who exhibited the same level of
dedication. Among the dyads with a collaborative
relationship, the nurse consultants demonstrated their
commitment by: taking the position seriously, providing
services beyond those delineated in the regulations,
offering availability and flexibility, and providing
support to the director and staff. In the estimation
of the directors, these characteristics were profoundly
appreciated and distinguished them from other
consultants. As one collaborative pair explained:
D: I think she takes the role seriously . . . She
seems to go the extra mile if her schedule allows
it, and I think that’s good.
HC: . . . the day-care consulting, if you really want
to do it right, you have to be able to do research
between your visits . . . write a letter for parents,
do a presentation for staff . . .
Several of the directors among the conflicted pairs
were frustrated by what they considered somewhat
rigid and limited availability of their consultants. The
directors also felt far less supported by their consultants.
As one pair described:
D: . . . the infection control is more facility
driven . . . I would rather have her spend more time
communicating with parents. . . The newsletter is
being worked on this weekend, would you have an
article? “No, I have no time for that.”
HC: I do what is called surveillance rounds of the
entire facility . . . The director asked me to do [a news-
letter article], and I said, “Not today, tomorrow . . .”
Although the consultant did not describe any tension
over the newsletter deadline, it was clear that while
82
the director perceived her as less available, the
consultant felt the director was inflexible. Both the
director and consultant were focused on their primary
responsibilities and saw each other as rigid and
uncommitted to meeting the other’s needs.
Mutual Respect
Among the five pairs of directors and consultants
who described a collaborative relationship, mutual
acknowledgement of each other’s expertise conveyed
respect and balanced the power across the dyads,
as illustrated by this collaborative pair:
D: And she asked, “What do you think of this?”
I said I think we should get the parents’ permission,
and you can call [the pediatrician] because [you] are
more knowledgeable [with] the terminology . . .
HC: She [director] has the final say . . . I don’t think
the nurse’s role is to dictate as to provide
information for the director.
The nurses in the collaborative pairs had high regard
for the directors and the quality of the programs they
administered. They were careful about checking with
the director before instituting changes, and they
inherently understood the importance of respecting
the directors’ role and the authority of parents and
directors. Although the nurse consultants had varying
educational backgrounds and clinical experiences, the
directors among the collaborative pairs uniformly con-
sidered the nurses to be knowledgeable and respected
their health expertise. This acknowledgement of the
nurse’s authority may have been enhanced by the
nurse’s respect for the director’s authority.
Similar to the collaborative pairs, most of the nurse
consultants among the conflicted dyads assumed the
role of health authority within the programs. This
was clearly a mutually agreed upon role. The nurses
accepted responsibility for addressing regulatory
requirements pertaining to health issues. However,
JSPN Vol. 13, No. 2, April 2008
the directors did not feel that reciprocal respect for
their role was acknowledged. Some of the directors
described relationships in which the nurses chal-
lenged their power and demonstrated clear lack of
respect for their authority. The nurses seemed un-
aware of how their needs or interests in health issues
threatened the directors’ authority, as illustrated by
this pair:
D: She [nurse] doesn’t understand that I am busy,
my job is busy . . . and she comes at all different
times . . . and she’ll expect me to just stop what I am
doing . . .
HC: . . . when I hear a hint of possibly jeopardizing
a child’s safety, I just can’t give it up.
Thus, the absence of mutual respect and the imbalance
of power between the director and the health consultant
impeded the relationship by creating resentment and
tension.
Congruent Philosophies and Values
Sharing similar philosophies and values about
caring for children and families was certainly one of
the single most important characteristics of the pairs
with a collaborative relationship. For those dyads who
discovered similar beliefs and values, their relation-
ships were strengthened, as one pair discussed:
D: It’s very important. Because if we’re not seeing,
we don’t have the same goal or philosophy, then we
could be working against each other . . . what she
sees as part of her role is to insure healthy families
. . . and I have the same philosophy . . .
HC: We seem to have a lot of similar thoughts,
approaches, philosophies on child care.
Unlike the collaborative pairs who discovered simi-
larities in their approaches to children and families,
JSPN Vol. 13, No. 2, April 2008
the conflicted pairs either identified opposing views
or one member of the pair was completely unaware of
how different the other perceived her, as illustrated by
this pair:
D: . . . she doesn’t understand, and I don’t think
that she really totally supports it [child care] . . . And
I think she thinks of me differently . . .
HC: I really like the fact that I was able to have my
children with me . . . I have children . . . I have been
a nurse for a long time, and she [director] is just
beginning . . .
Role Making
Stage 3: Achieving a collaborative relationship.
As their relationships developed, the directors and
consultants among the collaborative pairs often
spoke of how they felt comfortable with each
other, and their relationship “clicked,” as this pair
stated:
D: As far as staff members . . . I know they’re more
comfortable calling our nurse consultant because
they see her every week, and they know her, and
they have a relationship with her. And she actually
chose to have that relationship with staff; whereas,
other people have not in the past. So they know they
can trust what she has to say . . .
HC: I consider myself part of the team even though
I am only there once a week . . . I find that the
teachers are knowledgeable and they know their
kids, and so they know if they need to talk to me
about somebody . . . All these teachers are my
co-workers.
The nurse consultant was a team member. No longer
an outsider, the nurse had been accepted into the
system and was an essential member of the childcare
program.
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Collaborative Childcare Health Consultation: A Conceptual Model
An Expanded Role
Beginning with a few tasks delineated in childcare
regulations, a mandated frequency for consultation,
and little to no formal guidance on how to forge an
effective and productive relationship with a profes-
sional of another discipline, the collaborative pairs of
directors and nurse consultants not only succeeded
but defined and enhanced this role. The directors and
nurses co-created a health consultant role and director
role that included a range of services: parent and teacher
workshops; access to health information, resources,
and services for children, staff, and parents; health
and developmental assessments of children; nursing
participation in parent–teacher meetings; and on-call
accessibility. In addition, nurses acted as liaisons and
translators between pediatric primary care profes-
sionals and childcare providers. The nurses provided
health expertise and empowered staff in their roles
as caregivers. The directors also reported that the
nurses provided consultation and support for all
of the children in their programs, not only those
under 3 years of age for whom the regulations
mandate weekly consultation. Both directors and
nurse consultants acknowledged the importance of
this role and relationship and how it influenced the
quality of the program and their mission to support
the health and development of families. Directors
also came to rely on their nurse consultants as crit-
ical and respected partners, as several directors
commented:
D: I have to say that once you find a good person to
work with, and good, in terms of, again that it really
is a good relationship. It’s a big help, and it’s too bad
that we only have mandatory nurse consultants for
the infant/toddler programs . . .
D: . . . and we always mention her [to the parents]
because we feel she’s such an important part of the
program . . . We’re talking about families, not just
what the state requires but what’s important to a
84
child, . . . a program, . . . a family . . . so you take it
beyond the state [regulations] and . . . she gets right
in there with the family and . . . the staff. She does a
tremendous job . . . I don’t know what I would do
without a nurse.
During the interviews, the consultants and directors
were asked to describe important characteristics of
consultants. They uniformly listed: knowledgeable in
child health and access to information and community
resources, organized, good communication skills,
flexible, available, respectful, and values that were
consistent with the program. These same character-
istics reflected the themes that emerged in their
relationships.
A Conflicted Relationship and Limited Role
Similar to the collaborative dyads, the conflicted
pairs began with an ambiguous role and little to no
preparation. Unlike the collaborative pairs, most of
these dyads did not have previous positive health
consultation experiences, and one of the directors was
initially very negative about the concept of consulta-
tion. In addition, the relationships were confronted
with barriers that blocked further development of
the role. In all but one of the dyads, in which the
nurse was restricted from completing even minimum
responsibilities, the nurses conducted the tasks as
prescribed in the regulations. The directors found
benefit in assigning them the role of health authority.
However, the directors did not encourage their parti-
cipation in parent–teacher conferences, were less likely
to call them with questions, and rarely, if ever, sought
their assistance in communicating with pediatric
primary care professionals. While most of the directors
appreciated assistance with tracking immunizations
and health forms, which is required by regulations,
they did not consider them partners. In essence, these
nurses were never fully accepted into the childcare
team. Their comments reflected these sentiments,
as one director explained:
JSPN Vol. 13, No. 2, April 2008
 D: We have a working relationship. I’m not going
to say it’s a great relationship . . . I just don’t
think she always understands where I’m coming
from . . .
Despite the fact that these relationships and roles were
blocked by specific barriers, collectively, the directors
and health consultants identified key characteristics of
health consultants that were similar to those identified
by the collaborative pairs. Some of the directors also
emphasized the importance of trustworthiness and an
understanding of their early childhood perspective
and the dynamics and relationships within their
centers. The collaborative pairs did not include these
last two characteristics, perhaps because these attributes
were so integral to the relationships that they only
became apparent when absent.
Discussion
Achieving a collaborative, consultative relationship
between childcare directors and nurse consultants is
conceptualized as a developmental process. Similar to
the stages of role development described by Thornton
and Nardi (1975), the pairs moved from role taking to
role making. Consistent with the tenets of symbolic
interactionism, each director and health consultant
pair entered the role and counter-role with an identity
of self and the other. Figure 1 depicts a model that
illustrates the theoretical underpinning of role theory
and identity bargaining in achieving a collaborative,
consultative relationship.
To attain a collaborative relationship, each member
of the dyad was required to reexamine preexisting
perceptions, understand the perspective of the other,
and negotiate mutually agreeable identities. Therefore,
the two factors that influenced the development of the
role, previous experiences and attitudes about health
consultation, and critical themes in the relationship:
open and active communication, comprehensive com-
mitment, mutual respect, and congruent philosophies
and values, reflected the underlying process of negoti-
JSPN Vol. 13, No. 2, April 2008
ating an acceptable identity of self and other for the
director and health consultant.
To attain a collaborative relationship,
each member of the dyad was required
to reexamine preexisting perceptions,
understand the perspective of the other,
and negotiate mutually agreeable
identities.
These findings are consistent with Thornton and
Nardi’s (1975) concept of role socialization in which
individuals bring their past experiences into a role.
Among the pairs with a collaborative relationship,
similarity of experiences and attitudes across dyads
facilitated the process of creating mutually agreeable
identities. The transition was easiest for these pairs
because less negotiation was required to arrive at
satisfying, shared identities. In contrast, pairs in which
one or both partners had either a negative, a marginal,
or no previous experience with health consultation
required more effort and encountered greater diffi-
culties in developing the role.
Because identity is “self-meaning in a role”
(LaRossa & Rietzes, 1993, p. 145), the inadequate
preparation and lack of role clarity characterizing
those in conflicted pairs contributed to the directors’
and health consultants’ confusion about each one’s
own identity within the role as well as the identity of
the other. This finding is consistent with Burr’s (1973)
assertion that the ease of role transition is facilitated
or impeded depending on the degree of anticipatory
socialization and explicitness of expected behaviors.
85
Collaborative Childcare Health Consultation: A Conceptual Model
In the absence of a well-defined role, the health
consultants and directors utilized the childcare
regulations as a prescription for expected behaviors.
However, regulations provide no direction for negoti-
ating identities within roles. Therefore, because of the
ambiguity of the role, the quality of the relationship
between the director and health consultant, as defined
by their ability to negotiate mutually satisfactory
identities, guided the development of the role.
In the process of role making, four critical and
interrelated themes emerged: open and active commu-
nication, comprehensive commitment, mutual respect,
and congruent philosophies and values. These themes
are similar to those described by other investigators
who have studied the process of collaborative con-
sultation (Fagin, 1992; McDaniel, 1995; Safran, 1991).
For the pairs who achieved a collaborative, consulta-
tive relationship, in the course of role making, these
themes were evident. In contrast, for those pairs who
experienced a conflicted relationship, one or more of
these themes was absent.
The themes of commitment, respect, and shared
philosophies and values specifically define areas in
which identity bargaining occurs during relationship
development. And, although open and active com-
munication emerged as an essential theme of a collab-
orative relationship, it is the process through which
other themes are interpreted. Among the pairs who
described a collaborative relationship, during the stage
of role making and through frequent, open and active
communication, they negotiated identities that con-
veyed mutual commitment, respect, and congruent
philosophies and values. Furthermore, Berger and
Kellner (1966) explained that relationships require
continuous monitoring of each partner’s definition
of reality. The directors and health consultants who
achieved a collaborative relationship demonstrated
much greater awareness and sensitivity in this area.
Either because of past successful health consultation
experiences or other productive relationships, they
recognized the importance of nurturing the relation-
ship. Consequently, for the dyads in which the critical
86
themes of open and active communication, compre-
hensive commitment, mutual respect, and congruent
philosophies and values were mutually identified,
they achieved a shared set of identities, which they
described as “clicking.” The directors and health con-
sultants reached a level of trust and understanding
that permitted the expansion of the role and realization
of a collaborative, consultative relationship.
In addition, among the dyads who achieved a
collaborative, consultative relationship, the health
consultant role was expanded beyond regulation
requirements to include as one director described,
“. . . what’s important to a child, what’s important to a
program, what’s important to a family.” However,
the scope and effect of the role were contingent on the
director’s decision to permit full integration of the
health consultant within the childcare program. That
decision impinged on the establishment of a collabora-
tive relationship achieved through mutually agreeable
identities as expressed in commitment, respect, and
shared values.
Findings of the study should be considered in light
of several limitations. First, the sample included only
those childcare centers required by regulations to
employ a health consultant, as opposed to programs
that voluntarily seek consultation services. However,
these centers were purposefully selected because the
directors and nurse consultants were “information
rich,” that is, they had the experience of interest,
weekly, on-site health consultation (Patton, 2002). Due
to the sensitive nature of the data revealed during
the interviews, particularly among the conflicted pairs,
the researcher was unable to establish confirmability
by sharing summary findings with the participants
(Sandelowski, 1986). However, the participants often
concurred with the experiences of other directors and
health consultants, which the investigator shared at
the conclusion of the interview, while maintaining
confidentiality. Confirmability was further established
by presenting disconfirming evidence of the findings
and comparing and contrasting pairs with collabora-
tive versus conflicted relationships. Finally, fittingness
JSPN Vol. 13, No. 2, April 2008
and auditability were addressed by the two authors,
who reviewed the transcriptions and were
immersed in the data (Morse, 1991). Furthermore, the
findings were reviewed by two additional experts
who provided reality testing for the developing
theory. Finally, the first author has presented the
findings at state, regional, and national meetings to
multiple groups of health consultants and childcare
directors, who have consistently confirmed the
validity of the model.
The Maternal and Child Health Bureau has had
a sustaining interest in ensuring healthy and safe
childcare programs and recognizes the potential to
promote the health and development of children and
families in these settings. Growing evidence suggests
that childcare health consultants play a critical role in
this initiative. The Maternal and Child Health Bureau
has supported various initiatives, including the
National Health and Safety Performance standards for
childcare programs, the National Resource Center for
Health and Safety in Child Care, the National Training
Institute for Child Care Health Consultants (NTICCHC),
and grants to states to create systems of childcare
health consultants (American Academy of Pediatrics,
2004). Currently, 188 nurses and advanced practice
nurses have completed the NTICCHC Trainer pro-
gram, and more than 3,800 nurses and other profes-
sionals have been prepared by NTICCHC graduates to
practice as childcare health consultants (S. Cianciolo,
personal communication, December 12, 2006). The
NTICCHC curriculum includes content on health,
mental health, and safety issues in childcare pro-
grams and developing consultation skills for health
consultants.
This study advances an understanding of critical
factors that promote a collaborative relationship
between childcare directors and health consultants.
Furthermore, the proposed conceptual model provides
a parsimonious representation of the process of creat-
ing a collaborative, consultative relationship, which
can contribute to current preparation of childcare
health consultants. To date, the constructs of consulta-
JSPN Vol. 13, No. 2, April 2008
tion and collaboration have not been studied within
the framework of symbolic interactionism and role
theory. Evidence from this study suggests that future
investigations should explore the value of this theo-
retical perspective in understanding the process of
collaborative consultation in childcare programs and,
potentially, other settings.
How Do I Apply This Information to
Nursing Practice?
Childcare health consultation is an emerging field
in nursing and advanced practice nursing. For those
nurse health consultants who provide ongoing rather
than one-time consultation, establishing a collabora-
tive relationship with the childcare director or provider
is essential to ensure effective outcomes. Collaborative
relationships evolve in stages over time. At the start,
nurse consultants and childcare professionals should
discuss motivation for consultation, past experiences,
and an understanding of each other’s roles and per-
spectives. Partners should meet or communicate
regularly to review progress and goals. As consultation
continues, nurse consultants and childcare providers
should monitor their relationships with respect to
communication patterns, expressions of respect and
commitment, and philosophical perspectives. If
tension occurs, which can lead to a conflicted relation-
ship, issues should be explored and strategies devel-
oped to clarify and correct misunderstandings and
differences. Furthermore, these findings and the
Collaborative Child Care Health Consultation model
should be incorporated into curriculum preparing
nurse childcare health consultants.
Acknowledgment. The first author wishes to
acknowledge with gratitude her dissertation advisors,
Ronald M. Sabatelli, PhD, Jane A. Goldman, PhD, and
Steven K. Wisensale, PhD, and thoughtful review of
the manuscript by Leslie Curry, PhD. This work was
supported in part by the Research Foundation of the
University of Connecticut and Sigma Theta Tau,
87
Collaborative Childcare Health Consultation: A Conceptual Model
Delta Mu Chapter. This paper was presented at Sigma
Theta Tau International, Nursing Research Congress,
Dublin, Ireland, July 22, 2004.
Author contact: angela.crowley@yale.edu, with a copy to the
Editor: roxie.foster@uchsc.edu
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