Health system changes and the growing complexity of patient care have facilitated the emergence of new collaborative models of health care delivery within nursing teams (Canadian Nurses Association, 2008). The American Nurses Association (1995) described collaboration as working together in a “true partnership, where the power on both sides is valued by both, with recognition and acceptance of separate and combined practice spheres of activity and responsibility, mutual safe-guarding of legitimate interests of each party, and a commonality of goals that is recognized by each party” (p. 7). Apker, Propp, Zabava-Ford, and Hofmeister (2006) reported that collaboration is a nursing responsibility; similarly, Meretoja, Eriksson, and Leino-Kilpi (2002) recognized collaboration as a competency required by all nurses.
The literature pertaining to collaboration in health care is focused on nurse–physician interactions. Health care literature pertaining to collaboration has predominantly focused on the general concept (Henneman, Lee, & Cohen, 1995), the facilitators of collaboration (Baggs, Ryan, Phelps, Richeson, & Johnson, 1992; Baggs & Schmitt, 1997), and the barriers to collaboration (El-jardali, 2003; Resnick & Bonner, 2003). Aiken (2001) and Estabrooks, Midodzi, Cummings, Ricker, and Giovannetti (2005) discussed outcomes of collaboration and collaborative relationships. Other authors have reported on how collaboration can be measured (Baggs, 1994; Hojat et al., 2001; Sasahara, Miyashita, Kawa, & Kazuma, 2003; Shortell, Rousseau, Gillies, Devers, & Simons, 1991; Ushiro, 2009; Weiss & Davis, 1985).
Few studies have examined nurse-to-nurse collaboration in health care settings. Stefaniak (1998) explored the perceptions of collaboration among nurses and found three occasions that served as an impetus for nurse-to-nurse collaboration: knowledge and skills deficits, change and transitions, and communication gaps. Moore (2011) described the collaborative process among nurse practitioners and RNs in oncology units with two major findings: (a) collaboration was facilitated by the nurses not only working together but also by spending time interacting socially away from the clinical setting, and (b) although the nurses had conceptual knowledge of collaboration, they struggled to successfully collaborate in the practice setting. Both studies concluded that further research was needed to explore ways to improve nurse-to-nurse collaboration.
Dedicated education units (DEUs) might offer a strategy to improve collaboration among nurses. DEUs are innovative partnerships established between a school of nursing and a clinical site to integrate staff nurses into nursing students’ teaching–learning processes (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007; Murray & James, 2012; Murray, MacIntyre, & Teel, 2011). First developed in the late 1990s by Flinders University in South Australia, the model closely aligns staff nurses with nursing students during their clinical learning practice (Pappas, 2007; Rhodes, Meyers, & Underhill, 2012). The DEU concept requires commitment from both the clinical agency and the school of nursing to ensure that administrative supports are in place for consistent planning and assignment of staff nurse and students on a predictable schedule. Key learning objectives of DEUs include an increased focus on critical thinking, professional and personal accountability, technical and theoretical competency, empowerment, and collaboration (Pappas, 2007). Working as a DEU nurse may not only facilitate the development of the nursing student but also may enhance the professional development of the staff nurse (Moscato et al., 2007; Ranse & Grealish, 2007; Rhodes et al., 2012). DEUs are proving to be effective in optimizing the preparation of new nurses for clinical practice (Ranse & Grealish, 2007; Rhodes et al., 2012).
In our study, the model developed by the study school, nursing staff nurses (designated as clinical instructors [CIs]) volunteer to work with particular students and their assigned patients. Hospital nursing administrators encourage the model, manage the staffing complement, and compensate the CIs with preceptor pay. The participating CIs are oriented to the model, usually on the college campus, to promote their identification with the school of nursing. The college faculty member oversees the students’ assignments in partnership with the CIs, works closely with the partnered CIs and students to ensure learning according to curriculum objectives, and retains accountability for evaluating students. By having students directly aligned with the CIs, the school of nursing faculty member is available to focus on specific areas of need with individual students and their CIs. Students report that they establish a working bond with the CIs and other staff.
Extensive planning and ongoing follow up occurs between the agency and the school. Clinical instructors are oriented to their roles, and both students and staff are debriefed at the end of their rotations for the purpose of formative evaluations of the model. By working alongside the individual nurses, the students report that they gain more experience and benefit from close-up observation of the staff nurse role and the clinical decision-making processes. These benefits, and other clinical and educational benefits of the DEU model, are being actively studied.
The purpose of this quantitative descriptive study was to compare nursing student perceptions of nurse-to-nurse and nurse-to-nursing student collaboration in DEUs and traditional clinical instruction units. The study was undertaken within a constructivist paradigm, a theory of knowledge that is built on the premise of a social construction of reality, whereby truth is relative to one’s individual perspective (Lincoln & Guba, 1985).
The study answered two research questions:
- Do nurse-to-nurse and nurse-to-nursing student collaboration, as perceived by students in a baccalaureate nursing education program, differ by type of unit (DEU versus traditional)?
- Do nurse-to-nurse and nurse-to-nursing student collaboration, as perceived by nursing students in a baccalaureate nursing education program, differ by student status (junior versus senior student)?
Participants and Setting
The study participants were undergraduate nursing students in their junior and senior clinical rotations enrolled in a baccalaureate nursing program at one small, private college in western New York. The study was conducted with students who had clinical experiences on medical–surgical clinical units operating within four larger health care systems. In the traditional learning units, the college faculty member was the primary resource person and clinical instructor for a group of eight nursing students, each of whom was assigned to one to two patients, and staff RNs were the primary care providers for the patients on that unit. Faculty and students communicated with and consulted with the assigned staff RNs according to patient needs. One faculty member assigned student responsibilities and directly supervised all activities of all students in each unit. In the DEU, the college faculty member retained overall accountability for student learning; however, the staff RNs (as the CIs) worked directly with individual students, made their patient assignments, and supervised direct care delivered by the students. Two students were aligned directly with one of four staff RNs on each unit; each student was assigned one or two patients. The faculty member’s role was to provide resources for students and staff, to ascertain that students were prepared for and understood the patients’ care needs and interventions, and to work more closely with any students who required added instruction or supervision.
Approval was received from the college’s institutional research board. Permission to access the student population was received from the dean of the school of nursing. The nursing students received notice of the questionnaire from their nursing course classroom faculty who were not directly associated with the study. Potential participants were advised of their rights as participants in research and of the procedures in place to ensure confidentiality related to their participation. The researchers were not responsible for any student’s classroom or clinical instruction and had no influence over individual student evaluations or grades, nor did they have any supervisory or evaluative role related to any of the staff RNs. Participation or nonparticipation in the study had no bearing on the students’ progression through the nursing program. It was impossible to link any returned survey with any particular student because the surveys had no identifying marks. Submission of a completed survey indicated informed consent to participate. A personally unidentifiable, return-addressed envelope was provided with each survey tool. Participants were instructed to place no identifying marks on the surveys they returned and to return the surveys, whether completed or blank, in the provided envelopes within 1 week of receiving the survey tool. All data gathered from the demographic tool and from the surveys were aggregated for narrative reporting.
Data Collection Instrument
Data were collected by a survey questionnaire that included a demographic form, two visual analogue scales, and the Nurse-to-Nurse Collaboration Scale (NNCS) adapted from Dougherty and Larson (2010). The NNCS has 35 items across five subdomains: conflict management, 7 items; communication, 8 items; shared processes, 8 items; coordination, 5 items; and professionalism, 7 items. The NNCS had been developed following an extensive literature review to define the relevant subdomains of collaboration in nursing practice and to compare it with an instrument that had acceptable psychometrics for the items measured within nurse-to-nurse collaboration. Psychometric testing of the NNCS had included pilot testing for content and construct validity with recognized experts in the field (Dougherty & Larson, 2010). A modified scale was then field tested with staff nurses in four large tertiary medical centers in the northeastern United States. The overall Cronbach’s alpha was 0.89. Convergent validity was low to moderate, indicating five separate subdomains rather than a single global concept of nurse-to-nurse collaboration. The five subdomains had acceptable internal consistency ranging from 0.66 to 0.91. The authors obtained permission of the NNCS author to use the instrument in the current study.
Data were analyzed using descriptive statistics and t tests for comparison of nursing student perceptions of nurse-to-nurse collaboration by clinical unit type (DEU or traditional clinical learning unit) and by student status (junior or senior class). SPSS® version 19 software was used for data analysis.
The overall participant response rate was 41% (61 completed returns from 150 surveys distributed). Most (78.7%) of the nursing student participants were in the age range of 18 to 29 years. Most (69%) were senior students in the spring semester of school (31% were junior students). Ninety-three percent of the students were female, and 7% were male. Most of the participants had prior experience on traditional clinical instruction units (84%) and on DEUs (63%). At the time of data collection, 62.3% of the students were assigned to traditional units and 37.7% were assigned to DEUs.
Nursing Student Perceptions of Collaboration in DEUs and Traditional Clinical Learning Units
Participants were first asked to record their perceptions of nurse-to-nurse and nurse-to-nursing student collaboration using two 100-mm long visual analogue scales. The mean length of the scale ratings for nurse-to-nurse collaboration in the DEUs was 72.85 mm versus 55.08 mm on the traditional units, a significant difference (p = 0.01). Collaboration of unit nurses with nursing students was rated as 69.55 mm in the DEUs and 46.35 mm in the traditional units, also a significant difference. More detailed description of the collaboration experiences was sought using the NNCS, a Likert-type scale comprising 35 items distributed among five subdomains (conflict management, communication, shared processes, coordination, and professionalism). Each subdomain was scored according to a 4-point Likert-type scale (1= strongly disagree to 4 = strongly agree) on five to eight individual items. The mean differences of each total score were analyzed. Overall scoring on the NNCS showed no significant difference in total collaboration scores of the five combined subdomains. This result contrasts with the overall perspectives reported on the visual analogue scales. However, the mean overall shared process domain scores were significantly different (p = 0.01). Of eight items on the shared process subdomain, four were rated significantly different by students on DEUs versus traditional units, with all items rated higher (more positively) by the DEU students. The higher rated items may provide some insight into markers that students view as representative of collaboration. The differences concerned issues of autonomy and decision making, including making independent decisions, making decisions that affected them at work, being involved in making decisions about what happens at work, and contributing to decisions about what happens for patient care. By contrast, no difference was noted in items that concerned implementation of established protocols for patient safety and infection control, which are presumed to be in place in all units according to hospital regulatory policies.
For the conflict management subdomain, the means of two separate items were significantly different, even though the domain itself did not differ. On the DEUs versus the traditional units, students perceived more often that all points of view were carefully considered in arriving at best possible solutions to problems (p = 0.01) and that nurses would work together to resolve a conflict (p = 0.05). It is unclear whether such a difference actually exists or whether the DEU students were more aware of nurse interactions than were students on traditional units.
For the communication subdomain, a significant difference was found in only one item when compared between DEU and traditional unit students: “I can think of times when I received incorrect information from nurses on this unit.” More students on the traditional units than on the DEUs agreed (p = 0.01) with this item.
For the coordination subdomain, DEU students scored one item more positively than did the traditional unit students: “There are written evidence-based treatment protocols.” This could reflect the DEU’s use of evidence-based practice protocols, or it might represent more sharing of such information by the CIs than by the traditional unit staff nurses.
No significantly different item ratings were seen for the professionalism subdomain. Of note, the three highest mean scores for any of the NNCS items occurred in the professionalism subdomain for both the DEU and traditional units. The three items rated highest by all students concerned the nurses’ knowledge of patient drugs, nurses’ knowledge of patient disease processes, and nurses’ technical skills necessary for safe patient care. One could conjecture that the students are most focused on the gap between their own expertise and that of the staff nurses in these aspects of care or that the unit environment does not influence individual nurse knowledge and skill. Also of note, although the differences were nonsignificant, scores on this scale did trend higher when rated by students on the DEUs compared with those on the traditional units.
Differences in Perceptions of Junior and Senior Nursing Students
No differences were found when comparing perceptions of junior students and senior students when describing nurse-to-nurse or nurse-to-nursing student collaboration in DEUs versus traditional units. Data analysis revealed no significant difference on the NNCS total scale nor on any subdomain scale.
The main limitations of this study were the small sample size and the study’s single geographic location. Another possible limitation was the wording of the adapted NNCS tool items. It is possible that student responses to the items starting with “I” reflected each student’s own experiences with staff nurse collaboration, whereas the items not starting with “I” may have reflected the students’ observations of nurse-to-nurse collaboration. Although the findings have limited generalizability, the study does contribute to a better understanding of students’ perceptions of staff nurse collaboration.
The DEU model is built on the belief that the staff nurse’s role is vital to the development of nursing students’ knowledge, skills, and professional practice (Glazer, Ives Erickson, Mylott, Mulready-Shick, & Banister, 2011). Using an adapted questionnaire (Dougherty & Larson, 2010), we found that most nursing students believed there was greater collaboration among staff nurses working in DEUs than among those working in traditional learning units.
Our findings support what has been consistently noted in the literature—that collaboration is a complex process composed of certain key attributes. The attribute of sharing describes qualities that encompass the concept of collaboration (Petri, 2010). The presence of shared or mutual goals and objectives is necessary for individuals to work toward a common outcome (D’Amour & Oandasan, 2005). Another attribute—problem-solving or problem-focused process—centers on challenges related to patient care (San Martín-Rodríguez, Beaulieu, D’Amour, & Ferrada-Videla 2005). Finally, a third attribute—working together—requires individuals to be effective communicators and to cooperative with each other to meet a common goal (Baggs, 2002). Although nurses are expected to be autonomous practitioners, they are also expected to work together cooperatively to meet a common goal, plan care, and coordinate patient care (D’Amour & Oandasan, 2005). In the current study, shared processes comprised the most significantly different domain of nurse-to-nurse collaboration that nursing students perceived as more positive on DEUs than in traditional clinical learning units.
Nursing students also reported that nurses working on DEUs seemed less likely to communicate erroneous information. Having effective communication skills is an important quality in relation to the development of the interpersonal relationship needed to collaborate. Communication has been identified as a major facilitator of collaboration by Freeth and Reeves (2004) and by Hall (2005). This involves having an attentive style of communication that uses a nondominant approach to providing information (D’Amour & Oandasan, 2005), an openness to negotiation, and a willingness to resolve conflict (Bruner, Waite, & Davey, 2011; Freeth & Reeves, 2004).
Our study compared nursing student perceptions of collaboration among nurses working in DEUs and traditional clinical instruction units. Two research questions were answered. No differences were found when the perceptions of junior and senior nursing students about nurse-to-nurse collaboration were compared; however, the fact that many nursing students reported greater collaboration among nurses in DEUs compared with traditional learning units concurs with a central purpose of DEUs—to improve the integration of nursing students in clinical settings by providing increased opportunity for students to work in close and consistent alignment with staff nurses.
This study raises new questions for further study about nurse-to-nurse collaboration and DEUs: Can the results of this study be replicated to validate nursing student perceptions of the relationship between clinical learning unit types and nurse-to-nurse collaboration? Do staff nurses and the nursing students in DEUs and traditional units perceive nurse-to-nurse collaboration in the same ways? Which aspects of collaboration are considered most important among nursing students and staff nurses? Is there a cause-and-effect relationship between the culture in nursing units and the nursing staff’s willingness to support DEUs? Is there a cause-and-effect relationship between the DEU model and the culture created in DEUs? Can the experience of collaboration in DEUs contribute to a reduction in lateral violence among professionals?
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