Interdisciplinary Team Conflicts Among Forensic Nurses and Rape Victim Advocates

Abstract

To address the acute needs of rape survivors, forensic nurses and victim advocates provide integrated holistic care. Research suggests that conflicts between nurses and advocates can be common, but the nature and causes of these conflicts are largely unknown. Utilizing a qualitative case study approach, this study examined how and why an advocate–nurse team experiences conflict. The advocates reported experiences of subordination and disruption of their services, while nurses indicated that the advocates portrayed them negatively and distrusted their professional judgment. Role ambiguity contributed to these conflicts, whereas trust mitigated these conflicts but only existed among experienced nurses and advocates. The findings will be discussed from a feminist organizational lens.

Similar to many social work organizations, rape crisis centers (RCCs) began as volunteer-led grassroots organizations that eventually became professionalized (Woody & Beldin, 2012). RCCs were developed in the mid-1970s in the United States to provide crisis interventions that normalize rather than pathologize survivor reactions. These feminist organizations also engaged in political activism to address sexism and other societal factors that contribute to sexual violence (Campbell, Baker, & Mazurek, 1998; Kemp & Brandwein, 2010). Aligned with feminist principles, RCCs favored nonhierarchical structures because they believed organizational hierarchy emulated the dominance of males over females (Macy, Giattina, Parish, & Crosby, 2010; Riger, 1994). Thus, RCCs often practiced collective decision making and viewed all members as equal.

Over time, the original leaders left, and new leaders joined the RCCs with more conventional approaches to organizational development (Campbell et al., 1998). The RCCs began accepting government funding that required boards of directors to govern their agencies (Riger, 1994). Furthermore, social workers and other professionals joined RCCs to administer the programs or provide counseling, but there were concerns that these professionals lacked understanding of sexual violence within a feminist framework (Woody & Beldin, 2012). The addition of professional service providers also led to a stronger focus on counseling, but less on social change (Ullman & Townsend, 2007). While earlier RCCs publicly protested systems (e.g., legal), modern RCCs have taken a less confrontational approach by collaborating with systems. However, this approach can be problematic if RCCs avoid confronting systems that fail to meet survivor needs in order to maintain nonadversarial relationships (Ullman & Townsend, 2007).

As RCCs grew, many struggled to maintain their collectivist structures, as shared decision making can be time consuming and less efficient for larger organizations (Riger, 1994). Hierarchical structures replaced the flat structure, and bureaucratic practices supplanted some feminist organizational principles. For example, participation in decision making shifted from volunteers to administrators. While these changes yielded organizational stability, the shift to professionalization brought concerns that the feminist philosophy would no longer guide services and organizational practices. As a solution, some RCCs have transformed into feminist–bureaucratic hybrid structures to maintain organizational survival while embracing feminism (Ashcraft, 2001). However, this blend of hierarchical and egalitarian principles makes organizations vulnerable to conflicts and power struggles because of their opposing stances: Hierarchies promote dominance–submission interactions, while egalitarian models foster partnerships that support shared decisions and contributions. These tensions are further complicated when an organization has competing ideologies among its members. For example, some staff espouse feminist beliefs supported by the earlier RCCs, while others may be unaware of the antirape movement history or mission, operate from a gender-neutral ideology, and/or view their employment as a job rather than a cause (Nichols, 2011). These competing ideologies can have a profound impact on organizational functioning that causes conflict among staff.

These organizational and ideological shifts may provide a lens for understanding conflicts between RCC advocates and sexual assault nurse examiners (SANEs) that have been identified in recent research (Cole, 2011). SANE programs are staffed by specially trained forensic nurses who provide health care and medical forensic exams for rape survivors (Department of Justice, 2004). RCCs have working relationships with SANE programs and in some instances, the RCCs administer the SANE programs (Campbell, Patterson, & Lichty, 2005). RCC advocates work alongside the nurses by providing acute crisis intervention that includes providing emotional support, dispelling misperceptions of rape, and ensuring that the legal and health care systems treat survivors with sensitivity (Campbell, 2006; Patterson, 2011).

The few studies that have examined tension between the nurses and advocates found that the common sources of these conflicts revolve around autonomy, control, and “turf” issues (Cole, 2011). In a national survey, Cole and Logan (2008) found that 80% of SANE program coordinators reported power struggles between advocates and nurses within their programs. Similarly, SANEs interviewed in four East Coast states reported that the advocates engage in power struggles by overstepping their boundaries. In contrast, crisis workers from sexual assault programs in Virginia believed nurses overstepped their boundaries by trying to provide the emotional care typically provided by the crisis workers (Payne, 2007). Role ambiguity has been another source of conflict. Crandall and Heltizer (2003) found that the role of advocacy became less defined with the development of nurse–advocate teams. In addition, Cole and Logan (2008) found that 44% of SANE coordinators reported a lack of agreement between nurses and advocates about each member’s role.

The current study expands the literature by utilizing a qualitative case study framework that can provide an in-depth understanding of these tensions within the context of an organization’s history (Creswell, 2012; Stake, 2005). The current study aims to better understand the dynamics and complexities of conflicts experienced by an interdisciplinary team of advocates and forensic nurses. In particular, our study focuses on how an advocate–nurse team experiences conflict and why this conflict occurs during their care of survivors. Further, we will discuss the findings from a feminist organizational lens.

Method

Participants

This study was a result of a long-standing research partnership with a large Midwestern U.S. RCC that provides advocacy and SANE services. Similar to other RCCs, the organization began as a volunteer-run grassroots organization in the late 1970s and became professionalized in 1990s. The RCC has a feminist–bureaucratic hybrid structure with multiple layers, including an executive director and an assistant director who supervises department directors/coordinators of their therapy, advocacy, and SANE programs. The directors and therapy staff are primarily master-level social workers, while their advocacy program is staffed by volunteers. The forensic nurses are RNs who hold contractual employment with the organization. Both disciplines receive their own discrete training, but both learn how to approach survivors compassionately. However, only the volunteer advocacy training covers the history of the antirape movement, teaches them how to interact with survivors from a feminist empowerment model, and frames their work as part of a movement. The first author has observed these trainings and read program policies that informed the study. Sample eligibility includes advocates and nurses who provide services to rape survivors.

The first author attended staff meetings to introduce the study to potential participants who were asked to complete a contact form if they were interested in participating. All of the 11 nurses and 13 advocates completed a form and were contacted to schedule an interview. One nurse did not participate due to scheduling conflicts resulting in a final sample of 10 nurses and 13 advocates (96% response rate). This is a reasonable sample size for a qualitative study examining a phenomenon in depth (Creswell, 2012). The average years of experience were 5 years, with a range of 3 months to 15 years. The number of survivors served ranged from 3 to 900, with an average of 213 cases.

Procedures

The first author conducted the in-person interviews in a private location convenient for the participants. Field notes identified emerging themes and topics that needed more exploration in subsequent interviews (Creswell, 2012). The interviews, which were recorded and transcribed, ranged from 31 to 90 min in length, with an average of 54 min. The procedures used in this study were approved by the Wayne State University institutional review board.

Measures

The semistructured interview protocol was informed by the literature on the team dynamics of forensic nurses and advocates. In addition, we consulted advocates and forensic nurses locally and nationally and revised the interview protocol following those consultations. The interview explored the nature of the team functioning between forensic nurses and advocates and how to improve functioning. The current study examined the second and third areas with a primary focus on the interactions that occur during the team’s routine care of survivors. Specific interview questions included (a) what is similar and different between the role of the advocate and nurse, (b) in what ways do the advocates and nurses work well and not work well as a team, and (c) what would help the team work better together?

Data Analyses

Consistent with Creswell’s (2012) method of case analysis, data analysis began during data collection by writing a detailed description of the advocate–nurse team. Next, two analysts independently read the transcripts, wrote memos, and formed initial codes, which led to the identification of themes. The analysts discussed themes and revised the coding framework until there was consensus. Once the coding framework was finalized, we used an analytic induction method (Erickson, 1986; Patton, 2002).

Patton (2002) asserts that the “ultimate test” (p. 561) of credibility rests with the primary users of the findings, so the findings were shared with five supervisors/directors (two of whom participated in the study because they provide direct services to survivors) in the focal program as well as the advocates and nurses. The supervisors and the participants noted that the findings accurately reflected the current tensions between the nurses and advocates.

Findings

Devaluing Advocacy

Larger RCCs often become decentralized into multiple service programs that can result in members in each unit lacking an in-depth understanding of each other’s roles and services (Riger, 1994). In addition, decentralization can promote competition that may result in members failing to acknowledge or value each program’s contributions. The current study found that the advocates and nurses struggled with these decentralization effects.

Importance of advocacy

Most ¹ advocates believed that the nurses regarded the advocacy role as less important in the care of survivors:

I don’t think they realize how important we are. I’m not sure that even some of them care. They feel like they’re the nurse they’re collecting the evidence and the evidence is the most important thing and I see it differently because if I get a survivor in there that decides they don’t want the exam I still help them with their emotions and it’s your emotions that you have to live with. [A106]

This belief that nurses value evidence collection more than advocacy may be due to the fact that evidence collection is such a large focus of a nurse’s time with the patient. In addition, advocates believed that nurses may not recognize their contributions to the patients’ well-being because emotional care is less tangible than other types of health care services. Interestingly, several nurses viewed advocacy as equally important or more important than their own role.

They are actually more important to the patient than I am. In that acute care and even in the whole process, they are the star of the show with the patients…because of the support that they give them. We are a patient-centered program and that’s what they need. They’re vital; I couldn’t do it without ‘em. [N201]

These nurses explained that advocates were more important because they helped survivors feel comfortable with the medical forensic process. Four nurses did note, however, that other nurses or the program as a whole viewed the nursing role as more important.

I think that probably the advocates view the advocates’ and nurses’ role as equal, but I think probably overall that the nurses probably feel like their job probably [is] more important. I think sometimes as nurses we get so focused on the, the evidence part of it, that sometimes maybe we’re not really realizing how important it is on an emotional level for that patient, what they’re going through, how emotionally this can make a big difference in how they deal with this overall…The emotional part of it is just as important to that patient as the physical part of it. You may leave there with no injuries, but that doesn’t mean that you’re not hurting emotionally. [N206]

Some nurses noted that emotional care can be overlooked, given the strong focus on forensics in the nurses’ training, as well as the criminal justice system’s primary interest in evidence.

Subordinate role

The focal RCC also operates from a feminist–bureaucratic structure, where units may espouse opposing hierarchical and egalitarian principles. The findings suggest that the nurses may operate from hierarchical principles, as evidenced by the fact that most advocates said it was common for nurses to treat them like assistants.

There are the nurses that I get the feeling that they don’t understand or respect what we do. Like the ones that have been like, “Can you make these copies for me,” or kind of like just brushing [me] off, like I’m an assistant, or a secretary. I know that’s been an ongoing problem with a lot of advocates. In those cases no, I don’t feel like I am an equal. [A103]

The advocates embrace egalitarian relationships and thus, they believed these requests diminished their role. However, most nurses did not realize these requests might cause the advocates to feel like subordinates. From the nurses’ perspective, these requests were made to expedite the process, so they could leave the site quicker. The advocates and nurses leave the site together for safety reasons, and the nurses believed enlisting the advocates’ help would allow the team to leave sooner.

It’s that whole thing of being the team and do you want to sit in here and wait while I clean up that room and I’ve still got copies to make and I’ve still got the kit to close and la, la, la, la…If it’s two or three o’clock in the morning, why not? [N202]

The seasoned advocates, meanwhile, typically offer to clean the exam room and photocopy, but only for those nurses with whom they have an established egalitarian relationship.

Most of the nurses feel like we are their support net and they need to boss us around. They are the fully trained forensic nurse in charge of this whole shindig, when that’s not really the case. Now, not all of them feel this way. Some of them are really understanding and the more seasoned the nurse, the more they understand what our role is. So seasoned nurses and seasoned advocates really tend to work well together, new nurses and seasoned advocates not so great. The new nurses don’t understand what we do, they don’t know what our role is…Of course, if I’m treated like an equal and they say, oh my gosh can you please help me so we can get out of here, will you make these copies so I can do something else? Of course I’ll do them for you. But if you just throw paperwork at me and demand that I make copies, that’s not going to work out so great. [A102]

When the seasoned advocates feel like colleagues rather than assistants, these tasks feel less demeaning and are perceived simply as a mechanism to expedite the process. Only a few of the nurses, primarily those with the most experience, recognized that advocates are more likely to resist these requests when they feel treated like assistants.

That [cleaning and copying] definitely makes them feel like an assistant. Like what you’re doing is asking them to do a menial task. Like Xerox the chart or do this instead of really asking them, “Whattya feel about this case?” Because you don’t have time to communicate, but if you did have them do that and then you went to a meeting and talked about the cases, a case review…then they would understand that you {advocates} are important. [N208]

Seeking the advocates’ professional opinions about cases may signify that the nurses value the advocates and perceive them as colleagues. Several nurses and advocates indicated that case reviews, wherein the advocates can offer their opinions, may mitigate feelings of inequality.

Disrupting advocacy service

Feminist–bureaucratic models can result in dominance–submission dynamics among colleagues (Ashcraft, 2001). This dynamic was described by the advocates in the form of nurses disrupting them while they provide services to survivors.

I’ve had nurses—I don’t wanna say bust in—but just come in, tap on the door, open it up and say, “You ready?” I’ll let you know when I’m ready…I think sometimes they rush it along, they want to push it along to get out of there…But you gotta get these people to feel safe before they’re brought back into [the exam room], they’ve just been violated…[A113]

Advocates believed these disruptions usually occurred when the nurse was ready to begin the exam. In these situations, the length of the crisis intervention may become dictated by the nurses’ schedules rather than the advocates’ assessment of the survivors’ emotional needs, which minimizes the value of advocacy services. Further, the advocates believed these disruptions resulted from the nurses’ limited knowledge of their role. As noted earlier, limited knowledge of roles can occur in decentralized RCCs, because interactions often decrease between programs.

For their part, the nurses did indeed have a limited understanding of crisis intervention, with most describing an elementary process that would not require a high level of skills:

They’ve [advocates] got paperwork they’re filling out, but I think they’re just reassuring and letting the patients know that they’re there for them…[N204]

The nurses’ limited understanding of crisis intervention may be due to the fact that they are not allowed to witness the intervention for confidentiality reasons. This may also be why some nurses were confused about the varying lengths of crisis interventions that may last more than an hour for survivors who need time to process their emotional reactions, while others may take a few minutes for those who prefer not to speak with an advocate:

I mean every advocate sort of does something a little different because we’ll have some advocates that will sit with the patient for like a half hour, then I have other advocates that they go in, introduce themselves and the next thing I know, I’m going in. I don’t know what the big difference is, but I know the personalities of the people are different…They’re [advocates with lengthy interventions] very, very proactive, too overzealous, over-enthused. I wonder sometimes if their opinion isn’t being put on the people [survivors]…[N210]

Then there’s the other extreme, that’s overly motivated or whatever you want to call them. Where they’re in there for a half hour to 45 minutes, and lord only knows what they’re talking to them about, and then when you come in the room it’s like, {the advocate says} “we’re going to do this, this, this, and this,” and it’s like, uh no we’re not. You can just see them [survivors] kind of turning into themselves…The role is almost like a parent/child. You know how when a parent takes over and a child just kind of sits there and numbs up, and doesn’t say anything, and that type of thing? That’s what I see with a pushy advocate. [N204]

This suggests that the nurses may be confused about the purpose and process of crisis intervention, given that the length of an intervention depends on the needs of survivors. For example, some survivors may prefer having the advocate communicate their needs for them, making the advocate appear “overzealous” when in fact they are following the survivors’ wishes. This lack of understanding may cause nurses to become suspicious or distrustful of advocates, making it more likely that they will disrupt lengthier crisis interventions. Although the nurses are not witnessing the intervention, they are assessing its quality based on its length, the advocates’ communication following the intervention, and prior experience with the advocates.

Disrespecting Nurses

Unrecognized commitment

RCC advocates have a long-standing commitment to the antirape movement and may view their colleagues as less committed if they do not. In the focal program, several of the nurses interviewed believed the advocates viewed them as uncaring or doubted their commitment to survivors.

They {advocates} think that they are the ones who can help the patient, we {nurses} can’t help them {survivors}, we don’t care about them. I just feel like they can’t trust that anyone is going to provide anything good for the patient except for them…And I am not the ER nurse. I have put my own time, and money, and sweat and blood into this. Why would you think I’m not going to provide good care?…I’ve spent thousands of hours and thousands of dollars to be here to provide good care, and I don’t feel that I get that respect at all. I feel like I’m treated like the average Joe ER nurse, who doesn’t know crap about this and has no regard for the patient’s feelings. [N203]

The nurses attend several training sessions that require most of them to take time off from work and pay for some of their own trainings and educational resources. For nurses, this financial and time investment signifies their commitment to survivors because it develops their skill set to provide the best patient care. While the nurses view their commitment from an occupational standpoint, the advocates use participation in antirape initiatives as a measure of commitment. For example, several of the advocates expressed annoyance that nurses do not attend agency events aimed to rally against and raise awareness about sexual violence.

I’ve never seen them attend anything that we do, even Take Back the Night…I think you can make some allowances to support the program other than when you are getting paid and I don’t see them doing that. [A106]

Several advocates believed this absence meant the nurses will only participate in survivor-related events if they are being compensated and thus, they do not care about survivors outside of their compensated role. On a similar note, a few advocates perceived themselves as more committed to this work because they volunteered their time, while the nurses were paid. Interestingly, several of the nurses were unaware when these survivor-related events occurred, while the advocates appeared unaware of the financial investment that the nurses have made.

Being portrayed negatively

Decentralized RCCs often have less communication between programs that can limit their understanding of each other’s roles and fuel distrust, which presented as another theme. Several nurses felt disrespected when the advocates portrayed the nurses negatively to others, which may occur when advocates do not understand the boundaries of the forensic nursing role.

We’re [nurses] used to the shortfalls of health care and the limitations of health care. I don’t think advocacy understands that sometimes that there’s just nothing more you can do. And it doesn’t mean no one cares, it’s just their hands are tied…I don’t think they understand when to stop fighting the system and just say “I’m sorry it sucked. And not that anyone failed, and not that anyone didn’t care, it just sucks sometimes.” I don’t think they understand that sometimes there’s just limitations…Instead of understanding and respecting that there’s limitations, other disciplines get bad mouthed…They run their mouths and not appreciate limitations, and it ends up negatively on other disciplines. Like “they’re {nurses} bad, they didn’t do this, that’s awful.” As a nurse, I have some different legal obligations, as far as reporting and things like that, that are going to be different…[N203]

The forensic nursing role involves an inherent tension because it has multiple objectives: provide empowering patient care, collect medical forensic evidence, fulfill mandatory reporting requirements, and maintain objectivity. The nurses believed the advocates who do not recognize these role limitations tend to be the ones who speak negatively about them. Overall, it does seem the advocates have a narrow perception of the nursing role, with most describing the nurses’ primary goal as collecting evidence.

The nurses are going to treat the survivor as a crime scene. We {advocates} are going to be viewing her as somebody who is just trying to get through a really horrific situation. [A101]

The nurses feel that they service law enforcement and we feel like we service the survivor. [A102]

Most advocates appeared unaware of the nurses’ competing responsibilities, which may influence their view that nurses are case centered and apathetic toward survivors.

Distrusting the nurses’ judgment

Finally, nurses felt disrespected when advocates did not trust their judgment or tried to tell the nurses what should be done during the exam.

In fact, I really feel there are weak advocates that don’t trust nursing is going to do their job. I’ve been to a hospital because they’re {survivors} unconscious and I’m getting in trouble because I didn’t bring an advocate. Well, I’m respectful of their {advocates} time. She’s not alert. She’s not awake. There’s no family there. Please have enough respect for me to know that if I need you, I will call you. If I don’t, there’s a good reason. Trust me enough. I’m not the average ER nurse. Trust my judgment enough that I’m going to do my job too. [N203]

The nurses feel disrespected when the advocates do not trust their nursing judgment or regard them as the “average ER nurse.” The advocates never verbalized distrust of the nurses directly; however, an underlying theme of mistrust surfaced when the advocates described nurses who do not respect or value advocacy:

There has only been a slight few [nurses] that haven’t [respected me] and it just makes it difficult, it just makes it a little harder because as an advocate I personally feel a little more on edge for the survivor when it’s like that, and more concerned about what they’re going to say and what they’re not. If the relationship [is] not there then there’s a little more concern about what they’re going to say [to the survivor] when you’re not in the exam room with them. [A104]

This distrust was not evident between seasoned advocates and seasoned nurses who characterized their relationships as mutually trusting and respectful because they understood one another’s roles. Thus, staff with egalitarian relationships had fewer conflicts with each other.

Discussion

Similar to prior research, the advocate–nurse team experienced problems with power struggles, inequality, and disrespect. The primary contributing factors of these conflicts include role ambiguity, differences in values and norms, and distrust. To understand how these tensions manifest, we will utilize two feminist organizational frameworks that consider the organizational structure and growth as sources of conflicts. Riger (1994) identified multiple stages of growth in feminist organizations and posits that organizational growing pains influence many tensions within feminist organizations. The focal organization is in the final stage of Riger’s model (elaboration of structure), which occurs when the organization grows large enough to require decentralized multiunits for effective functioning. These units have specialized functions (e.g., advocacy, therapy, and SANE) and are often afforded more authority over their services. Because these units have smaller staff size, they have the capability to engage in participatory practices common in the earlier RCCs. However, Riger noted that conflict and competition can be common between units. Ashcraft (2001), meanwhile, examined RCCs with a feminist–bureaucratic hybrid structure that tried to maintain egalitarian practices within a hierarchical relationship. Ashcraft found that an organization with this structure vacillates between feminist and bureaucratic principles, leading to confusion and conflict.

In the focal organization, the advocacy program began during the grassroots period of the organization and then became decentralized as the agency grew. Because this program is decentralized and maintained by volunteers, it has been able to maintain its grassroots and avoid layers of hierarchy within its unit. While the program is coordinated by an employee, the advocates have noted that they engage in participatory decision making similar to feminist collectives from earlier RCCs (Kemp & Brandwein, 2010). It may be possible that they are less influenced by bureaucratic features of the larger organization because the advocates provide services at an off-site location and have minimal contact with staff beyond the advocacy coordinator and nurses. The SANE program was developed by the RCCs after they became professionalized. Although the SANE program could function as a collective, the unit appears to operate more like a traditional hierarchical structure found in health care settings (e.g., director-influenced decision making). The nurses also have minimal contact with RCC employees and thus, their structure may be influenced by their employment in other health care settings, primarily emergency departments (EDs), where hierarchical structures are common. In both Riger’s and Ashcraft’s work, organizational structure and ideologies can promote conflicts. The discussion section will draw on these frameworks to illuminate how organizational structure and ideologies may influence conflicts.

Ashcraft (2001) suggested that conflicts occur when an organization is operating from two opposing organizational structures. For instance, the advocates’ feminist framework emphasizes collaborative relationships that distribute power based on expertise rather than hierarchy (Bracken, 2011; Campbell & Hovmand, 2004; Kemp & Brandwein, 2010). In contrast, most forensic nurses have extensive experience working in hospitals and EDs, which are traditionally hierarchical in structure with less emphasis placed on equality and feminist discourse (Martin, 2005). Furthermore, the ED environment requires nurses to provide patient care and engage with other professionals expeditiously. Most participants mentioned the nurses’ desire to expedite the process in multiple contexts, which suggests that the fast-paced norms of the ED may contribute to the tension with advocates. Ashcraft also notes that hierarchical bureaucratic structures can promote a dominance–submission pattern. Although the advocates and nurses are technically equal on their organizational chart, the nurses seem to serve as the guardian of the process during service provision by disrupting the advocacy services and requesting clerical assistance from the advocates. In these instances, the nurses are showing a dominant pattern of power common in hierarchical organizations, while most advocates comply with these requests to “keep the peace” placing them in the submissive role. While the advocates desired equality similar to their experiences within their own program, many noted that they comply to avoid overt tension.

Riger (1994) suggested that conflict can occur as RCCs shift to bureaucratic organizations because veteran staff may hold onto their feminist principles, while newer staff may view sexual violence from a medical model. In particular, conflict occurs when members do not accept divergent beliefs. This appears to be one factor that has influenced tension between the programs. The advocates receive training grounded in a feminist framework that guides advocates to believe survivors and promote survivors’ self-determination by honoring their postassault decisions (Martin, 2005). The forensic nurses’ training emphasizes objectivity while providing compassionate patient-centered care (Maier, 2012). This training espouses that objectivity is essential to establishing their credibility as expert witnesses when testifying in court. The nurses stay objective by documenting whether the survivor has injuries, but they do not conclude whether a sexual assault has occurred (Rees, 2010). They also maintain some level of emotional detachment to remain objective. In contrast, the advocates’ feminist framework guides them to take a stance in accepting the survivors’ accounts (Martin, 2005). Advocates may interpret nurses’ objective stance as cold, uncaring, and conflicting with their philosophy.

While the advocates and nurses have different training and roles, it may be possible that the advocates and nurses hold similar values but express them differently. Advocates embrace feminist values that underscore a nonjudgmental approach. Supporting feminist ideas and values is less common among SANE programs (Patterson, Campbell, & Townsend, 2006). The focal SANE program embraces objective goals (e.g., accurate medical forensic evidence collection) rather than feminist values. Still, they do strongly value being patient centered because they have witnessed untrained health care clinicians treat survivors in a hurtful manner. Similar to the advocates, the nurses also approach their patients in a nonjudgmental, compassionate manner, but within the boundaries of objective patient care. Thus, the nurses’ compassionate approach may appear different than a compassionate response from advocates. Furthermore, the nurses believe that maintaining objectivity lends credibility to their expert witness testimony and the evidence yielded from their examinations (Campbell, Greeson, & Patterson, 2011). Therefore, the nurses and advocates appear to hold similar values of justice, caring, and respect, but these similarities appear nebulous to the nurses and advocates in the focal program.

During the shift from grassroots to professionalization of RCCs, advocates had concerns that professionals would view this movement as a job rather than a cause (Riger, 1994). This concern may resonate with the advocates in the focal program, as they have questioned the nurses’ commitment. Similar to advocates in the earlier RCCs, advocates embrace feminist discourse that views gender inequality as a root cause of rape, which can be prevented by changing female status in society (Kemp & Brandwein, 2010; Martin, 2005). The advocates’ presence at survivor-related events (e.g., Take Back the Night) symbolizes their commitment to ending rape and their concern for survivors. This may be the reason why advocates expressed annoyance that the nurses do not attend these events, viewing their absence as a lack of commitment to survivors. However, nurses conceptualize their own commitment as investing in their skill set to ensure quality patient care. Martin (2005) found that RCC advocates often fuse their advocacy values with their personal values more than other professionals who provide services to survivors. Thus, rape work may feel more personal than occupational for advocates. This fusion of values may explain why nurses’ commitment to survivors mattered to the advocates, and why conflicts arose when the advocates assessed commitment solely within the context of their own values. In order to improve the relationship between advocate and nurses, it is important for them to recognize and respect each other’s passion for this work and how each benefits survivors (Woody & Beldin, 2012). Future studies can further the literature by examining more in depth the similarities and differences of the values between advocates and nurses, assumptions made about each other’s values, and how these differences contribute to team conflicts.

On a similar note, the advocates’ volunteer status may have played a role in advocates’ perspective of the nurses’ commitment. Advocates in earlier RCCs feared that shifting to paid professionals would result in staff who did the work for pay rather than believing in the RCC mission. Similarly, the advocates in the focal program view themselves as committed to this work because, unlike the nurses, they are unpaid for their services and also attend events to raise awareness of rape. This perspective may have influenced the advocates to doubt the nurses’ commitment. Prior research has also indicated that the advocates’ volunteer status may contribute to the nurses’ devaluing their services (Cole & Logan, 2008). In the current study, only a couple advocates wondered whether the nurses viewed them as less valuable due to their volunteer status, while none of the nurses discussed the advocates’ volunteer status. Still, it is possible that the advocates’ volunteer status played a role in the distrust between advocates and nurses. The nurses’ distrust of advocates’ skills also may be influenced, in part, by the advocates’ volunteer status. Minore and Boone (2002) conducted qualitative interviews with health care professionals and found that they expressed doubt of paraprofessionals’ ability in an implicit manner. Thus, it is possible that the nurses’ concern of the advocates’ skills is shaped by their volunteer status even though they did not explicitly state this.

The focal RCC resembles the elaboration stage of organizational growth in Riger’s (1994) model, characterized by a decentralized structure of multiunits. While earlier RCCs were characterized by collectivist forums that fostered connectedness and a sense of community among staff, the decentralized structure may lead to distance and conflict between units, which our study also found. Although the nurses and advocates provide services as a team, they have little interaction outside of service provision, and their separate trainings do not provide in-depth coverage of each other’s role or philosophy. This separateness may explain why each discipline understood their own roles, but they lacked knowledge of the other discipline’s role and service provision. For example, the nurses provided an elementary description of the advocacy role as completing paperwork and offering reassurance to survivors, which would not require a lengthy intervention that would be vital to survivors’ emotional well-being. The advocates’ training, meanwhile, does not explain the nursing philosophy of treating the “mind, body, and spirit” or the complex balance of providing compassionate health care while maintaining objectivity (Campbell et al., 2011). Thus, the training limits the advocates’ perception of the nurses to evidence collectors rather than health care clinicians. This view may be contributing to the conflicts because the nurses believed that advocates with this limited perception tended to portray the nurses negatively during their communications with others.

Distrust between the nurses and advocates has been a common thread throughout the themes. The advocates sometimes distrusted the nurses’ judgment about patient care, while the nurses were suspicious of advocates who provided lengthier crisis interventions because they attributed the longer length to disempowering survivors. In other words, they lacked confidence in each other’s competence with patient care. The participants attributed this distrust to the absence of discussion between the advocates and nurses about their roles (King & Ross, 2004). Prior research has shown that interdisciplinary teams tend to be suspicious of other disciplines’ intentions when there is no opportunity for discussions and socialization (Minore & Boone, 2002; Pullon, 2008). After the inception of the SANE program, the supervisors provided frequent opportunities for the nurses and advocates to meet and socialize, but these ceased with changes in leadership. Therefore, the experienced nurses and advocates developed a mutually respectful and trusting relationship during those earlier years when they were provided opportunities to clarify their roles and passion for this work. While the trust remains between the experienced staff, the newer nurses and advocates have not had the same opportunities to develop trust. These findings underscore the important role that discussions play on trust, particularly during the early stages of the interdisciplinary relationship. Experienced nurses and advocates may have more trust because they simply work together more often, which may increase their familiarity with each other and result in more aligned values and goals (Minore & Boone, 2002).

A few methodological limitations of this study merit consideration. First, the retrospective design of the study relies on participants’ memories and self-disclosure, so important factors influencing team conflicts may have been omitted. For example, the advocates’ confidentiality policy prohibits them from sharing information with other professionals including the nurses, which may create tension. Although research has found confidentiality to challenge collaboration (Drabble, 2010), the participants did not identify this as a salient concern. In addition, only a few advocates indicated that their volunteer status may influence nurses devaluing their services. Further research is needed to systemically examine how confidentiality practices and the advocates’ volunteer status affect the dynamics of the collaborative relationship.

The sample included advocates and nurses from one program, so the findings may not be generalized to other advocacy–SANE service collaborations, especially those that do not provide similar training or follow the same survivor-centered philosophy. For example, certain types of rape cases can pose challenges to interdisciplinary collaborations when one discipline doubts the veracity of the survivor’s statement (Cole & Logan, 2010). In the current study, none of the participants mentioned particular cases causing these types of conflicts. This may be a result of the advocates’ and nurses’ training, which address common myths that contribute to blaming or doubting survivors. Future research should explore whether and how interdisciplinary partnerships are impacted when either discipline doubts the survivor’s statement. In addition, the focal study’s SANE program is administered by the RCC; it is more common for SANE programs to be administered by hospitals (Campbell et al., 2005). Thus, these conflicts may manifest differently among advocate–nurse teams in a hospital setting, where the advocate is an outsider or “guest” while providing services.

Despite these limitations, this study has several implications for practice for social workers who commonly administer and staff feminist or other grassroots–bureaucratic hybrid organizations. These types of organizations evolve over time, which require an examination of how their structure and history influence current staff relationships. This study suggests that organizational structure and divergent perspectives can influence team dynamics, such as power struggles. While large organizations are more manageable with multiunits, they may reduce the benefits found in collectivist structures such as relationship development. Explicit discussion of the power dynamics would be essential to improving the team climate and trust within feminist–bureaucratic organizations (Bracken, 2011). These discussions are essential because informal hierarchies develop when decision-making power is ambiguous (Riger, 1994). Thus, these discussions should clarify when each discipline has decision-making power during service delivery (Wallach & Mueller, 2006). Additionally, sharing the responsibility of problem solving and program planning would enhance equality between programs (Bracken, 2011).

Conflicts are common between disciplines and thus, the implications of these findings also extend to social workers who work in other interdisciplinary settings. For example, social workers should coordinate formal meetings to discuss interdisciplinary issues and informal gatherings to socialize. This current study’s findings indicate that formal meetings should emphasize that each discipline is essential and clarify each discipline’s role, services, and limitations. Finally, discussion of the similarities and differences in discipline values may clarify any shared values and reduce conflicts that result from misinterpretations (Pullon, 2008). Together, role and value clarification and shared power would enhance mutual trust, which is essential in resolving future conflicts in a constructive manner (Pullon, 2008).