Journal of Nursing Education

Major Article 

Joint Education Fosters Collaboration and Role Clarity Between Practical and Degree Nursing Students

Jacqueline M. Limoges, PhD, RN; Kim Jagos, MScN, RN

Abstract

Background:

Tensions and hierarchies among nurses who have different educational preparations can hinder effective communication and collaborative practices.

Method:

A 2-year longitudinal cohort study involving 214 participants explored the influences of joint education on Canadian Practical Nursing (PN) and Bachelor of Science in Nursing (BScN) students.

Results:

Joint education helps students dismantle unhelpful power relations, address myths and misconceptions about the other, and develop respect for each other's contributions to patient care.

Conclusion:

Joint education enhances collaboration between nursing designations by placing a focus on the actual knowledge, skill, and judgment rather than on the hierarchies established through credentialing. Joint education also assists students to see overlap in scope of practice and points of intersection requiring collaboration. This understanding promotes safe patient-focused care. Contextualizing the findings within broader discourses, such as the professions, institutions, regulating organizations, and sociopolitical relations within nursing, exposes future possibilities within nursing education. [J Nurs Educ. 2016;55(11):623–630.]

Abstract

Background:

Tensions and hierarchies among nurses who have different educational preparations can hinder effective communication and collaborative practices.

Method:

A 2-year longitudinal cohort study involving 214 participants explored the influences of joint education on Canadian Practical Nursing (PN) and Bachelor of Science in Nursing (BScN) students.

Results:

Joint education helps students dismantle unhelpful power relations, address myths and misconceptions about the other, and develop respect for each other's contributions to patient care.

Conclusion:

Joint education enhances collaboration between nursing designations by placing a focus on the actual knowledge, skill, and judgment rather than on the hierarchies established through credentialing. Joint education also assists students to see overlap in scope of practice and points of intersection requiring collaboration. This understanding promotes safe patient-focused care. Contextualizing the findings within broader discourses, such as the professions, institutions, regulating organizations, and sociopolitical relations within nursing, exposes future possibilities within nursing education. [J Nurs Educ. 2016;55(11):623–630.]

Effective communication and other collaborative practices support positive patient outcomes and patient-focused care through maximizing the individual and distinct contributions of each health professional (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). Nurses are the largest group of health care providers, and their work frequently intersects and overlaps during patient care and at end of shift handoff. Improving collaboration and communication among nurses could have a positive impact on patient safety and outcomes; however, it is not well understood how nurses learn to do this among themselves or with other health professionals (Meleis, 2016). In addition, the consequences of professional boundaries and hierarchies among the nursing designations that could impede collaboration are not well documented and yet are thought to influence patient care. Given the socializing role of nursing education, the authors of the current study examined how intraprofessional education could enhance social relations between the nursing designations and develop collaborative patient-focused care. The purpose of this article is to describe how joint education sessions involving Practical Nurse (PN) and Bachelor of Science in Nursing (BScN) students supported them to learn with, from, and about each other to develop effective collaborative practice. The analysis of the reflective writing and interviews from two cohorts of students is explained, and these results are contextualized within the broader discourses that influence nursing.

Background and Rationale

At least two nursing designations work in most health care contexts in Canada: the Registered Nurse (RN) and the Registered Practical Nurse/Licensed Practical Nurse (RPN/LPN). The RPN role in Ontario, Canada, is synonymous with the Licensed Practical Nurse (LPN) in other provinces and the United States and the Enrolled Nurse in Australia. In Canada, the RN requires a BScN from a university to achieve the greater depth and breadth of knowledge, clinical decision making, research utilization, leadership, and resource management required of that role. This is different from the United States, where the RN can also be educated through an associate degree from either a university or college in programs that last either 2 or 4 years. RPN/LPNs and RNs in Canada study from a similar body of nursing knowledge, but the RPN/LPNs study for 2 years in a community college. Throughout Canada, RNs and RPN/LPNs are permitted to use the title nurse and all nurses are self-regulated, autonomous professionals who are accountable to their respective regulatory body.

Although both nursing designations share a body of knowledge, values, and ethics and practice many of the same skills, the different types of nursing students rarely interact with each other in preparatory education. There can be structural reasons for this, including that RNs are generally educated in universities (and in colleges in the United States) and RPN/LPNs in community colleges. However, even when the BScN and PN students are co-located, as is the case with many of the collaborative nursing programs in Canada, little joint education is offered.

To unravel the social relations among nursing designations, it is useful to consider nurses' history of using credentials, knowledge, and higher education to demarcate professional boundaries (Kavanagh, 2003; McPherson, 1996; Witz, 1990). Professional boundaries delineate scopes of practice to protect the public and outline professional responsibilities, but they can also be used to protect professional turf, power, prestige, and expert status. Boundaries are often maintained with closure techniques that create barriers to prevent encroachment on areas of specializations or to promote superiority. Closure techniques in nursing include activities such as subordinating groups to subspecialties or by claiming exclusivity to science, high-tech skills, theory, and professionalism discourses obtained through the BScN credential (Witz, 1990).

The use of education to close boundaries occurred when both RPN/LPNs and RNs in Canada changed their entry to practice requirements in an attempt to gain status and legitimacy and meet the needs of an ever-increasing complex patient population. In Ontario, starting in 2002, RPN/LPNs engaged in a professional project, moving their credential from a certificate to a 2-year community college diploma. In 2005, the degree-as-entry-to-practice was used as a closure strategy for the title of RN. These concurrent and relatively recent changes in credential requirements have created confusion, as nursing roles are not well defined between designations, the boundaries around scope of practice are blurred, and considerable overlap exists in the education preparation among working nurses. For instance, prior to the degree-as-entry-to-practice, most RNs received a similar diploma to that which RPNs now receive. The impact of these changes on nurses' working relationships and patient outcomes has not been examined.

In the years preceding the degree-as-entry-to-practice requirement for RNs, the degree credential was touted as the required education level to support nurses practicing in the complex health care arena. But as the economic constraints in health care continued and with the increased education of RPN/LPNs, the RPN/LPNs experienced an unprecedented augmentation to their skills and areas where they could practice, sometimes replacing RNs because their rate of pay is considerably less than that of an RN. For example, RPN/LPNs now administer medications, run intravenous infusions, and perform most of the same skills as RNs at the bedside. RPN/LPNs practice independently in areas that were once the domain of the RN, such as the operating department and emergency department. These changes to the RPN/LPN practice are sometimes perceived as encroachment on RN turf, increasing the confusion around professional boundaries and prompting questions about the real differences between the two designations. In the midst of these credential and workplace intraprofessional issues, there is a growing recognition of patient safety, including the danger to patients through incomplete and ineffective communication between health care providers.

To ensure that the patient remains the focus of nursing care, both nursing designations in Canada must graduate with an understanding of what each contributes to patient care and the ability to collaborate with each other and other health care providers. This is particularly important when different types of nurses are providing portions of patient care. Coordination and collaboration are essential to prevent errors or omissions and to ensure that care is not fragmented. Some literature also points to the benefits to patient outcomes, such as lowered mortality and morbidity rates, when a nurse who holds a degree is involved (Aiken et al., 2014; Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015), further highlighting the importance of addressing tensions and collaboration between degree and diploma nurses. Joint education grounded in the principles of interprofessional education (IPE) is posited as an approach to encourage better communication and collaboration between nurses (Hoffart, Kuster-Orban, Spooner, & Neudorf, 2013; Khalili, Orchard, Spence Laschinger, & Farah, 2013; Orchard, 2010).

Little guidance exists for faculty teaching in nursing programs about how to address the various professionalizing strategies and workplace tensions that arise due to the two nursing designations working in the same context (Butcher & MacKinnon, 2014). Furthermore, there is a scarcity of literature on how to conduct intraprofessional education. Therefore, the current authors worked with the assumption that the education processes that support interprofessional collaboration would support intraprofessional collaboration. This assumption is informed in part by the description of the power relations that impede collaborative care by Baker, Egan-Lee, Martnimianakis, and Reeves (2011) and Meleis (2016) and that similar power relations exist among nursing designations.

When the intraprofessional and IPE literature is considered as a whole, three consistent ideas emerge that are helpful for planning joint education in nursing. The first idea is that joint education is an important strategy to improve communication and collaboration among health care providers (Nelson, Tassone, & Hodges, 2014; Limoges & Jagos, 2015; World Health Organization, 2010). The second idea is that effective collaboration and communication are core competencies for safe patient care and that these must be addressed through systematic and purposeful education (Chenot & Daniel, 2010; Dolansky & Moore, 2013; Reeves et al., 2013). A third emerging idea is the need to address hierarchy and power when providing joint education activities (Baker et al., 2011; Bainbridge & Wood, 2012; Butcher & MacKinnon, 2014; Khalili et al., 2013; Meleis, 2016). Addressing hierarchy between professionals is required because we must trust each other's competence and have confidence in the other's knowledge and skill to be receptive or even seek out their input (Bainbridge & Wood, 2012). Given the links between patient safety and effective collaboration, education that supports the development of better communication, role clarity, and stronger collaboration among nurses is important.

To help understand how joint nursing education can enhance the collaborative practices among nurses, the current study explored student experiences using a longitudinal cohort study over a 2-year period to establish how education prepares nursing students to understand their designation, responsibilities related to their role, and how to collaborate and consult with one another. The goal of these education events was to provide students with an opportunity to learn with, from, and about each other and to reflect on the hierarchy and power relations experienced by nurses that mediate their social relations. The ultimate aim of this joint education was to support students' awareness and understanding of each other as an antecedent to collaborative practice.

Method

This 2-year study was conducted at a college in Ontario, Canada, that offers both the BScN (in collaboration with a university) and a stand-alone PN diploma. The study is informed by the methods and sociology of Dorothy E. Smith (2005) and involves an analysis of texts and discourses. The data for this analysis include sets of texts from the scholarly literature and the social practices that surround nursing education that were obtained through interviews and reflective writing by BScN and PN students. This method includes an exploration of how knowledge and actions form social processes that create ruling relations. The analysis, informed by Smith's social ontology, involved an examination of how texts and discourses are activated by people and produce social relations. In this approach, the context, the historical influences, talk, texts, and related discourses are all explored during analysis.

Approval was obtained from the institutional ethics review board. The study and joint intraprofessional education events were described to students of both the PN and BScN programs from semesters one (fall 2013) and four (winter 2014 and 2015) with an invitation to participate in the research. Reflective writing was completed immediately after the joint education events, and an invitation was extended for students to be contacted for an interview, which was scheduled days after the events. The interviews were described as an opportunity for the students to provide additional details of their experiences with the BScN/PN joint event and with their nursing education as it relates to intraprofessional relationships. The interviews were audiotaped and transcribed verbatim.

The reflective writing and interview transcripts were read reflexively and iteratively. Given the volume of data from the reflective writing papers, numerical codes were applied and frequency was used to capture the extensiveness of an experience or idea. A new code was assigned each time a new concept emerged. The data were coded and grouped individually and then the findings were compared to one another. This comparison was a strategy to add to the integrity of the findings by ensuring consistency in the frequency, extensiveness, and intensity of findings. The authors then traced backward to examine how the most common experiences were socially constructed or mediated and forward to explore the consequences of the student experiences. The process was continued, comparing the statements from two separate cohorts (described below), to determine the mediating influences of education on the awareness and social relations between nursing students and how these are linked to collaborative practice.

Sample

There are two cohorts in this study. The first cohort is part of the longitudinal study that began in semester one during the fall of 2013 and ended in the winter of 2015 after the students received two joint education events over a 2-year period. This cohort will be referred to as the longitudinal cohort. The longitudinal cohort comprised 91 BScN and 22 PN student participants (Table 1).


Overview of the Sample

Table 1:

Overview of the Sample

To examine and compare the influence of ongoing exposure to joint intraprofessional education, the single-event cohort was established with 81 BScN and 20 PN student participants. At the time that the single event-cohort students started their program in the fall of 2012, no joint education was offered at their school of nursing. The single-event cohort had only one joint education event, which occurred in semester four during the winter of 2014. This was their only opportunity for joint education during their entire education.

Data for both study cohorts were obtained from a total of 172 BScN and 42 PN student participants. The average age of the BScN group was between 19 and 22 years, whereas the PN group was slightly older, at 26 to 30 years old. There were more male students in the PN group (22% versus 13% in the BScN). Close to half of the participants in the BScN (42%) and PN (55%) programs had postsecondary education prior to entering into their respective programs.

Description of the Activities

The aim of the longitudinal cohort semester-one joint education event in the fall of 2013 was to develop awareness of the other nursing designation by having students learn with, from, and about each other and to explore the similarities and differences between their roles, scope of practice, and their educational programs. Questions were used to guide the semester-one discussions and reflective writing (Tables 23). The longitudinal cohort had a second joint education event in the winter of 2015 during their fourth semester. The fourth-semester education event for the single-event cohort was structured identically to the activity of the fourth-semester longitudinal cohort. This activity was designed to deepen their learning with, from, and about each other by creating a code of civility using the ethical principles of respect, dignity, and social justice. This code was developed during the joint activity to outline agreed-upon methods to guide interactions that would support respectful communications and collaborative practice. We used questions to guide group discussion and reflective writing (Tables 45). All of the education events included introductory remarks by the professor, small-group discussions among the students, and plenary sessions to debrief the activity. The reflective writing became a part of the data for this study. Students were also invited to participate in interviews which were scheduled after the joint education events. The interviews provided an in-depth look at how students perceived their education was preparing them for collaboration and consultation work.


Semester One: Small-Group Discussion Questions

Table 2:

Semester One: Small-Group Discussion Questions


Semester One: Individual Reflective Writing Questions

Table 3:

Semester One: Individual Reflective Writing Questions


Semester Four: Small-Group Discussion Questions

Table 4:

Semester Four: Small-Group Discussion Questions


Semester Four: Individual Reflective Writing Questions

Table 5:

Semester Four: Individual Reflective Writing Questions

Findings

As the data from the two cohorts were analyzed, four key findings emerged:

  • Joint education is viewed positively by the students.
  • Joint education promotes recognition and respect for the different nursing designations, thus supporting collaborative practice.
  • The ability to recognize power relations improves with more dialogue.
  • With more time together, a greater awareness of the consequences of unaddressed power relations emerges and this motivates students to address hierarchy.

Although students in both cohorts were affected by the joint education activities, the data revealed stronger influences for those longitudinal cohort students receiving joint education early and then again later in their program.

Joint Education Is Viewed Positively by the Students

Both cohorts were influenced by the joint education and had overwhelmingly positive comments when they described their reaction to the event. Students thought that learning together was productive, beneficial, and a worthwhile use of their time because it helped them to understand their own and the others' responsibilities, roles, and designations. Between both cohorts, more than 150 positive statements were made, such as “We had a very open discussion and we worked well together,” “It was very interesting to learn about each other and how our education is organized,” and “It was productive and beneficial to work together.” The majority of students supported the continuation of joint education and requested more joint learning opportunities, offering further evidence that these sessions were valued.

Of note, only four negative statements about the joint education event in the longitudinal cohort were made, compared with 19 negative statements from the single event cohort. Those 19 negative comments mostly were related to the lack of engagement by the students in their discussion groups. One PN student from the single cohort stated, “We couldn't even work together on the code of civility.” Another PN student stated, “There seems to be a divide between us, that one is better than the other.” The variation in the frequency of negative comments suggests that early exposure and ongoing instruction is useful to promote collaboration and acceptance of the other and to dismantle negative barriers that are possibly being perpetuated during education.

Joint Education Promotes Recognition and Respect for the Different Nursing Designations, Thus Supporting Collaborative Practice

Both cohorts explained how the joint education events promoted understanding and awareness of the other category of nurse. Learning with, from, and about each other was essential to understanding and respecting each other's unique contribution to patient care. They also stated that teachers, in many cases, were unable to articulate the differences and similarities between both designations and therefore appreciated these opportunities to address the confusion about roles and role distinctions. Most participants asserted that education was needed to learn how to collaborate and how to address variable patient situations. Both groups agreed that co-location and interaction with one another was an important strategy to learn how to collaborate and communicate together.

Specifically, joint education helped students see how their shared body of knowledge was used in practice. The single-event cohort students were more limited in their understanding of collaborative practice. They referred to the PN students as being “more about skill” focusing on personal care, and the BScN students as “more about theory” focusing on paperwork. The following quote from a BScN student from the single-event cohort demonstrates this finding: “We're taught that they [RPNs] do a lot of the same things [as RNs], but don't have as strong critical thinking skills and don't get [theory], which already instills a hierarchy in my mind.” The PN students indicated a similar experience: “I feel that the RPNs have more of a practical knowledge base to draw from while the RNs have more of a theory base.” This oversimplified perspective was replaced in the longitudinal cohort with more openness and awareness that each was making important contributions to patient care.

The longitudinal cohort also had a deeper understanding of the shared roles and how they could use these commonalities to establish better working relationships with one another. As one longitudinal cohort BScN student stated, “Before entering the program, I was biased and I believed there was a large separation between RN and RPN, but now I know it is important that both groups work together to provide best quality care.” The PN students in the longitudinal cohort also felt an awareness had been created by exposure to one another. As one PN student stated, “Incorporating communication aspects and information of each position and what each nurse can do is a first step in breaking barriers and assumptions.” Another PN student further explained, “Learning about each other's role is beneficial and is an asset to positive work relationships and collaborative work environments. It's about health care working at its best.”

The longitudinal cohort students could see how dismantling the hierarchy would lead to stronger collaboration skills and also enable them to focus more on the patient. As one longitudinal cohort BScN student discovered, “It was shocking but good to hear the experiences by each colleague. We need to realize that we are basically the same but possess some different skills so that hopefully, when we get out in practice we can all work collaboratively together.” A PN student recognized that “more of these group sessions…[would] make it clearer as to how we can manage to work together and that would allow us to converse more openly with less bias.” Both BScN and PN students in the longitudinal cohort understood that openly discussing the contributions that each nursing designation makes to patient care would help dismantle hierarchy and the importance of this for patient care.

The Ability to Recognize Power Relations Improves With More Dialogue

The longitudinal cohort could name sources and structures of power relations influencing the social practices of nurses more often than the single-event cohort. This is an important finding, as awareness and recognition of power relations is the first step in addressing them. In the single event cohort, the topic of power was mentioned by only 13 informants, compared with the 48 separate accounts by the longitudinal cohort participants. For instance, longitudinal cohort students named the status of university over college as a source of tension between the nursing designations. Students could see how this hierarchy is perpetuated in their education to create a class system, where university students are seen as more intellectual and professional. For instance, one longitudinal cohort BScN student stated, “I was always under the impression that they were not nearly as educated as us RNs, but I see things differently now,” and a PN student indicated, “Last time we did this activity, the RNs didn't seem to think RPNs were as qualified. This time we all seemed to agree there is a problem and a stigma and that our scopes are very similar.” Although the longitudinal cohort used less ideologically based statements about university education, their ability to articulate how university education was linked or required for the practice of the RN eluded them. This was a troubling point for the students in the BScN program, especially as they gained awareness of their own work vis a vis the RPN/LPN and how they would be required to provide consultation and advanced knowledge to RPN/LPNs after graduation. This prompted them to question whether two nursing designations were in fact beneficial and to wonder exactly what they were getting from their university education. One BScN student in the longitudinal cohort concluded, “We will spend almost [twice the time in school] for our status. In terms of theoretical knowledge, I believe RNs in general are more knowledgeable.”

The longitudinal cohort detected more closure and boundary work in their education programs and discussed exclusionary and marginalizing practices more frequently, providing further evidence that more time spent together helped them recognize power relations. There was a striking difference between the cohorts in how they addressed their siloed education. For example, the single-event cohort frequently mentioned feeling segregated from the other type of nursing student and found this practice troubling and isolating. The actual term segregation was used by the single-event cohort students. This was poignant, given the historical use of segregation to oppress and control groups. Interestingly, the word segregation was never used by the longitudinal cohort. Instead, longitudinal data showed how joint education assists students with the negative feelings from siloed education. The longitudinal cohort exposed the educational processes that kept them apart as ones that perpetuate misconceptions about the other and described how this was problematic to collaboration. One BScN student from the longitudinal cohort explained, stating “When we're kept apart it makes us think we are taught different things.” Another PN student supported this finding, saying “We study many similar things and even have some of the same classes. We are divided from the beginning. Put us together more often.” By coming together and recognizing their common ground, students became aware that each was receiving quality education that was preparing them for the work of the RN or RPN/LPN.

The longitudinal cohort also addressed stigma, pay differences, common challenges faced by nurses, and how these influenced collaborative practice. They articulated how these problems are sustained and even perpetuated given the lack of clarity provided through education. Students in the longitudinal cohort appeared to have a stronger ability to identify and understand the discourses that mediate their abilities to practice collaboratively when compared with the students in the single-event cohort.

With More Time Together, a Greater Awareness of the Consequences of Unaddressed Power Relations Emerges, and This Motivates Students to Address Hierarchy

Although both cohorts articulated the importance of learning to collaborate, the longitudinal cohort described a stronger motivation. The longitudinal cohort students were able to articulate the social processes and closure techniques that are problematic in nursing practice and that could impede safe patient care. For instance, they identified how unresolved conflict challenges collaborative practice and pulls the focus away from patient care. This understanding motivated them to resolve the social processes that perpetuate this division. A PN student from the longitudinal cohort stated, “Our code of civility [the code created during the joint education] will create a respectful open communication so there will be less judgment and a stronger objective to serve the client.” Similarly, a BScN student from the longitudinal cohort stated:

You should know your role, and I should know my role, and I should know my boundaries, and I have to understand that we need to work together to make sure that the nursing environment is a caring environment because if we are [in conflict with] one another, that's not going to benefit anyone. It's not going to benefit us, it's not going to benefit the patients. So it's teaching us that we should just work as one, as one unit.

That quote eloquently highlights the progressive view common to the longitudinal cohort.

Discussion

When the discourse and ruling relations that mediate courses of action are identified, the opportunity exists to respond to them with greater discernment or to activate alternate discourses (Smith, 2005). Therefore, education that supports students to recognize the mediating structures of power relations is useful for dismantling hierarchies that create tension and problematic working relationships. Limoges and Jagos (2015) found that PN students and RPNs were viewed as lower in the hierarchy by their BScN-educated counterparts. Evidence that those lower in the hierarchy experience more oppression was reported by Rodwell, Demir, and Flower (2013). When the findings from these two studies are considered together, the urgency to address power structures among nursing students during their education becomes increasingly important.

IPE is more effective when the learning experiences are organized within a taxonomy, with intentional learning experiences related to the actual requirements of clinical practice (Bainbridge & Wood, 2013). The findings presented in this article demonstrate how systematic joint education that includes BScN and PN students supports students to learn the importance of collaboration and addresses social processes that interrupt collaboration. By having students create a code of civility to guide their clinical work, an opportunity was provided for them to think more concretely about the situations that could be problematic between RNs and RPNs and encouraged them to consider ethically responsible solutions.

Providing opportunities for students to learn how to clearly articulate what nurses know and do, and how this influences patient outcomes, can make nursing visible in interprofessional health care (Khalili et al., 2013; Orchard, 2010; Sommerfeldt, 2013). Creating dialogue through intraprofessional education teaches nursing students how to communicate and collaborate on patient care. Providing intraprofessional education throughout preparatory education is therefore essential so that all nursing students learn to explain their unique knowledge and practices to each other and subsequently to other professionals.

Furthermore, Bainbridge and Wood (2012) suggested that learning about the other is particularly effective when it occurs early in an education program through face-to-face interactions with other professionals. The current study findings would support their assertions. Bringing the students together, as the current authors did, provided them with an opportunity to recognize the contributions that each could make to patient care.

More research is needed to understand what is required and how to deliver learning strategies that support learning with, from, and about other health care providers and how this contributes to patient-centered care. This study demonstrates the value of joint education and the contributions that shared learning activities can make to nursing education. Moving forward, it would be particularly interesting to assess whether the benefits of joint education are sustained by graduate nurses as they move into employment and how joint education can be provided in ways to support collaborative nursing care to improve nurse-sensitive patient outcomes.

Study Limitations

It is important to recognize that these events happened in a particular context that was changed over time by the research, by the researchers' involvement in faculty and curriculum development, and by an increased awareness of how collaborative practice contributes to patient safety. Over the 2-year span of this study, the receptiveness of the research and the joint education series grew.

A second limitation is the difference in participation rates between the PN and BScN students. Approximately 80% of the BScN students participated in the joint education events and 56% of these BScN students joined the study, whereas only 25% of the PN students participated in the event and 20% of those PN students participated in the study. The authors attempted to interview PN students who did not attend the joint education event but were unsuccessful in recruiting them to the study. This attendance rate is likely meaningful but, regretfully, the authors are unable to explain it.

Conclusion

The current study provides evidence that participating in joint BScN and PN education resulted in additional competencies for the students that are considered essential for nursing practice. Joint education also provides opportunities for students to recognize and begin to address the social processes that create and sustain tensions and interfere with effective collaboration between the two nursing designations. When time is of the essence, as it is in most content-heavy nursing curriculum, finding ways to teach core competencies related to patient safety (i.e., collaborative and patient-focused care) is imperative. We have provided evidence that two sessions of joint education contributes positively to this learning. Students must practice and integrate collaboration and require co-location to do this.

The authors' use of professional closure and boundary theory in the data analysis was productive as it assisted them to explore the inclusionary and exclusionary practices of nurses in the educational setting. Providing students with education events that were purposefully structured to promote the discussion of power and hierarchy assisted them to identify and label power relations and mediating discourses to collaborative practice. This learning and awareness motivated them to address these ruling relations to develop collaborative skills to improve patient care. Providing education to unravel complex intraprofessional relations housed within nursing education brought an awareness to students that did not exist before. This type of joint education could benefit other groups of health care providers who have overlap in scope of practice and knowledge but receive different types of education, such as hygienists and dental assistants or physiotherapists and physiotherapy assistants, to name a few. This research demonstrates the nonneutrality of education and suggests intraprofessional joint activities within nursing education that help to specifically foster better working relationships between RNs and RPNs in practice, contributing to safe patient care.

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Overview of the Sample

CohortReflective WritingInterviews
LongitudinalPN = 22PN = 2
BScN = 91BScN = 5
Single eventPN = 20PN = 7
BScN = 81BScN = 8

Semester One: Small-Group Discussion Questions

Question

What have you been learning in your program so far?

What have you learned about the role of the nurse in your program?

How do you see your education preparing you to work within a health care team including the other category of nurse?

How will you offer something unique as a registered practical nurse/licensed practical nurse to your patients?

Semester One: Individual Reflective Writing Questions

Question

In a few sentences, describe your reaction to the group discussion at your table.

What ideas about your chosen profession were challenged or supported?

How can your nursing education prepare you to have the skills to promote collaboration versus division between the two categories of nurse?

Other comments:

Semester Four: Small-Group Discussion Questions

Question

What do you see as the key barriers to registered nurses and registered practical nurses working together?

What have you noticed in practice that might motivate you to learn to work together?

Using the ethical principles of respect, dignity, social justice, and equity, how can you build a moral community?

Working in your teams, create a code of civility (a code for working together) that addresses three barriers or strategies that promote collaboration versus division when working as nurses.

Semester Four: Individual Reflective Writing Questions

Question

In a few sentences, describe your reaction to the group discussion at your table.

How does your code of civility address the issues or barriers that prevent collaborative practice?

Has your education perpetuated division between the two categories of nurse? If so, please describe how this was so?

What do you wish you would have or should have learned in your education to help you better prepare for collaborative practice?

Other comments:

Authors

Dr. Limoges is Faculty, BScN Programme, and Ms. Jagos is Faculty, PN Programme, Georgian College, Carrie, Ontario, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jacqueline M. Limoges, PhD, RN, Faculty, BScN Programme, Georgian College, School of Health, Wellness & Sciences, 1 Georgian Drive, Barrie, Ontario L4M 3X9, Canada; e-mail: jacqueline.limoges@georgiancollege.ca.

Received: February 03, 2016
Accepted: July 13, 2016

10.3928/01484834-20161011-04

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