A SEMINAR ON

COLLABORATION
ISSUES AND MODELS
INSIDE AND OUTSIDE
NURSING

SUBMITTED TO
SUBMITTED BY
MS RIGI GEORGE
MRS LEKSHMI P
LECTURER
1ST YEAR MSC NURSING
JOSCO COLLEGE OF NURSING
SUBMITTED ON 31/12/13

INTRODUCTION
The 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.
MEANING
The 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.
DEFINITION
Collaboration is the most formal inter organizational relationship involving shared
authority and responsibility for planning, implementation, and evaluation of a joint effort
Hord, 1986
A 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 sideby-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 SERVICES
Worldwide 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 needs
Health 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 initiative
Responsibility 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 epidemiology
The 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 access
Several alternative health care delivery system have been implemented to control cost.
Technology advances
Technology 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 NURSING
Collaboration and the nursing shortage
For 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.
The hospital 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 Overtime
Staff 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 a nursing
shortage, is having a negative impact on patient care, fostering medical errors, and
driving nurses away from the bedside.
Safety on the Job
Staff 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 bulling
Workplace 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 respect
Nursing can be a gratifying profession; however, nurses continue to experience lack of
respect from 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 an ANA 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
unreported because 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 barrier
Societies 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 the American Association of Colleges of Nursing (AACN), nursing
represents the nations largest healthcare profession with more than 3.1
million nurses and 2.6 million licensed RNs. Being that nurses represent the majority of
the workforce, they are often targeted as 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 expectations
In 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 expectations is 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, the Emergency Department is becoming too crowded due to
blood tests and other diagnostic procedures that slow patient flow.

Lack of respect
Nursing can be a gratifying profession; however, nurses continue to experience lack of
respect from 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 an ANA 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
unreported because 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 barriers
Competitive 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 COLLABORATION
The 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 unitbased 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. .

CONCLUSION
All 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.

BIBLIOGRAPHY
Books
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 341
Website

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 COLLABORATOR
Nurse 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 situation
With 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 concerns
With legislation

Collaborates with other health care providers and consumes on health care
legislations to best serve the needs of the public.

NURSE PHYSICIAN COLLABORATION

Nurse 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

PERSONEL/IN
TERPERSONE
L INFLUENCE

ORGANIZATION
AL/PROFESSION
AL INFLUENCE

Complementary
management of
influencing variables

Patient outcome

Condition of power
symmetry

Improved
achievement of
clinical goal

Collaborative nurse
patient interaction

Lower patient
mortality

Mutual trust and respect

Co ordination of
admission/discharge
planning

Role perception

Higher job productivity

and satisfaction

Joint goal setting and

decision making

Increased
interdisciplinary
decision making and
problem solving

COLLABORATION WITHIN NURSING EDUCATION

Principle of nursing
education

Faculty

Nursing auditor

Director of nursing
education

Departmental
supervisors
Unit in charge

Nursing apex bodies INC,

KNC

Nursing superintendent
Staff nurse

COLLABORATION WITH ASSISTIVE PERSONNELS

Relationship 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

Affiliated

External
agencies

Non
affiliated

Medical team and

medical superintendent

Doctor of house
surgency
Principal of education
and nursing
superintendent

Paramedical dean
and paramedical
team
Government
agencies

Public health agency

COLLABORATION SKILLS
Human factors
All 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 together
Organizational factors
Just 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 COLLABORATION
COMMUNICATION

Collaboration 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 TRUST
Mutual 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 MAKING
The 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.