Although associate degree curricula have hardly been static since the development of this nursing education model by Montag 35 years ago, the focus has traditionally stayed on the role of the nurse in the acute, short-stay hospital. Today, societal events and trends, specifically the geriatric imperative, intrude on curriculum decisions everywhere and sharply question the historic emphasis on the role of the nurse in the acute care setting as the single focus of a curriculum. One of the current questions facing associate degree nursing educators is how shall a curriculum be adapted to meet the needs of an aging population?1
This question prompted the development and submission of a large scale project titled "The Community College-Nursing Home Partnership: Improving Care Through Education," which was funded by the WK Kellogg foundation. Six associate degree nursing programs regionally dispersed and purposefully representative of different settings, student populations, and resources are conducting demonstration projects to meet two major objectives: to develop nursing potential in long-term settings through inservice education; and to influence the redirection of associate degree nursing education to include active participation for nursing roles in long-term as well as acute care settings. The demonstration sites are Ohlone College, California; Community College of Philadelphia, Pennsylvania; Shoreline Community College, Washington; Triton College, Illinois; Valencia Community College, Florida; and Weber State College, Utah. Because each community college developed partnerships with several nursing homes, a total of 27 nursing homes are also participating in the project.
Since 1986, myriad activities have occurred at the six sites to meet project activities related to faculty, nursing home staff, and curriculum development.2 Early in 1989, as the project entered its final 18 months of funding, participants at the six sites began to focus on how to institutionalize successful project activities and foster their postfunding continuation. The belief that shared goals and values can provide the foundation for a successful partnership led to the formulation of an applied research study that used the Delphi technique. In an effort to strengthen and lengthen partnership activities, this Delphi study was undertaken to identify the opinions and values of project participants. Project participants were asked their opinions about what factors are essential in a successful community college-nursing home partnership. The Delphi technique is described below.
The Delphi Technique
The Delphi technique is defined as a method for structuring a group communication process so that the process is effective in allowing a group of individuals, as a whole, to deal with a complex problem."3 The Delphi technique was developed by the Rand Corporation during the early 1950s for forecasting. It was designed to obtain opinions from a group of people using a protocol that elicited a written response, thereby minimizing the undesirable effects of small group interactions, such as the influence of a dominant person, irrelevant or redundant material, and pressure to compromise.4 The Delphi technique effectively uses informed judgment by allowing a panel of individuals to respond to a series of mailed questionnaires.5 The technique has three distinctive characteristics: anonymity, controlled feedback, and statistical analysis of group response.4
In the field of nursing, the Delphi technique has been used in a variety of ways. It has been employed to forecast priorities for nursing research,6 to identify competencies of technical nursing practice,7 to clarify the meaning of nursing diagnosis,8 and to anticipate needs for nursing service.9 In addition, the Delphi technique has been used to forecast curriculum,10 to evaluate the impact of a teaching nursing home program, u to describe essential gerontological curriculum content,12 and to identify probable future events in nursing practice, education, and educational administration.13
Use of the Delphi Technique
The Delphi technique was chosen for this study for several reasons: it can be used to solicit opinions from a national group; it provides feedback to respondents; and it allows respondents to revise their opinions after review of an analysis of the group's response. Identifying essential factors of a successful partnership does not lend itself to precise analytical techniques but rather to subjective judgments. Because a national sample was desired and it was not feasible to hold face-toface meetings, the Delphi technique was employed as a vehicle for group interaction. Furthermore, because anonymity was assured and all group communication was written, participants were not subject to undue influence from prominent or forceful members of the group.
RESPONSES TO QUESTIONNAIRES*
ITEMS RATED DIFFERENTLY BY COMMUNITY COLLEGE (CC) AND NURSING HOME (NH) RESPONDENTS
ESSENTIAL FACTORS IN A SUCCESSFUL COMMUNITY COLLEGE-NURSING HOME PARTNERSHIP*
POPULATION AND SAMPLE
The population consisted of all personnel identified by each project site director as participating in the project. Each project site director was mailed 20 Round 1 questionnaires and asked to distribute them to those who were involved in project activities. Project site directors were told to duplicate the questionnaire if more copies were needed. These directors identified the sample of 86 people for the Round 1 questionnaire. The 86 people who responded to the Round 1 questionnaire were mailed a Round 2 questionnaire. In addition, project site directors were given five extra Round 2 questionnaires and were asked to distribute them to project nursing home personnel to ensure adequate representation of nursing home personnel in the study. All 105 people who responded to either Round 1 or Round 2 questionnaires were sent a Round 3 questionnaire.
Round 1 Questionnaire
On the first questionnaire, participants in the community collegenursing home partnership were asked to answer the broad, open-ended question: "What are the essential factors that contribute to a successful partnership between community colleges and nursing homes?" Eighty-six responses were received. All suggestions contained in the responses to the first questionnaire, regardless of frequency, were content analyzed and included in the second questionnaire. Ideas from respondents were grouped into conceptual statements whenever possible. As a check on possible investigator bias, the content analysis was reviewed by a nursing educator and two psychologists familiar with nursing education. Statements were then randomly assigned placement in the second questionnaire.
Round 2 Questionnaire
The objective of the second questionnaire was to provide respondents with a complete listing of all ideas generated in the first questionnaire and to have them rate each statement. The second questionnaire was sent to the entire sample that received the first questionnaire. In addition, each project site director was given five Round 2 questionnaires for distribution to nursing home personnel involved in the project who did not respond to the Round 1 questionnaire. This was done in an attempt to increase the participation of nursing home representatives.
A scale for recording the opinions of respondents was developed. Respondents were asked to rate each item using a five-point scale: essential, very desirable, desirable, optional, and not desirable. Each rating was assigned a numerical value to perform a statistical analysis on responses to statements on the second questionnaire. A five-point scale was used to analyze the data, with a rating of essential assigned a numerical value of 4 and a rating of not desirable assigned a numerical value of 0.
At the end of the second questionnaire, respondents were instructed, "If you can mink of anything else that is essential to a successful partnership between the community college and the nursing home, please list your ideas below. These comments will be incorporated in the Round 3 questionnaire." Seven respondents added comments to explain or add emphasis to their opinion or to voice an opinion on the Delphi technique. None of the respondents suggested new items.
Descriptive statistics on the statements were prepared on the second round data. A mean, also called the group rating, and standard deviation were performed for each statement. These data were returned to respondents in the Round 3 questionnaire for review and evaluation.
Round Three Questionnaire
The third questionnaire was mailed to all 105 people who had responded to either the first or second questionnaire. The purpose of the third questionnaire was to allow respondents the opportunity to review the group rating (mean) for each of the 63 statements and to revise their opinions. Respondents were asked to indicate agreement with the group rating or, if they disagreed with the rating, to provide a different rating using the same scale used in the second questionnaire.
Eighty-six people responded to both the Round 1 questionnaire and Round 2 questionnaire. Some respondents to the Round 1 questionnaire did not reply to the Round 2 questionnaire; some respondents to the Round 2 questionnaire did not reply to the Round 1 questionnaire. Eighty of the 105 people who received the Round 3 questionnaire returned it, representing a response rate of 76.2%. The respondents represented a sample of community college and nursing home employees from each of the six project sites as described in Table 1 .
On the Round 1 questionnaire, 32.5% of the respondents were employed by nursing homes and 63.9% were employed by community colleges. On the Round 2 questionnaire, 44.2% of the respondents were employed by nursing homes and 54.6% were employed by community colleges. Of the 80 respondents to the Round 3 questionnaire, 38.7% were employed by nursing homes and 61.2% were employed by community colleges.
LEAST IMPORTANT FACTORS IN A SUCCESSFUL COMMUNITY COLLEGENURSING HOME PARTNERSHIP*
Although the goal of this three-round Delphi study was to identify the values and opinions of project participants, each round of the study represented an opportunity to examine the responses from a different perspective. The Round 1 questionnaire provided respondents with a blank sheet of paper on which they were asked to write their own ideas about essential factors of a successful community college-nursing home partnership. After these ideas were content analyzed, they became the 63 items on the Round 2 questionnaire. Each respondent was asked to rate each item and a mean score was developed from the Round 2 ratings. Respondents to the Round 2 questionnaire were sorted into two groups: those representing community colleges and those representing nursing homes. Their responses were analyzed for differences based on this sorting. On the Round 3 questionnaire, respondents were given the group rating (mean) derived from responses to the Round 2 questionnaire and asked to consider each item again. Consensus was expected, and achieved, on the Round 3 questionnaire.
Although the overall goal of consensus remained throughout the three-step process, the responses to the Round 2 questionnaire provided an opportunity to examine differences in the values and opinions of nursing home and community college respondents.
Areas of Consensus
For the purposes of this study, only items receiving a group rating, or mean, of 3.5 or higher (highest possible score is 4.0) in the Round 3 questionnaire have been termed essential. Respondents from nursing homes and community colleges indicated that essential factors in a successful partnership are the 16 items contained in Figure 1. These 16 factors represent 25.4% of the total items.
For the purposes of this study, items receiving a group rating, or mean, of 2.6 or lower on the Round 3 questionnaire have been termed least important. Respondents from nursing homes and community colleges indicated that the least essential factors in a successful partnership are the 10 items contained in Figure 2. These 10 factors represent 15.8% of the total items.
Areas of Divergence
In analyzing responses to the Round 2 questionnaire, respondents were sorted into two groups: those representing community colleges and those representing nursing homes. This sorting provided an opportunity for a clearer understanding of differences in the values and opinions of the two groups. A comparison of means of the 63 statements on the Round 2 questionnaire was performed for both groups. The f-test was used to determine differences between the mean scores for each Hem on the Round 2 questionnaire after the population was divided into two groups: those employed by nursing homes and those employed by community colleges. Different ratings on the Round 2 questionnaire, which were found to be statistically significant in r-tests, were noted for the five items listed in Table 2. The rating for only one item was significantly different for the two groups on the Round 3 questionnaire.
Analysis of responses to the three questionnaires in tins study provided a clearer understanding of the factors that contribute to a successful partnership.
Areas of Consensus
Consensus was achieved on the essential (Figure 1) and least important (Figure 2) factors contributing to a successful community college-nursing home partnership. Respondents agreed that to be successful, the partners should be committed to high quality education for students and high quality service for patients. In addition, partners should be pragmatic in goal setting and allow adequate time to plan, implement, and evaluate partnership activities. Mutual understanding and respect is essential, although both parties wish to remain autonomous.
Faculty and nursing home personnel should be knowledgeable and skillful clinically, although certification in gerontology it not essential. Communication using established channels should be clear and ongoing. Respondents felt that the benefits of and contributions to the partnership need not be equal by both partners. Finally, the respondents indicated that sharing the resources and benefits of the partnership with the professional community and the community at large was one of the least important factors in the success of a partnership.
Areas of Divergence
The areas of divergence were found on the Round 2 questionnaire when respondents were sorted into two categories: those employed by community colleges and those employed by nursing homes. Analysis of data based on this sorting found several significant differences in values. Respondents employed by community colleges placed a higher value on the community college being geographically accessible to the nursing home; communication occurring at all levels of both organizations; both partners sharing tasks and responsibilities; and involving a variety of personnel from both settings in partnership activities. The ratings of these items by community college and nursing home respondents were not significantly different on the Round 3 questionnaire. On the other hand, nursing home respondents placed a higher value on personnel from both sites being involved in the decision-making process at both sites. The difference in the rating of this item by community college and nursing home respondents remained significant on the Round 3 questionnaire.
When the rank order of Round 2 questionnaire items for the two groups was compared, several differences were found. Respondents from nursing home settings ranked the following items higher than those from community college settings: staffs at both sites should be flexible and willing to change; and both partners should benefit and believe that each partner is benefiting from the partnership. Respondents from community colleges ranked the following items higher than those from nursing home settings: time should be provided to plan, implement, and evaluate partnership activities; the community college and the nursing home should be geographically accessible; and communication should occur at all levels of both organizations.
APPLICATION AND IMPLICATIONS
The purpose of this Delphi study was to identify characteristics of a successful community college-nursing home partnership so that project activities could be strengthened and continued after funding. Using this perspective as a lens for viewing the results, it seems that the foundation for solid partnership is based on the 16 essential factors listed in Figure 1 . The basis for a solid partnership includes mutual respect and understanding, a commitment to high quality education for students and high quality service to patients, clear communication, and a collaborative approach to managing the partnership. Both partners (the community college and the nursing home) wish to remain autonomous while collaborating on management of the partnership. One partner, most likely the community college, needs to assume responsibility for doing the majority of the work to maintain the partnership, as respondents felt that the benefits and responsibilities need not be equal.
Two issues emerged from this study that warrant further research. Sharing the resources and benefits of a partnership was found to be a low priority in this study, especially by nursing home respondents. This closed system approach, which values decreased interaction with the community at large, is puzzling. Perhaps it is a reaction by nursing home personnel to a history of limited resources for care of the elderly, or perhaps it is simply a statement that this kind of activity is not essential to the strength of a partnership. In addition, the intricate relationship between the perceived benefits and the work of maintaining a partnership needs to be explored more fully. Specifically, what are mese benefits from the perspective of each partner and which benefits are valued most? Understanding this complex interaction could provide a more solid base for a partnership.
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RESPONSES TO QUESTIONNAIRES*
ITEMS RATED DIFFERENTLY BY COMMUNITY COLLEGE (CC) AND NURSING HOME (NH) RESPONDENTS