Partnership between academic nursing and clinical practice: A qualitative study

Objective: To assess the impact of a partnership between a nursing school and a large-scale urban hospital on healthcare education, practice and research. Methods: The qualitative study was conducted from April 2013 to January 2014 at a nursing school and an urban hospital at University of Pennsylvania, Philadelphia in the United States, and comprised health professionals including nursing faculty members, nurse clinicians and nurse managers from the two institutions. Data was collected through in-depth interviews using an open-ended questionnaire. Data was subjected to qualitative content analysis. Results: Of the 16 health professionals, 8(50%) were faculty members at the school of nursing, and 8(50%) were nurse clinicians/manager at the hospital. Major themes that emerged were mutual gains and benefits; clinical educators as the cornerstones of the partnership; leaders as key actors; and roadblocks to sustaining collaboration. The partnership benefitted both parties, particularly those in clinical practice, despite some challenges to long-term sustainability. The roles of clinical educator and team leader were critical in both settings. Conclusion: The partnership between academics and practice carried critical importance in terms of enhancing quality patient care, student training, professional development and increasing research capacity.


Introduction
Academic/Practice-Clinical Partnerships (APPs) play an important role in strengthening nursing education, increasing research capacity and improving patient care. 1- 3In 1990, the American Association of Colleges of Nursing (AACN) 4 published a declaration recommending that educational and clinical institutions engage in effective partnerships to achieve excellence in nursing practice, nursing education, and training and research.In 2010, the Institute of Medicine (IOM) released its highly anticipated Report on the Future of Nursing, 5 which called for significant changes in nursing education to reduce medical errors and improve health outcomes, 1,5 as well as major initiatives to redesign both nursing education and practice in order to better prepare nurses to lead during and beyond healthcare reform. 1,5n the profession of nursing, APPs are generally defined as strategic relationships established between educational and clinical practice settings to advance their mutual interests related to practice, education and research. 5veloping partnerships between higher education and clinical practice is an essential tool for enhancing healthcare education and practice, but establishing and maintaining such relationships is often difficult after the end of the first year.There is a need for information on the impact of long-lasting partnerships on education, healthcare and research. 6The current study was planned to identify factors that facilitate and hinder collaboration between a nursing school and urban hospital, and to examine the impact of their partnership on nursing education, practice and research.

Subjects and Methods
The qualitative study was conducted from April 2013 to January 2014 at a nursing school and an urban hospital at University of Pennsylvania, Philadelphia in the United States, and comprised health professionals including nursing faculty members, nurse clinicians and nurse managers from the two institutions.Data was collected through in-depth interviews using an open-ended questionnaire.Purposeful sampling was employed because the participants were already involved in a partnership model between a hospital and school of nursing, 7 and saturation principles 8 were applied by using the following three inclusion criteria: being a faculty member at the nursing school, being a nurse or nurse manager working at the hospital, and being fluent in both verbal and written English.There were four main research questions: What kinds of factors influence partnerships between academic and clinical sites?; How do partnerships impact on education, practice, and research in both school and clinic?;What are the benefits of academic-clinical partnerships for both settings?;What roles in each setting are important to the sustainability of partnerships?Each interview session lasted 40-60 minutes.All digitally recorded data was de-identified, and the participants were assigned a number.The researcher requested clarification and further elaboration of the students' responses when needed for data saturation.Ethical approval for the study was obtained from the institutional review board of University of Pennsylvania, Philadelphia in the United States.
Participant's answers were audio-taped and transcribed verbatim for content analysis 9 , and a thematic analysis extracted key themes pertaining to the research objectives by grouping words, phrases and statements with similar meanings into categories.The final coding and themes were approved by an external expert through consensus.Initially, there were five major themes and 32 sub-themes or categories.However, data analysis continued until the point of saturation, at which point 32 sub-themes were collapsed into nine sub-themes and organised according to a condensed group of four major themes.Methodological robustness was enhanced by taking measures that ensured validity, reliability and rigour. 7

Results
Of the 16 health professionals, 8(50%) were faculty members at the school of nursing, and 8(50%) were nurse clinicians/manager at the hospital.Overall, 15(94%) were females, and 12(75%) had been employed for 10 years or longer.
Themes that emerged were mutual gains and benefits; clinical educators (CEs) as the cornerstones of the partnership; leaders as key actors of the partnership; and roadblocks to sustaining the partnership.The definition of each theme was developed based on the participants' statements.
Under mutual gain and benefits, three sub-themes were identified: shared expertise, resources, and opportunities; increased quality of education; and contribution to the overall institutional reputation.
Most of the participants reported that shared expertise, resources and opportunities (e.g., work experiences, resource-building, power, human resources, financial capabilities and mutual sharing of opportunities) accruing from APPs were both institutionally and individually beneficial for the parties (i.e., the nursing school and the hospital).One clinic participant reported that "…the hospital is a giant laboratory for researchers and students, and the school was a power centre of theoretical knowledge" (Participant M).All of the participants reported that close cooperation increased communication, thus providing both sides with the opportunity to better understand each other and helping to build a common culture --or, as one of the participants claimed, "…this close collaboration also provided a blending of cultures and a common language…" (Participant B).All participants reported increased quality of education, such that students were educated in a strong academic programme and also had the opportunity to practise in a positive environment at a progressive hospital.One respondent reported that "… our students were granted a good quality of education and the faculty was able to transfer not only theoretical, but also practical knowledge into the classroom" (Participant F).
Most of the participants reported that both institutions were already reputable organisations, but collaboration contributed a great deal to further enhancing their standing.In particular, the respondents stated that the scientific studies conducted by the chief nursing officers and CEs and the evidence-based healthcare models they developed made a significant contribution to the visibility of nursing services at the institutional and national levels.One clinical participant reported that "…thanks to the collaboration, they published their works and attended to many national and international conferences" (Participant N).Another respondent informed that "we had the magnet hospital.As a result, our hospital had a very good reputation in nursing, mostly since they built it through the partnership" (Participant H).
Under the second theme, CE as the cornerstones of the partnership, all participants agreed that the CEs, who perform dual roles as faculty in the school of nursing and CEs in the hospital, were cornerstones in the sustainability of the partnership, and one sub-theme identified was that "…CEs are the bridges between the two worlds."The respondents perceived CEs as the key persons in the partnership who played a role in eliminating the gap between theory and practice and facilitating mutual understanding between the two sides: "they were familiar with both environment and could understand each side better; therefore, innovations could be transferred to both sides simultaneously" (Participant D).The majority of the participants believed that the CEs contributed significantly to the knowledge and career development of nurses working in clinical roles, which some attributed to CEs taking their research questions from the real world of practice and developed models of care that ultimately resulted in positive patient outcomes.
Under the theme, 'Leaders as key actors', two sub-themes were identified: there should be leaders that believe in the importance of collaboration and both leaders --the dean and the chief nursing officer --should have good communication and a broad vision.
All the participants believed that the leaders' belief in the importance of collaboration was vital in sustaining the partnership and achieving success.One respondent opined that "if both managers had not believed in partnership and opened their doors to one another, it would have never worked" (Participant K).The participants emphasised the significance of leaders for collaboration and agreed that the leaders needed to possess sound knowledge of both the hospital and academic world.
As for the fourth theme, 'roadblocks to sustaining collaboration', four sub-themes were identified: it is not always easy to work together; difficulty in measuring direct cost-effectiveness; financial issues; and two different worlds/cultures.
In general, the participants reported that collaboration was mostly challenging due to differences in the organisational cultures, discontinuity between demands, the extra workload due to the dual role, and being responsible to managers in both settings.One CE explained that it was difficult to engage two different cultures and worlds in the working area (Participant M).In particular, the CE participants reported feeling challenged by the need to create balance between the two institutions: "… they had to think according to two individuals and two managers whose priorities were different, as well as on two levels, and they had to keep a very good balance between them" (Participant D).Almost all of the respondents reported lacking any concrete data as to whether the APP had a direct impact on costs.Participants observed that it was difficult to isolate the effect of cost from the multiple additional factors related to patient outcomes.One senior manager reported that "…it was very difficult to conclude that the partnership either increased or reduced costs, as there were many factors influencing the costs…" (Participant L).
Clinicians, CEs and executive nurses particularly believed that the partnership had a positive impact on costs by accelerating the healing process of patients and reducing hospitalisation length, reasoning that patient satisfaction increased, complications reduced, and patient recovery and hospital stay periods became shorter, indicating that costs were positively affected and the hospital could earn money as a result of the partnership.
Many of the respondents believed that the partnership also provided motivation and synergy, thereby preventing nurse turnover.
The financial issue was more commonly reported by the CEs and clinicians, several of whom expressed concerns that budget shortages at the hospital might hinder sustaining effective collaboration by reducing financial support for this aspect of CEs' roles.The clinicians reported that CEs losing their jobs would have a negative impact on training and patient care.
Despite emphasising the importance of collaboration and partnership, clinicians and CEs defined themselves as two separate organisations, as reflected in continuous references to the institutions as "two sites," "both sites," "two worlds," and "different cultures."One participant reported that the two sides needed each other, but another acknowledged that "it was very difficult to engage in different cultures in the working environment" (Participants C and M).

Discussion
The study demonstrates the potential for mutual sharing of specialties, resources and opportunities to strengthen education, healthcare practice and research among members of both institutional partners of APPs.The mutual sharing of experiences and opportunities provides faculty members with a positive research environment and enhances career opportunities for nurse clinicians.Inter-organisational collaboration facilitates mutual understanding and effective communication through creation of synergy and a common language, which ultimately improves the quality of student training.The study's results align well with findings from previous studies. 1,2,10,11Murray et al. 12 found that students were better involved in clinical settings at institutions where the partnership was available, showing high levels of critical thinking as well as clinical decision-making and research skills.Similarly, Debourgh 13 reported that academic and service partnerships improved safety by augmenting the quality of existing knowledge and increasing students' confidence in their ability to positively impact patient care outcomes.Some studies have found student training to be the most significantly influenced component from the academic-service partnership. 2,14This notion was supported by participants in this study, who believed that the partnership significantly improved their regional and national credibility.Smith and Tonges 15 suggested that strong and visible nursing services require quality projects and dual-titled staff, which is only possible through APPs.
7][18][19][20] Parslow 19 reported that clinical faculty valued its experiences bridging the gap between theory and clinic by sharing practical knowledge and skills with the academic community.In a study by Svejda et al., 20 students reported increase in their self-esteem and competence in patient care as a consequence of working with experienced health professionals.
The identification of leaders as key actors sustaining APPs reflects a belief that their broad vision and good communication skills are instrumental in the continued success of such partnerships.The result identified in this study are also consistent with those reported by Smith and Tonges. 15Another important finding was that assigned leaders are expected to appreciate the benefits of a partnership between academia and practice, which echoes findings from a study, 21 wherein the leaders emphasised the significance of willingness for the partnership, and asserted that collaboration helped overcome difficulties more easily.
An effective leader should anticipate changing health needs in the world and in his/her own country and remain abreast of advancing technology in health services so as to better shape nursing education and patient care.Therefore, the advancement of education and care requires that both sides believe they need each other's area of expertise.
The results of this study indicated that it is not always easy for members of two different cultures (academic and hospital) with different agendas, to collaborate, which is also consistent with previous studies. 1,22Most of the participants in our study suggested that the best means of overcoming the difficulties posed by two different cultures and agendas was to clearly delineate common goals, advantages and opportunities.Nurses participating in a study by Beal et al. 23 identified culture clash, lack of time and resources, lack of stability in leadership politics, staff workload, and misperceptions as barriers to sustaining academic-service partnerships, and McDonald 24 similarly found that nursing faculty was hindered by issues related to insufficient knowledge, culture and support as well as clinical practice salaries and workloads.However, Beal et al. 1 also listed additional barriers to academic-service partnerships, such that faculty were often not prepared, faculty had too many students, faculty was disrespectful of staff, and a lack of normalised rules of engagement for faculty and staff.Based on our study results, the two institutions should develop strategies for orientation, respectful behaviour, clear delineation of roles and engagement to ensure that the partnership is accepted and successfully maintained.
Our findings also emphasised the difficulty measuring the direct effects of APPs on healthcare costs.Although the participants believed that clinical work, patient satisfaction, and reduced infection rates positively affected hospitalisation duration and re-admission rates, no empirical data in the literature was available to verify these perceptions.De Geest et al. 2 reviewed a total of 114 articles describing 119 academic-service partnerships and reported a great gap in literature in terms of studies evaluating the economic impact and success of APPs.Previous findings indicate that contribution of a partnership increases an institution's income; however, there are no study findings, including ours, that address the direct impact of financial factors.In other word, studies are lacking that identify variables associated with APPs that specifically (or directly) have an impact on costs.A review of our findings suggests that patient care is shaped by a range of tangible and intangible factors such that it is difficult to pinpoint the effect of the academia-practice partnership.Therefore, we conclude that there are methodological challenges to measuring the direct impact of a partnership on patient healthcare costs, and cost measurement remains a fertile field for further studies.
The language used by the participants was also interesting.The lack of full integration was evidenced by the fact that despite the apparent successes of the partnership, respondents defined themselves as members of two separate organisations, although they also consistently acknowledged the need for this partnership.The clinicians regarded the school as a place that provided them with support and counselling.Some of the participants perceived the partnership as a model created in accordance with certain rules and objectives under the initiative of the leaders of the two institutions, and a number of the respondents expressed concerns that the partnership would end if those leaders left for new roles or lost interest in devoting energy to the collaboration.

Conclusion
Powerful partnerships were found to build strong systems that enabled the nurses to increase their practical and academic knowledge, thus broadening and deepening their qualifications and paving the way for lifelong learning.Reliable instruments should be developed to accurately measure and evaluate the contribution and cost-effectiveness of such a partnership to the institutional mission and patient outcomes.

Disclaimer:
The abstract was presented at the 15th National Nursing Congress held at Erzurum, Turkey from September 10-12, 2015.