Developing the synergy between university and industry-based nursing courses : Lessons in engagement

On the surface the process of engagement seems functional, however, if the engagement process does not take into account people dynamics and the effects of the wider social, organisational and cultural context, multiple tensions may occur. This paper shares the story of the tensions related to culture, relationships, communication and the impact of change in bringing a University-Community project to its completion. The scholarship of engagement revealed the nature of this complex process and uncovered the need for a richer understanding of the people involved and their mindset. The challenges and opportunities encountered in the engagement process will be identified and the “how to” and “how not to” manage the process and the consideration of the people will be discussed.


Introduction
In response to health industry needs and to the demands of the University engagement, a post-graduate academic teaching team engaged in discussion and review of hospital based graduate nurse programs that were on offer in six hospitals in the state. Graduate nurse programs in Australia, are usually twelve-month employee bound arrangements which facilitate the transition of newly graduated registered nurses into the role of confident nurses. The history of such hospital based programs has not seen the conferment of academic credit to theseworkplace integrated learning courses, despite recent moves to use workplace learning to increase the employability of students. As such, the courses, though practical in content and based in competency attainment, did not have a formal assessment and appraisal components in line with higher degree assessment and conferring of award policies.
This challenge of university community engagement with the health sector in order to develop an industry-focused course which could be translated to academic credit and award presented the academic teaching team with the opportunity to demonstrate its commitment to 'community engagement' in the real sense.For the purposes of this paper, 'engagement' is used as a generic inclusive term to describe the broad range of interactions between people. It includes a variety of approaches such as consultation, involvement and collaboration in decision-making, to empower action in formal partnerships. The word 'community' is also a very broad term used to define groups of people and encompasses stakeholders and interest groups involved in the delivery of healthcare, defined by geographic location and professional identity. The linking of the term 'community' to 'engagement' serves to broaden the scope shifting the focus from the individual to the collective, with the associated implications for inclusiveness to ensure consideration is given to the diversity that exists within any community [1]. This engagement alliance fosters learning and teaching programs responsive to individual and community needs and opportunities and links to specific learning goals and experiences for students required by University teaching outcomes. Programs are designed and managed in partnership with communities, and are socially inclusive and globally and locally relevant. University and community alliances are a vibrant field of interest for higher education institutions [2,3].
University engagementis an interaction between the University and the broader community characterised by a two way flow of perceived benefits to both parties and collaboration for mutual outcomes. Engagement is a planned process with the specific purpose of working with nurse educators in hospital settings with the mutual goal of conferring academic credit to their hospital based educational programs. This ensures that the graduate skills the neophyte registered nurse presents with, in the clinical environment, are sustained and developed [4]. This model of education aligns so that the University and the hospitals work together to monitor partnerships, measure impacts, evaluate outcomes, and make improvements to their shared activities [5].
The purpose of this paper is to recount the process ofthat engagement. It highlights the strengths and weaknesses of engaging; and, the importance of working from the 'same page' or mental model, particularly when the engagement process is strongly aligned to change and the fears and confusion which surround the acceptance of that change. It also explores dealing with stakeholders who may not be committed to the changes brought about by the engagement, andthe potential for sustaining the change over time.These are necessary attributes to build a sustainable mutually beneficial partnership over time.

The Community Engagement Project-Strategic Intent
Existing hospital-based graduate education programs are based on the premise and have a strategic recruitment function, to attract nurses to the hospital to undertake training, and at the most fundamental level, lock in the nurse's labour for the duration of the program with the potential for ensuring an ongoing workforce in the longer term.
The University's engagement is also strategic. That is, course development is reliant upon meeting the strategic intent of the University, which promotes the integration of engagement in the curriculum and the student experience. Further, postgraduate nursing programs require an increase in student numbers in areas relating to advanced clinical nursing for sustainability of the program. Hence, the University entered the collaboration with an agenda to align hospital-based programs with an academic award principally to increase student enrolment. On the surface the strategic intents of both parties was clear. For, by aligning the hospital based courses with the University's academic awards, the intent of the hospital to provide education to ensure a well-educated and competent workforce in demanding and technologically specialised areas in nursing, was met; whilst the University's requirement to secure student numbers was also addressed [6].

The process of engaging
The process of engaging used the seminal work of Brown and Isaacs [7] Model of the Six C's of Community Engagement namely: Capability, Commitment, Contribution, Conscience, Collaboration and Continuity as the framework for engagement. Capability provided the starting point as Mersino [8] believe that to assess the capability of the people, not the project, ensures that the stakeholders have an understanding of, and experience in, the tasks at hand before commencement. This also requires commitment, contribution and conscience. Commitment requires active participation in decisionmaking processes which strengthens capacity to mobilise personal resources. This is significant because the engagement often requires a redefinition of goals and values challenging existing ideals and rituals. Contribution or effective participation requires setting boundaries that define participants' roles and responsibilities to each other, not as a matter of imposing control, but so that trust, shared understandings, and a shared mental model may develop. When it occurs, each participant willingly is accountable for their problems, and accepts the responsibility to take steps to address them. In line with contribution and commitment the concept of conscience creates trust and mutual respect between stakeholders thereby strengthening the partnership of the engagement. These abilities may be developed over the duration of the project, but the project must commence with those who are able to champion it because of their expert understanding of the processes required to negotiate successful engagement, including collaborative communication which brings together the stakeholders on an equal footing to consider important issues.

Measurement parameters and analysis methods
In reality however, the story of engagement was not as simple as following the principles described above. If all attributes of this model are not present, the project will stall. This may be due tostakeholders not having the personal and professional resources to understand the agendas, nor the capability to decision -make or to focus on what is important. Previous work by Hendricks, Cope and Harris [9] highlighted the pragmatic truths of engagement which noted that each stakeholder group may have underlying tensions that are compounded by individual agendas and cultural artefacts which may make the engagement process disheartening, conflictual and prone to failure.
de Souza Briggs [10] terms this 'process paralysis' . Interestingly within this engagement the university academics focused on the practical elements of nursing, the 'doing' to build graduate confidence, whilst the hospital educators had difficulty in moving away from theoretical and academic components. This isjuxtaposed to the usual intent of both parties, that is, hospital educators usually focus on building practical skill and purport that newly graduated nurses are not adequately prepared for the clinical environment [11]. From the academic standpoint, academics were convinced that the preparation of new nurses was being theoretically met and the focus should be more on gaining confidence in their abilities and practicing their skills. It may be postulated that hospital educators had not made the 'transition' themselves to having a previously un-awarded program, to one that is offered by a tertiary education center which valued clinical practice and understood the stages necessary to be met for graduates entering the workforce.

The stalemate
The theoretical juxtaposing of the two foci of theory and practice engendered a stalemate of this engagement story. This stalemate caused the project to stall and almost ended the engagement as the acknowledgement of the fundamental necessity of managing the 'people dynamics' at play in the engagement were not fully anticipated [9]. Mutual benefits were lost as the focus of the engagement turned to the minutiae and to issues outside the projects scope. Unfortunately, failures in engagement between stakeholders are often not accidental [12]. Many engagements are limited to superficial planning, cursory input, limited discussions of the real ramifications of decisions, and poor supports to help stakeholders become informed and capable of exerting a real influence. This may occur because the collaboration begins with is an over emphasis on the rituals of the 'doing' rather than on group dynamics. The 'how-to' management, tactics and process, rather than 'how to manage and work with people' takes precedence to get the project underway [10,13].
Reflection on the issues related to the stalemate from both parties was required, and after deep retrospection it was gleaned that there were many challengesassociated with fulfilling the brief. However, with a refocusing of direction and a focus on the opportunities that the project afforded, the project could continue.With this redirection as key, stakeholders decided to reconsider: What was important? Did the hospital understand academic requirements and award bestowal? Did the University academics understand the fears that accompany organisational change?
The emphasis of the project now became intentionally focused on 'sameness' rather than difference. This assisted in developing a sense of group cohesion and common spirit. Sameness meant that the centre of attention now moved from the content of the educational program to a common theme central to nursing: patient outcomes, educational standards, and the delivery of healthcare. This sharedvision provided the common ground for moving forward. Meetings became productive with new ground rules established and cooperative rather than competitive relationships came to the fore. Consensus formed the basis of action and acknowledgement of conflict as a natural occurrence, rather than an obstacle to progress, reframed group dynamics.

Lessons learnt
On paper, engagement seems so simple. However, there were many lessons that were learnt when the story was told. The process of engagement is exciting and creates a self awareness of all stakeholders' abilities if one is able to step back and reconsider what is important. That is, the achievement of what practitioners consider to be the skills and behaviours of an effective people project manager getting the job done! [13]. Lessons learnt from face-to-face encounters and self-completion evaluation similar to those described by Hart and Northmore [14] included: the valuing of culture; the importance of communication; the establishing of respectful relationships; and the impact of change. It is important to remember that the process for engagement is interactive requiring common goals and the creation of different solutions to problems and concerns [3].

Culture and Communication
Culture is comprised of the assumptions, values, norms and tangible signs or artefacts of an organisation and its members [15]. It is a learned set of shared interpretations which affect the behaviour of stakeholder groups and therefore needs consideration prior to commencing any community engagement project because to be truly 'engaged' necessitates shared interpretations of the reasons for engagement, as well as mutuality in benefits. Inherent cultural differences became evident when the mapping of the alignment processes or the initial development stage began. Two mental models, one academic and one hospital based became overt. The academic team failed to initially acknowledge the importance of the hospital based culture. The seminal work of Schein [16] asserts that members operate unconsciously with learned responses to the groups problems when a perceived threat to survival from external environment is presented. Vis a Vis the University and the hospital both represented the external environment in this case. Hence, the threat came from a lack of understanding of the others values and the inability of either party to clearly articulate or acknowledge them [17]. Maginn [18] state that resistance is a signal that something is wrong with the change and that resistance should be a legitimate expectation of those involved in the process of change. People issues, value clashes, mistrust and frequent uncertainty are often expressed through resistance [19].This will be discussed later in the paper. Some time and attention was given to acknowledge the group's dynamics so that the group sustained its forward movement. This required that everyone involved shared opinions, facts or feelings that they may have had, and put their cards on the table via respectful communication with each other. It is through this sharing of contributions that the group was able to come to a decision that satisfied everyone and was able to foster a relationship of respect and tolerance for differing standpoints. Emotionally intelligent behaviours may develop when there is diversity of culture and differences to agenda. When the group is able to rank alternatives and listen to the views of others, group members are provided with enough information to take the best action possible in relation to the engagement. This means that only through listening to someone who thinks differently can one begin to see something in a different way. Explaining the reason behind one's thought can help others to see its merit. Finally, when everyone is committed to a common purpose, the task is more easily accomplished. Wodak, Knon and Clarke [20] assert that this means achieving the right balance. Commitment to a purpose helps one move past one's own initial thinking, and allows one to listen to a diversity of ideas and to make an emotionally intelligent response [8]. Providing multiple solutions, while knowing the bottom line, ensured that stakeholders were seen to be flexible, acknowledging and open to all issues presented at the table. In fact, this dialogue can create energy, creativity and innovation [20].

Relationships
The experience of community engagement with hospital stakeholders highlighted the difficulties of not adequately knowing the people. That is, a focus on the managing of tasks to align the hospital based course to the university curriculum was initially overriding.
Both stakeholders appeared to have reached consensus about the need for alignment and how the alignment would be undertaken, however, communication at this point was superficial because in reality neither party truly understood what this alignment meant.
As the engagement progressed it emerged that hospital stakeholders perceived that alignment meant loss of ownership and control, identity of, and identification with, their program. They believed that the University was getting 'their program for nothing!' On reflection, University stakeholders did not comprehend their attachment to 'a program' and the fears of the loss of that identity with that program making them feel vulnerable in terms of their employment and role. University academics assumed that the hospital participants should have felt fortunate that the University was collaborating with them to confer an academic award and of the academic guidance they were providing to them. However, understanding of educational curriculum and its ramifications and merit may not have been the remit of educators within the hospital employ. This lack of synergy in goal orientation left both stakeholders feeling frustrated and resistant, indicative of multiple tensions [3].
Lack of agreement about the direction of the alignment of the program, tensions within and between groups, individuals working in silos, lack of openness, role ambiguity and unclear lines of accountability resulted. Competing goals undermined the project as the lack of focus on collective performance and shared objectives saw both stakeholder groups considering individual output and not working together. University stakeholders relied on the appointed project manager, the local champion to 'deal with' the personalities and problems within the hospital group, to ensure a shared purpose and to get the work done. This placed the local champion in a precarious role, torn between the culture of the organisation and allegiance to hospital peers and the university project for which they were employed. The local champion whilst wearing the lens of the University was cognisant of work related requirements of staff to the hospital and this relationship, from their perspective, still took precedence.

The Impact of Change
The process for Community Engagement and the Six C's Model while providing the framework for engagement is limited by the Model's lack of support in ways to manage people, communication and culture. This is particularly apparent when that process is strongly aligned to change and the fears and confusion which surround the acceptance of that change in the first instance. The model also does not fully support the potential for sustaining the change over a period of time when dealing with stakeholders who may not be committed to the changes brought about by the engagement. Here, this meant that the hospital educators were required to amend their programs and support the enrolment of students into the University award program over a sustained period of time.
To deal effectively with change, it is important to realise that every change requires psychological adaptation or a period of transition so that time for adjusting to shared interpretations of meaning and a shared vision develops [21]. This is difficult even when the change is wanted. Therefore, 'engagement champions' should anticipate stakeholders going through an ending of the old ways and an adjustment time in the beginning phase of planning to the new ways of the engagement process. This takes considerable energy and it is easy to run out of reserves, which can lead to unwise actions and frustration that may, in itself, thwart the engagement project. This is aptly described in the seminal work on psychological response to change developed by Russell-Jones in 1999 [22], explaining the movement from uniformed optimism, to informed pessimism, hopeful realism, and informed optimism. Finally the completion of a project is a healthy characteristic human reaction to the acceptance of a change plan.

Conclusion
In conclusion, the process of engagement seems functional, however, if the plan does not take into account individuals, their different representations of the situation, and the influence of the wider social, organisational and cultural context on their individual perceptions, behaviours and actions, the project is bound to stall. The denouement of this engagement story is that this paper has highlighted the need to consider culture, relationships, communication and the impact of change to develop a shared mental model to generate a shared commitment to the project at hand. Reflection on the scholarship of engagement and discussion between the parties involved aided the explication of a complex process and uncovered important features in engagement and the need for refocusing on the vision to be achieved for both.
This experience illuminated the need for a richer understanding of the people and their systems, partnership dynamics and a rethinking of the process of community engagement to promote a shared stakeholder vision and ensure engagement success where engagement is a rich platform for social learning.