ADVANCED NURSING PRACTICE

UNIT X: NURSING PRACTICES

(Collaboration Issues and Models- within and outside nursing)
INTRODUCTION:

Collaboration is a process in which two or more individuals work together jointly

influencing one another, for the attainment of goal. The word collaboration
implies working together for the greater good, but it actually encompasses far
more. Several preconditions must be in place for collaboration to be successful.
Collaborative health care practices facilitate better patient outcomes. The health
team works as a group utilizing individual skills and talents to reach the highest
of patient care standards. A multidisciplinary plan of care should be decided by
all of the team members. Individual disciplines must be willing to work together,
have the same objectives and goals, and provide a plan of care which is
individualized to the patients needs. A multidisciplinary approach to care sounds
simple in theory, but collaboration of different skill levels and expertise has its
problems.
MEANING OF COLLABORATION:

The word collaboration, namely co and laborare, combined inlatin to mean

work together.
DEFINITION OF COLLABORATION:

Collaboration is a process by which members of various disciplines (or

agencies) share their expertise. Accomplishing this requires these individuals
understand and appreciate what it is that they contribute to the whole.
Henneman et al
Collaboration as a mutually beneficial and well- defined relationship entered
into by two or more organizations to achieve common goal
Murray and Monsey2001.

CHARACTERISTICS OF COLLABORATION:

Shared goals: First collaboration in community health nursing is goal directed.

The nurse, clients and other involved in the collaborative effort or partnership
recognize specific reasons for entering into relationship.

Mutual participation: Collaboration involves mutual participation; all team

members contribute and are mutually benefitted. Collaboration involves a
reciprocal exchange in which team players discuss their intended
involvement and contribution. The professional including the nurses
involved in the collaboration will offer their own specific ideas and
expertise to design the wellness program.

Maximized use of resources:A third characteristic of collaboration is that it

maximizes the use of community resources. The collaborative partnership
designed to draw on the expertise of those who are more knowledgeable
and in the best positions to influence a favourable outcome.
Clear responsibilities:Collaboration team members work in partnership and
assume clearly defined responsibilities. As in a football team, each member
in the partnership plays a specific role with related tasks. The nurse must
may play a case management or group leadership role, whereas others
assume roles appropriate to their areas to expertise. Effective collaboration
clearly designates what each members will do to accomplish the identifies
goals.
Set boundaries: Collaboration in community health practice has set
boundaries, with a beginning and end that fall within the goals of
communication. An important part of defining collaboration is determining
the condition under which it occurs and when it will be terminated. The
boundaries sometimes are determined by progress towards the goal,
sometimes by the number of team member contacts.

NEED FOR COLLABORATION:

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Reduce gap between nursing education and nursing services.

Graduate nurses often lack practical skills despite their significant
knowledge of nursing process and theory.
For health promotion requires efficient, cost-effective health care services,
demand patient collaboration, collaboration requires informed, involved
consumers.
Nurses, as the single largest health care provider group and the group with
the most sustained contact with patients, have opportunities and
responsibilities to use their communication and teaching skill to facilitate
patient collaboration in their care.
Collaboration practice provides more effective care delivery and better use
of resources and enhances job satisfaction.
It also reduces conflict between physicians and nurses as both become more
focused on patient outcomes than on protecting their own turf.

COLLABORATION AS A SOLUTION TO MAJOR ISSUES IN NURSING IN INDIA:

Poor quality of nursing and midwifery care due to:

Inadequate standards and guidelines for nursing practice
Poor quality of nursing education to produce qualified graduates for service:
Shortage of qualified nurse educators
Inadequate infrastructure for nursing education
Limited production of academic work and research.
STRUCTURE OF COLLABORATION RELATIONSHIPS:

Effective collaboration occurs within a particular structure and sequence. During

this process, the work of identifying and meeting the clients needs takes place.
The structure involves several phases.
A beginning phase: When the team relationship is just being established.
A middle phase: When relationship works.
A termination phase: When the relationship ends.
The first phase is the period of establishing and defining the team relationships.
All of the team members including client are getting to know each other, they
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seek to establish communication patterns and develop trust, from this they
identify the client needs, and determine the goals toward which they will work.
The middle phase occurs when team members start working together to
accomplish desired goals. Their work may include assessment and planning as
well as implementation and evaluation. It is repeated until the goal
accomplishment.
The termination phase occurs when the needs for team members to work together
has ended. When team members have grown close in relationship, termination
can be difficult.
It often requires careful advance preparation to make certain that all parties
understand when and why it is taking place.
MODELS OF COLLABORATION BETWEEN EDUCATION AND SERVICE:

The nursing literature presents several collaboration models that have emerged
between educational institutions and clinical agencies as a means to integrate
education, practise and research initiatives as well as providing a vehicle by
which the theory clinical practice gap is bridged and best practice outcome are
achieved.
Clinical School of Nursing:
It is one that 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. This occurred
within a context of a long history of collaboration and cooperation between these
two institutions going back many years culminating in the establishment of the
Clinical School in February, 1995. The development of the Clinical School offers
benefits to both hospital and university. It brings academic staff to the hospital,
with opportunity for exchange of ideas with clinical nurses with increased
opportunities for clinical research. Many educational openings for expert clinical
nurses to become involved with the universitys academic program were evolved.
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.
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Dedicated Education Unit Clinical Teaching Model(1999)

In this model, a partnership of nurses executives, staff nurses and faculty
transformed patient care units into environments of support for nursing students
and staff nurses while continuity of the critical work of providing quality care to
acutely ill adult. Various methods were used to obtain formative data during the
implementation of this model in which staff nurses assumed the role of nursing
instructor. Result showed high student and nurses satisfaction and marked
increase in clinical capacity that allowed for increase enrolment.
Collaborative Approaches in Nursing Care (CAN-Care)Model(2006):
The CAN-Care model emerged as academic and practical leaders
acknowledge the need to work together to promote the education, recruitment,
and retention of nurses at all stages of their career. The idea of partnership model
emerged when the Christian E.Lynn College of Nursing, Florida, Atlantic
University, was awarded a grant from Tenet Health Care Foundation to initiate an
accelerated Second degree BSN Program.
The model emerged from a dialogue among leaders from the academic and
practice setting focusing on the areas of expertise and potential contribution of
each partner. The essence of the CAN-Care model is the relationship between the
nurse learner (student) and nurse expert within the context of each nursing
situation. The learner is responsible and accountable for engaging in learning
process and for taking an active role in establishing a dynamic partnership with
the nurse expert. Unit-based nurses are expert in the work of nursing care. The
title unit-based nurse expert was chosen to recognize the grifts they engage in a
partnership for the purpose of nurse meeting the need of the assigned patient
population as well as to reflect on and to come to know the different models of
collaboration between Nursing education and Art and Science of Nursing
Practice. The faculty member promotes the growth of the nurse expert as a
professional and the journey of the learner in coming to know a career in nursing.
The primary role of the faculty member in the model is to nurture the nurse
expert/nurse learner relationship and to support the growth and development of
both expert and learner in their respective roles and responsibilities. The on-site

faculty member becomes an advisor, resource, role model and educator for both
the nurse expert and learner in their respective roles and responsibilities.
The Bridge of Practice Model(2008)
Key features of model:
First, student complete all of the 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 educational
department, and is then available to serve as a resource for not only the
clinical associate but also for the hospital nursing staff
Third, students are acutely involved in selecting their clinical placement.
The Bridge to Practice Model provides undergraduates nursing students with
continuity in medical surgical education through placement in the same hospital
for all medical-surgical clinical rotation. Hospital that participates in the bridge
model provides senior clinical nurse preceptors whose time is paid for by the
university, The bridge to practice model emphasizes professional incentives for
hospital nurse to participate in nursing education. Planned incentives includes the
rewarding of hospital nurse with continuing education credits for participation in
the short-term training on educational methodology and approaches. A tuition
discount is offered for graduates course work at the university for institutional
students and faculty, more involvement with clinical support services and care
management, and more informed employment choices by senior students.
Nurse Consultant Model:
Collaboration for in service/ Continuing educational programs
The key ingredients is a partnership between educational and nursing service
institutions and personnel. Partnership relationship combines the strength of the
practical application and practical knowledge from nursing service sector and
education/theoretical knowledge from educational sector.

The benefits of collaboration in nursing education and nursing practice:

It provides assistance in staff development program and conducting in
service and continuing educational program.
Aim is to further education and smooth functioning of peer professionals
Leads to flexible options for incorporating new ideas, new approaches, in
nursing practice and nursing education.
Accessible to nurses who are unable, not ready or not interested in further
formal education.
Ex-nursing updates, workshops,etc., conducted by nursing students.
Nurse Clinician Model:

Share teaching and service staff responsibility.

Join appointment to describe shared staffing arrangements.
Shared appointments in which one individual has a specific responsibility
in both education and service organization and involves a sharing of cost
and time commitment.
Full time teachers are involved in direct patient care.
Full time nursing service staff are involved in teaching activities, i.e.
clinical preceptors, instructors or lecturers. Teaching responsibility.
Nurse Researcher Model:
Aim is to improve nursing practice through research and to further education
and functioning of peer-professionals leads to strengthening the theory base for
nursing practice and the practice base for research and theory development
efforts. A major prerequisite for working together is the desire on the both the
sides to become involved in collaboration research. It is particularly clinical in
initial stage of identifying the research issues and questions. Nurses observation
and experience provide the clinical perspective and practice knowledge of
setting to the researchers. Service and continuing education programs are the
particularly effective as flexible option for incorporating new information and
new approaches in nursing practice and education.

BARRIERS OF EFFECTIVE COLLABORATION:

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Lack of communication
Lack of understanding and appreciation
Lack of mutual trust and lack of respect
Dominance of one discipline over the other
Territoriality
Attitude
Administrative and organisational structure and procedure
Work roles and organizational responsibilities
Working relationships
Practices and changes in outcomes.

COLLABORATION IN NURSING:

Collaborating with Patients:

Nurse and patient shares responsibility for implementing the plan. The goal is
to enhance patients self-care competencies so they can achieve and maintain
optimal health. Active participation in a mutual exchange of information
promotes learning. Patients assume a learner role when acquiring new self-care
competencies and a teacher role when communicating their personal perspective
of health. Nurses assume a learner role as they strive to understand patient
beliefs, motivation and desires and a teacher role when sharing professional
knowledge and skills.
Health care professionals considered themselves qualified to decide what
knowledge and skills patients needed to improve their health however, patients
are the experts about their personal perceptions, beliefs about health and desires
for learning. A collaborative approach to health teaching effectively meets patient
needs for information and for participation. Through shared responsibility,
patient and nurse can see learning goals and objectives.
Collaborating with Other Healthcare Professionals
When several health care professionals are involved in teaching, it is important
that each professional communicates with the others about content, progress and
approaches being used. When providers collaborate, they reinforce each other
teaching. This not only facilitates patients learning and retention but also
promotes trust in the providers.
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Multidisciplinary Healthcare Team:

Patient: Patient with a collaborative philosophy, the goal of optimal health
for patient, can be accomplished only when patients are control members of
the healthcare team. Patients bring a particular expertise and life
experience to the interaction with health care professionals. The ANA social
policy statement identifies the importance of patients participation in
healthcare.
Registered nurse: Professional nurses being unique perspectives to the
interdisciplinary team. Nursing also facilitates the practice of other health
care professional, e.g. nurses assist physicians and other health care
professionals carry out diagnostic and therapeutic procedures. By
collaborating in assessment, diagnosis and patient care and other health care
providing. Nurses role as team members extend to the community in
ambulatory care, healthcare and agency setting.
Advanced practice nurses: The roles of advanced practice nurses include
direct care, managing system of care and serving as consultants among
others. Coordination and mentoring are particularly important to effective
team functioning.
Licensed vocational nurses: Perform specific nursing care functioning
under hospitals, health clinics and physician, offices.
Nurse extenders: Nurse extenders are cross-trained staff, whose title and
job descriptions vary. They are expected to be multi skilled and assume
some tasks formally performed by RNs as well as functions previously
assigned to support personnel such as clerks and housekeepers.
Physicians: Physicians role to diagnose, treat the disease. Physicians use
treatment modalities such as medication and surgery. The frequently consult
with others on the team as well as make referrals for therapies provided by
other professionals.
Occupational therapist: Assist the patient to attain optimum
musculoskeletal functioning after injury, illness or surgery. Physical
therapists prescribes specific exercise and therapies to strengthen muscles
and prevent further loss of function.
Social workers: Social workers focus primarily on discharge planning,
referral to community agencies and patient and family counselling. Social
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worker are knowledgeable about sources of many supportive services in

communities and collaborative with other members of the health care team
such as community health nurses to share such information and make
recommendations for referrals.
Registered dieticians: Provide nutritional counselling and therapy. In
hospital, lone-term care facilitates and ambulatory care centres, dieticians
assess patients nutritional states and make recommendations for dietary
therapy.
Case manager: Case managers monitor progress of their patients from
admission to the system through discharge and coordinate access to home
or community care needed. Although case management is geared to
maintain continuity of care and optimum outcomes.
Utilization managers: Utilization manager monitor patient admission and
length of stay. To criteria set by Medicare and other third party payers. They
are responsible for acting to prevent loss from exceeding established
guidelines. Ums communicate with providers to arrange for care in
alternative setting when patients are not for discharge within the limitations
of guidelines.
Pharmacists: Dispense medication prescribed by qualified professional and
provide important information to patients such as written material about a
medication and instructions for its use. They also collaborate with members
of the healthcare team about indication for specific drugs, drug interactions
with other drugs or foods, drug side effects and over-the-counter
medication.

SIX EFFECTIVE STEPS FOR SUCCESSFUL COLLABORATION:

Clearly identify the value: Team members must understand the value they
are expected to deliver, whether its increasing revenue or moving the
business into a new market.
Link to the organizations strategies: Collaboration that are closely
enmeshed with corporate strategy will deliver the need value. For example,
to ensure high customer satisfaction, Cisco created a collaborative
environment between various experts throughout the company and
customer account teams in an initiative called Specialist Optimization
Access and Results (SOAR).
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 Select team players who are engaging, creative and expert: Almost 70
percent of the executives surveyed in the EIU Designing Effective
Collaboration study stated that creativity is essential in each team member.
They also said that each member must be personally excited and optimistic
about the project and bring a unique expertise.
Build trust among the co-workers: More important than employees
trusting their managers is co-workers trusting each other. Although people
who cooperate and coordinate say mutual trust is important, they are the
same people who are working successfully without trust. For collaborators,
on the other hand, lack of trust is a deal breaker.
Define or modify processes: Collaborators require flexibility and may
follow processes that are unique to their role in the collaboration. Each
team member should have a specific responsibility and the opportunity to
clarify objectives, and the team needs a clear timeline.
Employ technology that is flexible and secure: Collaboration need tools to
communicate securely and flexibly. Virtual interaction such as tele presence
can be just as effective as face-to-face meetings when they replicate the inperson experience.
COLLABORATION OUTSIDE THE NURSING:

A collaborative relationship between nurse and patient provides a on optimal

environment for identifying and incorporating cultural values, beliefs and
practice that influencing patient care. To facilitate intellectual collaboration,
nurse must be knowledgeable about a patients cultural background and free of
ethnocentric behaviours and attitudes. The principles cultural relativism, cultural
sensitivity transcultural reciprocity in an intercultural context Should be
followed.
Cultural Relativism: Asserts that any culture is different from, but not superior
or inferior to any other culture. This perspective encourages nurses to view their
own values, beliefs and behaviour objectively, as one of many cultural traditions.
Cultural Sensitivity:
It refers to an individual awareness of which issues or concerns are important
to ones own culture or others. Nurses can begin this educational process by
reading about other cultures, attending seminar and continuing educational
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programs, attending cultural events, participating in medical mission trips and

meeting with other members of cultural groups in their communities.
Transcultural Reciprocity:
It is process in which both patient and nurse are equal participants, with
nurses shaping care to the parameters of a patients culture. It involves ongoing ,
intentional bridging of cultural disparities between nurses and patients and a
recognition that providing culturally sensitive care is a central level rather than
peripheral level.
CONCLUSION:

Collaboration is working with others to do a task and to achieve shared goals. It

is a recursive process where two or more people ororganizations work together to
realize shared goals, this is more than the intersection of common goals seen in
co-operative ventures, but a deep, collective determination to reach an identical
objective.
BIBLIOGRAPHY:

1. NavdeepKaurBrar. Rawat.Textbook of Advanced Nursing Practice.p.983990.

2. Shabeer P. Basheer.A Concise Book of Advanced Nursing Nursing
Practice.
3. www.scribd.com.

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