Development of collaboration guidelines for nursing education and related healthcare services

Background A theory-practice gap in nursing education often occurs, and the staff from the nursing education institution and the associated healthcare services should find ways to improve their collaboration to reduce the gap during the training of nursing students. Aim This study aimed to develop context-specific collaboration guidelines for a nursing education institution and associated healthcare services. Setting Private hospital in the Gauteng province of South Africa. Methods Guidelines were developed from the findings of an integrative literature review. Thereafter, it was contextualised in a qualitative study with focus group discussions (FGDs) involving 9 theoretical lecturers and 10 clinical facilitators. Results In the partnership between the nursing education institution and the associated healthcare services, bilateral communication, cooperation between the theoretical lecturers and the clinical facilitators in delivering evidence-based patient care, intensified innovation in teaching and learning practices and an environment conducive to theory-practice integration should be emphasised. Conclusion A set of context-specific guidelines was developed to enable the theoretical lecturers and the clinical facilitators to collaborate in supporting nursing students to apply their theoretical knowledge in the development of clinical competencies. Contribution The guidelines can be adjusted to suit the context of other nursing education institutions and their associated healthcare services to improve collaboration between theoretical lecturers and clinical facilitators to the benefit students’ skills development in theory-practice integration.


Introduction
Nursing students often face confusion when there is a mismatch between theoretical knowledge and its application in real clinical settings (Factor, Matienzo & De Guzman 2017:84;Kerthu & Nuuyoma 2019:24).The practical experience in healthcare services often differs from the idealised scenarios presented in theory classes.While simulation laboratories are well-equipped with the necessary resources, the associated healthcare services often lack such resources (Mina, Reza & Dimitrios 2019:403).As a result, students frequently struggle to implement what they have learned in theory into rendering care to patients (Greenway, Butt & Walthall 2019:5).Poor collaboration between theoretical lecturers and clinical facilitators contributes to the challenges that students experience to integrate theory in practice (Günay & Kılınç 2018:84).It is crucial for theoretical lecturers and clinical facilitators to collaborate effectively to support students in bridging theory-practice gap.
This study aimed to develop context-specific collaboration guidelines for the theoretical lecturers of a designated nursing education institution and the clinical facilitators of its associated healthcare services.To gain data for the development of the guidelines, a comprehensive literature review on collaboration between theoretical lecturers and clinical facilitators to improve theory-practice integration was conducted.The guidelines were then contextualised with the input of theoretical lecturer and clinical facilitator participants.
Background: A theory-practice gap in nursing education often occurs, and the staff from the nursing education institution and the associated healthcare services should find ways to improve their collaboration to reduce the gap during the training of nursing students.

Research methods and design
The research was done in two phases.In the first phase, the researcher conducted a literature review using five databases: PubMed, Science Direct, Medline and EBCHOST, CINAHL and Scopus, to collect evidence on good collaboration practices between nursing education institutions and healthcare services, particularly between theoretical lecturers and clinical facilitators, to enhance theory-practice integration during clinical training.The search led to the selection of 2939 articles, which were then screened.After removing duplicates and excluding articles that were not related to collaboration in nursing education, 47 full-text articles were reviewed.Finally, 17 articles met the inclusion criteria of being published in English, having full-text availability, and being peer-reviewed publications.These articles were published between January 2016 and January 2021 (refer to Figure 1).
The first author conducted a thematic analysis of the findings.It involved a familiarisation with the content and searching for themes.She also drafted collaboration guidelines from each article (refer to Table 1).The summarised articles and themes formed the basis for the draft guidelines.
In phase two of the study, a descriptive qualitative study through focus group discussions (FGDs) was done to contextualise the drafted collaboration guidelines to fit the unique circumstances of the designated nursing education institution and associated healthcare services.

Setting
The study was conducted at one nursing education institution and its associated healthcare services in the Gauteng province in South Africa.The nursing education institution is accredited with the South African Nursing Council (SANC) for the Diploma in Nursing Science (R171 of 2013) leading to registration with the SANC as general nurses.

Study population and sampling
The study population consisted of 10 theoretical lecturers who were responsible for theoretical teaching and 10 clinical facilitators for clinical training.Participants were purposively selected and invited to FGDs.Nine theoretical lecturers and 10 clinical facilitators participated in four focus groups discussing the contextualisation of the collaboration guidelines.Refer to Table 2 for the participants' demographic information.

Data collection
Draft guidelines were contextualised through four FGDs at a suitable venue at the nursing education institution.The discussions were audio-recorded with the participants' permission.The first author facilitated the discussions, and participants provided input by discussing each guideline, deleting irrelevant ones, and adapting others to their specific collaboration needs.Four FGDs were necessary before the participants agreed upon the set of contextualised guidelines.The first author made field notes of the participants' interaction that was not audio-recorded.

Data analysis
The audio-records of the FGDs were transcribed and together with the field notes were read several times by the first author to familiarise herself with the content.Themes were identified and coded, grouped into sub-categories and categories.The categories and sub-categories informed the contextualisation of the collaboration guidelines between the nursing education institution and healthcare services.

Trustworthiness of the findings
The researcher involved theoretical lecturer and clinical facilitator participants in contextualising the draft guidelines.Their expertise and experiences were valuable to adjust the guidelines to suit the unique circumstances of the designated nursing education institution and associated healthcare services.

Ethical considerations
A study information leaflet explaining the aims and research process, with draft guidelines, was provided to the https://www.hsag.co.zaOpen Access

Results
The participants through their input during FGDs contextualised the collaboration guidelines.Their discussion to contextualise the draft guidelines is reflected in categories and sub-categories (see Table 3).

Maintain a healthcare service and nursing education institution partnership
Shared values and goals enhance collaboration for improved teamwork: 'Teamwork should include academic staff and hospital management staff.They should know what values and ethics we strive for so that there is better integration between hospital management staff and us.' (TLP4, M Cur, PhD, 40 years) Relationships between facilitators and lecturers foster shared responsibility, commitment and connectivity in the partnership, vital for team development and expanding teamwork:

Maintain bilateral communication
Implementing an organised, goal-driven communication plan is crucial for facilitating regular sharing of relevant information among clinical facilitators and theoretical lecturers.This ensures effective collaboration and supports the integration of theory and practice: 'Clarity of expectations of communication is required from both clinical and theory.' (CFP2, Diploma in Nursing Education, Management, 25 years)

Maintain cooperation between theoretical lecturers and clinical facilitators in evidencebased practice
Collaborative leadership and teamwork between clinical facilitators and theoretical lecturers are essential for implementing evidence-based practice, enhancing academic staff skills, and facilitating the transfer of knowledge between hospitals and nursing education institutions.This joint effort addresses the theory-practice gap, promotes the development of evidence-based practice, and fosters a culture conducive to learning: 'Collaboration and shared leadership that clinical facilitators and lecturers should identify the need in the clinical field for an assignment and clinical project in the research, to fill the gap.' (TLP2, B Cur and BA of Social Science, 14 years) Sharing evidence-based practice processes and knowledge generated in hospitals may motivate staff and students to improve their clinical practice and advance their knowledge.
Utilising evidence-based practice may enhance the students' learning environment and improve theory-practice integration: 'Manage a positive working environment by strengthening the lecturers and clinical facilitator's skills in teaching and learning through sharing of evidence-based practices.'(TLP8, M CUR, 33 years)

Intensify innovation in teaching, learning and assessment processes
The implementation of an operational plan by the nursing education institution management may be instrumental in supporting the integration and alignment of theory and practice.Such a plan may effectively structure the collaboration between clinical facilitators and theoretical lecturers: 'Operational plan has a structured clinical for learning programme for the day.' (CFP6, B Cur, 17 years) 'Academic staff is responsible for planning, implementation and execution of operational programme.'(TLP 7, M CUR, 34 years) Innovative and creative teaching and learning methods that prioritise student-centred methods are crucial for accommodating diverse types of nursing students in both classroom and hospital settings.Clinical facilitators and theoretical lecturers should therefore use innovative methods to foster critical thinking, clinical judgement, and reflective thinking, effectively addressing the unique learning needs of the students: 'We need to find ways to improve our teaching, like, seminars, journal clubs on teaching to develop us or enhance our skill in teaching.'(TLP5, B Cur, 11 years) 'We need to be equipped for the types of students with different learning styles, we need to be able to accommodate them in the teaching and learning environment.'(CFP10, B Cur, 21 years) Active participation is a core value for team success and achieving desired outcomes.To ensure competent nursing students, clinical facilitators must actively engage in the design of clinical assessments: 'We need to be involved or participate in designing and evaluating.It's about participation.' (TLP4, M Cur, PhD, 40 years)

Build an environment conducive to theorypractice integration
Mentorship programmes play a vital role in fostering a sense of belonging within a group, which in turn supports theorypractice integration.It is crucial for clinical facilitators and theoretical lecturers, to possess mentorship skills.Therefore, providing mentorship training is essential to ensure adequate support for new staff and foster the development of relationships that enhance collaboration: The participants agreed that theoretical lecturers and clinical facilitators need to be experts in theory-practice integration, to support students with theory-practice integration: 'Clinical facilitators and lecturers need to become specialists in a discipline for teaching and skill.' (TLP4, M Cur, PhD, 40 years)

Discussion
Effective collaboration between nursing education institutions and healthcare services' management is crucial.Each partner should have defined responsibilities, with coordination overseen by designated persons.A structure is needed to facilitate the creation, translation and application of knowledge, benefiting student learning and patient care (Gilliss et al. 2021:4,5).The appointment of clinical coordinators can enhance cooperation between theoretical lecturers and clinical facilitators, supporting students' skills development (Munangatire & McInerney 2022:2).
A shift is necessary for theoretical lecturers and facilitators to transition from individual ownership of students' teaching to a partnership model of student support (Huston et al. 2018:32).Partnerships foster commitment, clarify roles and responsibilities, and facilitate the integration of theory and practice in the hospital setting.By improving the understanding of roles and responsibilities, coordination between clinical facilitators and theoretical lecturers can be enhanced, leading to better team outcomes and theory-practice integration (Munangatire & MCinerney 2022:2).Clinical facilitators play a crucial role in theory-practice integration when they apply theoretical knowledge during clinical training of students.
Sharing theoretical class content with clinical facilitators promotes cooperative teaching in the hospital, facilitating theory-practice integration (Ryan & McAllister 2020:2).Open, trustful and supportive communication is imperative for improving cooperation (Bvumbwe 2016:320).When clinical facilitators and theoretical lecturers engage in collaborative thinking and reasoning, their collective output enhances students' learning and skills development (Askari et al. 2020:2).
Evidence-based practices play a vital role in addressing patient care challenges, generating new knowledge, and improving the learning environment for students (Ramis et al. 2019:11).The implementation of evidence-based practice also encourages the professional growth of theoretical lecturers and clinical facilitators by enhancing their clinical skills.Integrating evidence-based practice into routine patient care should be a key focus of the partnership between nursing education institutions and healthcare services.This integration aims to enhance patient outcomes and improve the quality of care provided (Kleinpell et al. 2016:706).
An operational plan is crucial in facilitating the teaching and learning process both at the nursing education institution and in hospitals, aiming to align theory teaching with practical training.Such plans promote the acquisition of clinical skills while integrating theory, minimising the theory-practice gap and fostering students' professional development (Ngozika Ugwu et al. 2023:11).Strategic clinical planning activities are essential for supporting the operational plan and ensuring effective theory-practice integration for students (Hoda Ahmari et al. 2021:265).
Innovative assessment strategies should be created by theoretical lecturers and clinical facilitators (Van Wyngaarden, Leech & Coetzee 2019:4).Joint assessment practices between them can standardise expectations and promote understanding.Collaborative decision-making in assessment can prevent inconsistencies (Dev et al. 2020(Dev et al. :1135)).
Mentorship is essential for enhancing teaching practices, skills and collaboration within the academic team (Glover et al. 2021:272).It provides support for clinical facilitators and theoretical lecturers as they transition into their roles as educators, fostering excellence (Huston et al. 2018:32).
Theoretical lecturers and clinical facilitators should focus on improving their teaching and learning skills to enhance the learning environment.Sharing innovative student-centred strategies and skills such as student feedback, mentoring, engaging in research activities and embracing management diversity is essential for fostering teamwork and positive relationships (Mallek & El-Hosany 2020:379).These actions contribute to an enhanced teaching and learning experience.

Context-specific guidelines to improve collaboration and narrow the theory-practice gap in nursing education
The guidelines are the outcome of a thorough literature review to obtain published research evidence, the identification of draft guidelines from the evidence, and a contextualisation with the input of theoretical lecturers and clinical facilitators who may benefit from its implementation.The categories and subcategories as the product of the analysis of the data of the FGDs feature in the final set of collaboration guidelines.Refer to Figure 2 for description of the contextualised guidelines.

Strengths and limitations
Although the study was conducted at one nursing education institution and its associated healthcare services only, the authors described the process of the development and contextualisation of the guidelines thoroughly to enable researchers to repeat the research to benefit other nursing education institutions and associated healthcare services.

Implications for nursing education institutions and healthcare services
The guidelines can be adjusted to suit the specific context of the nursing education institution and the associated healthcare services, and can be used to improve collaboration between theoretical lecturers and clinical facilitators to benefit students' endeavours to integrate theory and practice.Effective collaboration and relationships between clinical facilitators and theoretical lecturers can narrow the gap that often exists between nursing education institutions and healthcare services to advance optimal support of theory-practice integration.

Conclusion
The challenges faced in applying nursing theory to clinical practice necessitate evidence-based interventions derived from the research literature.In this study, the researcher, with the guidance of supervisors, conducted a literature review to gather evidence.Based on this review, guidelines were formulated and contextualised through FGDs involving clinical facilitators and theoretical lecturers.The implementation of these guidelines has the potential to support nursing students in effectively applying nursing theory in practice.

Contextualised guidelines
Guideline 1: Manage a healthcare service and nursing education institution partnership: Strengthen the partnership through capacity building of theoretical lecturers and clinical facilitators using mentoring, and knowledge and skills improvement programmes; Co-development, review and implement an integrated unit for clinical teaching with a shared educational philosophy aimed at theory-practice integration in clinical training to benefit patient healthcare and student learning outcome; Co-create structures and encourage processes to enable fusion and sharing of responsibilities and roles of theoretical lecturers and clinical facilitators in teaching for and facilitating theory-practice integration; Co-design and manage innovative ways to share resources to benefit both institutions' staff empowerment and the development of the clinical learning environment; and Build a trusting relationship between theoretical lecturers and clinical facilitators of mutual commitment to the quality clinical training of nursing students.
Guideline 2: Maintain communication between the healthcare service and the nursing education institution: Manage structured meetings between representatives from both partners on pre-determined dates set by the beginning of the academic year to: Plan how to link theory that is covered during lectures on the nursing campus to objectives for theory-practice integration in the healthcare service; Allocate resources to theory-practice integration during clinical training; Monitor students' progress in theoretical tests, clinical assignments and the development of skills in theory-practice integration; and Annually evaluate the success of the teaching and learning processes used to further theory-practice integration to: Gain compliance from theoretical lecturers and clinical facilitators to implementing clinical training according to plan; Monitor and record the implementation of theory-practice integration in the clinical training plan; Appropriately address problems encountered with the implementation of theory-practice integration; Manage ad hoc meetings between theoretical lecturers and clinical facilitators to facilitate interpersonal challenges and prevent or manage conflict; and Manage structured and ad hoc meetings with students to discuss their progress andͭor challenges with theory-practice integration.Co-explore and share innovative teaching and learning approaches to enhance theory-practice integration; Co-create and collaboratively use simulated clinical learning opportunities for teaching and learning and assessment of student's knowledge and skills; and Share responsibilities regarding the development and use of assessment instruments.
Guideline 5: Building an environment conducive to theory-practice integration.
Co-design and use continuous professional development programmes; Optimally use memberships of professional organisations to update knowledge and skills in clinical teaching and supervision; Instil and support mentorship programmes for newly appointed theoretical lecturers and clinical facilitators to develop skills in facilitating theory-practice integration; and Appreciate and use the clinical and nursing education expertise of theoretical lecturers and clinical facilitators to improve the knowledge and skills of the team.

Guideline 3 :
Clinical facilitators and theoretical lecturers involve students in research for and implementation of evidence-based practice: Strengthen the co-responsibility of theoretical lecturers and clinical facilitators in teaching and facilitation of student learning in the planning and execution of research to create and use knowledge to solve clinical problems; Encourage shared leadership of theoretical lecturers and clinical facilitators in the implementation of evidence-based care to help students to understand the need for research to maintain quality patient care; Co-create a clinical teaching and learning environment conducive to the use of theory in practice (evidence-based care) and the identification of practice problems that necessitate research to create evidence (practice-based research); and Knowledge sharing between theoretical lecturers and clinical facilitators to maintain quality clinical training of students.Guideline 4: Theoretical lecturers and clinical facilitators co-design and collaboratively implement a structured operational nursing education plan to facilitate students' development for theory-practice integration required for evidence-based practice: Create and use opportunities for theoretical lecturers to become familiar with the clinical training of nursing students; Create and use opportunities for clinical facilitators to become familiar with the theoretical education of nursing students; Co-explore and collaboratively use clinical learning opportunities that fit the theoretical lectures to enhance theory-practice integration; Acknowledge the contribution of theoretical lecturers in clinical training and the contribution of clinical facilitators in theory lectures;

TABLE 1 :
Summary of the articles.

TABLE 1 (Continues…): Summary of the articles. References Study aim Design, methods, setting, participants Key findings of the study Guidelines drafted from the publication
Create a direct communication structure between academic lecturers and clinical facilitators to communicate student objectives, and feedback on identified learning needs and concerns.Implement an orientation programme for newly appointed clinical facilitators regarding the learning programme or curriculum, practice guidelines of the hospital, and required level of competence during clinical assessment.Joined clinical assessments between clinical facilitators and lecturers, to ensure the quality of assessments and consistence in teaching and learning.Employ alumni staff from nursing intuition to support students in a clinical setting as preceptors.Promote student placement in different care settings for comprehensive understanding and application of nursing knowledge and skills (e.g., Geriatrics, long-term care facilities, weekend support in community clinics, convenience care clinics).Intensify clinical training with a focus on speciality training and assessment in specialise areas (e.g., medication administration and handling, infection control, mother and baby wellness, theatre safety).Plan and collaborate with other health professionals to integrate curriculums to expand students' learning experiences, promote teamwork and communication, and understand each role and responsibility.Build clinical training capacity within services to improve stakeholder relationships through preceptor development, simplify the student evaluation process and assurance of student readiness for practice.
Dev, M.D.B., Rusli, K.D.B., McKenna, L., Lau, S.T. & Liaw, S.Y., 2020, 'Academic-practice collaboration in clinical education: A qualitative study of academic educator and clinical preceptor views', Nursing and Health Sciences 22(4), 1131-1138.Efficient communication between preceptors, clinical instructors and academic educators is important for collaboration.All stakeholders need to be involved in the development of learning objectives and structured learning and practice guidelines to support students.Preceptors and academic educators need to be familiar with each other's responsibilities.Drayton-Brooks, S.M., Gray, P.A., Turner, N.P. & Newland, J.A., 2017, 'Building clinical education training capacity in nurse practitioner programmes', Journal of Professional Nursing 33(6), 422-428.Inter-professional collaboration of lecturers and the involvement of students from different year groups may contribute to quality clinical training.Shared goals regarding teamwork, communication and values may contribute to efficient inter-professional collaboration.Maximising academic faculty practice partnerships to provide students with well-coordinated clinical experiences in evidence-based practice.Use electronic portal resources for communication.Hussein, M.T.E.L. & Osuji, J., 2017, 'Bridging the theory-practice dichotomy in nursing: The role of nurse educators', Journal of Nursing Education and Practice Table 1 continues on next page → https://www.hsag.co.zaOpen Access

methods, setting, participants Key findings of the study Guidelines drafted from the publication
Involve lecturers and clinical facilitators in research projects to address problems in the clinical setting and to implement evidence-based practice.It might lead to an improved student learning environment, quality care of patients and research culture in hospitals.Promote working relationships between lecturers and clinical facilitators.Clinical facilitators and lecturers are co-responsible for the improvement of practice and the integration of theoretical knowledge in hospital settings.

TABLE 2 :
Participants' demographic data and qualifications status.

methods, setting, participants Key findings of the study Guidelines drafted from the publication
'Relationship is the most important thing we are having.'(CFP4, B Cur Honours PHC, 20 years) Clinical facilitators require knowledge of the theory content taught to support and align theory-practice integration in hospitals, bridging the gap between theory taught in class rooms, and its application in the hospital environment: 'Clinical facilitators should know the textbook content; should know the theoretical questions to facilitate better at hospital.' (TLP6, D Litt et Phil, 43 years) 'Clinical facilitators should know the theoretical content to improve theory-practice integration.'(CFP6, B Cur, 17 years)

TABLE 3 :
Categories and sub-categories.