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Guest Editorial

Collaboration: Integrating Education And Clinical Practice: The Case of La Trobe University/The Alfred Clinical School of Nursing

Helen Forbes
Senior Lecturer, Coordinator of Studies, La Trobe University, Alfred Clinical School of Nursing The Alfred, Prahran VIC

Rosalie Strother
Project Coordinator, La Trobe University; Alfred Clinical School of Nursing, The Alfred, Prahran VIC

Abstract

A Clinical School of Nursing combines resources, opportunities and benefits for hospital and university staff as well as students.

Collaboration is essential in the partnership between the two institutions and aspects will be explored in this paper, including antecedent conditions of organisational commitment, cooperation and trust, identification of costs, and a formal agreement. Collaboration itself is built on cooperative endeavour, willing participation, shared planning and decision making, a team approach, and shared responsibility and power. These attributes are readily identifiable in this exciting initiative.

Keywords

collaboration, organisational commitment, clinical practice, education, shared responsibility, power, teamwork, trust, cost-benefit assessment, cooperative endeavour

Article Text

Background

While the reasons for the transfer of nursing education to the tertiary sector were multi-factorial, an outcome of the separation of education from service is that nursing has been able to define its disciplinary knowledge and build a 'culture of scholarship' (Henry, 1995: 255). Against a background of changing nursing roles, an escalating knowledge base and reform of the health care system it is time for the reunification of nursing education and service. Collaboration is the vehicle for such integration. While collaboration is a complex phenomenon, this guest editorial describes one approach to a collaborative effort towards unify nursing education, service and practice from the point of view of antecedent conditions, defining attributes and barriers to collaboration.

The concept of a Clinical School of Nursing is one that encompasses the highest level of academic and clinical nursing research and education. The initial catalyst for the La Trobe University/The Alfred Clinical School of Nursing University Clinical School) was a meeting of like minds of visionary nurses from both university and hospital, in the early 1990s. This occurred within a context of a long history of collaboration and cooperation between the two institutions going back many years and culminating in the establishment of the Clinical School in February, 1995.

In the first few years, the focus was on the transfer of post-basic courses in critical care and perioperative nursing to the university sector. The first clinical professor of nursing associated with the Clinical School was appointed in 1999. In 2001 there was a considerable impetus to the further development of the Clinical School, as the La Trobe University School of Nursing and Midwifery embarked on a structural re-organization, with the establishment of another four Clinical Schools, in midwifery, aged care, community health, and a second, in acute nursing. This demonstrated a major step in the development of collaborative partnerships with health care agencies. Lecturing staff began to be established within practice settings, as part of these arrangements.

Clinical school development

The goals and major activities of the Clinical School reflect a combining of the overall direction of the School of Nursing and Midwifery and the unique opportunities offered by The Alfred. The Alfred is an acute tertiary referral hospital that provides a comprehensive range of specialist medical and surgical services in Victoria, including several State-wide services. The Clinical School aims to promote interdisciplinary and inter-institutional collaboration in health care delivery and research, and to establish a reputation as a leader in acute nursing research. It is in the process of establishing a centre of excellence in acute nursing at both undergraduate and postgraduate levels The goals of which is to become a leading centre for honours and postgraduate research in acute nursing. Other goals include the development of clinical consultancies around areas of identified need, and conduction of continuing education activities at The Alfred.

The development of the Clinical School offers benefits to both hospital and university. It brings academic staff to the hospital, with opportunities for exchange of ideas with: clinical nurses; increased opportunities for clinical nursing research; undergraduate students who are socialized to the Hospital and who have opportunities for continuity of clinical practice: and, many openings for expert clinical nurses to become involved with the university's academic program.

Collaboration

Collaboration is a crucial component of all aspects of the Clinical School development, as it is through this ongoing and continuous process that a common vision and common goals and realities are developed and maintained. Collaboration is more than just a partnership: it is a complex phenomenon that is characterized by mutual goals and commitments, and is ‘a cooperative venture based on shared power and authority' (Henneman et al, 1995). Many approaches to collaborative partnerships are reported in the literature. For example, the Johns Hopkins University School of Nursing and the Johns Hopkins Department of Nursing have formalized a university/hospital partnership through the establishment of the Institute for Johns Hopkins Nursing (Sabatier, 2002). This links the two institutions in the offering of professional development and leadership education in non-degree programs, and is seen as entrepreneurial.

The American Association of Colleges of Nursing (AACN) (2002) has published a list of 'Successful Partnership Profiles'. In this publication the collaborative arrangements at thirteen universities across the United States are described, and cover a range of partnerships with one or several health care facilities.

The AACN has also published a position statement on ‘Education and Practice Collaboration: Mandate for Quality Education. Practice, and Research for Health Care Reform' (Approved by Membership, October 25, 1993). In this publication, reference is made to the responsibility of nursing leaders to ‘direct the future of nursing's role in health care reform through a sharing of values and principles'. They recognize that the principles of collaboration should form the basis of all collaborative relationships but that specific models of collaboration will be unique to each setting. Reference is made to a continuum of collaboration, which could span a range from an all-encompassing model to one with a much more limited focus. The position statement goes on to list benefits and barriers to collaboration. The latter are of special interest, as they reflect some of the current issues being worked through in the establishment of the Clinical School. Some of the most relevant include debate around the competing demands and lack of exclusive control over practice and education; these test the process of collaboration with opportunities to develop negotiation skills and participative decision-making in the achievement of consensus. Limited resources, in both practice and education settings are an issue which constantly tests the collaborative partnership. The ACCN position statement goes on to identify a number of principles in a ‘Blueprint for Collaboration'. These largely reflect the principles and approach outlined by Sullinger and Ostmoe (1998).

Sullinger and Ostmoe (1998) describe the collaborative nature of the development of a university-hospital relationship in a clinical school in Wisconsin USA, and draw heavily upon the collaboration theory of Henneman et al. (1995). This includes a number of antecedent conditions that will be outlined and related to the progressive development of the Clinical School.

Sullinger and Ostmoe (1998) state that the first step in the collaborative process is to identify whether the partnership is needed or whether there are more appropriate options than the development of a clinical school model. It is noted that the need to share expenses or resources is not seen as a sufficient reason to proceed. The move to the concept of the clinical school is founded on recognition of the fundamental importance of the close and continuing link between the theory and practice of nursing at all levels. The location of Schools of Nursing in universities has presented difficulties in maintaining close links with the practice field both geographically and philosophically. The collaboration of university and hospital in establishing the Clinical School begins with discussion around the vision, values and goals of both institutions, in order to ensure that both are congruous and meet in the Clinical School. This must form the basis of all further developments.

Organizational commitment

The second antecedent condition is recognition of the importance of organizational commitment to ensure that the loss of individuals would not affect the viability of the partnership. In the establishment of the Clinical School, the commitment of both institutions is evident, with development proceeding regardless of the loss of most of the ‘key players' since the initial development in the early 1990s. It is recognized that the comprehensive `briefing' of new players is important in ensuring that a full understanding of, and commitment to the clinical school concept remains. There is a ‘point of no return', where it is too late to retreat. The Clinical School has reached this point, thus it is important that the necessary commitment and impetus are maintained.

Benefits versus costs

Cooperation and trust are recognized as critical to building new partnerships. One way in which this may be done is by identifying the benefits to all parties, and to specify these so that all involved understand that the process in itself is useful in the opportunities it provides for sharing common values, beliefs, goals and activities.

According to Sullinger and Ostmoe (1998) it is important to weigh up the benefits against the fiscal costs. They also suggest that consideration should be given as to whether the outcome or purpose is worth the costs of planning and the resources required. They acknowledge that in their situation the establishment of the arrangement was labour intensive and required the involvement of top-level administrators. The detailed identification of costs is extremely complex and although an attempt to do this is currently in progress it will occur in conjunction with the development of the Clinical School. It is of interest to note that Sullinger and Ostmoe recommend that the cost of failure should also be calculated. In their situation this had the effect of committing everyone involved to make the venture succeed. In relation to The La Trobe/The Alfred Clinical School of Nursing the cost of failure would involve the dissolution of clinical schools and the centralization of all activities of the School of Nursing and Midwifery at the Bundoora campus once again. Dissolution would not be acceptable to any who have the vision of the Clinical School and all it brings to the advancement of the nursing profession and to the provision of excellence in patient care.

The formal agreement suggested by Sullinger and Ostmoe (1998) was drafted and signed in the first year of the Clinical School's establishment in 1995. However, developments have overtaken the agreement that will be redrafted to reflect the requirements of the five clinical schools of the University, rather than The Alfred alone.

Cooperative endeavour

The defining attributes of collaboration, as described by Henneman et al. (1995) have been clearly demonstrated in the partnership between La Trobe University and The Alfred. The venture is a joint one with cooperative endeavour being evident in all aspects of Clinical School activities. The Postgraduate Diploma clinical stream subjects in critical care, perioperative and perianaesthetic nursing courses are coordinated by university faculty and are conducted on site at the hospital. Expert clinical nurses and, where appropriate, medical staff, are involved in presentation of content and university faculty have access to clinical areas. The university faculty onsite have some involvement with undergraduate students, although this aspect of the Clinical School is in the earlier stages of development than the postgraduate courses. A pilot project for the clinical placement of third year undergraduate students was conducted in Semester 2, 2003, for which a `tripartite' model of clinical support has been developed. This involves the identification of a more active role for student, clinical nurses and University; it allows greater flexibility in keeping with student and clinical needs, and will form the basis of an expanded program for undergraduates in 2004 and beyond.

Research activities are another aspect of the Clinical School in which cooperation is evident. A clinical professor of nursing works closely with clinical staff in areas of interest and need, in the facilitation and development of research. This area is expanding rapidly at the present.

Sharing of power, resources and expertise are important in the quest for improving the quality of nursing care (AACN, 1993). Shared planning and decision making, a team approach, shared responsibility and shared power, are all evident in the work of the Steering Committee of the Clinical School. This Committee has representation from senior management of both the Hospital and University, including the Director of Nursing and Head of the School of Nursing and Midwifery, who are able to debate and discuss directions in keeping with the goals of the Clinical School, and have the authority to make it happen. The Committee also has representation of those who are closer to the day- to- day activities and are able to identify issues and propose solutions. The most constant consistent collaboration occurs between the Coordinator of Studies, Clinical School, a member of University faculty located at The Alfred, and the Project Coordinator, Clinical School, a member of the Hospital nursing staff who has had experience with the Clinical School and nursing education over a number of years. The Manager, Nursing Education at The Alfred is also involved regularly in discussions.

Conclusion

The Clinical School is a collaborative endeavour between The Alfred and La Trobe University that offers enormous capacity for advancing the profession of nursing. The Clinical School allows the combination of resources of academic and clinical practice fields into an entity that transcends both and provides unprecedented opportunities to integrate the full range of activities. This will encourage the interchange of ideas and blurring of boundaries between university and hospital at all levels, including undergraduate and postgraduate education, continuing education, a range of research activities, and nursing specialist clinical development. There will be a continuum between clinical nursing practice and the more theoretical aspects of nursing education, at both undergraduate and postgraduate levels. It is also anticipated that there will be openings for collaboration with medicine, both undergraduate and postgraduate in the future.

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