collaboration and its model (including new model 2019 Integration model)

COLLABORATION
ISSUES
AND
MODELS
INSIDE AND OUTSIDE
NURSING

INTRODUCTION
• Derived from a Latin word collaborare, ‘to labor
together’
• To collaborate isto ‘work jointly with others
or together’

DEFINITION
• Collaboration is a process by which members of
various disciplines or agencies share their
expertise. Accomplishing this requires these
individuals understand and appreciate what it is
that they contribute to the whole.
-Hanneman et al

DEFINITION
• Collaboration is the most formal inter-
organizational relationship involving shared
authority and responsibility for planning,
implementation and evaluation of a joint effort.
- Hord, 1986

OBJECTIVES
• To seek creative, integrated solution where need
and goal of both the sides are important
commitment and consensual decision.

• To learn to grow through co-operative problem
solving resulting in greater understanding and
empathy.
• To identify, share and merge vastly different
viewpoints.

• To be honest about work through difficult
emotional issue interfering with morale,
productivity and growth.

KEY ELEMENTS
Co-operation Assertiveness
Communication
Autonomy
Co-ordination
Responsibility

NEED OF COLLABORATION
 Reduce gap
 Help graduates
 Health promotion

 Use of communication and teaching skills in
patient care
 Effective care delivery
 Reduce conflict

CHARACTERISTICS
OF
COLLABORATION

Interdisciplinary Multidisciplinary
Transdisciplinary Inter
professional

Interdisciplinary collaboration
 It is the term used to indicate the combining of
two or more disciplines, professions,
departments, or the like, usually in regard to
practice ,research, education and theory.

Multidisciplinary collaboration
 It refers to independent work and decision
making, such as when disciplines work side-by-
side on a problem.

Transdisciplinary collaboration
 Its efforts involve multiple disciplines sharing
together their knowledge and skills across
traditional disciplinary boundaries in
accomplishing tasks or goals. Transdisciplinary
efforts effects reflects a process by which
individuals work together to develop
a shared conceptual framework that integrates
and extends discipline specific theories,
concepts, and methods to address a common
problems.

Interprofessional collaboration
 It has been described as involving “ interaction
of two or more disciplines involving
professionals who work together , with intention,
mutual respect and commitments for the sake of
a more adequate response to a human problem” .

STRUCTURE
OF
COLLABORATION
RELATIONSHIPS

PRINCIPLES OF COLLABORATION
 A
 Asserts, attitude and value that each potential
partner brings
 Accountability to each other

 Agreements to be mutual and documented
 Acknowledgement of each other contribution
 Achievements monitored

 R
 Reciprocal benefits
 Respect for each partners
 Responsibilities well defined and agreed upon

 T
 Time and timing
 Tact and talent
 Trust

BARRIERS IN EFFECTIVE
COLLABORATION
 Lack of Communication
 Lack of understanding and
appreciation
 Lack of mutual trust and
respect
 Dominance of one
discipline over other

 Territoriality
 Attitude
 Administrative and organizational structure and
procedure
 Work roles and organizational responsibilities
 Working relationships
 Practices and changes in outcomes

SIX STEPS FOR SUCCESSFUL
COLLABORATION
1. Clearly identify the value
2. Link to the organization’s strategies
3. Select team members who are engaging, creative
and expert

4. Build trust among co-workers
5. Define or modify processes
6. Employ technology that is flexible and secure

CLINICAL SCHOOL OF NURSING MODEL(1995)
DEDICATED EDUCATION UNIT CLINICAL TEACHING
MODELS (1999)
RESEARCH JOINT APPOINTMENT MODEL(2000)
PRACTICE RESEARCH MODEL(2001)
COLLABORATION CLINICAL EDUCATION EPWORTH
DAKIN (CCEED) MODEL (2003)
COLLABORATIVE LEARNING UNIT(BRITISH
COLUMBIA) MODEL (2005)
COLLABORATIVE APPRAOACH TO NURSING CARE
(CAN- CARE) MODEL(2006)
M
O
D
E
L
S

CLINICAL SCHOOL OF NURSING
MODEL(1995)
PRACTICERESEARCH
EDUCATION

CLINICAL SCHOOL OF NURSING
MODEL(1995)
 Encompasses the highest level of academicand
clinical nursing research and education.
 This was the concept of visionary nurses from
both La Trobe and The Alfred Clinical School of
Nursing University.

 The development of the Clinical School offers
benefits to both hospital and university.
 Opportunities for exchange of ideas with
clinical nurses with increased opportunities
for clinical nursing research.

DEDICATED EDUCATION UNIT
CLINICAL TEACHING MODELS (1999)
CLINICAL STAFF
INSTRUCTOR
STUDENTSTUDENT
FACULTY MENTOR

DEDICATED EDUCATION UNIT
CLINICAL TEACHING MODELS
(1999)
 In this model a partnership of nurse executives,
staff nurses and faculty transformed patient
care units into environment of support for
nursing students and staff nurses while
continuing the critical work of providing quality
care to acutely ill adults.

Key features of DEU are:
 Uses existing resources.
 Supports the professional development ofnurses.
 Allows for the clinical education of increased
number of students.
 Exclusive uses of the clinical unit by school of
nursing.

 Use of staff nurses who want to teach as clinical
instructor.
 Preparation of clinical instructor for their teaching
role through collaborative staff and faculty
development activities.
 Faculty role to work directly with staff as a coach,
teaching/ learning resources to develop clinical
reasoning skills, to identify clinical expectationsof
students , and evaluate student achievement.

RESEARCH JOINT APPOINTMENT
(2000)
 A Joint appointment has been defined by Lantz
et al. (1994),as “ a formalized agreement
between two institutions where an individual
holds a position in each institution and carries
out specific and defined responsibilities”.

 The goal of this approach is to use the
implementation of research findings as a basis
for improving critical thinking and clinical
decision making of nurses.
 In this arrangement the researcher is a faculty
member at the educational institution with
credibility in conducting research and with an
interest in developing a research programme in
the clinical setting.

 Outcomes identified by Donnelly ,Werfel, Wolfe
(1994) for the educational institutions are that it
becomes more in touch with the real world and
more readily able to identify research questions
that have the potential.

PRACTICE RESEARCH MODEL
(2001)
PRACTICE
EVIDENCE
THEORY
EVIDENCE
RESEARCH
EVIDENCE

PRACTICE RESEARCH MODEL
(2001)
 It is an innovative collaborative partnership
agreement between Fremantle Hospital and
Health Service and Curtin University of
Technology in Perth, Western Australia.

 The partnership engages academics in the clinical
setting in two formalized collaborative
appointments. This partnership not only enhances
communication between educational and health
services, but fosters the development of nursing
research andknowledge.
 This model encouraged a close working relationship
between registered nurses and academics, and has
also facilitated strong links at the health service
with the Nursing Research and Evaluation Unit,
medical staff and other Allied HealthProfessionals.

 Key Concepts:
Practice – driven researchdevelopment
Collegial Partnership
Collaborative Partnership and Best Practice

COLLABORATION CLINICAL
EDUCATION EPWORTH DAKIN
(CCEED) MODEL (2003)
 In an effort to improve the quality of new
graduate transition, Epworth Hospital and
Dakin University ran a collaborative project
(2003) funded by the National Safety and
Quality Council to improve the support base for
new graduates while managing the quality of
patient care delivery.

 The Collaborative Clinical Education Epworth
Dakin (CCEED) model developed to facilitate
clinical learning, promote clinical scholarship
and buildnurse workforce capability.

 Key findings of the 2005 CCEED program were-
 Students learning objectives were metand
satisfaction was high.
 Undergraduate clinical education was valued
by preceptors and managers as a workforce
investment strategy.

 Preceptors were enriched in their clinician
role as a result of their participation in the
program and reflection on theprocess.
 Preceptors managed multipleroles in order to
meet demands of patient care and student
learning

THE COLLABORATIVE LEARNING
UNIT (BRITISH COLOMBIA)
MODEL 2005
 The collaborative learning unit model was based on
the ‘dedicated education units’ concept develop,
successfully implemented and researched in
Australia. The collaborative learning unit model of
practice education for nursing is a clinical
education alternative to preceptorship. In the CLU
model, students practice and learn on a nursing
unit, each following an individual set rotation and
choosing their learning assignment , according to
their learning plans.

 Clinical nurses preparing to adopt the CLU
model have described a positive learning
environment as one where questions are expected .
In CLU approach the students are not attached to
the units as an ‘extra set of hands’ to augment the
nursingworkforce.
 In this model , nursing faculty , clinical nurses
and students work collaboratively to enhance
learning opportunities as well as develop the
professional knowledge base of nursing.

THE COLLABORATIVE APPROACH TO
NURSING CARE(CAN- CARE)
MODEL(2006)
 The CAN-care model emerged as academic and
practice leaders acknowledge the need to work
together to promote the education , recruitment
and retention of nurses at all stages of their
career.

 The goal was to design an educationally dense ,
practice based experience to socialize second
degree students to the roleof professional nurse.
 A secondary goal was to enhance and support
the professional and career developmentof
unit based nurses.

 The essence of the CAN-care model is the
relationship between the nurse learner (student)
and nurse expert (unit based nurse ) , within the
context of each nursing situation.
 Through this model the student comes to know
the organizational context of nursing practice,
the multifaceted role of professional nurses,
andassumes responsibility for coming to know
the meaning nursing in each uniquesituation.

THE BRIDGE TO PRACTICE
MODEL (2008)
 The Bridge to Practice model is distinctly
different from other clinical models.

 First, students complete all of their clinical
experiences in one participating hospital.
 Second, one full-time teaching faculty serves as a
liaison for each bridge hospital.

 This faculty member is given a space, usually in
the nursing education department, and is then
available to serve as a resource for not only the
clinical associates but also for the hospital
nursing staff.
 In this model, therefore, there can be numerous
clinical associates in one hospital with one full-
time University faculty overseeing the clinical
experiences.

 Third, students are actively involved in selecting
their clinical placements.

Integration of Nursing
Education and Service
(Dual Role)

• The Indian Nursing Council has resolved in its General
Body Meeting held on 2nd December, 2018 that the
concept paper for “Integration of Nursing Education and
Service – Dual Role” aiming to achieve optimal patient
care and to improve quality of Nursing Education
through effective utilization of qualified faculty be
approved for adoption with an aim to improve quality of
Nursing Education and quality of patient care.
• This model adopted on 4th April, 2019.

INTRODUCTION
• Adequate and effective human resources are
critical for people's health. Competent and
adequate nursing workforce with high relevance
to today's healthcare system and delivery are
important thrust areas that need to be addressed
worldwide.
• In today's health care in India, providing quality
of education and clinical training to provide
quality health care is a great challenge.

CONCEPT OF INTEGRATION
• Implementation of integration involves
unification of the nursing service and
nursing education to improve the quality of
nursing care provided in the hospital,
wherein qualified faculty from the CON will
contribute their knowledge in the clinical
field and the senior nursing fraternity from
the hospital will be involved in the training
and supervision of nursing students.

OVERALL AIM
• The aim is to provide high quality nursing
care to patients and clinical education and
training to students by optimum utilization
of all cadres of nursing manpower in the
academic and clinical settings

OBJECTIVES
• To achieve maximum and effective utilization
of HR (nursing) resources.
• To provide quality patient care.
• To provide quality clinical education and
training to students.
• To bridge the gap between nursing education
and practice

• To foster commitment and accountability on the part of
teaching staff and nurse practitioners towards patient
care.
• To provide for ongoing staff development through a
collaborative effort
• To synergize the effort of nursing educators to teach and
give patient care simultaneously
• To work in collaboration with all nursing personnel.

OUTCOMES OF INTEGRATED
ROLE:
To organization:
• Provides effective utilization of nursing manpower
by pooling in of knowledge and skills of different
cadre of nurses
• Prevents duplication of HR utilization, thereby
ensures cost containment
• Promotes decentralization
• Improves image of the hospital through better
patient care with qualified and competent nursing
workforce
• Promotes interdisciplinary interaction

Contd…
To clinical learning environment:
• Promotes the use of a humanistic approach to
learning
• Maintains a good working team spirit in the clinical
area
• Facilitates an efficient but flexible management style
with teaching being recognized
• Fosters teaching and learning support of nursing
from qualified faculty/staff

Contd…
To the patient:
• Achieves improvement in standard of care by
holistic approach
• Pools in of ideas for patients' benefits
• Ensures team approach
• Enhances better planning, implementation and
evaluation of care
• Leads to framework for quality assurance practices
(standard setting and nursing audit).

Contd…
To the student:
It promotes
• Uniformity/consistency in teaching and practice
• Positive learning environment
• Exposure to current trends and practices
• Exposure to ideal role modelling
• Continuous supervision and learning

Contd…To the nursing service staff:
• Promotes on going staff development by qualified faculty/nurse
managers
• Achieves mentoring and incidental teaching to staff
• Orients new staff to ethos, values and expectations of institution
• Fosters team spirit
• Promotes job satisfaction and staff retention
• Develops problem solving, decision making and communication
skills
• Promotes staff-student interaction
• Is able to mould committed, compassionate and competitive
nurses

College of Nursing and Hospital
Nursing Service
(As per INC & SIU norms)
COLLEGE OF NURSING HOSPITAL NURSING SERVICE
1. Principal-1
2. Vice Principal/Professor-2
3. Associate Professor-4
4. Assistant Professor-6
5. Tutor-28
40 (1:10 faculty student)
excludes principal-
400 students/4years
1. Chief Nursing Officer (CNO)-1
2. Deputy Nursing
Superintendent-1
3. Assistant Nursing
Superintendent (ANS)-9
4. Senior Nursing Officer (SNO)/
Charge nurse - 54 ratio
(CNO-1 for 500 or > 500
1 DNs for 6 ANS
1 ANS for 6 charge nurses

Qualification and equivalent
positions

• Principal cum professor -MSc
with 15 years experience (12
years teaching of which 5years
in college with minimum 3
years clinical experience) with
PhD Nursing
• Vice Principal cum professor-
MSc with 12 years of
experience (10 years teaching of
which 5years in College with
minimum 2 years clinical
experience) PhD in Nursing is
desirable
• Professor (Senior Nurse
• Nursing Superintendent - MSc
with 15 years experience
(3years teaching)
Or BSc with 18 years of
experience (2years
teaching)
• Deputy Nursing Supdt (DNS) -
MSc with 10 years experience
(3years

• Associate Professor (Senior
Nurse Manager ).
MSc with 8years experience
(5years teaching with minimum
2years clinical experience)
• Assistant Professor(Nurse
Manager/ANS) - MSc with
3years teaching experience with
one year clinical exerience
• Tutor- BSc/ PBBSc/MSc with l
year experience
• Assistant Nursing Supdt (ANS)-
MSc with 3 years experience
(1year teaching) Or BSc with 6
years experience ( 1year
teaching)
• Senior Nursing Officer
(SNO/Charge nurse) BSc/PBSc
with 2 years experience Or
Diploma with 6 years of
experience or Post basic
diploma in a specialty with
minimum 5 years after GNM
clinical experience may be
considered)

JOB DESCRIPTION
 Chief Nursing Officer: (M.Sc Nursing/
Ph.D)
Eligibility: M.Sc Nursing/Ph.D with
minimum of total 18 years experience in
college and hospital of which a minimum of 5
years should be administrative experience at
the hospital and 5 years of teaching &
administration at the college with 3-5 years of
clinical experience at the hospital.

• Exemplifies the mission, vision and philosophy of
the academy through nursing practice and education.
• Accountable for smooth conduct of both nursing
service and nursing education.
• Updates director on all matters concerning nursing
service and nursing education.
• Reports to concerned HR manager/Officer all
matters relating to nursing service and education.
• Accountable to Finance officer /ADF for all
financial matters pertaining of nursing education.
• Supervision and performance appraisal of nursing
superintendent and principal.

Contd…
• Recruitment and selection of staff for both service and
education
• Plan budgeting for nursing services.
• Policy making in all matters relating to nursing service
and education.
• Maintains professional affiliation with other
organization for patient care and nursing education.
• Champions new initiatives and catalyses change for
improvement of nursing services and education
including research activities.
• Establishes performance indicators with measures to
establish excellence.

JOB DESCRIPTION
 Principal (M.Sc. Nursing/Ph.D)
Eligibility: M.Sc/Ph.D with a minimum
of 15 years experience (12 years teaching
of which 5years in college with minimum
3 years clinical experience)

• Directly responsible to CNO in all matters
pertaining to nursing education
• Supervision and performance appraisal of college of
nursing faculty
• Responsible for students discipline and welfare
• Co-ordinates with nursing superintendent for patient
care in hospital
• Plan and revise budget for college
• Co-ordinates with CNO in recruitment and selection
of the college faculty

Contd…Research:
• Responsible for research activities in College
of Nursing,
Educational functions:
• Accountable for all matters concerning
nursing education.
• Co-ordinates with Universities and
accreditation bodies regarding academics,
planning and implementation in curriculum.

JOB DESCRIPTION
 Nursing superintendent: (M.SC Nursing;
Ph.D in Nursing is desirable)
Eligibility: MSc with 15 years experience
(3years teaching) or BSc with 18 years of
experience (2years teaching)
• Accountable for overall patient care in
hospital.
• Ensures quality control in nursing service.

Contd…Supervision and administration:
• Directly reports to CNO in all matters of patient
care.
• Supervision and guidance and performance
appraisal of all levels of nursing staff in hospital.
• Plan co-ordinates CNE, HICC, NABH.
• Promotes welfare and discipline of all staff nurses.
• Co-ordinates with principal CON in dual role.
• Involved in education and research in nursing
service.

JOB DESCRIPTION
Deputy Nursing Superintendent (DNS):
Eligibility: MSc with 10 years experience
(3years teaching) Or BSc with 12 years
experience (2years teaching)
Patient care:
• Responsible for patient care in area
assigned
• Conducts supervisory round in rotation

• Report to NS for patient care matters
(approx.300beds)
• Responsible to principal and vice principal in
academic matters
• Supervision and guidance of all ANS under her
• Problem solving of matters related to patient care
• Plan and supervises duty roaster prepared by ANS
• Perform specific assignments entrusted

Contd…
• Responsible for all disciplinary matters within her areas
• Maintains communication and IPR with all channels.
• Fullfill specified assigned responsibilities.
• Responsible to heads of department in college of
Nursing, for all academic responsibilities allot to her
• Overall responsible for training and supervision of
students in her clinical area

JOB DESCRIPTION Assistant Nursing Superintendent/ANS (M.Sc
N/Assist Prof CON)
Eligibility: MSc with 3 years experience (1 year
teaching) Or BSc with 6 years experience (1 year
teaching)
Patient care:
• Responsible for patient care of assigned area
• Responsible to the DNS for patient care matters
• Problem solving related to direct patient care
• Conducts supervisory rounds for staff and students

• Plans and executes duty roster of nurses posted in
her wards
• Plan and conduct ward meetings
• Supervision and guidance of staff nurses and
students
• Acts as a liaison between the DNS and the staff of
her units.
• Performs periodic appraisal of staff

Contd…
• Responsible to HOD, CON, for academic matters
allotted to her.
• Participates in curriculum implementations in
college
• Identify learning needs of staff and students
• Conducts nursing rounds for students for the
purpose bedside teaching
• Nights supervision in rotation

JOB DESCRIPTION
Tutor/Senior Nursing Officer:
Eligibility: MSc with 1 year experience or B.Sc/ P.B.B.Sc
nursing with minimum 2 years of experience or Diploma
with 6 years’ experience or Post basic diploma in a
specialty with minimum 5 years after GNM clinical
experience.
Direct patient care:
• Ensures proper admission and discharge procedures for
her patients
• Assists in the direct care of the patient as and when
required
• Implements doctor's instructions concerning patient
treatment, investigations and any other procedures.

Contd…
• Co-ordinates patient care with other
departments
• See that the new admissions are seen by the
treating doctors at the earliest.
• Ensures entry of above activities
electronically as per the institute
rules/protocols

• Ensures safe and clean environment for the ward
• Makes duty and work assignments
• Maintains good public relations in her ward
• Handle medico-legal cases in the ward as per the
existing rules/ protocols
• Gives incidental teaching to patients, relatives, staff
nurses, students and the house keeping staff.
• Assists the clinical instructor in the evaluation of
students.

CHIEF
NURSING
OFFICER
(CNO)
Role: Teaching & Patient care Role: Patient care Teaching
Principal/ Dean
Nursing
Superintendent
Professor/
Associate
Professor
(DNS/ Senior
Nurse
Manager)
Deputy
Nursing
Superintendent
(DNS)
CQM CICN CNE
Assistant
Professor
(ANS/ Nurse
Manager)
QM ICN NE Senior Nursing
Officer (SNO) /
Charge Nurse
Vice
Principal

ORGANOGRAM
• In Institutions having both college of nursing offering UG & PG
nursing programs and large medical college hospital with more
than 500 beds, and integration model is practiced, it is beneficial
to have a senior nurse leader to assume the role of Chief
Nursing Officer (CNO), the head of nursing. This person must
be an expert in both education and service, to contribute
effectively to both areas. The individual must possess Ph.D /
M.Sc Nursing qualification with minimum of 5 years clinical
experience in patient care and 5years teaching in a college
having a total of 15-18 years of experience. Both leaders, the
Head of Nursing education / Head of nursing services (Principal
/ Nursing Superintendent) must possess Ph.D / M.Sc Nursing
qualification with minimum requirements spelt out earlier. Both
leaders must have equal qualification and experience and the
remuneration must be equal.

• Professor/associate professor who will be the clinical
nursing head of department (or cluster of wards/units) in
the hospital will report to nursing superintendent for
matters concerning patient care. Dotted lines mean
equivalent positions in the hospital nursing service
having responsibilities for student/staff teaching as well
as patient care as per the job description. The size of the
department may vary but however the optimum is
specified in the worked out example. The assistant
professor can assume the responsibility of ANS. The
assistant professor/ANS can be responsible for 2-3/3-4
wards/units but the tutor will be responsible for one
ward/unit.

• The college faculty will assume dual designation
and appointment as professor/DNS or senior
manager and assistant professor/ANS or nurse
manager. They are involved in planning,
implementation, and evaluation of student
education & training alongside management of
patient care in their respective departments and
will be members of committees chaired by
Principal and Nursing Superintendent at the top
managerial level. All the faculty with dual
designation along with DNSs, ANSs and SNOs
headed by HOD of the respective department
must meet together periodically every week to
plan concerning matters related to student
teaching and patient care.

• Nurse educators must assume leadership
roles in the hospitals and involve in policy
making in the clinical areas. Similarly the
postgraduate nurses/ nurse managers/charge
nurses working in the hospital must involve
themselves in sharing their expertise with
students through clinical training. Nurse
leaders would take responsibility in
developing and implementing protocols /
policies/ clinical pathway contributing to
individualized patient care. The college
faculty can fill the DNS and ANS posts in the
hospital. The faculty positions of the college
and staff positions of the hospital will be
maintained.

• In hospitals, appropriate positions to be made
available for the postgraduate nurses. Various
positions that could be offered to the post graduate
nurses are Chief Infection Control Nurse, Chief
Quality Nurse, Chief In service Educator at the level
of Deputy Nursing Superintendent/ANS. These
positions could be offered to the postgraduates of
both college and hospital depending on the number
of faculty available in an institution. The faculty
may also assume these positions as additional
responsibility.

• The nursing superintendent and principal can
become CNO on rotation basis. The
professors/HODs of the college can be made
as principal or nursing superintendent on
rotation basis. Chief Nursing officer,
Principal and Nursing Superintendent should
be representing in all the decision-making
bodies of the hospital and college to address
patient care as well as student education
issues.

IMPLEMENTATION GUIDELINES
As per IPH Standards for inpatient
& Outpatient clinical services
(wards, ICUS, OT, OPDs and other
clinical services) for 500 bedded
District Headquarters Hospital and
SIU staffing norms, the following
guidelines are prepared.

Contd…
• Integration Model is recommended for 500
bedded medical college/teaching Hospital
that has College of Nursing offering at least
BSc Nursing with student intake of 100 and
both should be under same administration.
• MSc Faculty who are professor’s/Associate
professors/Assistant professors are given
dual appointment for teaching and
managerial responsibilities at the college and
hospital.

Contd…
• Similarly DNS and ANS in the hospital
with the required qualification can be
involved in teaching students with dual
appointment besides their managerial
responsibilities at the hospital. If they do
not have the required qualification and if
they are only BSc, they can be involved in
clinical teaching of students only. How
ever, in due course of time, they can be
encouraged to get the required
qualification.

Contd…
• 18 Tutors out of 28 tutors from the college may
also be given dual appointment to teach and
manage unit at the hospital besides teaching at the
college. The rest 10 of them can be posted in
Foundations of Nursing (FON) department to
teach First year students with the ratio of 1:10
(tutor student ratio).
• BSc charge nurses/SNOs and BSc staff nurses
with required qualification can be offered dual
appointment to manage ward/unit as well as
teaching students in the clinical area.

Contd…• Faculty positions (Professor/Associate professor/Assistant
Professor) have to remain as per INC norms. However, they can
fill in DNS/ANS positions at the hospital (20% of them may be
permitted- Example 2 DNS/ANS may be reduced when their
total DNS & ANS positions are 10).
• Tutors -10 % of them either at college/Hospital can be
shown/filled to reach the INC norms (Example-3 BSc nurses
with dual appointment at the hospital can be shown against
tutors).
• Interchangeability between education and service can be built in
protecting the seniority, service and salary/financial benefits of
the concerned managers/faculty opting for change.
• Equivalent salary & positions on both sides must be offered, if
the qualification and experience are same.

Assignment of clinical areas to Faculty and hospital nursing
supervisors/managers- Example
• The assignment of clinical areas can be based on the
availability of faculty and hospital nursing
supervisors/managers (DNS/ANS/charge nurses) and existing
areas/wards/ICUs/OPDs/OTs of the hospital. An example is
worked out to illustrate the optimum span of control for
faculty (Professor/Associate professor/Assistant professor/
Tutors) and nurse mangers. If more faculty and managers
with required qualification is available, then the span of
control/number of wards/units can be reduced for every
manager. The combination of units may also be changed as
per institutions' needs/policies and location of areas (E.g.
Medical wards+ICUS or surgical wards+ICUS). A 500
bedded hospital and its clinical services/units/wards/ICUS
can be divided into six departments as follows for allocation
to faculty/nurse managers.

I. Medical/Surgical/Specialty wards
• 1 DNS/Professor/Associate Professor for 6-8 wards (one
ward-25-40 beds, maximum of 200-250 beds)
• 2 ANS/Assistant professor (1 ANS for 3-4 wards)
• 8 Charge nurses/Tutors (1 ward-1 charge nurse)- 4 Charge
Nurses + 4 Tutors
II. ICUS/HDUs/Casualty
• 1 DNS/Professor/Associate Professor for 4-6 critical care
areas/units
• 2 ANS/Assistant Professor (1 ANS for 2-3 ICUS)
• 6 Charge nurses/Tutors (1 ICU-1 charge nurse)- 4 Charge
nurses + 2 Tutors

III. OTs (7-8)
• 1 DNS/Professor/Associate professor for 7-8 OTS
• 2 ANS/Assistant professor (1ANS for 3-4 OTS)
• Charge Nurses/Tutors (1 charge nurse for 2 OTs)- 2 Charge nurses+2
Tutors
IV. Maternity wards, New born Unit, Labor Room, Eclampsia room
& Septic LR
• 1 DNS/Professor/Associate professor
• 2 ANS/Assistant professor for 4-6 wards with 160-200 beds (1ANS
for 2-3 wards)
• 2 ANS for Labor room & other areas
• 6 Charge nurses/Tutors for wards (3 Charge nurses+ 3 Tutors)
• 6 charge nurses/Tutors for Labor room & others (3 charge nurses + 3
Tutors

V. Pediatric wards & ICU
• 1 DNS/Professor/Associate professor
• 2 ANS/Assistant professor (1 ANS for wards, 1 ANS for ICUS)
• 4 Charge nurses/Tutors (2 Charge Nurses + 2 Tutors)
VI.OPDs & diagnostic services
• 1 ANS for 7-8 OPDs
• 4 charge nurses/Tutors (2 charge nurses+2 Tutors)
Summary
• DNS/Professor/Associate professor- 5 (Prof/Associate professor-5
excludes Vice Principal-VP&DNS)
• ANS/Assistant Professor- 13 (ANS-7 + Assistant professors-6)
• Charge nurses/Tutors- 35 (Charge nurses- 17+ Tutors-18)

• Charge nurses who are BScs with required
qualification can be given dual appointment to teach
students besides their managerial responsibilities.
BSc qualified staff nurses with required qualification
may also be given dual appointment to perform the
dual role. At the time of introducing the integration
model, if adequate number of MScs and BScs are
not available, the existing staff with specified work
experience on a temporary basis may be utilized
until the qualified are appointed or the existing staff
upgraded with in stipulated time period of 4-6 years
maximum.

IMPLEMENTATION PROCESS -
STEPS
I. CREATING AWARENESS AND COMMITMENT TO INTRODUCE
INTEGRATION MODEL
• The concerned administrators and senior faculty and nursing service staff
should understand the concept, its implementation process, dual roles and
responsibilities of faculty and hospital nurse managers. This can be
clarified by them visiting and observing institutions and gaining first hand
information regarding its application of the concept, its benefits and
challenges.
• The institution's administration and heads of college of nursing and
hospital nursing service should become committed to the concept of
integration and its major benefits and outcomes of patient care.
• Communicate to all involved in the implementation process, the benefits to
patients, staff and organization, opportunities and challenges. Prepare the
entire team from college and nursing service by holding discussions
preparing the ground for implementation

Contd…
II. DEALING WITH RESISTANCE AND GAINING SUPPORT
• Gain full support from the top administration.
• Address fears by showing individuals and groups how the change is
going to help them do their jobs more effectively or how it supports
the direction of the practice.
• Initiate the change on a trial basis (Pilot test the process)
• Make plans to assess the pros and cons after a set period of time
III. IMPLEMENT THE PROCESS
• Identify or appoint NS with the required qualification (MSc
qualified with required experience equivalent to principal). If not
available, the existing MSc/BSc as indicated may continue until new
appointment or upgrading of existing BSc to MSc within 1-2 years.
This is permissible on a temporary basis only.

Contd…
Categorize the clinical departments as per the worked example or as per the
size of the hospital and existing services. Six areas are shown in the
example, Every college with 100 student intake must have 5
professors/associate professors (Professor-1 & Associate professor-4,
excluding vice principal). Five of them with dual appointment as senior
nurse managers or DNS can be designated as clinical heads of the five areas
and one (OPD & diagnostic services) may be allocated to one
ANS/Assistant professor.

Contd…A total of 13 ANS/Assistant professor is required (Assistant professor-6
from college is available and 7 ANS from hospital are required). Nine ANS
is the requirement for the hospital as per SIU norms. Seven ANS with
required qualification if available may be appointed with dual designation,
who can be posted to different clinical areas as per worked out example. If
only BScs are available, then, two during first year and two in the second
year and three in the third year may be sponsored to undergo MSc that
means by 2 years two will be upgraded and by three years 4 will be
upgraded and four years 7 will be upgraded to MSc or two new
appointment is done by 2years, by four years, two will be upgraded, by six
years three will be upgraded (Table 3). Until then the existing BSc with the
required experience will continue to work as ANS with dual designation.

Contd…A total of 35 tutors/charge nurses with BSc are required for dual
appointment. 18 tutors are available at the college. The rest 17 of them, if
qualified BScs are available, then they can be posted with dual appointment
as per guidelines in example. If not available, Diploma with required
experience may serve aas charge nurses and be involved with only clinical
teaching, Then every year for 4 years, existing 4-5 diploma charge nurses
can be sent to undergo PBBSc and by 5 years all of thess nurses can be
upgraded to BSc and given dual appointment. It is preferred if any
permenant BSc staff nurses are available, then they may be considered or to
appint 50 % of BSc/MSc staff as charge nurses and the rest 50 % of
existing diploma charge nurses be upgraded.

S.N
o
Faculty
/nurse
manger
designatio
n
1st option-maximum period 2nd option-maximum period
2 years 3years 4-5years 2 years 3-4 years 5-6years
1 NS New
appointm
ent -initial
Upgradin
g existing
NS to
MSc
2 DNS Do Do
3 ANS Upgradin
g existing-
2
Upgradin
g existing
staff-2
Upgradin
g existing
staff -3
by 4 yrs
New
Appointm
ent- 2
Upgradin
g existing
staff-2
Upgradin
g existing
staff - 3
4 Charge
nurses
Upgradin
g existing
staff-4
Upgradin
g existing
staff -4
Upgradin
g existing
staff -4
New
Appointm
ent- 4
New
Appointm
ent- 4
New
Appointm
ent- 4

IV. REVIEW OF THE PROCESS & MEASUREMENT OF
OUTCOMES
• The entire process is assessed identifying pros and cons and
outcomes are measured. Modifications can be suggested if
required.
• The proposed integration model would have numerous benefits
to both education and service. Quality of nursing education
would improve with increased skill development measured by
competency assessment of new graduates. Dual appointments
will reduce the cost by reducing the staff numbers to some
extent and enhancing staff retention that can be measured by
financial audit.
• In the hospitals, it would also enhance quality care. Positive
quality indicators are reduction in morbidity, mortality, adverse
events, medication errors, pressure ulcer, HAIs and hospital
stay. Periodical audits will facilitate objective measurement of
these outcomes. Research must be conducted to identify short-
term and long-term outcomes on patients, staff and organization.
It would also promote interdisciplinary collaboration that can
also be assessed.

CHALLENGES / ISSUES
Implementing the above organogram will face great resistance
from the current nursing service staff, which is unavoidable.
However, the following measures can be undertaken to
overcome this resistance:
• Ensure that the existing position and promotion of
nurse leaders in the hospital will not be affected
• Give stipulated time for the current Diploma nurse
leaders to upgrade themselves
• Providing dual appointment and involvement in
student teaching may increase the morale of hospital
nurse managers

Contd…
• Faculty will be able to upgrade their skill and dual appointment
may enhance their job satisfaction
• Provide competency building and competency assessment for
the nurse leaders at every level
• Make it mandatory for nursing faculty to have a minimum of
25% credit hours from competency development
• Conduct Joint collaborative meetings for the leaders from both
education and service on a regular basis and provide
continuous guidance, support and encouragement
• The institution experiencing positive outcomes may introduce
inbuilt system with incentives such as awards/opportunities to
leaders based on their performance

Conclusion
• Implementing the proposed integration improves the quality of Nursing
care to the patient. It is necessary to formulate cadre and recruitment
rules accordingly and formalize the same in their respective governing
boards/ government gazettes, which can go on the public domain to
make it official and binding.
• This proposal is an ideal system to implement completely. However, in
order to protect the current nursing personnel, the suggested proposals
to be followed in all the new appointments and to be implemented, in a
phased manner over a period of time. The organizations can also
prepare inter seniority list in order to protect every one's interest and
take declaration from them that they are satisfied and will abide by the
same.

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