Dr. Campbell is Interim Dean and Professor, and Dr. Jeffers is Professor of Nursing and Director of Graduate Programs, Research, and Scholarly Activities, Illinois State University, Mennonite College of Nursing, Normal, Illinois.
Address correspondence to Sara L. Campbell, DNS, RN, NEA-BC, Interim Dean and Professor, Illinois State University, Mennonite College of Nursing, Campus Box 5810, Normal, IL 61790-5810; e-mail: firstname.lastname@example.org.
© 2008 Istock International Inc. /Andrew Johnson
Nursing homes are rapidly changing as nursing home resident health becomes increasingly more complex with rising acuity levels. According to the National Commission on Nursing Workforce for Long-Term Care (2005), “more than 12 million Americans receive formal long-term care services each year” and more than “75% of nursing home residents are sufficiently disabled that they are unable to perform three or more activities of daily living” (p. v). As adults live longer, the complexity of their health care needs increase, resulting in nursing home residents requiring comprehensive, specialty advanced care. In addition, nursing home administration and staff are burdened with heavy regulatory mandates and the need for efficient organizational functioning. These mandates and need for efficiency are designed to improve care but are often time consuming (Jensen & Cohen-Mansfield, 2006).
All of these factors limit staff members’ ability to develop, implement, and evaluate up-to-date educational programming that is essential for nursing staff to meet the care demands of current and future nursing home residents. The purpose of this article is to present the initial experiences of a nursing home and academic partnership. The purpose of this partnership was to provide a model of diverse teaching-learning experiences for nursing students, share resources among and between clinical nursing home sites and the college of nursing, and increase the attractiveness of long-term care as a career option for new nursing graduates.
Mennonite College of Nursing (MCN) at Illinois State University developed a rendition of the teaching nursing homes of the 1980s (Mezey, Lynaugh, & Cartier, 1988; Mezey, Mitty, & Bottrell, 1997). Teaching nursing homes of the past typically involved one nursing home; however, MCN received a congressionally directed U.S. Department of Education Grant for Improvement of Postsecondary Education and engaged four nursing homes within the same enterprise, working exclusively with the nursing homes while building the foundation for the Joe Warner Teaching Nursing Home project. This teaching nursing home project was developed for the primary purpose of increasing the attractiveness of long-term care as a career option for graduating RNs. Thus, mechanisms were needed that would facilitate this endeavor.
One such mechanism was the development of a model to provide an impetus for professional cultural change within the nursing homes that would be attractive to new nursing graduates. Success of this model hinged on buy-in support from all constituents, bringing about the need for a feedback loop. It was also crucial that the model facilitated ongoing, positive, communicative working relationships between the MCN and the participating nursing homes. Thus, a partnership model—the Sister Model (Figure)—was developed as a framework to guide communication, dissemination, and delivery of best practice care for older adults residing in nursing homes.
Figure. The Sister Model. Arrows indicate partnership and working relationships.
The original teaching nursing home model surfaced in the 1980s and was lauded as a model that would influence care delivery for residents (Williams, 1985). This model was deemed to be influential in improving care of nursing home residents by supporting nursing students’ clinical education in the nursing home setting (Chilvers & Jones, 1997; Mezey & Lynaugh 1991; Mezey et al., 1997).
Teaching nursing home projects eventually faded from existence by 1990, but discussion has recently resurfaced related to teaching nursing homes as potential projects capable of affecting quality of care once again in nursing homes and recruiting nursing students to work in geriatric care settings. There are current models of care between academia and practice, but these are focused primarily in community-based and acute care settings, rather than on relationships between nursing schools and nursing homes. These academic-service/practice partnerships have been found to be innovative, efficient in sharing resources, significant in improving health outcomes, and helpful in preparing the next generation of health care providers (Campbell, Prater, Schwartz, & Ridenour, 2001; Hewlett & Eichelberger, 1999; Kinnaman & Bleich, 2004; Nies, Bickes, Schim, & Johnson, 2002). However, within existing models, clear conceptualization and operationalization of communication pathways are often lacking. The Sister Model serves as such a pathway within the larger Joe Warner Teaching Nursing Home project.
Sister Model Components
Conceptually, the Sister Model is based on participation of two primary and two secondary nursing homes. Two larger, urban nursing homes were each linked with a smaller, rural “sister” nursing home, all of which were places where faculty and students conducted clinical practice. Several factors were considered in the decision to connect larger urban nursing homes and smaller rural ones. The model design accounts for differences in participating nursing homes related to variations in numbers of residents, needs of residents and staff, and available resources. These resources include the proximity and depth of available services in the community, and other resources such as finances and staffing patterns.
All of the differences in urban and rural nursing homes mentioned above offer varied teaching-learning opportunities that can be shared between the participating nursing school and the nursing homes, as well as among the sister nursing homes themselves, thus maximizing information and experiences. This kind of model reduces resource disparities between nursing homes in urban and rural settings. For example, rural nursing homes typically have fewer available resources than do urban homes because of geography and economic considerations, but they usually have similar resident needs, placing rural nursing homes in a more vulnerable position (Brown, 2006; Weech-Maldonado, Shea, & Elmendorf, 2007).
The Sister Model provides a “purposeful” framework to increase communication, share resources, allow interactive learning, and use nursing expertise to develop competence of nursing students (Table 1). Primary components embedded within the model include communication, sharing resources, interactive learning, and nursing expertise. It was determined that, initially, these would be the components focused on within the project, but it was anticipated that over time there would be more naturally occurring components. The model offers a visual depiction of the formal relationships established with all four components, moving in two directions between participants.
Table 1: The Sister Model Components and Activity Examples
The model is not composed of necessarily new or futuristic concepts but was developed with the following belief in mind. Many partnerships and collaborative endeavors are created with the intent to share resources and ideas, but in reality, unless it is “purposeful,” participant energy wanes and these kinds of activities end. Although simplistic, the model structure was to serve as a stark reminder of the relationships between and among participants and the need to nurture such relationships. Inclusion of the model to the project added a new component to the original teaching nursing home projects.
Implementation of the Sister Model first required formation of an organizational structure supportive of a feedback loop. Model structure consisted of a collaborative committee composed of select nursing faculty, project team members, and nursing home staff and administrators. Collaborative orientation and committee meetings were established on a regular basis to build rapport and trust and to gain influence for grant activities. These planned meetings provided networking opportunities not only between MCN and the nursing homes but also among the four sister nursing homes.
Although the project coordinator would be the primary source for project activities, a successful feedback loop could not occur without direct involvement from a key nursing home staff member at each home. Nurse liaisons were chosen from each nursing home to provide service-side project leadership, and one RN was hired for the grant team to serve as the practice link between the service and academic sides. The nurse liaison served as a role model and worked with the project nurse to create positive clinical environments for nursing. The liaison was also responsible for facilitating project activities and serving as the contact person and link between the nursing home and grant staff.
Central to the Sister Model were activities that would facilitate communication among participants. Computers for nursing staff use were installed in each home, and technology training was provided by grant staff, thus facilitating exchange of information among the sister nursing homes. This endeavor required close working relationships between MCN and nursing home technology staff to overcome technology infrastructure and firewall barriers. Additional communicative structures within the Sister Model included development of a Web site to disseminate project goals and activities. Video and digital photographs of nurse liaisons were also placed on the Web site to increase liaison credibility and showcase their expertise.
Traditionally, nursing schools use nursing homes as clinical rotation sites, coming to the home and engaging in clinical practice, thus making use of nursing homes and their staff and residents. The Sister Model was designed to encourage reciprocity between MCN and the nursing homes. Resources that were made available through the project, as well as resources available at MCN, were made accessible to nursing home project participants. For example, educational materials were purchased based on nursing home staff recommendations for student learning. These materials, such as a model with decubiti at various stages, were made available for nursing student and nursing staff learning. Another example is that MCN laboratory simulation equipment was used by the liaisons to update their skills. In addition, all nursing homes and clinical nursing faculty were given copies of evidence-based protocols for use in caring for older adults.
Project activities designed to share expertise among nursing homes and MCN were promoted via brochures and registration forms that were available on the Web site. The project supported the first Long-Term Care Career Fair and Seminar in the state of Illinois and a national speaker event. The nurse liaisons assisted with these events and promoted nursing home staff attendance. These events facilitated continued networking among the sister homes and began building expectations for increased professionalism in the nursing home setting. These events also facilitated professional interactions between nursing home staff and nursing students.
Interactive learning was another key component of the Sister Model. Project activities were created that engaged both academic and nursing home learners. Basic to this kind of learning, technology upgrades were needed at the participating nursing homes, including the computer installation described above. Ultimately, a Web-based geriatric nurse resource icon was placed on the desktop in each nursing home, and a resource list of Web sites was placed by computer workstations for easy access.
The Sister Model also sought to develop the nursing homes’ capabilities to participate with MCN in distance learning activities. These activities were designed to model excellence in long-term care and bring nursing students into long-term care. Interactive videoconferencing equipment was purchased and placed in two sister nursing homes, allowing for interactive learning among several groups. For example, a research presentation on technology and medication errors in nursing homes was held at MCN and was available in an interactive mode to one of the nursing homes. Nursing staff and even a few nursing home residents viewed the presentation and asked questions of the speaker via the interactive technology. This event created energy and excitement for all participants.
Another source of interactive learning was encouraged through the availability of MCN computer modules aimed at best practices in caring for older adults. These modules were produced in an earlier grant project and included topics such as ethics, hearing loss, and advance directives. Nursing home staff and students were able to access these modules at the nursing homes and MCN.
As conceptualized, the Sister Model called for an advanced practice nurse (APN) to help with role-modeling and mentoring activities with nursing students and nursing home staff. Because a geriatric APN was not available, a master’s prepared nurse fulfilled this role. The project nurse floated among the four participating nursing homes, including days when students were present. This facilitated networking among project and nursing home staff and helped prepare the nursing homes for student clinical learning.
The project nurse also developed individualized case studies and inservice sessions that were requested by nursing home staff. Nursing students and faculty were present for these sessions. In addition, the project nurse developed educational materials for the nursing homes and focused select teaching-learning materials for specific groups of nursing home personnel, such as certified nursing assistants. In addition to the formal educational sessions, the project nurse provided an avenue for ongoing professional development of the nursing home staff, specifically the nurse liaisons. Professional development experiences occurred through activities that helped nurse liaisons update their skills and knowledge. Liaisons had opportunities to learn about best practices in geriatric nursing by attending geriatric nursing conferences and speaking engagements, practicing skills simulations in the MCN clinical laboratory, and having access to national geriatric care norms. The project nurse served as a role model and mentor, providing encouragement and support in all of the professional development activities.
Early Evaluations of Model Activities
At the end of the first year, anonymous surveys were distributed to nursing home administrators and collected by the project coordinator. Nursing home administrators, directors of nursing, and assistant directors of nursing from each nursing home participated in the survey. Open-ended survey questions asked administrators to evaluate the impact of the model on nursing home professional practice culture, technology use, and communication among the homes and MCN (Table 2). The responses to the open-ended questions were read, and a descriptive summary compiled. Early evaluations of model activities have been positive. Nevertheless, several challenges have been encountered in the implementation of project activities. From these evaluations, several challenges, as well as factors that indicate project and feedback loop success, have been identified.
Table 2: Evaluation Survey
Nursing home administrators stated that students and faculty must maintain a sense of realism when working with the nursing home to achieve project goals. A practiced “learning approach” was considered important to administrators as faculty and students worked to improve care for residents. Limited exposure of nursing faculty, nursing students, and grant staff to the Sister Model homes on a daily basis makes it difficult for them to understand the big picture of care delivered within the homes and may lead to negative perceptions of care delivery. Administrators stated that faculty needed to guide students to reflect positively on the learning experiences, as well as offer more educational presentations to staff and seek input regarding staff needs. Some administrators believed students needed to spend additional time with the nurses while they were performing their daily work (e.g., administering medications) to enhance project goals and outcomes in the future. Other administrators believed the project goals needed to focus less on them as administrators and more on providing learning opportunities for nursing home staff via the project nurse.
The project goals of upgrading technology and increasing nursing home staff access to Web-based best practice resources presented several challenges within the Sister Model homes. Time, available physical space, location of technology within the home, technical difficulties, and lack of familiarity with staff use were identified factors that decreased potential use.
Indicators of Project Success
The nursing home administrators believed the impact of the model activities on the professional culture of the nursing home was positive. The opportunities to interact with students helped some staff see their work ethic from the student’s point of view. The Sister Model acted in some cases as a mirror of the nursing home culture to staff, with several positive outcomes, such as increased professionalism of some staff, identification of areas for growth within the homes, and an awareness of how staff members’ practice methods influence new nurses. The more frequent and structured interactions among MCN and the nursing homes helped make student clinical experiences less chaotic.
Sustainability of Model Activities
Sustainability of model activities requires continued purposeful nurturing of academic and nursing home relationships. Integrating model activities so they become a permanent part of the college culture has been a key approach taken by MCN to encourage model sustainability. For example, a national speaker event is held yearly to share education, skills, and best practices among MCN and the nursing homes. Routine updating of best practice resources within the college and nursing homes helps keep faculty and nursing home staff knowledge current. Integrating model activities within the nursing curriculum ensures accountability within courses to continue collaboration with Sister Model nursing homes. For example, MCN used information from nursing home key informants to evaluate how students could improve their geriatric nursing practice skills. This information led to the expansion of the MCN nursing skills laboratory, which now includes a geriatric learning station. The station includes a geriatric mannequin, handheld computers with geriatric-specific information, and a model that allows students to increase skills in wound care.
These practical applications of the partnership model lead to sustainable processes that ensure continued sharing of resources and knowledge within the model framework. Unanticipated outcomes of the model have resulted in informal observations about the sister connections between the urban and rural nursing homes. For example, bringing nursing staff together for project activities has allowed staff to network more frequently and at a higher level. In addition, there has been a somewhat competitive nature evolving between sister nursing homes. This positively encouraged one home to strive to attain the professional culture that the sister home was exhibiting. MCN and nursing home administrators now continue to seek innovative program funding to expand the work started.
Academic and nursing home collaborative endeavors are a win-win situation. Nursing home administrators and staff are burdened with heavy care demands and regulatory implications that consume much of their daily time, leaving little time for continuing education and researching of best practices. The faculty role in academia includes conducting research; reviewing literature; educating; and developing, implementing, and evaluating best practice care in multiple settings, such as nursing homes.
It is evident that collaborative projects between service and academia can be successful, but many aspects of these kinds of projects must be considered. For example, communication patterns tend to be underestimated. There is a need for clear, planned, structured, purposeful communication pathways. Even when intentions are good, it is easy to forget to inform all parties, to overlook some individuals, or to not even consider that something needs to be communicated. The relational aspect of the partnership also cannot be underestimated. There is the need for networking among participants and plans to bring the groups together for socialization. Teaching nursing homes of the past were designed to provide care in one nursing home, but the teaching nursing home project described in this article engaged four nursing homes, thereby spreading the impact of the project. However, this may also have diluted the effect and led to more complex communication needs.
There are pertinent implications for nursing home and nursing school staff and administration. It is vitally important that nursing home and nursing school administrators understand and accept the responsibility of ensuring that learning is occurring and that best practices are being used in the care of older adults. Expectations for nurses and nurse faculty should be clear, and support provided. Support includes access to necessary resources, such as technology, learning opportunities, and time.
It is also crucial that, at minimum, one nurse liaison at each nursing home serves as a leader for the rest of the nursing home staff. The nurse liaison needs to welcome nursing students and work with nursing home staff to continue to develop a working professional environment all of the time, not just on the days when nursing students are present in the facility. In turn, nursing school faculty need to better understand the constraints that nursing homes work under and approach teaching-learning activities in ways that respect these constraints. Ultimately, it is the responsibility of nursing schools and nursing homes to collaborate to improve care and create a professional environment that is attractive to nursing students.
Development and use of a purposeful model to guide communication, dissemination, and delivery of best practice care for nursing home residents was crucial for the teaching nursing home collaborative project between this college of nursing and four nursing homes. The number of personnel involved in the project presented communication issues that were vital to success of the program. The Sister Model facilitated success for year 1 of the Joe Warner Teaching Nursing Home Project. While somewhat exploratory in nature, the Sister Model helped build the foundation for more advanced, comprehensive partnership activities between MCN and the participating nursing homes. The Sister Model can be replicated in other collaborative projects that merge academia and practice to work toward a common goal. This model should serve as an example to motivate nursing schools and nursing homes to engage in focused sharing of resources and expertise.
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The Sister Model Components and Activity Examples
|Communication||• Structured orientation and meetings|
|• Nurse liaisons|
|• Computer availability|
|• Project Web site updates|
|• Networking opportunities|
|Sharing resources||• Long-term care career fair and seminar|
|• National speaker event|
|• Guest speakers|
|• Clinical laboratory and simulation materials|
|• Clinical laboratory equipment|
|Interactive learning||• Interactive video|
|• Technology training|
|• Geronurse Online icon on the desktop|
|• Developed resource list of Web sites|
|• Computer learning modules|
|Nursing expertise||• Individualized inservice sessions|
|• Nurse liaison professional development|
|• Development of educational materials|
|Evaluation Area||Sample Question|
|Professional practice culture||Identify two or more ways the Joe Warner Teaching Nursing Home project influenced the culture of your nursing home in terms of professional practice. If no influence, please state No Influence.|
|Technology use||How useful overall have the computers been for [your nursing home] nurses?|
|Communication||If students or faculty have suggestions for improvement related to care delivery, would you like to be apprised of these suggestions? If so, how?|
|Do you feel the communication between [the college] and [your nursing home] is adequate?|