In the following section, we will present three cases that illustrate important aspects in the work of academic chairs.
Case of the academy-clinic collaboration
Outpatient nursing practice for patients with advanced lung diseases and their families—a long-term project
Identification of need for action
Unmet needs of people with advanced lung diseases and their families for comprehensive nursing care had become prominent in the national and international literature. The most important issue was to address the chronic nature of lung diseases and to work in a targeted way to prevent exacerbations Bringing
different perspectives together
At the time the main form of nursing at the LSH was acute care of hospitalized patients. The most viable structure of a new service was that of an outpatient care. The academic chair for chronically ill adults approached two head nurses and worked with them on a proposal for the service. The document was presented to administrators, followed by the hiring of one nurse in the year 2005. Since the beginnings of the outpatient clinic/care, a close collaboration between the academic chair and the nurse, a clinical nurse specialist was realized, with the purpose of advancing nursing practice through research. They constructed a framework for the practice—partnership with patients with chronic obstructive pulmonary disease and their families—based on research of the patient group, research made by the academic chair and not the least the clinical nurse specialist’s extensive clinical experience of taking care of lung patients at the LSH. The structure of the outpatient care was set for patient visits to the hospital clinic, telephone communication, and home visits. Soon extensive home visits were added as well as consultations on hospital wards
Keeping things running
With the large patient load, the clinical nurse specialist has been joined by an increasing number of nurses. At present time they are five. Meetings by the nurses and the academic chair have become a part of the routine of the practice.
Stories from the practice that the nurses elicit between themselves to consult each other on best practices have served as triggers to solve individual and family problems and to improve the practice. Simultaneously the stories were essential for creating meaningful research questions. There have mainly been two lines of research that, respectively, aimed to (1) increase knowledge of experiences and characteristics of patients with advanced lung diseases, who have particularly complex and taxing health- care needs and (2) create and test useful and innovative components to enhance nursing practice. Demonstrating the effectiveness of the nursing practice as demonstrated through research has been essential for the practice itself but equally important to convince administrators of the value of the nursing practice.
Disseminating research on national and international conferences has become some of the highlights of the collaboration.
Educating nursing students—undergraduate and graduate—is interwoven into the practice.
Intra- and interprofessional partnership within the hospital and between health and welfare institutions has become essential in the practice.
Key findings:
↑ Health-related quality of life
↓ Hospital admissions and length of hospital stay
↑ Body mass index
Feelings of being safe and secure Security, stability, self-direction Unified family efforts—transformation
Finding coherence in life with symptoms and treatment regimens Living life fully and taking things as they come [28–30]
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Case of the academy-clinic collaboration
Outpatient nursing practice for patients with advanced lung diseases and their families—a long-term project
Future The nursing practice has been running since the year 2005 with growing intensity and scope. Staff development, particularly graduate education of nurses in respiratory care, including creating research projects of interest to young nurses, stronger collaboration with nurses taking care of lung patients in other sectors of the health system in Iceland and internationally, as well as collaboration with other health professionals, is ongoing. An extensive research proposal was approved by the ethical committee of LSH early in the year 2018 followed by initiating data collection in the spring of that year
Case of the academy-clinic collaboration
When technological possibilities exceed service capacity—engaging the health and welfare systems in collaboration on the advancement of service for people dependent on home mechanical ventilation
Identification of need for action
Insufficient service for people who need around-the-clock ventilation- assisted service, particularly those with motor neuron diseases, has gained an increased weight in Iceland. At present time the service is fragmented, and people are not entitled 24/7 service in the home, a necessity for those totally relying on mechanical ventilation. The people themselves have fought for years for “a life that is worth living” but until now with limited success. The main dispute regards who should finance the service—the government vs. municipalities—who should do what, and where, how, and by whom should the service be delivered
For years, patients needing home mechanical ventilation have been cared for in the outpatient nursing practice for patients with advanced lung problems at the LSH in collaboration with the motor neuron disease team and the sleep unit at LSH. With the void between technological treatment possibilities and workforce resources growing bigger [31], an ethical dilemma has risen in the practice Bringing
different perspectives together
In 2016 the clinical nurse specialist in care for patients needing home mechanical ventilation, along with other practice nurses and the academic chair, put together a strategic plan to move the issue forward. The group wrote an evidence-based position paper where needs and the situation of people dependent on home mechanical ventilation and their families are outlined, also containing
suggestions for a strategic plan [32]. Building up capacity for 24-h home service for people receiving mechanical ventilation is not only a hospital issue but reaches much further into the society. Therefore, the group established collaboration with the Centre for Ethics at the University of Iceland and the Institute of Nursing Research at the University of Iceland. The group also contacted members of the parliament who had put forth a parliamentary resolution on launching a governmental task force that would make a strategic plan for an acceptable service for these people. That collaboration, led by the clinical nurse specialist, culminated in a public seminar on the issue. It attracted significant public attention and news reports in the media
Keeping things running
Based on the parliamentary resolution and the position paper officials of the ministries of health and welfare recruited relevant stakeholders to a task force group. The result was a strategic plan between the ministries of health and welfare and the municipalities—the Icelandic Association of Local Authorities—
containing nine actions, several of which were outlined in the position paper.
LSH is responsible for 5 of the actions, for which it composed a highly specialized, interdisciplinary team with 16 members and a project manager.
Team members involve other relevant specialists as needed. Of particular significance is collaboration between specialized nurses in neurology and respiratory care. This has helped to build up professional capacities, nurture togetherness, and mobilize important resources in patient care
11 Complexity Leadership in the Collaboration Between Academia and Clinical…
Case of the academy-clinic collaboration
When technological possibilities exceed service capacity—engaging the health and welfare systems in collaboration on the advancement of service for people dependent on home mechanical ventilation
Future Stakeholders are currently working together and will continue to do so. There are good prospects of a financial resolution in the near future. Collaboration between specialized nurses in neurology and respiratory care is materializing. The clinical nurse specialist is in the frontline of the project. She regularly informs and discusses issues with the academic chair and the nurses in the practice. Plans are being made of how to support the project with research activities. Recruiting nurses into this specialty area followed by providing opportunities for graduate education is in process.
It is acknowledged that promoting this project is particularly strenuous, in part, because of how vulnerable the patient population is. The complexity reaches its heights in the manifold levels at which it needs to be worked on: hospital, home, respite homes—economical, ethical, political, societal—health-care managers and administrators, politicians, patient organizations, governmental officials, and more. Still the vision is clear: comprehensive health care that supports “a life that is worth living”
Case of the academy-clinic collaboration
Grasping ideas from clinical practice to identify patients with cognitive disorders following stroke and to acquire viable interventions
Identification of need for action
Needs of patients who are cognitively impaired subsequently to stroke are a challenge in nursing care. The patients’ needs are complex, and they themselves may be unable to sufficiently express their needs and concerns.
Tools to guide nursing care of patients with hemispatial neglect following stroke are lacking and the current assessment strategy does not sufficiently capture patients’ deficits, experiences, and needs. An abundance of screening tests has been developed in the previous 50 years and tested mostly in laboratory settings. Their sensitivity in daily nursing situations has received very little attention. An overarching aim of a recent doctoral thesis was to advance comprehension of unmet needs of people with hemispatial neglect with the aim of advancing nursing care and ultimately to improve rehabilitation outcomes. Comprehensive clinical experience had revealed limitations of identifying and acting on problems related to hemispatial neglect. In particular, because many problems associated with these disorders are latent to staff, patients, and the family alike and become eclipsed by more obvious problems, such as paralysis, swallowing difficulties, and more, unless specialized screening occurs
In a part of the doctoral thesis, the usefulness of conventional screening tests for hemispatial neglect (quantitative) was compared to challenges in daily life as illustrated in interviews and clinical observations (qualitative). The encounters with the patients were long-lasting, reaching from the acute admission until after discharge from rehabilitation to home. Findings revealed that several components in the qualitative data were insufficiently captured by the quantitative measurements. The need to develop more wide-ranging assessment strategies was apparent alongside a need to develop ward-based rehabilitation interventions for patients and their relatives, as well as educational programs for clinical nurses
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Case of the academy-clinic collaboration
Grasping ideas from clinical practice to identify patients with cognitive disorders following stroke and to acquire viable interventions
Bringing different perspectives together
A research collaboration team was originally formed in 2011 consisting of the academic chair of the chronical ill adults at LSH, a PhD student in nursing, a neurologist specialized in spatial neglect, two phenomenologists, and a specialist in stroke rehabilitation. Several pertinent interventions for clinical nursing care were identified [33] alongside with valuable information to improve nursing assessment [34–36]. Since, the team has expanded to also include a neuropsychologist, a physiotherapist, and a group of clinical nurses.
Close collaboration is also in place with the national patient organization The research team has composed a long-term vision for research as illustrated in a research proposal that is partly funded and running and for which an extended grant application to competitive national and international funding programs is in progress.
In 2017 a position was established for the former PhD student for an academic chair with focus on nursing in the area of neurology and neuro-rehabilitation Keeping things
running
Currently, the academic chair as a researcher spends long hours in on the neurological ward in data collection. Her presence and visibility of her research endeavors has created interest among the staff nurses, which is highly significant to nursing research and its usefulness for clinical practice Three newly graduated nurses have started master’s education, all with distinct research focuses within the field of neurology: amyotrophic lateral sclerosis, deep brain stimulation and nursing management in Parkinson’s disease, and nursing management of patients with acute stroke. These topics fall within a larger target plan to educate clinical nurse specialists within main areas of neurology and neuro-rehabilitation
Future At the moment, we particularly emphasize strengthening, even further, the collaboration between the academia and the special areas of neurology and neuro rehabilitation. There is yet a long way to go to achieve systematic nursing care that is sensitive to the unique needs of patients and their families. Especially for those with highly complex diseases that demand highly specialized health-care
11.6.1 Bringing the Three Icelandic Cases Together
The cases exemplify how enabling mind-sets and approaches have been used to strengthen the bond between academia and clinical practice at LSH and the FoN at the University of Iceland. Across the cases we have illustrated examples how aca- demic chairs engage with nursing practice on many levels. An inherent part of lead- ership involves the relationship between individuals, communication between the hospital and educational institutions, motivation, agreement, establishing need for changes, and considering the social impact—all in a meaningful interpersonally friendly and socially responsible way.
To facilitate perceptions of togetherness, the academic chair should be visible in clinical practice and be receptive to the wealth of indications that arise from nurses’
experiences. Their responses must nurture freedom in thinking and facilitate trans- formative ideas that make sense. They should continually seek out opportunities,
11 Complexity Leadership in the Collaboration Between Academia and Clinical…
find resources, and search for information. Academic chairs should help nurses to flourish and embrace diverse ways of feeling, thinking, and “doing” nursing and provide links between past experiences and future research projects in and for clini- cal practice.
The academic chairs often need to establish creative solutions on how to climb the hurdles and react to ongoing changes: technological, staffing, and integration of new knowledge and financial boundaries. Academic leaders continuously scrutinize their experiences, not merely accepting good or bad outcomes but more profoundly making assessment to attach meanings and really learn from their experiences.
The invisibility of complexity leadership may reveal itself in many ways as was alluded to in the cases because the main strength of such leadership lays in the fact that it is enabling. Hence, academic chairs are not always in the forefront of projects but help to push things forward across different systems. Such work is often context specific and may differ between leaders and contexts. Building up a body of knowl- edge and competence in a sustainable way takes time.