A SEMINAR ON COLLABORATION ISSUES AND MODELS INSIDE AND OUTSIDE NURSING

SUBMITTED TO SUBMITTED BYMS RIGI GEORGE MRS LEKSHMI PLECTURER 1ST YEAR MSC NURSINGJOSCO COLLEGE OF NURSINGSUBMITTED ON 31/12/13

INTRODUCTIONThe nursing profession is faced with increasingly complex health care issues driven by technological and medical advancements, an ageing population, increased numbers of people living with chronic disease, and spiraling costs. Collaboration is a substantive idea repeatedly discussed in health care circles. Though the benefits are well validated, collaboration is seldom practiced. The complexity of collaboration and the skills required to facilitate the process are formidable. Much of the literature on collaboration describes what it should look like as an outcome, but little is written describing how to approach the developmental process of collaboration. According to Abramson & Mizrahi 1996 the effects of Collaboration are, improved patient outcomes, reduced length of stay, cost savings, increased nursing job satisfaction and retention, improved teamwork. MEANINGThe word collaboration is derived from the Latin word co and laborare which mean work together. That means the interaction among two or more individuals, which can encompass a variety of actions such as communication, information sharing, coordination, cooperation, problem solving, and negotiation. Teamwork and collaboration are often used synonymously. The description of collaboration as a dynamic process resulting from developmental group stages as an outcome, producing a synthesis of different perspectives. The collaborative process involves a synthesis of different perspectives to better understand complex problems. An effective collaboration is characterized by building and sustaining win-win-win relationships. DEFINITIONCollaboration is the most formal inter organizational relationship involving shared authority and responsibility for planning, implementation, and evaluation of a joint effort Hord, 1986A mutually beneficial and well-defined relationship entered into by two or more organizations to achieve common goals. Mattessich, Murray and Monsey (2001)

TYPES OF COLLABORATION Interdisciplinary Multidisciplinary Transdisciplinary Inter professional collaboration

Interdisciplinary It is the term used to indicate the combining of two or more disciplines, professions, departments, or the like, usually in regard to practice, research, education, and/or theory.

Multidisciplinary It refers to independent work and decision making, such as when disciplines work side-by-side on a problem. According to Garner (1995) and Hoeman (1996), the interdisciplinary process, expands the multidisciplinary team process through collaborative communication rather than shared communication.

Transdisciplinary It is the efforts that involve multiple disciplines sharing together their knowledge and skills across traditional disciplinary boundaries in accomplishing tasks or goals (Hoeman, 1996). Transdisciplinary efforts reflect a process by which individuals work together to develop a shared conceptual framework that integrates and extends discipline specific theories, concepts, and methods to address a common problem.Interprofessional collaboration It has been described as involving interactions of two or more disciplines involving professionals who work together, with intention, mutual respect, and commitments for the sake of a more adequate response to a human problem (Harbaugh, 1994). Interprofessional collaboration goes beyond transdisciplinary to include not just traditional discipline boundaries but also professional identities and traditional roles. Interdisciplinary collaboration team members transcend separate disciplinary perspectives and attempt to weave together resources, such as tools, methods, and procedures to address common problems or concerns.

NEED FOR COLLBORATION IN HEALTH CARE SERVICESWorldwide there are number of significant on health and health care that will require international collaboration. Some of the factors that contribute to the need for collaboration are

Consumer wants and needsHealth care consumers are demanding comprehensive, holistic and compassionate health care that is also affordable. They want expert, humanistic care that integrate the available technology and provide information and services related to health promotion and illness prevention. Previously people expected a physician to make decision about their care: today however consumers expect to be involved in making any decision.

Self help initiativeResponsibility for the self is a major belief-underlying, holistic health that recognize the interdependence of body, mind and spirit. Today many individuals seek answers for acute and chronic health problems through non traditional approaches to health care. Alternative medicines and support groups are among two of the most popular self help choices. The most commonly used therapies are relaxation techniques, chiropractic treatment, massage imagery, spiritual healing etc.

Changing demography and epidemiologyThe growing number of older adult combined with the fact that the average older adult has three or more chronic conditions, will greatly influence the health care system and the insurer in the future. Closely related to various epidemiology influence posted by chronic illness. Limited access to health care services significantly impacts the health of the poor and the homeless

Health care accessSeveral alternative health care delivery system have been implemented to control cost.

Technology advancesTechnology has a major influence on health care cost and services with advances in medicine and technology. An individuals life span can be in many cases expanded.

NEED FOR COLLABORATION BETWEEN EDUCATION AND SERVICES Considerable progress has been made in nursing and midwifery over the past several decades, especially in the area of education. Countries have either developed new, or strengthened and re-oriented the existing nursing educational programmes in order to ensure that the graduates have the essential competence to make effective contributions in improving peoples health and quality of life. As a result nursing education has made rapid qualitative advances. However, the expected comparable improvements in the quality of nursing service have not taken place as rapidly. The gap between nursing practice and education has its historical roots in the separation of nursing schools from the control of hospitals to which they were attached. At the time when schools of nursing were operated by hospitals, it was students who largely staffed the wards and learned the practice of nursing under the guidance of the nursing staff. However, under the then prevailing circumstances, service needs often took precedence over students learning needs. The creation of separate institutions for nursing education with independent administrative structures, budget and staff was therefore considered necessary in order to provide an effective educational environment towards enhancing students learning experiences and laying the foundation for further educational development. While separation was beneficial in advancing education, it has also had adverse effects. Under the divided system, the nurse educators are no longer the practicing nurses in the wards. As a result, they are no longer directly in the delivery of nursing services nor are they responsible for quality of care provided in the clinical settings used for students learning.The practicing nurses have little opportunity to share their practical knowledge with students and no longer share the responsibility for ensuring relevance of the training that the students receive. As the gap between education and practice has widened, there are now significant differences between what is taught in the classroom and what is practiced in the service settings. Most nursing leaders also assert that something has been lost with the move from hospital based schools of nursing to the collegiate setting. The familiar observation that graduate nurses can "theorize but not catheterize" reflects the concern that graduate nurses often lack practical skills despite their significant knowledge of nursing process and theory. Nursing educators know that development of technical expertise in the modern hospital is possible only through on-the-job exposure to the latest equipment and medical interventions. Schools of nursing have tried to bridge this gap using state-of-the-art simulation laboratories, supervised clinical experiences in the hospital, and summer internships. However, the competing demands of the classroom and the job site frequently result in a less than optimal allocation of time to learn technical skills and frustration on the part of the nursing student who tries to be both technically and academically expert. The hospital industry has also recognized the need to support a graduate nurse with additional training. As a result, graduate nurses are required to attend an orientation to the hospital and have additional supervised practice before they can function independently in the hospital. The cost of orienting a new nursing graduate is significant, particularly with high levels of nursing turnover (Reiter, Young, & Adamson, 2007).

COLLABORATION ISSUES WITHIN NURSINGCollaboration and the nursing shortageFor the practicing RN, staffing is an issue of both professional and personal concern. Inappropriate staffing levels can not only threaten patient health and safety, and lead to greater complexity of care, but also impact on RNs' health and safety by increasing nurse pressure, fatigue, injury rate, and ability to provide safe care.This stress can lead to ineffective collaboration work among the nurses. Thehospital staffing crisis, a long drawn out problem, is intensifying as healthcare costs are increasing. This problem may be worsening due to more hospital CEOs investing in advanced medical technologies and failing to pay attention to maintaining adequate staff levels. Corporate greed has seemed to have taken precedence over safe patient care as well. The problems are systemic, primarily because the focus of the corporate giants that control most hospitals now is on profits, not on safe patient care.

Mandatory OvertimeStaff nurses across the nation are reporting a dramatic increase in the use of mandatory overtime as a staffing tool. This dangerous staffing practice, in part due to anursing shortage, is having a negative impact on patient care, fostering medical errors, and driving nurses away from the bedside. Safety on the JobStaff nurses work hard on the job, but they shouldn't have to risk their health to do so. Unless and until a safe environment is provided for the nurse the quality of care that they provide also get hindered. Workplace bullingWorkplace bullying is a serious issue effecting the nursing profession. It is defined as any type of repetitive abuse in which the victim of the bulling behavior suffer verbal abuse, threats, humiliating or intimidating behaviors or behavior by the perpetrator that interfere with his or her job performance and are meant to place risk.

Lack of respectNursing can be a gratifying profession; however, nurses continue to experiencelack of respectfrom their patients, doctors, administrators, and even from their coworkers. Medscapes online survey early this year reported that 31.4 percent of the respondents interviewed identified "lack of respect from other healthcare providers/non-nurses" as being one of the most distressing job factors in 2011.

Also, in anANA 2011 Health and Safety Survey, physical assault and verbal abuse were shown to have gone down but the issue still remains to be a big concern. RNs in the survey reported that on-the-job assault was one of their top-three safety concerns. The survey reported that within a 12-month period, 11 percent of RNs were physically assaulted and 52 percent were either threatened or verbally abused. Many cases go unreportedbecause some feel that this problem is just part of their job.

These are only three problems nursing is facing today. Many of the problems in nursing are due to the lack of legislation to address these issues. Because the healthcare industry is constantly evolving due to health reform, more problems will continue to emerge.

Regulatory barrierSocieties of medical profession continue to try limit advanced practice through legislative and regulatory reforms. Legislation and regulation have been barrier to the implementation of collaborative role. Collaboration cannot be mandated. It is a process that develop over the time

COLLABORATION ISSUES OUTSIDE NURSING

According to theAmerican Association of Colleges of Nursing (AACN),nursing representsthe nations largest healthcare profession with more than 3.1 millionnursesand 2.6 million licensed RNs. Being that nurses represent the majority of the workforce, they areoften targetedas a way for hospitals to decrease their costs now that healthcare costs are increasing. Nursing, as a profession, can be very rewarding and challenging, however many problems exist and most are becoming worse due to lack of legislation to address these issues.

Disciplinary difference Often clinicians differ in their basic philosophy of care. In earlier days it was practiced as physician supervise advanced nursing practice. But now the view advanced that supervision precludes the development of a collaborative relationship and that physicians not fully supervise nurse but works in collaboration with them. Rather than supervision there should be preferably the scope of autonomous nursing management and identify high risk population within a particular population or practice.

Meeting patient expectationsIn a the one out of three patients who stayed in a hospital at least one night, reported that nurses weren't available when needed or didn't respond quickly to requests for help."Meeting patient expectationsis hard enough as it is and some people fear it may worsen as healthcare and the elderly population increases. They also worry that nurses will be stretched too thinly and may not be able to achieve the needs and demands for their patients. Currently, theEmergency Departmentis becoming too crowded due to blood tests and other diagnostic procedures that slow patient flow.

Lack of respectNursing can be a gratifying profession; however, nurses continue to experiencelack of respectfrom their patients, doctors, administrators, and even from their coworkers. Medscapes online survey early this year reported that 31.4 percent of the respondents interviewed identified "lack of respect from other healthcare providers/non-nurses" as being one of the most distressing job factors in 2011.

Also, in anANA 2011 Health and Safety Survey, physical assault and verbal abuse were shown to have gone down but the issue still remains to be a big concern. RNs in the survey reported that on-the-job assault was one of their top-three safety concerns. The survey reported that within a 12-month period, 11 percent of RNs were physically assaulted and 52 percent were either threatened or verbally abused. Many cases go unreportedbecause some feel that this problem is just part of their job.

Problems with Nursing Informatics Informatics is the process of advancing in a discipline with a combination of data, information and knowledge. Nursing informatics encompasses the devices, machines, resources, and methods of utilizing information, computers, and nursing science in nursing. It is a recognized specialty for registered nurses, but does present challenges that academics and medical practitioners are working to improve or eliminate. Significance In 2007, the Healthcare Information and Management Systems Society Nursing Informatics Awareness Task Force estimated that 50 percent of a nurses time is spent on documentation. Because of explosive strides in information technology and the huge body of medical knowledge amassed, controlling medical errors and health care costs are paramount in the health care professions, including nursing. According to RN Journal, handwriting on a piece of paper has been largely replaced by reports from medical devices at the point of care, and nurses have to master. For the mastery over this technology as well as knowledge to deal with this devices, the nurses should be well equipped.Organisational barriersCompetitive situation can arise that can interfere with collaboration among APN and other disciplines. The inability of nurses to be a part of managed care panel has in many settings made the collaboration difficult. Patient as a consumer of health care are important players in the quest for successful collaboration. Patients are sensitive to the relationship between care giver and are quick to pick up on the lack of respect or trust between their providers.

MODELS OF COLLABORATIONThe nursing literature presents several collaborative models that have emerged between educational institutions and clinical agencies as a means to integrate education, practice and research initiatives (Boswell & Cannon, 2005; McKenna & Roberts, 1998; Acorn, 1990), as well as, providing a vehicle by which the theory -clinical practice gap is bridged and best practice outcomes are achieved (Gerrish & Clayton, 2004; Gaskill et al., 2003).

Clinical school of nursing model (1995) Encompasses the highest level of academic and clinical nursing research and education. This was the concept of visionary nurses from both La Trobe and The Alfred Clinical School of Nursing University. The development of the Clinical School offers benefits to both hospital and university. Opportunities for exchange of ideas with clinical nurses with increased opportunities for clinical nursing research.

Dedicated Education Unit Clinical Teaching Model (1999)In this model a partnership of nurse executives, staff nurses and faculty transformed patient care units into environments of support for nursing students and staff nurses while continuing the critical work of providing quality care to acutely ill adults. Various methods were used to obtain formative data during the implementation of this model in which staff nurses assumed the role of nursing instructors. Results showed high student and nurse satisfaction and a marked increase in clinical capacity that allowed for increased enrollment.

Key Features of the DEU are Uses existing resources Supports the professional development of nurses Potential recruiting and retention tool Allows for the clinical education of increased numbers of students Exclusive use of the clinical unit by School of Nursing Use of staff nurses who want to teach as clinical instructors Preparation of clinical instructors for their teaching role through collaborative staff and faculty development activities Faculty role to work directly with staff as coach, collaborator, teaching/learning resource to develop clinical reasoning skills, to identify clinical expectations of students, and evaluate student achievement

Practice-Research Model (PRM) (2001) It is an innovative collaborative partnership agreement between Fremantle Hospital and Health Service and Curtin University of Technology in Perth, Western Australia. The partnership engages academics in the clinical setting in two formalized collaborative appointments. This partnership not only enhances communication between educational and health services, but fosters the development of nursing research and knowledge. This model encouraged a close working relationship between registered nurses and academics, and has also facilitated strong links at the health service with the Nursing Research and Evaluation Unit, medical staff and other allied health professionals. Practice driven research development Collegial Partnership Collaborative Partnership and Best Practice

The Collaborative Approach to Nursing Care (CAN- Care) Model (2006) The CAN-Care model emerged as academic and practice leaders acknowledged the need to work together to promote the education, recruitment and retention of nurses at all stages of their career. The goal was to design an educationally dense, practice based experience to socialize second-degree students to the role of professional nurse. A secondary goal was to enhance and support the professional and career development of unit-based nurses. The model emerged from a dialogue among leaders from the academic and practice setting focusing on the areas of expertise and potential contributions of each partner.

The Bridge to Practice Model (2008) The Bridge to Practice model is distinctly different from other clinical models. First, students complete all of their clinical experiences in one participating hospital. Second, one full-time teaching faculty serves as a liaison for each bridge hospital. This faculty member is given a space, usually in the nursing education department, and is then available to serve as a resource for not only the clinical associates but also for the hospital nursing staff. In this model, therefore, there can be numerous clinical associates in one hospital with one full-time Third, students are actively involved in selecting their clinical placements.

Collaborative Clinical Education Epworth Deakin (CCEED) model (2003) In an effort to improve the quality of new graduate transition, Epworth Hospital and Deakin University ran a collaborative project (2003) funded by the National Safety and Quality Council to improve the support base for new graduates while managing the quality of patient care delivery. The Collaborative Clinical Education Epworth Deakin (CCEED) model developed to facilitate clinical learning, promote clinical scholarship and build nurse workforce capability. KEY ELEMENTS The collaborative partnership was formed by nursing health professionals, from the community health service and the university who recognized the need to bridge the theory-clinical practice gap and acknowledged the futility of continuing to work in isolation from each other. In practical terms, this involved a formal contractual arrangement between the organizations that led to the establishment of a Nurse Research Consultant (NRC) position. In the PRM, the role of the Nurse Research Consultant (NRC) was articulated as that of mentor and consultant on issues related to research, methodology publications and dissemination. Although the PRM was specifically designed to enhance nursing research activity and the implementation of evidence-based community health nursing practice, the Model also encouraged the involvement of the multi-disciplinary team to work to achieve the aims of the partnership agreement. .

CONCLUSIONAll the models pursue collaboration as a means of developing trust, recognizing the equal value of stakeholders and bringing mutual benefit to both partners in order to promote high quality research, continued professional education and quality health care. Application of these models can reduce the perceived gap between education and service in nursing thereby can help in the development of competent and efficient nurses for the betterment of nursing profession.

BIBLIOGRAPHYBooks Shabeer p basheer , S yaseen khan. A concise text book of advance nursing practice. 1st edition. emmess publishers. pg no: 698 D Ellekuvana Baskara Raj, Nima Bhaskar. Text book of nursing education. 1st edition. Emmess publishers. Page no 435 Ann B Hamric, Judith A Spross. Advanced practice nursing. 3rd edition. Saunders publishers. Page no 341Website www.wikipedia.com www.googlebooks.com www.gobookee.com www.authorstream.com

CHARACTERISTIC OF COLLABORATION Joint venture Co operative endeavor Willing participation Shared planning and decision making Team approach Contribution of expertise Shared responsibility Non hierarchal relationship Shared power (based on knowledge and expertise)NURSE AS A COLLABORATORNurse collaborates with nurse colleague and other health care personnel. In any type of agency setting or framework, nurse collaborates with other members of the health care team to plan, provide and evaluate patient care. The primary goal of each member of the health care team is to promote and restore health.With nurse colleagues Shares personal expertise with other nurses and elicits the expertise of others to ensure quality client care. Develops a sense of trust and mutual respect with peers that recognize their unique contribution.With other health care professionals Share health care responsibilities in exploring options, setting goals, and making decision with clients and families Listens to each individuals views Participate in collaborative interdisciplinary research to increase knowledge of clinical problems or situationWith professional nursing organizations Seeks opportunities to collaborate with and within professional organizations. Serves on committee in state and national nursing organizations or speciality groups Supports professional organizations in political action to create solutions for professional and health care concernsWith legislation Collaborates with other health care providers and consumes on health care legislations to best serve the needs of the public.

NURSE PHYSICIAN COLLABORATIONNurse patient collaboration is the ideal form of implementing the role. Nurse and physician working together create a synergism that can result in a product that is greater than can be produced by the professional alone.

CONCEPTUAL MODEL OF COLLABORATIVE NURSE PATIENT INTERACTION

Patient outcomePERSONEL/INTERPERSONEL INFLUENCEComplementary management of influencing variables

Improved achievement of clinical goalCondition of power symmetry

Lower patient mortalityCollaborative nurse patient interaction

Co ordination of admission/discharge planning

Mutual trust and respect

Higher job productivity and satisfactionORGANIZATIONAL/PROFESSIONAL INFLUENCERole perception

Increased interdisciplinary decision making and problem solvingJoint goal setting and decision making

Principle of nursing educationCOLLABORATION WITHIN NURSING EDUCATION

Faculty

Departmental supervisorsNursing auditorDirector of nursing education

Unit in chargeNursing apex bodies INC, KNC

Nursing superintendent

Staff nurse

COLLABORATION WITH ASSISTIVE PERSONNELSRelationship between the registered nurse and unlicensed assistive personnel known as nurses aids and nursing assistants, affect the quality of care given to hospitalized patients. Ethnic and cultural difference complicate the relation between the nurse and unlicensed personnel. Difference in beliefs values perception and priorities create conflict, poor team work and reduced job satisfaction and ultimately a negative impact on patient care. Team building sessions were developed with registered nurse and unlicenced personnel. The purpose was to identify and align work related relationship needs of both groups with needs of the nursing units. This is used to encourage collaboration between two groups.

COLLABORATION OUTSIDE NURSING

Medical team and medical superintendentAffiliated

Paramedical dean and paramedical team

Doctor of house surgencyExternal agencies

Principal of education and nursing superintendent

Government agenciesNon affiliated

Public health agency

COLLABORATION SKILLSHuman factorsAll the collaborating parties must be willing to work together if the collaboration is to be successful. They must have attained a level of readiness to collaborate through education, maturity and prior experience. They must understand their own limits and their disciplines and boundaries while respecting what other professionals can contribute. They must communicate effectively trust one another and be committed to working togetherOrganizational factorsJust as the people involved must have certain attributes that facilitate collaboration, the organization in which the collaboration takes place also must be supportive. Collaboration organizations have values that support equality and interdependence, creativity and shared vision.ELEMENTS OF COLLABORATIONCOMMUNICATIONCollaboration to solve complex problems requires effective communication skills. Effective communication can occur only if the involved parties are committed to understand each others professional roles and appreciating each other as individuals.MUTUAL RESPECT AND TRUSTMutual respects occur when two or more people shows or feel honor or esteem towards one another. Trust occurs when a person is confident in the action of another person. Both mutual respect and trust imply a mutual process and outcome.DECISION MAKINGThe decision level process at the team level involves shared responsibility for the outcome. To create a situation the teams must follow each steps of the decision making process beginning with a clear definition of the problems. Team decision making should be directed at the objectives of specific efforts. Members must be able to verbalise their perspective in a non threatening environment.