Clinical education delivery A collaborative, shared governance model provides a framework for planning, implementation and evaluation

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1 Clinical education delivery A collaborative, shared governance model provides a framework for planning, implementation and evaluation Jenny Owen, formerly University of Canberra Laurie Grealish, University of Canberra Following a scheduled review of a university pre-registration Bachelor of Nursing program, a decision was taken to introduce a new model of clinical education delivery. Principles of collaboration, as used by other university nursing programs, were applied to the change management process. As the process of change progressed, a model incorporating collaboration and shared governance emerged to address the challenge posed by multiple stakeholders from culturally different organisations and the genuine commitment by those stakeholders to share control in the planning, implementation, and evaluation of the clinical education delivery model. Using a case study approach, this article demonstrates how the principles of collaboration and shared governance were combined to effectively manage change in the delivery of clinical education across several different organisations, and provides an extended framework for collaborative change management involving multiple stakeholders. Keywords: Collaboration, shared governance, change management, multiple stakeholders Corresponding author: Jenny Owen RN Med OR Cert MRCNA, Former Lecturer in Nursing (Position held during the described case study), School of Health Sciences, University of Canberra j.owen@bigpond.net.au Laurie Grealish RN MN Grad Dip Nsg St (Edn) Onc Cert FRCNA, Senior Lecturer in Nursing, School of Health Sciences, University of Canberra Introduction In 2002, in response to regulatory accreditation requirements, a Bachelor of Nursing curriculum was submitted for a full review, including wide consultation with stakeholders. The curriculum review emphasised the need to provide a collaborative, rather than university directed, approach to clinical education delivery that would better meet the needs of the students, industry partners and the profession. In response to these findings, the authors initiated a process of change that would facilitate a collaborative approach to clinical education delivery in the curriculum. Principles of collaboration in planning education (Clare et al 2003) were adopted to guide the collaborative change process. These principles assumed a two-partner arrangement and proved insufficient for managing change with multiple stakeholders. Principles of shared governance (Porter-O Grady 1992) were incorporated to address this deficit. However, shared governance principles, developed within single organisations, had not been applied across organisations. This paper describes how the principles of collaboration and shared governance were combined to effectively manage change in the delivery of clinical education, and offers a framework, the Collaborative Change Model, for collaborative change management involving multiple stakeholders from several, culturally different, health agencies. Background Recent national reviews of the Australian nursing profession emphasise the need to strengthen collaboration between the education sector and industry partners in the delivery of clinical education (Reid 1994; Senate Report 2002; National Review of Nursing Education 2002). The notion of partnerships being integral to quality practice and education is a resounding theme in all three reviews. The university-health service partnership is often based on clinical practice agreements between the two partners for student placement, and is directed by the university (Gassner et al 1999). Collaboration in these partnerships can be hindered by conflicting expectations of those involved (Clare et al 2003). Indeed providing clinical education through a collaborative partnership goes beyond a clinical practice agreement and should involve all stakeholders in the planning, implementation and evaluation of clinical education Collegian Vol 13 No

2 delivery. The collaborative elements of willing participation, trust, mutual benefit and, above all, shared planning and decisionmaking, are required in the Collaborative Change Model (Downie et al 2001; Henneman et al 1995). Literature Review Collaborative partnerships Partnership can be defined as a mutually beneficial and well-defined relationship, entered into by two or more partners to achieve common goals (Cornes 1998 p656). The value of a partnership is the ability to meet the partners needs in ways that they could not complete alone (Cornes 1998; Edmond 2001; Ferguson & Jinks 1994; Glen 1995; Lasker et al 2001; Plsek 1997). By combining the individual perspectives, resources, and skills of the partners, the group creates something new and valuable together a whole that is greater than the sum of its individual parts (Lasker et al 2001 p184). Collaborative partnerships are a response to the increasing interdependence in the health care system as it undergoes rapid, and at times turbulent, economic and technological change (Lasker et al 2001; Sebastian et al 1998). Many health care professionals and organisations are asked to do more with less and are held accountable for results that are beyond their direct control (Lasker et al 2001 p180). Collaborative partnerships that successfully combine the skills of multiple partners can provide greater flexibility in meeting the demands of this turbulent environment (Sebastian et al 1998). Collaborative structures are common in nursing and education (Clare et al 2002), and usually begin with a strong platform derived from a history of cooperation, mutual respect, understanding and trust, and well-established communication links (Cornes 1998). However, collaborative partnerships cannot succeed based on good will alone (Beattie et al 1996). Important attributes of collaboration include the participation of individuals who see themselves as members of the team, contributing to a common goal; they offer their expertise freely and share responsibility for outcomes (Clare et al 2002; Henneman et al 1995; Linden 2002). Individuals who participate in collaborative partnerships have the opportunity to learn and develop personal skills, including creativity and support (Chenger 1988; Mann et al 1997; Plsek 1997), feel positive when their unique contributions are recognised and appreciated (Clare et al 2002; Gassner et al 1999; Henneman et al 1995) and cultivate collegial relationships that may not otherwise occur (Cornes 1998). The dynamic tension that may exist between different cultures working together in a collaborative partnership can be used to constructively challenge ideas to create meaning (Gassner et al 1999). Communication at the individual and group level is essential for successful collaborative partnerships (Chenger 1988; Henneman et al 1995; Sebastian et al 1998). Discourse can sharpen how meanings about project issues are made (Fear et al 2003) and provide insights that may not otherwise occur when thinking happens individually (Huntington et al 2000; Lasker et al 2001). Early in the partnership, expectations and abilities should be clearly shared by individuals in the group (Chenger 1988; Clare et al 2002; Murray & Broad 2002). Strongly held assumptions, or the paradigm of the way we ve always done it here, must be questioned, as blind acceptance of these can stifle progress and innovation (Plsek 1997). When collaborating, it is important to negotiate on matters such as finance, authority and authorship (Beattie et al 1996). Thus when the collaborators come from different contexts, there is a particular need for clear articulation and the development of shared language to describe differences and similarities (Clinton et al 1997; Gassner et al 1999). When such sharing does not occur there is an increased risk of lack of trust and project failure (Gaskill et al 2003). Problems with collaborative partnerships can also emerge in the areas of decision-making authority (Campbell & Taylor 2000), lack of commitment to the notion of collaboration (Cornes 1998), not involving key stakeholders (Cornes 1998), maintaining group enthusiasm over time (Campbell & Taylor 2000), ownership (Beattie et al 1996; Campbell & Taylor 2000), and different values about goals, commitment and control (Campbell & Taylor 2000). Successful collaboration depends on a team-oriented environment, with a flat rather than hierarchical structure where reward systems recognise group rather than individual performance, and equality is valued (Henneman et al 1995). Effective collaborative partnerships in health care have been shown to produce certain types of outcomes: satisfaction of stakeholders; quality of partnership plans; sustainability of the partnership; changes in community programs, policies, and practices; improvements in utilization, responsiveness, and costs of health services; and improvements in health indicators (Lasker et al 2001). Collaborative partnership theory does not provide clear guidance for how power should be shared. For this project, the authors were committed to a collaborative approach with power for decisionmaking shared by the collaborative team. In order to do this, a shared governance model was investigated. Shared Governance Complex socio-economic and environmental components contribute to challenging problems in health care systems that do not respond to top-down management or single-solution approaches (Lasker et al 2001). Early health care management models consistently reinforced oppressive nursing behaviours. In these models health care staff learned how to manoeuvre through traditional control-andcommand approaches to management (Porter O Grady 2001). As a result staff develop manipulative, passive-aggressive and dependent forms of behaviour (Porter-O Grady 2001; Stumpf 2001). Under these management models nurses were essentially excluded from contributing to problem solving and decisionmaking that affected their practice and professional development. Survival in a rapidly changing economic and technological environment depends on management approaches that: 1) Use environmental feedback for rapid improvement and response; 16 Collegian Vol 13 No

3 Clinical education delivery A collaborative, shared governance model provides a framework for planning, implementation and evaluation 2) Value the commitment, contribution and the potential of staff members; and 3) Work smarter not harder (adapted from Edmonstone 2000). Devising and implementing appropriate solutions to problems in health care systems must involve parties closest to the problem (Lasker et al 2001). Bringing those closest to the problem together requires different relationships, procedures and structures to those worked with in the past, requiring time and resources to overcome difficult challenges (Lasker et al 2001). An appropriate form of governance is a crucial component of these management processes. Traditional governance in nursing is defined as hierarchical, bureaucratic form of government with a head nurse to plan, organise, direct, and control administration of the unit and the staff (Stumpf 2001 p197). Shared governance is defined as an approach to nursing management which seeks to grant nursing staff control over their professional practice and development and make a genuine contribution to the wider corporate agenda (Gavin et al 1999 p194). Shared governance can also be explained as a structure through which a body exercises its authority and performs its functions while valuing concepts of partnership, accountability, equity and ownership (Caramanica 2004; Porter-O Grady 2001). Shared governance is an alignment of the values of the system, or the work of management, with those of service, or the work of the workers (Caramanica 2004). Indeed emphasis is placed on a change in personal patterns of behaviour, not only organisational change (O May & Buchan 1999; Porter-O Grady 2001), and efforts must be applied to support staff through behaviour and performance change (Porter-O Grady 2001). Shared governance appears to have had a widespread effect on management in health care in the USA. The more recent adoption of shared governance in the UK has been less enthusiastic, and has seen authors advising caution in light of limited evidence to support the value of shared governance (Burnhope & Edmonstone 2003; Gavin et al 1999). Barriers to shared governance have been identified as the reluctance of staff nurses to assume the required accountability, inadequate time to release clinicians for committee work, and difficulty in creating partnerships between workers and managers (Caramanica 2004). Particular criticism had been levelled at the way in which shared governance has been evaluated and reported in the literature. Critics warn that shared governance is a philosophical approach; an ongoing, fluid process not a singlestep implementation process, and must be considered and evaluated accordingly (Burnhope & Edmonstone 2003; O May & Buchan 1999). Although the values of a shared governance approach were important to our work, the authors were aware that most models of shared governance reported in the literature had been limited to singular diverse organisations, such as tertiary level hospitals. There was little evidence of the usefulness of shared governance across several culturally different organisations or of its usefulness in managing change in education delivery. There is evidence that increasing interdependence in the health care system means partners are exploring more collaborative approaches to problem solving and decision-making to meet the demands of the changing environment (Ireson & McGillis 1998; Lasker et al 2001; Miller 2002, O May & Buchan 1999). And there are some who believe, like us, that in the increasingly networked world, the focus of partnerships has moved from within organisations to between organisations and their partners (Linden 2002). The application of collaborative principles and shared governance across culturally diverse organisations appeared possible. The components of collaborative partnerships and shared governance useful to our study include: willing participation (Gassner et al 1999; Murray & Broad 2002); defined mutual relationships and goals (Cornes 1998; Gassner et al 1999); jointly developed structure and responsibility (Cornes 1998; Gassner et al 1999); mutual authority and accountability for success; contribution of expertise (Gassner et al 1999); sharing of resources and rewards (Cornes 1998); and shared power - based on knowledge or expertise (Gassner et al 1999). The following case study demonstrates how these components were applied to managing change in the delivery of clinical education. The case study Adopting the principles of collaboration and shared governance A review of the collaborative problem-solving literature was conducted to identify collaborative theory that could be applied to manage change in the delivery of clinical education. The work of Clare et al (2002, 2003) was selected as it focused on collaborative partnerships in clinical nursing education in Australia. Their twophase study confirmed the significance of a university-health service collaborative partnership in the quality of clinical education. Phase two of the study went on to develop and evaluate these partnerships in three Australian states. The notions of mutuality, commitment, valuing, nurturing and the need for evaluation underpinned these collaborative partnerships (Clare et al 2002; Downie et al 2001). Clare et al (2003 p18) raise a number of issues integral to collaborative partnerships. The issues identified include: 1. Establishing and convincing both parties of the need to collaborate 2. Open and authentic communication 3. Building capacity by valuing all members of the partnership equally 4. Mutual respect and trust in actions 5. Demonstrating professional behaviour at all times 6. Deciding the parameters and scope of the partnership 7. Clarifying the desired outcomes 8. Developing the structure and models that sustain and nurture authentic collaboration These issues were adopted as the principles to guide the change management process in this case study. As the change management process began, it became apparent that these principles, designed for a university-agency partnership, were useful for effecting collaborative partnerships. However, the desired collaboration needed to occur in both effecting a partnership and governing the process of change in clinical education delivery. Thus principles of shared governance were also explored and employed. Collegian Vol 13 No

4 Shared governance can provide direction in managing conflict and disquiet in the process of change and the complexities of multiple sites and groups (Miller 2002). The literature suggests that few partnerships are truly collaborative (Cornes 1998; Henneman et al 1995; Gassner et al 1999; Linden 2002), and it was evident that decentralising, or sharing, governance across the partnership could have strengthened this collaborative venture. The work of Porter-O Grady (1992), which focuses on the concept of shared governance in nursing, was selected to guide and enhance the collaborative partnership in this case study. The following principles of shared governance were adapted from Porter- O Grady (1992): 1. Identify those with a mutual vested interest 2. Enable stakeholders to set the infrastructure for the profession 3. Establish representative stakeholder groups based on function 4. Confirm group s function 5. Confirm stakeholder representation in groups 6. Identify group s roles, responsibilities and accountabilities 7. Distribute decision-making power according to accountabilities 8. Establish and maintain effective network of communication These principles were also incorporated in the plan to guide the change management process throughout the case study. The leaders of the representative organisational groups adopted the final set of principles. Each organisational group shared decision-making power and was professionally accountable for performing the group s function and meeting the agreed outcomes. Using this approach, governance was effectively shared by several organisations working toward a shared goal: the introduction of a new clinical education delivery model. Table 1: The Collaborative Change Model - Managing collaborative change with several organisations: integrating collaborative principles and shared governance Collaborative Change Model Establish and confirm the need for stakeholders to collaborate and share accountability for the project (change) Clarify the shared goal Involve those immediately affected by the project in the management process Adopt a shared governance model Implement collaborative group process to: Establish and accept the scope of the group s work Generate and accept agreed parameters for the group s work Establish formal terms of reference based on agreements Establish and maintain open, authentic and professional communication Build capacity by valuing the views of all members equally Monitor the shared governance process ensuring decisions honour agreed scope and parameters Formally evaluate all collaborative group processes Act on evaluation data Nurture the structure and models that sustain authentic collaboration The Collaborative Change Model Combining these principles of collaboration and shared governance to manage the process of change in the delivery of clinical nursing education provided a framework for the change process when multiple organisations are involved. This framework is presented as the Collaborative Change Model and is outlined in Table 1. The following provides an overview of how the Collaborative Change Model can be effectively applied in practice. 1. Establish and confirm the need for stakeholders to collaborate and share accountability The full review of the Bachelor of Nursing curriculum established the need for a collaborative approach to clinical education delivery, with shared accountability for the outcome. This finding was supported by published reviews of nursing (Commonwealth of Australia 2002) and nurse education (DEST 2002). The stakeholders, representing the organisations that contributed to the curriculum review, agreed to constitute a clinical education implementation group. 2. Clarify the shared goal The shared goal, the need for a new clinical education delivery model, was clarified by the curriculum review. Many of the stakeholders from the curriculum review were also crucial to the successful implementation of a new clinical education delivery model within their organisations. These stakeholders, through mutual agreement, made a commitment to pursue a collaborative approach to the delivery of clinical education. These activities are consistent with the need for collaboration to be established and confirmed by the parties involved (Clare et al 2003). During this phase, models of collaborative clinical education delivery were explored. A review of the literature and further consultation with stakeholders identified a preferred model. 3. Involve those immediately affected by the project in the management process The Collaborative Change Model proposes that those groups immediately affected by the project (intended outcome) should be represented on a management committee. This is consistent with Porter-O Grady s (1992) view that the representative stakeholder groups should be identified based on function. In this case, a collaborative organisational partnership was formed. The partnership included senior representatives of four major organisations, or agencies, currently involved in supporting clinical education in the Bachelor of Nursing program: The Canberra Hospital; Australian Capital Territory (ACT) Health-Community Health; Calvary Health Care-ACT; and the University of Canberra. This group became known as the Agency Leaders Group. The Agency Leaders Group identified criteria used to assess the new model of clinical education for possible implementation, and conducted a collaborative study tour of Flinders University of South Australia, School of Nursing where the preferred model was established (Edgecombe et al 1999; Gonda et al 1999). 18 Collegian Vol 13 No

5 Clinical education delivery A collaborative, shared governance model provides a framework for planning, implementation and evaluation Based on the evidence collated from the study tour, there was unanimous agreement from the Agency Leaders Group to progress the implementation of the preferred model. At this point it was agreed that a Reference Group, consisting of representatives of the workers within each organisation, would be established. Those workers who would be most affected by the introduction of the new clinical education delivery model were identified as stakeholders and approached to become members of the Reference Group. The Stakeholder Reference Group consisted of representatives from: Each of the three main health organisations and included the Clinical Development Nurse, the Nurse Educator, the Clinical Nurse Consultant, and the Agency Clinical Leader (from the Agency Leaders Group); Australian Capital Territory (ACT) Department of Health; The Nurses Board of the Australian Capital Territory; The Australian Nurses Federation; University of Canberra staff; and University of Canberra students. 4. Adopt a shared governance model The principles of collaboration, derived from the collaboration and shared governance literature, were presented to the newly established Stakeholders Reference Group and supported. Using the agreed principles, the processes for decision-making in planning, implementing, and evaluating the new clinical education delivery model was developed. The diverse group of representatives, with a range of interests, some of these competing, was managed through the development of several working groups (Figure 1). These groups maintained close contact through cross membership and circulation of formal summaries of meeting discussion and decisions. Figure 1: Shared governance structure in the case study Agency Leaders Group Standing Sub-Committees Agency Implementation Groups Student Group University staff Group Stakeholders Stakeholder Reference Group Work Sub-Committees Evaluation Group Personnel Training Group The initial group, the Agency Leaders Group, was established to determine which clinical education delivery model would be implemented. Once this decision was made, this group continued to meet to guide the establishment of the Stakeholder Reference Group, ensuring appropriate identification and inclusion of those affected by the new model. The members of the Agency Leaders Group held senior leadership positions in stakeholder (health agency) organisations. The members positions afforded them the power to negotiate on issues such as mission, purpose, funding and resource allocation at their respective agencies. Each representative also held the important role of agency change agent. The administrative management of each health agency was informed of the introduction and progress of the new clinical education model through the Agency Leaders Group representative. Contractual arrangements between the university and stakeholder health agencies emanated from this group. Once established, the Stakeholder Reference Group became the governing body for decisions regarding the planning, implementation and evaluation of the new clinical education delivery model. The Stakeholder Reference Group eventually absorbed the work of the Agency Leaders Group, leading to the dissolution of the Agency Leaders Group. Two types of sub-committees were employed to undertake the consultation and work associated with the change process: Standing sub-committees and Work sub-committees. In line with a shared governance approach, membership of a sub-committee was defined by area of interest or professional expertise. Consistent with the principles of collaboration and shared governance, group function was clearly articulated, accountability was determined, and decisionmaking power was vested in each sub-committee (within the limits agreed by the Stakeholder Reference Group). Sub-committee reports were tabled at each Stakeholder Reference Group meeting and summaries of the Stakeholder Reference Group meetings were distributed to sub-committees. The Standing sub-committees included the: Agency Implementation Groups consisting of agency employees active in the implementation of the new model of clinical education delivery at their agency; Student Group an informal group that met with student representatives on the Stakeholder Reference Group; and University Staff Group a group constituted by those staff directly involved in the delivery of clinical education. The Work sub-committees included the: Evaluation Group identified the information required for successful widespread implementation of the clinical education delivery model and design of evaluation program; and Personnel Training Group developed training workshops for students, academics and clinicians involved in the implementation phase. The Stakeholder Reference Group, Agency Leaders Group and sub-committees worked collectively and in parallel to govern and manage the process of change in the introduction of the new model of clinical education delivery. There was significant overlap in membership across the sub-committees and Reference Group. This group configuration is consistent with Porter-O Grady s (1992) concept of disseminating functions and accountabilities across representative groups to facilitate shared governance. Collegian Vol 13 No

6 5. Implement collaborative group processes Establish and accept the scope of the group s work The Stakeholder Reference Group developed the parameters and policy for the new clinical education delivery model. The Stakeholder Reference Group function was later extended to include monitoring and evaluating the introduction of this new model across two clinical sites. As the function of the Stakeholder Reference Group changed, the membership was adjusted to include those people immediately affected by the additional functions. Generate and accept agreed parameters for the group s work Initially, the Stakeholder Reference Group and Agency Leaders Group worked collaboratively to establish a matrix of communication, accountability and shared decision-making practices. The practices adopted for the Stakeholder Reference Group are outlined in Table 2. Establish formal terms of reference Formal terms of reference for the group were collaboratively developed to determine the membership, aims, desired outcomes, timelines and meeting schedule. A University representative nominated to chair the Stakeholder Reference Group and was supported. The terms of reference were adjusted as the focus of the work shifted from planning to implementation and monitoring/evaluation. Establish and maintain open, authentic, and professional communication Formal meeting practices were adopted for all groups within the governance structure. A summary of meeting outcomes, rather than minutes, was used to permit frank group discussion during the meetings and captured the negotiations that were undertaken by the group as they arrived at an agreed position rather than naming individuals who expressed a particular view, as would occur in minutes of a meeting. The process of arriving at a shared position and then the consensus decision was recorded. The meeting summaries were circulated to group members within seven days of the meeting to provide adequate time for dissemination and Table 2: Colloborative group practices Formal terms of reference were developed from the agreed parameters Regular group meetings were scheduled timing was determined by the group Formal meeting procedures were employed Ideas were generated through small group work during meetings All contributions were acknowledged, actioned and reported through formal record keeping An agreed approach to decision-making was adopted The groups ensured that all decisions honoured their agreed scope and parameters The tabling and unrestricted dissemination of documents occurred among all groups Discussion and evaluation of the agreed scope and parameters of each group was conducted regularly discussion with stakeholders more generally. Information from the wider discussions informed decision-making at the next meeting. Build capacity by viewing all members equally The role of the chair was to facilitate group process. Decisionmaking power rested with the group members. Small group work was used for problem solving and to generate ideas. Issues raised within groups were presented to the whole group for discussion and consensus agreement. Small group work during meetings provided an opportunity for those who consider themselves less powerful, such as students, to raise their views without personal risk. These views were then incorporated into the small group view and became part of the negotiations as the Stakeholder Reference Group moved toward a decision. This strategy, in addition to the recording of meeting summaries rather than identification of individual views, proved to be a useful strategy to improve the group s capacity to achieve its intended outcomes. Monitor shared governance process ensuring decisions honour agreed scope and parameters Regular monitoring of the practices adopted by the group, in terms of their effectiveness to achieve the shared goal, was conducted at the beginning of each meeting. Through a brief review of the summary of the previous meeting, the group took the opportunity to revisit those decisions in light of the shared goal as identified in the terms of reference. This strategy reminded the group of its purpose and provided a clear focus for each meeting. 6. Formally evaluate collaborative group practices and act on evaluation data The collaborative group practices were evaluated using a survey designed by the Stakeholder Reference Group. Members of the group completed the survey and the findings led to the recommendation to establish reference groups for the implementation and monitoring of the new education model in each clinical setting. 7. Nurture the structure and models that sustain authentic collaboration Due to its success in achieving significant outcomes in a timely way, the Collaborative Change Model has sustained the effective management of the new clinical education delivery model in a range of settings. It is currently being considered for application to other university-health agency work. A new framework for collaborative change management Combining the principles of collaboration and shared governance led to the successful establishment, monitoring and evaluation of a new model of clinical education delivery for undergraduate nursing students in the Australian Capital Territory. The experience of supporting a change process of this magnitude has led the authors to develop a new framework for collaborative change management involving multiple stakeholders from a range of culturally diverse organisations (Table 1). This model combines the essential features of the collaborative and shared governance approaches drawn from the literature in a new context. 20 Collegian Vol 13 No

7 Clinical education delivery A collaborative, shared governance model provides a framework for planning, implementation and evaluation The collaborative principles proposed by Clare et al (2003) were used and found to be helpful in effecting a collaborative approach to change management. In applying the principles to partnerships with multiple stakeholders, the list of issues integral to collaborative partnerships was refined: The principles can be applied to collaborative work beyond two parties, and apply to groups or communities with a shared goal; Determining the scope of the problem and the parameters for the group s functions are separate activities; The shared goal must be established and agreed before the parameters for the group s activity can be established; and Applying shared governance (Porter-O Grady 1992) was effective in extending the collaborative approach to include governing the change process by multiple stakeholders from more than one organisation. Of particular note from the case study, the membership of the Stakeholder Reference Group need to change as its focus shifted from planning to implementation and monitoring/evaluation. Including the people immediately affected by the change was consistent with the principles of shared governance. The Collaborative Change Model provided a clear framework for planning and implementing a change process using a collaborative approach with multiple stakeholders. The model was successfully applied to a problem that required change from many stakeholders, from different agencies and disciplinary cultures. The Collaborative Change Model has potential for use in the development of clinical policies for undergraduate nursing students. For example, this approach would be useful to inform policies around occupational health and safety for students (manual handling, safe handling of sharps) and the development of a shared approach to indemnity for student nurses as workers. Conclusion This paper describes the experience of managing change in the delivery of clinical education in one Australian undergraduate nursing program. In seeking a collaborative approach to change management, principles of collaboration in planning education (Clare et al 2003) were adopted. These principles of collaboration were useful for effecting change but incomplete for governing change with multiple stakeholders from culturally diverse organisations. Incorporating a shared governance approach into the change management process led to practices that nurtured an effective and sustained change in the delivery of clinical education. The Collaborative Change Model for multiple stakeholders, developed by the authors through this experience, is proposed for further testing and development by others challenged to deliver nursing education in a contemporary environment. 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