Different Models of Collaboration between Nursing Education and Service

Different Models of Collaboration between Nursing Education & Service Page.

DEPARTMENT OF NURSING

Chair Person Prof. (Dr.) K. Reddemma Dean, Behavioral sciences, NIMHANS, Bengaluru

Presenter Bivin, J.B II MSc. Psychiatric Nursing, NIMHANS, Bengaluru

Index
S. No 1 2 3 4 5 6 Introduction Meaning Definition Types of collaborations Need for collaboration between education and service Models of collaboration between education and Service 6.1. Clinical school of nursing model 6.2. Dedicated Education Unit Clinical Teaching Model 6.3. Research Joint Appointments (Clinical Chair) 6.4. Practice-Research Model (PRM) 6.5. Collaborative Clinical Education Epworth Deakin (CCEED) model 6.6. The Collaborative Learning Unit (British Columbia) Model 6.7. The Collaborative Approach to Nursing Care (CAN- Care) Model 6.8. The Bridge to Practice Model 6.9. Collaboration of Nursing Education and Service in India 7 8 Conclusion Bibliography 13 14 Content Page No 1 1 2 2 3 4-12

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Different Models of Collaboration between Nursing Education & Service

DIFFERENT MODELS OF COLLABORATION BETWEEN NURSING EDUCATION AND SERVICE 1. 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. Collaborative partnerships between educational institutions and service agencies have been viewed as one way to provide research which ensures an evolving health-care system with comprehensive and coordinated services that are evidence-based, costeffective and improve health-care outcomes1. Collaboration is a substantive idea repeatedly discussed in health care circles. Though the benefits are well validated, collaboration is seldom practiced. The lack of a shared definition is one barrier. Additionally, 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. Many researchers have validated the benefits of collaboration to include improved patient outcomes, reduced length of stay, cost savings, increased nursing job satisfaction and retention, and improved teamwork (Abramson & Mizrahi 1996).1The focus on benefits of collaboration could lead one to think that collaboration is a favorite approach to providing patient care, leading organizations, educating future health professionals, and conducting health care research. Contextual elements that influence the formation of collaboration include time, status, organizational values, collaborating participants, and type of problem. 2. Meaning Collaboration is an intricate concept with multiple attributes. Attributes identified by several nurse authors include sharing of planning, making decisions, solving problems, setting goals, assuming responsibility, working together cooperatively, communicating, and coordinating openly (Baggs & Schmitt, 1988). Related concepts, such as cooperation, joint practice, and collegiality, are often used as substitutes. The roots of the word collaboration, namely co-, and laborare, combine in Latin to 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 reality is that collaboration evolves in partnerships and in teams. Baggs and Schmitt (1988) reframe the relationship between collaboration and teamwork by defining collaboration as the most important aspect of team care but certainly not the only dimension. A description of the concept of collaboration is derived by integrating Follett's outcomeoriented perspective (1940) and Gray's process-oriented perspective (1989). Both authors strengthen the definition of collaboration by considering the type of problem, level of interdependence, and type of outcomes to seek. According to them: Collaboration is both a process and an outcome in which shared interest or conflict that cannot be addressed by any single individual is addressed by key stakeholders. The collaborative process involves a synthesis of different perspectives to better

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Different Models of Collaboration between Nursing Education & Service

understand complex problems. A collaborative outcome is the development of integrative solutions that go beyond an individual vision to a productive resolution that could not be accomplished by any single person or organization. It is critical in collaboration that all existing and potential members of the collaborating group share the common vision and purpose. Several catalysts may initiate collaboration a problem, a shared vision, a desired outcome, to name a few. Regardless of what the catalyst may be, it is essential to move from problem driven to vision driven, from muddled roles and responsibilities to defined relationships, and from activity driven to outcomes. Collaboration is an inclusionary process with continuous engagement that reinforces commitment, recognizing the building of relationships as fundamental to the success of collaborations. An effective collaboration is characterized by building and sustaining win-win-win relationships8. 3. Definition Henneman et al. have suggested that 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. "Collaboration is the most formal inter organizationl relationship involving shared authority and responsibility for planning, implementation, and evaluation of a joint effort (Hord, 1986). Mattessich, Murray and Monsey (2001) define collaboration as '... a mutually beneficial and well-defined relationship entered into by two or more organizations to achieve common goals'8. 4. Types of Collaboration Terms, such as interdisciplinary, multidisciplinary, transdisciplinary, and interprofessional, which further delineate and describe teams, teamwork, and collaboration, have evolved over time. 4.1. Interdisciplinary 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. 4.2. Multidisciplinary refers to independent work and decision making, such as when disciplines work side-by-side on a problem. The interdisciplinary process, according to Garner (1995) and Hoeman (1996), expands the multidisciplinary team process through collaborative communication rather than shared communication. 4.3. Transdisciplinary efforts 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. 4.4. Interprofessional collaboration 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

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Different Models of Collaboration between Nursing Education & Service

members transcend seperate disciplinary perspectives and attempt to weave together resources, such as tools, methods, and procedures to address common problems or concerns2. 5. Need for Collaboration between Education and Service 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 hospitalbased 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).

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Different Models of Collaboration between Nursing Education & Service

The challenge to nursing education is how to combine theoretical knowledge with sufficient technical training to assure a competent performance by a professional nurse in the hospital setting. Clearly, a partnership between nursing educators and hospital nursing personnel is essential to meet this challenge13. 6. Models of Collaboration between Education and Service5 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). 6.1. Clinical school of nursing model (1995) The concept of a Clinical School of Nursing 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 and 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 opportunities for exchange of ideas with clinical nurses with increased opportunities for clinical nursing research. Many educational openings for expert clinical nurses to become involved with the university's 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 levels10. 6.2. 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

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Different Models of Collaboration between Nursing Education & Service

Commitment by all to collaborate to build an optimal learning environment.

6.3. Research Joint Appointments (Clinical Chair) (2000) A Joint Appointment has been defined by Lantz et al. (1994), as a formalised agreement between two institutions where an individual holds a position in each institution and carries out specific and defined responsibilities. The goal of this approach is to use the implementation of research findings as a basis for improving critical thinking and clinical decision-making of nurses. In this arrangement the researcher is a faculty member at the educational institution with credibility in conducting research and with an interest in developing a research programme in the clinical setting. The Director of Nursing Research, provides education regarding research and assists with the conduct of research in the practice setting. She/he also lectures or supervises in the educational institution. A formal agreement exists within the two organisations regarding specific responsibilities and the percentage of time allocated between each. Salary and benefits are shared between the two organisations. Outcomes identified by Donnelly, Warfel and Wolfe (1994) for the educational institution are that it becomes more in touch with the real world and more readily able to identify research questions (and the subsequent study), that have the potential to make a difference to quality of consumer care delivery. There is also an increasing collaborative relationship with the service provider, which is important for long term workforce planning. The position has benefits to nursing/midwifery students due to more explicit focus on directly linking the education setting to the clinical context. For practice the outcomes are increased staff involvement in professional activities including writing for publication, presenting at seminars and conferences and preparing submissions on professional issues. The clinical chair also facilitates improved access and support to external research project funding6. 6.4. 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. The process of the collaborative partnership agreement involved the development of a PracticeResearch Model (PRM) of collaboration. 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. The key concepts exemplified in the application of the model include practice-driven research development, collegial partnership, collaborative ownership and best practice. Many specific outcomes have been achieved through implementation of the model, but overall the partnership between registered nurses and academics in the pursuit of research to support clinical practice has been the highlight. The key elements underlying the process of collaboration and development of the PRM are: Collaborative partnership: - 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

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between the organizations that led to the establishment of a Nurse Research Consultant (NRC) position. Core values and aims of the collaborative partnership: - Before the actual framework of the collaborative partnership was decided, a literature review of the most common models of collaboration in nursing practice was used to promote discussion between the organizations to clarify and formalize the assumptions underlying the core values, roles and responsibilities of the partners, as indicated by Spross (1989). During this phase, four key concepts emerged: firstly, that 'practice drives research'; secondly, the principle of 'collegial partnership'; thirdly, 'collaborative ownership', and finally, 'best practice' (Downie et al., 2001).

Nurse Research Consultant (NRC): - 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 agreement5. 6.4.1. Operational framework of the PRM To fulfill the aims of the partnership several key elements formed the operational framework of the collaborative agreement. One important element of the framework was to enhance nursing staffs' knowledge of the research process via research experience. To achieve this 'Journal Clubs' were established in the community health service on a monthly basis. The Nurse Research Consultant then worked with staff to identify, plan and implement changes to practice based on research evidence. A second important element of the PRM was to encourage nursing staff to reflect on current nursing practice and identify clinical problems based on their knowledge and experience of nursing in order to develop meaningful research proposals and best-practice guidelines. The main reason for the success of the collaborative arrangement has been the provision of infrastructure to support the dissemination of research and quality improvement findings through clinical meetings, workshops and conference presentations by the nursing staff involved in the various projects. 6.5. Collaborative Clinical Education Epworth Deakin (CCEED) model (2003)7 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.

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As a consequence of this process of clarification and negotiation, the Practice-Research Model was developed to operationalise the agreed aims of the partnership, which were: To encourage nursing staff to reflect on current nursing practice in order to develop meaningful research proposals; To teach staff the research process via research experience; To enable nursing staff to have a key role in the professional development of other staff via the dissemination of research and quality improvement findings; and To plan and implement changes to practice based on research evidence.

Students coached by Nurse Clinician

Nursing education supported by Clinical Facilitators

Clinical facilitators are supported by Hospital administration and university

The Collaborative Clinical Education Epworth Deakin (CCEED) model developed to facilitate clinical learning, promote clinical scholarship and build nurse workforce capability. This model provided a framework for the first initiative, a CCEED undergraduate program that nested the clinical component of Deakin University's undergraduate nursing curriculum within Epworth Hospital's health service environment. The CCEED undergraduate program sees undergraduate nursing students attending lectures at Deakin University in the traditional manner but completing all tutorials, clinical learning laboratories and clinical placements at Epworth Hospital throughout their three year course. Tutorials, laboratories and clinical placements are conducted by Epworth clinicians who are prepared and supported by Deakin School of Nursing faculty. These clinicians also support the student-preceptor relationship in the clinical learning component of the curriculum. The expectation was that increased integration between hospital and university would enhance clinical education resulting in improved students application of knowledge and skill as well as increased socialization to the clinician role.

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Key findings of the 2005 pilot CCEED program were 1. Students learning objectives were met and satisfaction was high. 2. Undergraduate clinical education was valued by preceptors and managers as a workforce investment strategy 3. Preceptors were enriched in their clinician role as a result of their participation in the program and reflection on the process. 4. Preceptor continuity promoted a trusting relationship that enabled preceptors to confidently encourage student initiative. 5. Preceptors managed multiple roles in order to meet demands of patient care and student learning. 6.6. The Collaborative Learning Unit (British Columbia) Model, 2005 The Collaborative Learning Unit model was based on the Dedicated Education Units concept developed, successfully implemented, and researched in Australia. The Collaborative Learning Unit (CLU) model of practice education for nursing is a clinical education alternative to Preceptorship. In the CLU model, students practice and learn on a nursing unit, each following an individual set rotation and choosing their learning assignment (and therefore the Registered Nurse with whom they partner), according to their learning plans. Unlike the traditional one-to-one preceptorship-, an emphasis is placed on student responsibility for self-guiding, and for communicating their learning plan with faculty and clinical nurses (e.g., the approaches to learning and the responsibility they are seeking to assume). All nursing staff members on the Collaborative Learning Unit are involved in this model and, therefore, not only do the students gain a wide variety of knowledge but the unit also has the ability to provide practice experiences for a larger number of students. Specifically, a Collaborative Learning Unit is a nursing unit where all members of the staff, together with students and faculty, work together to create a positive learning environment and provide high quality nursing care. Clinical nurses preparing to adopt the CLU model have described a positive learning environment as one where questions are expected. In the CLU approach the students are not attached to the units as an extra set of hands to augment the nursing workforce, but are present as learners with a primary interest in gaining entry-level knowledge and competency associated with baccalaureate-prepared nursing practice. As learners in the CLU model, students are supported by experienced clinical nurses, faculty and, ideally, nurse researchers. Students recognize a positive learning environment when they perceive their questions are welcomed, and when they receive thoughtful responses at mutually selected times for students and staff. For faculty (e.g., academic instructors), key questions focus on determining what nursing knowledge is needed to provide high quality nursing care. Thus, in a CLU, where critical questioning is promoted, students can systematically learn to think like a nurse and can demonstrate what they know and can do, as undergraduate nurses who are members of a health care team. While staff and faculty work together to support and advance student learning and promote high quality nursing care, the CLU model enables a level of student independence that helps them move into the work-world. As well, the CLU concept bridges a perceived gap between academic and clinical expectations. In this model, nursing faculty, clinical nurses and students work collaboratively to enhance learning opportunities as well as develop the professional knowledge base of nursing.8

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The Collaborative Learning Unit (British Columbia) Model, 2005

Clinical Nurses

Clinical Site coordinators

Student Nurses

Nurse Educators

Nurse Researchers

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6.7. The Collaborative Approach to Nursing Care (CAN- Care) Model (2006)12 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 idea of a partnership model emerged when the Christine E. Lynn College of Nursing, Florida Atlantic University, was awarded a grant from Tenet HealthCare Foundation to initiate an Accelerated Second-degree BSN Program. The goal was to design an educationally dense, practicebased 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. A commitment to a constructivist approach to learning, an immersion experience to recognize the unique needs of accelerated second-degree learners, and to emphasize the partnership among the academic and practice setting, were guiding forces in the creation and enactment of the model. 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.

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The essence of the CAN-Care model is the relationship between the nurse learner (student) Care and nurse expert (unit-based nurse), within the context of each nursing situation. The semantics of the based nursing student as learner and unit-based nurse as expert, in place of the more common traditional labels of based preceptor and preceptee are critical to the intentionality of the collegial focus of the model. The label nurse learner was designated to place the emphasis on the learning role and the reflective and as continuous nature of knowledge construction. The learner is responsible and accountable for engaging in the learning process and for taking an active role in establishing a dya dyadic learning partnership with the nurse expert. Unit based nurses are experts in the work of nursing care. The title Unit-based nurse expert was chosen to recognize the gifts they bring to the profession and share with the nurse learner. The nurse learners and nurse experts engage in a dyadic partnership for the purpose of nurse meeting the needs of the assigned patient population as well as to reflect on and to come to know the art and science of nursing practice. The onsite faculty member is the expert in educational p processes and is essential in the support and nurturing of the expert/learner partnership. 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. This is a major change in focus from the more traditional role of faculty change being in control of the teaching of students By the application of CAN-Care model the focus of the students. Care students activities moves from the demonstration of discrete skills and prescribed outcomes to an immersion into the professional nurse role, learning to hear and respond to patient needs, and to mersion provide nursing care to achieve quality outcomes. Through this model the student comes to know the organizational context of nursing practice, the multifaceted role of professional nurses, and assumes responsibility for coming to know the meaning of nursing in each unique situation. The unit-based nurse acquires new skills based in mentoring, exposure to evidenced evidencedbased practice, and to theoretical knowledge through association with the college. This approach to education in the practice setting is thought to be more consistent with the educational needs of nurses who are preparing for the challenges of professional practice in todays acute care settings. The most dramatic change with this model is the re reconceptualization of the work of the faculty member. The faculty is the education-focused expert pert who supports and nurtures the nurse expert/nurse learner partnership. The faculty member must relinquish control of the students. While the faculty still has accountability for

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overall evaluation of the students achievement of the nursing practice course objectives, even the process of the on-going evaluation becomes a collaborative effort with the nurse expert. 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 the nurse learner. The work of the faculty is re-conceptualized as the creator of the environment to support learning and professional growth as opposed to the direct teaching of preselected content. In this model, the healthcare organization becomes an active participant in creating learning environments and contributing to the learning activities, as opposed to just being a setting in which college-affiliated faculty appear with students for a teaching encounter. In return, the college becomes an active partner in the professional development and retention of nurses at the practice facility. 6.8. The Bridge to Practice Model (2008)11 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 University faculty overseeing the clinical experiences. Third, students are actively involved in selecting their clinical placements. The Bridge to Practice model proposed by Catholic University of America, school of Nursing (2008), uses a cohort approach in which students complete medical-surgical clinical nursing education at the same facility. Students must apply for clinical placement in the hospital of their choice via a clinical application form. Clinical placement decisions are based on academic performance and maturational level. Participating students undergo 415 hours of clinical experiences (nine academic credits) focused on medical-surgical nursing. These clinical practice progresses from Adults in Health and Illness: Basic, an introductory nursing course, to Medical-Surgical Nursing Leadership, a senior level course taken in the last semester of baccalaureate study. Thus The Bridge to Practice Model provides undergraduate nursing students with continuity in medical-surgical education through placement in the same hospital for all medical-surgical clinical rotations. Hospitals that participate in the bridge model provide senior clinical nurse preceptors whose time is paid for by the university. The Bridge to Practice model emphasizes professional incentives for hospital nurses to participate in nursing education. Planned incentives include the rewarding of hospital nurses with continuing education credits for participation in the short-term training on educational methodology and approaches. A tuition discount is offered for graduate 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. Challenges include recruitment of interested senior clinical nurses, retention of clinical liaison faculty, and management of the trade-off between institutional stability offered by clinical site continuity and the variety of experiences offered by rotation across several clinical settings.

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6.9. Collaboration of Nursing Education and Service in India 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 hospital, it was the students who largely staffed the wards and learned the practice of nursing under the guidance of the nursing staff. However, 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 to provide an effective educational environment towards enhancing students learning experiences and laying the foundation for further educational development4. While this separation has been beneficial in advancing nursing education, it has also had adverse effects. Under the divided system, the nurse educators are no longer the practicing nurses in the wards or directly involved in the delivery of nursing services, nor responsible for the 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 the 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. The need for greater collaboration between nursing education and services calls for urgent attention. We have two institutions which are practicing dual role, education & practice : NIMHANS, Bangalore and CMC, Vellore. More institutions need to adopt this model. This will help improve the quality of Nursing Education with overall objective of improving the quality of nursing care to the patients and community at large4. 6.9.1. Dual role model in NIMHANS Following the amalgamation of 1974 resulting in NIMHANS, the faculty of the nursing department took up the dual responsibility of providing clinical services as well as conducting teaching programs. In 1975, all the Grade II nursing superintendents working in the hospital were designated tutors to maintain uniformity in the department. Combined workshops were conducted under the guidance of WHO consultant Mrs.Morril to prepare the tutors who came from Grade II Nursing Superintendent cadre for teaching purpose and to make the Lectures and tutors associated with educational programmes (DPN course& 9-months course in psychiatric nursing) comfortable with clinical supervision. After both groups felt comfortable to assume the dual responsibility, the areas of supervision were designated. The Head of the Department of Nursing was given the responsibility for both the service and the education component of the department. Integration of education with service raised the quality of patient care and also improved the quality of learning experiences for nursing students, under the close supervision of teachers who were also practitioners. 6.9.2. Integrative Service-Education approach in CMC Vellore College of Nursing under Christian Medical College, Vellore, where nurse educators are practicing in the wards or directly involving in the delivery of nursing services. This enables the practicing nurse to share her practical knowledge to the student nurse who is practicing in the concerned wards. Government of India conducted a pilot study on bridging the gap between education and service in select institutions like one ward of AIIMS. The project was successful, patients and medical

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personnel appreciated the move but it required financial resources to replicate this process. 7. Conclusion Estimating the future need for Registered Nurses with various educational backgrounds is complicated by differing perceptions of educators and employers about the appropriate base of knowledge and skills new graduates need. These differences began to be apparent when nursing education moved away from its historical base in hospitals in response to abuses and inadequacies that were believed to characterize the apprentice type of training they provided. They continue to plague the profession3. Many nursing service administrators believe that academic nurse educators, removed from the realities of the employment setting, are preparing students to function in ideal environments that rarely exist in the real and extremely diverse worlds of work. In turn, many nurse educators believe that nursing service administrators fail to provide work environments conducive to the kinds of nursing practice their graduates--particularly baccalaureate RNs--are equipped to conduct and that, furthermore, new graduates of baccalaureate, and diploma programs should be differentiated in their functional work assignments. The report of a task force of the American Association of Colleges of Nursing observes that " conflicting philosophies, values, and priorities between nurse educators and nursing services administrators have generally served to deter a mutual understanding and acceptance of responsibility for quality patient care." To succeed, nursing educators and care providers alike must strengthen their response to these challenges with innovative solutions built into the program design and administration. Closer collaboration between nurse educators and nurses who provide patient services is essential to give students an appropriate balance of preparation12. 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. The literature supports the utility of such collaborations. For example, the most frequently cited positive outcomes are job satisfaction, improved educational experiences for pre-registration nursing students, increased self-confidence and improved knowledge base for nurses2. The majority of these models are based on a joint appointment model where the nurse is initially employed by a health service or a university and divides his or her time between teaching and clinical practice. Application of these models can reduce the perceived gap between education and service in nursing there by can help in the development of competent and efficient nurses for the betterment of nursing profession.

Thank You!

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