Indices of successful partnerships in academic and clinical nursing: A literature review

The purpose of this literature review was to systematically evaluate prevailing literature to identify indices of successful academic and clinical nursing partnerships. A multiple database search was used and of 131 documents from 2008 to 2018, eight articles were reviewed and met both inclusion and exclusion criteria. The systematic review yielded three emerging themes in sustaining academic partnerships namely: Valuing Partnership, Collaborating-Transforming Leadership and Learning from the Outcomes. The findings of this study will facilitate thorough understanding of academic and clinical partnership concepts, and propose a pragmatic future investigation towards policy formulation and sustainability.


Introduction
*The integration of theory and practice is described as a cyclical process to effective nursing care leading to good learning experiences and effective education leading to effective nursing care (Weatherston, 1981). This integration begins at nursing education institutions that prepare graduates to use current knowledge, theory, and research to develop the ability to evaluate nursing care outcomes, participate and utilize research findings and most importantly to reshape the health care delivery system. This collaboration empowers nursing leaders in academia and practice to improve the profession and to create "a powerful coalition" (Petersen, 1981) that achieves a holistic transformation from student to professional and such collaboration will maneuver the most debated issue in bridging the gap between theory and practice notably described since 1943 (Higginson, 2004). Ousey and Gallagher (2010) observed that from the time Australia, Canada, New Zealand, the United Kingdom, and the United States moved nursing education out of its traditional hospital base into colleges and universities, there had been a longstanding physical separation resulting in a failure to apply theoretical learning in clinical application and this gap is increasing (Spouse, 2001). According to Weger et al. (2004) there is a "dissonance between desired learning and demonstrated learning"; while from the lens of clinical practice, there is a lack of awareness of the theory that guides a practice or the failure to incorporate research in current nursing practice (Hanberg and Brown, 2006). Further, Higginson (2004) espoused that a gap exists because of a lack of research education and appreciation of research in nursing education; most research activities are conducted by academicians and results are seldom disseminated in clinical practice. However, when research-based evidence is implemented within the clinical environment, it is usually seen by clinical nursing staff as irrelevant, too academic and of little practice value (Ousey, 2000;Higginson, 2004). Although several attempts have been made to reverse this, issues remain, including failure or excessive lag time in incorporating or deleting clinical practices based on current evidence; and problematic outcomes such as diminished patient care and inefficient nursing practice (Hanberg and Brown, 2006). Today, nursing leaders address a myriad of issues including faculty and clinical nursing staff shortages, inadequate college preparation, redesigned nursing roles, a heightened need for evidence-based practice, the impact of regulations, generational differences, information technology, rising health care costs, and other international forces associated with globalization (Adams and Scheuring, 2000;Cuellar and Zaiontz, 2013). Efforts have been made to transform the nursing profession through strong academic and clinical partnerships since the 1950s to strengthen professional regulation that employ strategic, rather than operational, oversight for nursing (de Geest et al., 2010;Cronenwett, 2011). This partnership underpins the goal of nursing to harmonize the strategic initiatives of different nursing organizations throughout the globe, no matter where nursing is practiced.

Purpose
Despite many academic and clinical nursing partnerships, there is still a gap in the body of knowledge that addresses the indices that describe how these collaborations are sustained. The purpose of this literature review was to systematically review prevailing literature to identify indices that lead to a successful academic-practice partnership and to facilitate thorough understanding of the concepts that promote academic and clinical partnerships in order to propose pragmatic strategies towards policy formulation and sustainability.

Method
This study utilized a systematic literature review. It is a method to "retrieve, sort and analyze the literature from [peer-reviewed journals] comprehensively and reproducible by peers" and this process was adopted from guidelines proposed by Im and Chang (2012). Multiple databases of published literature from refereed journals between 2008 and 2018 were retrieved from Ovid ® , ProQuest ® , CINAHL ®, and MEDLINE ® . From key search words: Academic, clinical, practice and partnership, 131 articles written in English were found through full text or abstracts. Table 1 shows the systematic search process referring to the participants, the phenomenon of interest and context.
The abstracts or full-texts of the 131 articles were reviewed. Inclusion and exclusion criteria: (a) only those published in English, (b) peer-reviewed in reputable nursing journals, (c) written by nurse authors from various settings, (d) "focused on the process of professional socialization in the nursing context" (MacLellan et al., 2011), and (e) solely based on academic-practice partnerships in nursing, resulted in selecting 8 articles for close review. Relevant grey literature was not considered. The search flow process based on the PRISMA framework was presented in Fig. 1.  Im and Chang (2012) suggested it is essential when conducting a systematic literature review, to embed the process in a theoretical perspective to guide the analysis of the articles, though, it is not a Records identified through database searching (n = 131)

Included Eligibility Identification
Records after duplicates removed (n = 44) Records screened (n = 28) Full-text articles assessed for eligibility (n = 18) Full-text articles excluded, with reasons (n = 10) Qualitative and quantitative synthesis (n = 6) Studies included in quantitative synthesis (n = 2) common practice. However, for integration, analysis, and application, this study based its theoretical perspective on the Critical Social Theory of Habermas. This theory posits that to effect change and self-understanding, one cannot be constrained by socioeconomic and cultural issues (Ekstrom and Sigurdsson, 2002).
To assess the credence of articles in this review, this study adopted the quality appraisal tool used by Nabavi et al. (2012). This tool ensured that peerreviewed articles met the criteria for relevance, significance, and quality along with the literature review process (Im and Chang, 2012). The quality appraisal tool describes the clarity of experiences in the implementation, goals, outcomes, and requisites to sustaining academic and clinical partnerships. To maintain accuracy, consistency and non-biased judgment, inter-rater reliability was utilized by the primary researcher and two other experts in the research that resulted in the selection of the 8 articles. Then the articles were printed, reviewed and coded. Reviewed articles that met the "inclusion and exclusion criteria" were summarized in Table 2 based on content. This facilitated integration and synthesis by which similar contents were fused and analyzed thematically. Statistical data analysis was not possible in the literature review, thus AtlastTi® was used to ascertain that coding and indexing were appropriately undertaken; analysis and interpretation were done by the primary researcher. The summary of the literature for systematic review was shown in Table 2.

Results
Based on the current literature review that described the successful implementation and requisites of sustaining partnerships, three themes emerged namely: (a) valuing partnerships, (b) collaborating-transforming leadership, (c) learning from outcomes.  Provide the opportunity to meet children's health needs and to improve the practice in school settings Beal et al. (2011) Learning from the outcomes of best-established practices in academic-practice partnerships Hallmarks of best practices in academic and clinical partnerships

Valuing partnerships
Valuing partnerships between nursing education and nursing service is imperative to strengthen collaboration, and encourage a strategic alliance. Existing literature shows an increased interest in academic and clinical partnerships since the 1980s to find the links and connectivity of education and care services provided to the stakeholders to effectively produce quality graduates, respond to the societal needs in the healthcare workforce and improve patient care outcomes (Frank, 2008). To achieve these goals, quality education is required to ensure the competence of future nurses. Factors associated with competency building have been linked to the preparation nurses receive during their foundational education. The NLN (2003) Position Statement on Innovation in Nursing Education: A Call to Reform, requires collective mandates on quality standards of nursing education to prepare the nurses for practice. NLN further proposed that intensive education includes both education and clinical service industries (hospitals and other care institutions) to prepare future nurses for a more hybrid healthcare environment. Valuing partnerships between academia and clinical services encourage a culture where evidence-based practice is stressed. This type of partnership allows academic and clinical services, utilizing evidence-based practice in care paradigms, will allow both institutions to foresee problems and be able to identify and evaluate them (Frank, 2008). Technological advancements have increased anxiety in the profession since they may require innovative interventions that have not been taught in schools and healthcare institutions (Sowan et al., 2004). However, working collaboratively provides a strategic approach that can accelerate adaptation and response to technology.
From the recent systematic review, the process of forming partnerships is dependent on the mutual benefits and interests of both education and clinical services. If issues are clearly identified by both organizations, such as lack of academic and clinical staff, how to implement quality, knowledge transfer, and the lack of clinical learning environments for students, more tangible and effective solutions are to be developed (Nabavi et al., 2012).
Outcomes research has proven that valuing the partnership between academia and clinical settings increased educational capacity and qualifications of both entities, created a strong framework of evidence-based culture and practice, increased opportunities for continuing education and staff development, and student placement and employability (Barger and Das, 2004;Smith and Tonges, 2004;Fetherstonhaugh et al., 2008;Horns et al., 2007).

Collaborating-transforming leadership
The success of academic and clinical partnerships is through collaborating-transforming leadership. According to Nabavi et al. (2012), if competition between academic and clinical organizations still exists it needs to be abrogated. If the goal is to establish strategic alliances to effectively implement various strategies for the common goal of sustaining excellent education and service outcomes, the competition will no longer exist. The IOM (2010) strongly recommended that a partnership between academic educators and health care organizations needs to be framed to willingly "develop and prioritize competencies so curricula can be updated regularly.to meet the current and future health needs of the population". This avers that these partnerships are expected to yield better outcomes including increased enrollment and a more resilient nursing workforce that can adapt to changes in healthcare (Allen et al., 2007;Stanley et al., 2007). A collaboration that shares decision making in planning what is best for the partnership, shares goals and objectives, crafts strategic approaches to gain deliverable outcomes, can transform nursing education and nursing service industries, including potentially increasing productivity and decreasing a company's health care costs (Clark, 2003;Jahng et al., 2005). Partnerships require courage and a vision to come together as outlined by Foss et al. (2003).

Learning from the outcomes
Certainly, effective outcomes of academic and clinical partnerships are important, but what is most imperative is the sustainability of the strategic alliance amidst shifting paradigms in the healthcare delivery system. The growing need to adapt, respond, innovate and revolutionize e requires more than just the implementation or evaluation of processes and products. This can be done through communication, sharing resources, interactive learning, and the use of nursing expertise (Campbell and Jeffers, 2008;Xu et al., 2002). Frank (2008) said faculty must be engaged to facilitate the growth of partnerships. Conducting interdisciplinary scholarly research with clinical staff may build a strong commitment towards a culture of evidence-based practice and strengthen the research because it is not solely academic driven (Burrage et al., 2005;Frank, 2008).

Discussion
While the evidence is abundant to supports building academic and clinical services partnerships with specific established goals, there is a paucity of information that speaks to sustaining these initiatives (Nabavi et al., 2012). This systematic review identified the existing literature that outlined attributes beneficial to sustaining academic and clinical partnerships. The literature review approach in this study used guidelines proposed by Im and Chang (2012) and did not include the author's search, other grey literature, and unpublished works in the review process. The idea for this study emerged from a realization that sustaining the growth of partnerships and learning from the outcomes of previous successful projects that are essential in both nursing education and nursing service. Partnerships have been recognized as a strategy to respond to dramatic changes that are inevitable in the nursing profession and to achieve quality outcomes that benefit stakeholders in both industries.
Sharing a vision purports that partnerships will yield better organizational performance and sustainable results. This literature review revealed some effective examples. The University of Alabama Capstone College of Nursing with DCH Regional Medical Center, Tuscaloosa, Alabama (Barger and Das, 2004) developed a system that evaluates the performance of graduates through a shared leadership to determine the competencies required by graduate nurses to transition from school to practice through a culture of flexible problemsolving served to translate theory into practice. The input of each paradigm (academia and clinical services) resulted in quality graduates who met the needs of that facility and could deliver improved patient care outcomes (Heller et al., 2000;Campbell et al., 2001;Granger et al., 2012). Continuing professional education, training, and development, and the engagement of students, faculty and nursing staff in a culture of research contributing to evidence-based practice strengthens collaborations between academic and clinical services. This is the existing practice between The University of North Carolina at Chapel Hill and the University of North Carolina hospitals. In addition to valuing partnerships, is support for student financial needs and graduate placement (Cronenwett, 2004;Smith and Tonges, 2004). Despite being on opposite coasts of the U.S., California State University at Los Angeles and the University of Massachusetts at Amherst, have forged an effective partnership (Williams and Widman, 1998). The University of Texas Medical Branch at Galveston values its partnerships with clinical service, with research by faculty and staff on quality care delivery services, consequently, reducing the costs to service partners (Schultz et al., 1997;Watson et al., 2006).
The findings of the study revealed that to sustain a partnership it is imperative to earn buy-in from both academic and clinical services, to foster collaborative-transformative leadership to address issues such as shortages of qualified faculty and clinical nursing staff, scarcity in clinical learning sites, and lack of nursing school capacity to effect better student outcomes. Innovative approaches to addressing these issues can come from transforming nursing education and clinical service partnerships. For instance, efforts made between nursing schools in Oregon and Hawaii created statewide nursing consortium curricula; transcending the traditional approach with a more innovative partnership by an urgent call for transformation (Stanley et al., 2007). This resulted in a seamless transition to a bachelor's in nursing degree for nurses with associate degrees after one additional year of full-time study. State-bystate initiatives have brought together health care administrators, academics, state regulators, and legislators to increase the number of graduates. Other collaborations have increased nursing capacity (enough seats in a classroom, enough jobs, etc.) between practice and education (Allen et al., 2007); student national nursing certification rates and positive student learning outcomes (Tanner et al., 2008) and smoother adjustment to the professional nursing role (Udlis, 2008). Furthermore, service industries (hospitals and other care settings) benefitted through collaborating-transforming leadership as exemplified in the partnerships between academic and clinical service (Kelly and Starr, 2013). Reshaping evidence-based literature is becoming more ubiquitous. The academic-clinical service partnership yielded preventable readmissions; improved quality and coordination across the continuum of care (Kelly and Starr, 2013).
Learning from empirically-based outcomes in building academic and clinical partnerships will strengthen the nursing capacity to establish nexus on the quality standards and outcomes initiated by the organizations. One question that arose from the literature review was how to sustain the collaborations. Despite lack of funds, a partnership between the Humboldt State University Nursing Department and St. Joseph's Health System, Humboldt County, California, was able to continue the program by sharing resources and expertise. In their program, student nurses served as boosters for the program to get the attention of philanthropic organizations. Known as Humboldt Care Transitions Program, the collaboration has contributed to improved patient safety and increased patient satisfaction, while decreasing the cost of care and avoidable re-admissions (Kelly and Starr, 2013).
Since the early 1980s, academic and clinical partnerships have been established and are being continued to benchmark the best indices that guarantee meeting the standards of quality nursing practice. This can be utilized as a framework for the organization to meet and maintain continuous quality improvements and build a culture of care supported by evidence (Bender and Schuh, 2002;Millett et al., 2008).

Conclusion
Academic and clinical partnerships are a strategic approach to strengthening nursing education and professional practice that resulted in empiricallybased outcomes, including professionalization of student roles; transition from classroom to practice; research engagement of students, faculty and clinical staff for evidence-based practice; selection, retention and recruitment of quality graduates; excellent performance in the licensure examination; and improvement of students' academic performance. Partnerships facilitate the goal of better patient care outcomes, patient safety and encourage a culture of quality, decrease readmission rates, encourage clinical research and increase commitment to excellent patient care. Based on the outcome of this study, the literature is replete with examples of successful collaborations. However, the literature lacks studies that identified the requisites for sustainable processes and outcomes for academic and clinical partnerships. This study thematized the requisites that may be helpful to nursing education and clinical nursing services. Partnerships that meet the needs of both key players and stakeholders, while maintaining the collaboration, allow the partnership to become more responsive to paradigm shifts, innovations, and technological advancements. Learning from outcomes through benchmarking can facilitate strengthening and sustaining the partnership. To this end, further investigation of barriers to building collaboration or partnerships between nursing education and nursing clinical services within a socio-economic-demographic, political and cultural context needs to be undertaken.