The critical elements of effective academic-practice partnerships: a framework derived from the Department of Veterans Affairs Nursing Academy

In a business context, strategic alliances may be conceptualized as formal or informal collaborative relationships between parties who come together to achieve a common goal while remaining separate organizations [1]. In the nursing profession, strategic alliances are typically created between an academic partner or nursing school and a practice partner, usually an inpatient healthcare facility, that are geographically proximate to each other. The potential benefits of such alliances, or “academic-practice partnerships,” may include increased capacity for students to matriculate into nursing programs [2] and the ability to better prepare nursing students to meet the demands of the practice setting [3]. Medicine has benefited from such academic-practice partnerships for decades, but nursing is comparatively new to the academic-practice partnership model [4].

The Department of Veterans Affairs (VA), as a major employer of nurses and other healthcare professionals, has an abiding interest in clinician education, and, while not an educational institution itself, does make its facilities available for clinical instruction. Moreover, for disciplines such as medicine, VA has been a major employer of clinical teaching staff and an active participant in shaping clinical experiences. VA recently extended this academic-practice partnership framework to nursing education on a pilot basis. In 2007, the VA Offices of Academic Affiliations and Nursing Services established the VA Nursing Academy (VANA), a five-year, $60 million pilot program, to address the nursing and nurse faculty shortage occurring both within VA and the nation by providing pilot funding for 15 strategic partnerships to be established between competitively selected VA facilities and nearby nursing schools nationwide [5].

The VANA partnership model was designed to develop strong, mutually beneficial relationships between participating nursing schools and VA facilities by (1) expanding educational faculty through career development, (2) increasing student enrollments, (3) cultivating educational and practice innovations, and (4) increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education. In addition, the VANA model was designed to allow for substantial local variation in its structure and application. This approach afforded each partnership with the ability to adapt the program to meet local contextual needs and demands, and also permitted significant experimentation to ascertain the relative success of various approaches.

The nursing profession is currently exploring how such arrangements may be most effectively operationalized to maximize the potential benefits for each partner and for the field. The nursing literature provides many examples of partnerships that include one nursing school and one or more practice partners, but the evidence for the success of these partnerships is poor [6]. Many of these articles describe the development and nature of the partnership model, but collectively they provide little empirical evidence to guide organizational decision-makers when they seek to design new partnerships or modify existing ones [7]–[14]. Recent recommendations from a task force established by the American Association of Colleges of Nursing (AACN) and the American Organization of Nurse Executives (AONE) on academic-practice partnerships [15] provide some guideposts for such partnerships, but they are guiding principles rather than recommended practices for their implementation.

With five years of funding for fifteen partnerships, VANA provided an oppportunity to increase the evidence base on the implementation effectiveness of partnerships. Towards this end, the VA funded a six-year, multi-dimensional evaluation of the VANA program. As part of this evaluation, the evaluation team sought to identify specific indicators of successes and challenges that characterized VANA partnerships during the “start-up phase” of each partnership. This article proposes a framework of critical features that have emerged from our qualitative data analysis during an examination of the first year, or “Launch Year,” of each partnership. In so doing, we propose certain features as early, evidence-based indicators of progress toward achieving desired outcomes, and provide practical, real-world details that extend the guiding principles in the aforementioned AACN-AONE report. These findings, drawn from a comparative analysis of partnership development at 15 sites from across the United States, provide critical insight into effective approaches for structuring and implementing academic-clinical partnerships in nursing.

This article addresses the following two research questions:

This formative evaluation [16] was designed to qualitatively analyze data collected using in-person interviews and focus groups from 364 key informants involved in implementing these 15 partnerships. As Figure 1 illustrates, an ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement.

Data collection included 142 in-person interviews with faculty and administrators during prescheduled site visits to each locale and 23 focus groups with nursing staff and students. Each site was visited one time within the first 18 months of joining the VANA pilot. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. Both the interviews and the focus groups included open-ended questions concerning the general background of the institutions and their motivation to participate in VANA, various structural and operational aspects of the partnership, opinions about the potential effectiveness and possible impacts of VANA on the respondent and their organization, and perceptions regarding the effectiveness of VANA in improving the VA’s ability to recruit new graduates. Each interview lasted approximately 60 to 90 minutes; the focus groups were typically 60 minutes. Two to four doctorally-prepared investigators were present at each interview or focus group session with one investigator serving as the primary interviewer, and the other(s) keeping detailed field notes, verifying observations, and ensuring that all key topics were covered [17]. All interviews and focus groups were audiotaped. Participants were informed that data was kept confidential and anonymous. Verbal informed consent for participation was obtained from participants. This study was approved by the Institutional Review Board of the VA Greater Los Angeles Healthcare System.

The research team used a structured tool, derived from the interview guide and the team’s collective expertise and ongoing experience, to organize and analyze the interview and focus group data. Directly after each site visit, the investigators who participated in the interviews met and debriefed each other using this tool to capture impressions and comments in a timely manner. Investigators often referred to their field notes during this process. Recordings, notes and transcriptions were used to settle disagreements until consensus was reached for each question in the analysis tool.

Our qualitative analyses focused on identifying the essential elements of program progress during the Launch Year. We defined progress as achieving the programmatic goals designated for VANA by VA. For each goal, we identified two categories of elements that influenced success: implementation activities undertaken by the program organizers and outputs or near term products (often predetermined by the VANA grant).

We searched for variability within each element that would indicate a spectrum of progress ranging from “proceeding well according to plan” (i.e. successful) to “addressing impediments and therefore lagging behind schedule” (i.e. challenged). Operational definitions for each theme and element, and observed indicators of success were collectively drawn from the data. Disagreements among the analysts were settled by consensus. Note that the indicators under each of the domains are not structured to strictly parallel each other; the data are presented in this manner to limit the size of the tables. Thus, the presence or absence of a particular indicator generally characterizes whether a partnership may be considered successful or challenged within that domain.

When analyzing these implementation activities and outputs critical to successful launch, it should be noted that the initial inputs into the program and the program’s environmental context also influenced the partnership’s launch. We applied a similar qualitative approach to analyzing these elements, with progress being defined as achieving programmatic goals more generally, rather than specifically for each goal.

Tables 1, 2, 3, 4 and 5 present the critical implementation activities and outputs that were associated with a successful launch of the partnership, as well as with a challenged launch, by each of the five VANA goals.

In this systematic evaluation of a nationwide academic-practice partnership program conducted during the VANA program’s Launch Year, we identified indicators of both successful and challenged launches. These indicators are the results of our observations obtained during the launch of the 15 ongoing academic-practice partnerships that were established between nursing schools and proximally-located VA medical centers. VANA’s nationwide breadth combined with the variation in the structure of each individual VANA partnership, allows this study to provide more generalizable information on academic-practice partnerships than prior studies that have been limited to small samples in single locations [6].

Five key themes emerge from this analysis. First, inter-organizational collaboration (“teamwork”) is a critical factor in enabling these partnerships to be successful. Such collaboration would include teamwork between direct and indirect participants across partnering institutions regarding specific issues, strategies, and decisions. Factors that facilitate building strong collaboration include prior working relationships and personal contact between leaders of the partnering organizations (often borne from preexisting clinical education relationships), a sense of equal participation and equitable burden on partners, clear and realistic expectations of the benefits and responsibilities of each party, and building ongoing and frequent opportunities for formal and informal communication between program participants at all levels. These processes were challenged when leaders failed to commit the time and effort to establish and maintain the collaboration, when informal communications were weak, when formal meetings and communications were sporadic or limited, and when commitments such as achieving enrollment targets or providing clinical instructors or preceptors were not fully met. In the VANA program, developing a proposal for funding from VA provided a vehicle for defining how the collaboration would be structured and time to consider issues before implementation began. In other contexts, where no such external mechanisms exist, the experience of the VANA sites suggests that formal, intensive planning processes will be invaluable to successful implementation.

Second, major challenges to creating the partnerships arose not just from blending different cultures, but also from having to integrate activities across divergent organizational processes and constraints. In the VANA context, for example, time keeping requirements and expectations about working on site for those working directly for the VA facility (as opposed to those working at schools of nursing) clashed with the nursing school’s expectations about time commitments across and between semesters. Similarly, nursing faculty expected greater flexibility to prepare for classes and grade assignments off-campus. Not all these challenges were anticipated during the planning stages, and sites differed in the speed with which these challenges were identified and addressed. In the VANA program, subsequent cohorts learned from earlier cohorts and better anticipated these challenges. The issues of operational integration identified in Table 1 should be expanded and extended to examine the experience of non-VA partnerships to see whether they differ from what we observed.

Third, there are specific challenges associated with identifying and recruiting nurses in clinical settings to take on faculty roles in a timely fashion, expanding the number of students recruited to programs when additional faculty are made available, and scheduling clinical and didactic courses. In the VANA program, these challenges were common across a number of sites. In some cases, these challenges proved daunting and substantially weakened the partners’ commitment to the success of the partnership. Expectations about ramp-up time need to be realistic, and operational problems should be closely and continually reviewed on a joint basis by partnership leadership.

Fourth, expectations for these partnerships extended beyond merely building faculty or increasing the number of students and included such activities as using nursing school faculty to improve the use of EBP in clinical settings or increasing the use of simulation-based learning for in-service training of nursing staff. Oftentimes, planning for these activities and how they would be implemented was much less well developed than were the plans for expanding clinical and didactic education. Implementation was thus more inconsistent. Partnership planning and management need to be more explicit and detailed about how these components of a partnership are to be implemented. Nevertheless, based on the partnerships that we observed, it would appear that such efforts are better aimed at implementation after the Launch Year in a sequential planning and development process. Our findings contain lessons that can be applied to these efforts. Moreover, this theme suggests that academic-practice partnerships may be an effective means to achieve the full involvement of nurses in efforts to improve practice environments and outcomes of care as called for by the Rob Wood Johnson Foundation Initiative on the Future of Nursing in its 2011 report [20].

Finally, the immediate drivers for the VANA initiative – a critical nursing shortage, the desire of the VA to address it by adding clinical nursing faculty, and VA’s goal of increasing nursing student interest in employment at VA facilities – have been tempered by the economic downturn and the temporary easing of the nursing shortage. Nonetheless, partnerships are long term commitments for both clinical sites and nursing schools. Partners need to find ways to build stable relationships based on long-term interests and commitments even as they adjust to short-term changes in the supply and demand for nursing care.

The present study focuses on the critical elements of a successful academic-practice partnership launch, as informed by three successive annual cohorts. As the partnerships continued to evolve after the first year, it became evident that, as expected, partnerships responded in various ways to the identified challenges. Therefore, while we believe that the launch year is critical to a program’s eventual success, it should be recognized that partnerships evolve over time by confronting existing challenges and responding to new challenges. For VANA, this organic process benefited from interactions between the partnerships and also from the involvement of VA Headquarters personnel. Future studies will examine the growth of the partnerships and address the long-term effectiveness, efficiency, and sustainability of the VANA program.

The AACN-AONE Task Force on Academic-Practice Partnerships recommended a number of principles to guide such partnerships. These principles include collaborative relationships, mutual respect and trust, and shared knowledge, as well commitments to maximizing the potential of all nurses, effectively transitioning them into practice, highlighting their academic achievements, redesigning practice environments, and analyzing the needs of the nursing workforce [15]. While aligned with these principles, our findings suggest more specific implementation strategies for launching academic-practice partnerships. The critical implementation activities and outputs that emerged from our research provide a more basic level of operational guidance for implementing such partnerships, although some, such as those critical for promoting collaboration (Table 5), directly address a Task Force principle (collaborative relationships) as well.

While the framework we present can serve as a guide to best practices for establishing academic-practice partnerships [6],[21],[22], some limitations to our study should be acknowledged. First, each of the domains that influence partnership performance includes observations from our site visits that we believe delineate whether a partnership’s performance can be characterized as successful or challenged. The indicators of relative success of a partnership in a particular domain are based on our actual observations and not necessarily indicative of ultimate success in the latter stages of partnership development. Second, each of the domains represents different influences on performance and should be considered independently. In other words, partnerships could be viewed as successful or challenged in one or more of these domains, but when all of the domains are considered together, the overall partnership could still be considered to have largely met VANA’s programmatic goals overall. Finally, all of the studied partnerships include only VA as the practice partner. Thus, our results may not generalize to other practice partners due to dissimilarities of VA healthcare institutions compared to others in the same communities.

Although our evaluation examined academic-practice partnerships within nursing, it is likely that our framework would be applicable to academic-practice partnerships that involve other clinical practitioners. Future work should examine whether this Critical Elements approach is applicable to partnerships that include other types of healthcare professionals.

Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. This can be a daunting task. Furthermore, understanding how these partnerships emerge, and are nurtured and challenged also requires adopting a conceptual model in which partnerships can evolve over time as they learn from experience and attempt to address operational challenges. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. The findings provide practicable, actionable guidance on strategies for successfully launching academic-practice partnerships in nursing. By paying attention to the critical implementation activities and outputs identified here, decision-makers will be able to make better informed decisions about how to structure an academic-practice partnership for greatest success during the critically important initial year of the partnership’s creation.

^aFull details of the grant requirements of the VANA partnership model are described in Bowman et al., [5].