Nursing colleges need to conform to higher education requirements to offer a bachelor’s degree for professional registration, as required by SANC. Phasing out the 4-year diploma and conforming to higher education requirements need time and could affect continuity in the production of professional nurses. Colleges produced most of the professional nurses in the North West Province (NWP): 259 as opposed to 91 from the universities according to SANC statistics, 2015. Researchers saw a need for collaboration between colleges and universities.

The aim of the study was to develop a model of collaboration between nursing education institutions (NEIs) in the NWP for offering a bachelor’s degree to produce professional nurses for the NWP. The goal of such a collaboration would be to provide an option for solving the problem perceived.

Complex challenges and changes in healthcare and education require interdependence of available expertise, individual contributions, participation and pooled resources to maximise output and create synergy.

Cronenwett (2004) posits that the 21st-century nursing profession faces challenges that necessitate collaboration between academic and service entities. Increasing evidence shows that there is a direct relationship between better patient outcomes and nurse staffing levels, educational levels, and professional practice environments (Cronenwett, 2004). In the face of nursing staff shortages, both academic and practice entities have vested interests in increasing the supply of new nurses as well as faculty members who educate them.

O’Neil and Krauel (2004) also acknowledge the need to address nursing workforce issues through collaborative efforts because unilateral efforts have their limitations. They distinguish between two types of partnerships, namely vertical and horizontal (Williamson 1985, in O’Neil & Krauel 2004). The vertical partnership integrates functions along the continuum of production. In nursing, one might think of the vertical processes of recruitment of students, provision of education, recruitment to work, retraining as needed and development of new skills as required.

Horizontal partnerships, in contrast, involve aggregation between similar functions within an area (Doz & Hamel 1997, in O’Neil & Krauel 2004). Traditionally limited to geographic proximity, horizontal partnerships have been more possible in the advent of information technology. An example in nursing might be where nursing faculty in comparable programmes share their teaching strategies for similar courses or develop a common curriculum. Such partnerships often allow for elimination of duplication and improve efficiency.

O’Neil and Krauel (2004) observe that many successful entities have achieved partnerships across both vertical and horizontal axes, but that it is difficult to create both simultaneously. They further suggest five key things that nurse leaders must keep in mind when considering such partnerships.

These include development of a coherent institutional strategy; screening potential partners against the strategy; assessment of core competencies, assets, and weaknesses; advancement of mutually beneficial strategies; and structuring accountability to each other (O’Neil & Krauel 2004).

Primary healthcare development is impeded by weak strategic inputs, which could be improved by intersectorial collaborations to mobilise all stakeholders for cumulative experiences and evidence (Adeleye and Ngozi 2011)

Casey (2011) focuses on the need for collaboration to avoid the risk of exacerbating the ‘theory-practice gap’ in nursing. Like many contexts, the European Union has been pushing academic and service entities in nursing to move toward a more harmonised system where theoretical and practical learning are combined to produce more competent nurses.

Another trend is to resolve challenges related to curriculum and training issues. In some contexts educators are expected to train professionals for quality patient-centred care, effective team membership and moving the leadership and research agendas according to Herrin et al. (2006).

The SANC (2011) issued a circular for new qualifications, including a bachelor’s degree for registration as a professional nurse. The last intake for the 4-year diploma was extended to June 2015, and later 2018. While the 4-year diploma is being phased out, there is a need for the colleges to prepare for changes, and other NEIs to assist by closing possible gaps over the phasing out period and beyond. A closer cooperation of the NEIs could, through collaboration, continue adequate production of nursing professionals.

Objectives were to explore and describe perceptions of nurse educators and stakeholders about a collaboration between the college and the university in the NWP; identify and describe factors that would facilitate an effective collaboration between the NEIs in the province; and develop a collaborative model for training nurses according to new SANC qualifications.

Collaboration is work done jointly with others, especially in an intellectual endeavour (Freshwater & Maslin-Prothero 2005). In this study, collaboration refers to a joint endeavour for nurse education and training between the multi-campus nursing college, North West University (NWU) nursing departments, and other nurse training stakeholders in the NWP.

The Higher Education Act defines a college as any college established or declared as a college under the Act. In this study, college refers to the multi-campus nursing college in the NWP of South Africa.

Nurse educators are professional nurses who are qualified in teaching, and/or work in NEI of the NWP.

Nurse training stakeholders are officers managing nurse education matters in the Department of Health, the North West Province Department of Health (NWPDoH), the college, university and the clinical learning areas.

University refers to the North West University in the NWP of South Africa.

This study contributes a model of collaboration between NEIs in the NWP based on the perceptions of nurse educators and other stakeholders and the relevant legal framework in South Africa. Literature assists in coping with and solving challenges because of change, such as conforming to higher education requirements. O’Neil and Krauel (2004) address workforce issues, and Herrin et al. (2006) address curriculum and training issues, as examples. Input from stakeholders and nurse educators contributes suggestions assisting policy-makers with appropriate decisions for a positive impact on all role players in the province and beyond.

Literature has shown that partnerships between academic institutions, healthcare organisations and governments help deal with varied challenges such as clinical learning, professional development, and policy changes in other countries (Hall 2009).

The purpose of the collaboration in this context was to facilitate working together of the NEIs, and other stakeholders to maximise the use of resources and skills for the production of professional nurses in the province. An effective collaboration between the nursing college and the university could facilitate maximisation of quality and quantity in nursing education for the province.

There are three case examples presented by the authors to challenge nurse leaders to be bold and think ‘out-of-the-box’ to work toward the full potential of nursing service to the public, instead of limiting themselves to ‘traditional’ forms of partnership (Bleich et al. 2004).

The first example was derived from a study by the Institute of Medicine (IOM 2003) in the United States. The report identified a number of important stakeholders in public health, including the community, healthcare delivery systems, employers and business, the media, academia and governmental/public health infrastructure. Given this analogy, authors challenged nurse leaders in academia to engage the entire continuum of stakeholders, not just hospitals or those that fell under the healthcare delivery system (Bleich et al. 2004).

In the second example, members of the University of Mississippi School of Nursing (USA) and the Sisters of Mercy-Vicksburg (USA) collaborated to plan and implement innovative initiatives to improve the health of rural citizens (Bleich et al. 2004).

In the third example, the University of Kansas School of Nursing (USA) faculty collaborated with the Cerner Corporation of Kansas City in order to advance clinical informatics in nursing education for baccalaureate and high-degree students. Together, they developed an information technology product that utilised relevant current clinical content (Bleich et al. 2004:285–294).

Collaborations between colleges and universities can be used for resolving training- and curriculum-related issues in nursing. In many contexts, nursing educators are challenged to train professionals who are not only competent in skills for quality patient-centred care but are also able to function effectively within a team and move the nursing research and leadership agenda forward. In a departure from diploma-based training, hospitals are progressively seeking to increase their nursing staff skills mix to include more bachelor’s-trained nurses. Collaborative partnerships were formed to address training-related challenges.

Casey (2011) presents a variety of definitions for ‘partnership’ and ‘collaboration’ and points out that successful partnerships are non-hierarchical and partners share decision-making roles and have joint ownership of the resolutions of challenges. Further, the relationship involves commitment to improvement of efficiency. A framework for partnership developed from consultation with five nursing and midwifery education organisations in Ireland is presented in Figure 1.

Seven key concepts were identified as cornerstones of this partnership framework: context, environment, inputs, processes, skills, outcomes, and the role of a coordinator. The author argued that the role of a coordinator and partnership framework are crucial to the maintenance of collaborative relationships that bridge the theory/practice gap (Casey 2011:304–308).

In the United States, eight states have established mandated articulation agreements – which assure diploma graduates admission into a Bachelor of Science in Nursing (BSN) programme, establish the number of transfer credits to be accepted, and ensure consistency through the academic system. Twenty-four states have state-wide articulation agreements, where nurse educators/regulators/legislators have voluntarily established models of academic mobility for registered nurses (RNs) wishing to gain BSN training (Spencer 2008).

Collaboration is an important aspect of academic–clinical learning. Problem-based learning is the most innovative strategy to enhance problem-solving and prepares clinicians to cope in rapidly changing environments such as healthcare (Rakhudu, Davhana-Maselesele & Useh 2016)

In the Western Cape Province of South Africa, national policy imperatives prompted the need for consolidation, mergers, and a new way of approaching nursing education (Daniels 2010:42–48). This national imperative meant that institutions needed to collaborate to join the efforts of global and national transformation in education.

In addition, there was a need to increase operational efficiency and effectiveness so routine administrative and service functions were merged to pool resources and lower the costs. A project team consisting of representatives from all participating institutions developed a proposal for the development of a common teaching platform that encompassed an integrated planning framework and a Memorandum of Understanding (MOU).

Poor competencies among nurses in Malawi indicate a gap in theory and clinical practice. Varied academic–clinical partnerships improve competences and the healthcare system (Mvumbwe 2016).

The interdependence, contributions, participation and sharing of resources can be facilitated in a healthy collaboration with honest communication, mutual trust and respect, and common goals (D’Amour et al. 2005). The Social Exchange Theory was used by Gitlin, Lyons and Kolodner (1994) in a five-stage model to analyse collaboration. Basic assumptions of the Social Exchange Theory are ‘exchange’ and ‘negotiation’, and that social structures can be understood through an analysis of interpersonal transactions (D’Amour et al. 2005).

Theoretical assumptions of the Social Exchange Theory are that people will join a group or organisation that provides specific benefits or needs, and where they will, in turn, help to attain group or organisational objectives. Along with the exchange comes negotiation which continues to optimise benefits, reduce costs and move forward under conditions that will be fair to all stakeholders. Gitlin et al. (1994) expanded the Social Exchange Theory into a four-parameter model to include the following: exchange, negotiation, building an environment of trust, and role differentiation.

Collaboration between the college and university in the NWP could assist in improving quality and quantity in producing professional nurses, maximising the use of varied human and other resources and facilitating development in nursing education.

The convergence variant in triangulation design of mixed methods research was used. The purpose of the design was to combine different, but complementary data with the same purpose to understand the perceptions about collaboration, and to bring together the overlapping strengths and weaknesses of the quantitative and qualitative methods to obtain data. In the Convergence Model of Triangulation (Figure 2), qualitative and quantitative data have equal weighting, are collected and analysed concurrently, and results from both are compared, contrasted and merged for interpretation (Creswell & Plano-Clark 2011).

The study was conducted in the nursing college and university campuses, and health service facilities of the NWP used by the NEIs for student placement.

An all-inclusive population of 120 nurse educators who had been teaching for at least 1 year, and 15 purposely sampled stakeholders, who were leading officers in varied clinical facilities and North West provincial offices (Figure 3). A total of 68 questionnaires were received from nurse educators (57% compliance) and 15 stakeholders (100% compliance).

Collection of data was concurrently done by the researcher. Semi-structured in-depth interviews were conducted at agreed appointments and venues with stakeholders to collect qualitative data, and quantitative data were collected using a questionnaire with a four-point Likert scale (four options indicating the extent of agreement or disagreement with a given statement). Questionnaires were sent to educators electronically and followed up with manual copies. The questionnaire and interview guide were based on the concepts of exchange, negotiation, role differentiation and building an environment of trust, from the Social Exchange Theory.

Benefits of the involvement in this study were opinion contributions for a possible solution to the challenge of policy changes for the benefit of the profession and the society. There were no hazards involved.

Participants were recruited by telephone and e-mail to offer their opinions freely, for the benefit of the profession and the society. They were entitled to withdraw at any stage if they chose to.

Informed consent was provided in the form of an information sheet that participants could read and sign to indicate their consent to participate in interviews, and on a separate page of the questionnaire.

Data were protected by keeping it under lock-and-key where no one except the researcher could have access.

Ethical approval and permission to conduct the study were obtained from the North West University (NWU-00070-12-AD) and the North West Province Department of Health. Permission (8/8/2013) to collect data was sought from campuses and clinical facilities involved. Informed consent was also sought from individuals interviewed and participants who responded to the questionnaires. Anonymity was upheld in both quantitative and qualitative data collection and safekeeping of data observed by the researcher. The protection of human rights was observed. Participants were not obliged to share what they chose to withhold. Interviews were conducted in privacy, and data were handled confidentially by the researcher. Interview transcripts were only identified by codes.

Trustworthiness also refers to the degree to which the results of the research are truthful, authentic, accurate and credible. Measures to ensure trustworthiness are applied as shown according to the strategies in Table 1.

The measuring instrument was found to be reliable, according to Cronbach’s alpha = 0.814 – which is a strong reliability. Sub-scale reliability is summarised in Table 2.

Themes and categories were used to analyse qualitative data. The number of occurrences of the codes or themes could be counted and entered in a spreadsheet to facilitate mixing with the quantitative data. SPSS version 21 software was used to obtain means and standard deviations to analyse and describe quantitative data from the questionnaire. Analysis of variance (ANOVA) was used to compare groups of educators from different NEIs or campuses. Frequency tables, pie charts and bar charts were used to summarise the demographics and responses. The two sets of data were converged for comparison, contrasting and interpretation through discussion (Creswell & Plano-Clark 2007).

Factors and perceptions that may influence collaboration between NEIs in the NWP.

This was acquired by a 4-point Likert-type questionnaire comprising a collaboration exchange construct, negotiation construct, role differentiation construct and trust environment construct. All responses were captured on SPSS V21 and to compare groups, t-test, ANOVA and Chi-square were used for cross-tabulations. Perceptions and collaboration facilitating factors for each construct of the Social Exchange Theory were indicated by percentages. Agreement levels of more than 50% can be accepted as positive responses, but if more than 50% strongly agree, the item concerned can be accepted as one that could facilitate collaboration, and one with disagreement at more than 50% could also be accepted as enhancing decision-making for the item concerned. Factors enhancing decisions for the collaboration are readily identified when they are strongly agreed or strongly disagreed with by more than 50%.

The following themes were identified:

Clarification of collaboration goals including implementation of SANC qualifications and improvement of stakeholder relationships:

Establishment of a conducive environment including mutual trust, sound negotiation, political will and stakeholder commitment:

Maximising exchange of human and material resources:

Role clarification concerning responsibility and accountability:

Perceived challenges such as fear, uncertainty and organisational culture:

The quantitative results were stated and followed up by statements from the qualitative results to compare and contrast findings. The high levels of agreement (100% to 53.97%) in all basic concepts of the Social Exchange Theory, were supported or confirmed by categories and subcategories of the themes developed in the qualitative results, which add to the validity of the results. Significant disagreements were clarified by comments from the respondents in the quantitative sample and also compared with statements from participants in the qualitative results. There is more agreement than disagreement in the comparison of results about the perceptions of stakeholders regarding collaboration between NEIs in the province.

A model of collaboration (Figure 5) was developed using a five-stage process according to D’Amour et al. (2005). Quantitative and qualitative findings of the study were applied in the process. According to D’Amour et al. (2005), the five-stage process includes assessment and goal setting, identification of resources and expertise to share, determination of a collaboration fit for the situation, refinement of how the collaboration could be implemented and feedback to evaluate progress. The framework for model development can be viewed as a situation-producing theory, with a specified aim or goal, prescribed activities to attain the goal and a survey list guided by aspects of activity for the theory (Dickoff, James & Wiedenbach 1968). The survey list was related to aspects of activity in the model framework within a table (Table 3).

Figure 5 is a schematic representation of the model of collaboration between NEIs of the NWP, including the agents, who should guide the collaboration, the beneficiaries of the process that could be followed to achieve the collaboration, factors that could help to drive the process, the context necessary to support it and outcomes that should be expected from the collaboration.

The responsibility of leading the process of developing collaboration between the NEI in the NWP can be given to leaders of the NWU, the NWPDoH and the NW college of nursing. These authorities participate in the current affiliation agreement between the university and the nursing college. The leaders of the institutions understand the needs of each stakeholder and how they could support each other.

The NWPDoH administers public health facilities used by the NEIs for student placement, and also administers and funds the college. The three structures are relevant to lead the development of a closer collaboration between them, as equal partners to achieve more than what they do currently. The agents are indicated in a circular diagram within the model to show equality.

The stakeholders in the NWU, the NWPDoH and the North West college will need to maintain the process of collaboration in spite of challenges that might occur. According to the participants, commitment is essential from all stakeholders. There is a need for trust, respect and openness to continue sound negotiations during the process of collaboration. Political will from the government leaders will encourage progress and determination to achieve expected outcomes. In Figure 5 the above factors are shown as arrows impacting on the agents.

A five-stage process described by D’Amour et al. (2005) was utilised to develop collaboration, which will take time and daily efforts. The stages of the process are within the circle of the agents indicating engagement of the agents in the procedure from assessment and goal setting to evaluation and feedback. A cyclical repetition of the stages can be done during the process to advance the collaboration.

The development of the model of collaboration must occur within the context of legal, political and professional Acts and policies. In the schematic diagram of the model (Figure 5), the context is represented as a framework with all the relevant Acts and policies enclosing the agents, procedure, dynamics and collaboration outcomes which must be according to the context.

Beneficiaries of the collaboration will be students of the NEIs, and health consumers using the public facilities of the NWP for healthcare. In the model (Figure 5) they were placed in a framework within the context and surrounding the agents, process, dynamics and outcomes of the collaboration. Students should benefit from the efforts of all the stakeholders, and their success should benefit communities.

Expected results of the collaboration are well-trained professional nurses, and sustained production of nurses for the NWP. The outcome is represented by a green ribbon above the agents, process and dynamics within the model. All aspects of the survey list as stated by Dickoff et al. (1968) were combined to form a schematic diagram of the collaboration between NEI in the NWP.

The framework for a model of collaboration between the NEI in the NWP is a contribution to the use of the Social Exchange Theory in guiding or evaluating a collaboration process within a specific context, and provides an alternative decision to address the challenge of changed policies and common goals. The demographic information and perceptions explored can contribute to planning by stakeholders within the institutions of the NWP.

The study was conducted only in the context of the NWP and may require adjustments for other provinces if replicated, because of differences in context. However, important lessons can still be learned from the study.

There is a need to improve scholarship among nurse educators and clinical mentors, and to share rare skills. It is necessary to address perceived challenges ahead of policy changes.

Educators and facility managers should work jointly to improve the integration of theory and practice, and use opportunities for joint research to benefit practice and education.

Formal and informal interprofessional briefings, forums and meetings would benefit various parties. NEIs should be aware of clinical expertise needs of the facilities in order to align their plans to meet the needs.