Creating and Sustaining Academic–Practice Partnerships: Lessons Learned

Creating and Sustaining Academic–Practice Partnerships: Lessons Learned

CREATING AND SUSTAINING ACADEMIC–PRACTICE PARTNERSHIPS: LESSONS LEARNED EILEEN BRESLIN, PHD, RN,⁎ MARY STEFL, PHD,† SUZANNE YARBROUGH, PHD, RN,‡ DIANE...

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CREATING AND SUSTAINING ACADEMIC–PRACTICE PARTNERSHIPS: LESSONS LEARNED EILEEN BRESLIN, PHD, RN,⁎ MARY STEFL, PHD,† SUZANNE YARBROUGH, PHD, RN,‡ DIANE FRAZOR, EDD, RN, CNE,§ KATHERINE BULLARD, MS, RN, NEA-BC,‖ KATHY LIGHT, PHD, RN,¶ MICKEY PARSONS, PHD, RN,# AND ASHLEY LOWE, MBA⁎⁎ This article outlines how one community's academic–practice partnership evolved over time as it sought to address the community's needs for a qualified competent nursing workforce. Both organization and system changes were essential in the establishment of formal structures to address nursing workforce shortage needs. Both practice and education leaders were actively engaged in setting the strategic priorities at multiple system levels in the creation of these formal structures. We anticipate that the formation of these new formal structures will advance and sustain our academic–practice partnerships. Five key lessons were learned: (a) change is inevitable, (b) leadership matters at all levels, (c) succession planning is essential, (d) persistence toward established goals is necessary, and (e) relationships are the glue to sustain forward movement. (Index words: Academic; Practice; Partnership; Lessons; Learned) J Prof Nurs 27: e33–e40, 2011. © 2011 Published by Elsevier Inc.

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Background

HE CURRENT NURSING shortage and difficult economic times and the changes in health care demographics challenge academic institutions and health care organizations to rethink their relationships with each other and align in new ways to meet the need for a qualified, competent professional nursing workforce (Hewlett & Bliech, 2004; Reinhard & Hassmiller, 2009; Warner & Burton, 2009). This realignment is crucial

⁎Dean, The University of Texas Health Science Center at San Antonio, School of Nursing, San Antonio, TX. †Professor and Chair, Department of Health Care Administration, Trinity University, San Antonio, TX. ‡Associate Dean for Undergraduate Nursing Program, The University of Texas Health Science Center at San Antonio, School of Nursing, San Antonio, TX. §Dean, School of Nursing, Wayland Baptist University, Plainview, TX. ‖Regional Chief Nursing Officer, Providence Health and Services – California, Los Angeles, CA. ¶Dean, School of Nursing and Health Professions, University of the Incarnate Word, San Antonio, TX. #Professor, The University of Texas Health Science Center at San Antonio, School of Nursing, San Antonio, TX. ⁎⁎Development Officer, The University of Texas Health Science Center at San Antonio, School of Nursing, San Antonio, TX. Address correspondence to Dr. Breslin: UTHSCSA School of Nursing, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: [email protected] 8755-7223/11/$ - see front matter

given the needs of the local workforce to address recruitment and retention of nurses and nurse educators, changing nursing roles, and society's changing health care needs, all of which place different demands on our respective systems. A key way to realign is to engage in a partnership model. Partnerships require common values and interests, engagement in common goals, communication, respect, and mutual trust (Harvath et al., 2007; McNamara, 2000). Recognition of the importance of excellent innovative partnerships is occurring; however, the challenges are many (Kirschling & Ives Ericson, 2010; O'Neill & Krauel, 2004). Feldman et al. (2000) stated, “As these partnerships evolved, organizations, people and systems changed.” This article tells the journey of how one community's academic–practice partnership evolved over time as it sought to address the community needs for a qualified competent nursing workforce. We moved from being an informal group of nurse leaders committed to advancing the health of South Central Texas into two formal organizations, each with specific goals to advance our core mission, quality health care for South Central Texas citizens. We anticipate that the formation of these new formal structures will advance and sustain our academic– practice partnerships. We do so mindful of the changing context of the state needs for nurses.

Journal of Professional Nursing, Vol 27, No. 6 (November–December), 2011: pp e33–e40 © 2011 Published by Elsevier Inc.

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This effort was made possible through the generous support of the Partners Investing in Nursing's Future (PIN) grant, a collaboration between the Northwest Health Foundation and the Robert Wood Johnson Foundation, intended to support involvement and leadership of local foundations in advancing the nursing profession in local communities. We discovered, through work in the past 3 years, that organizations, people, and systems change. Sustaining the work of this grant required ingenuity, flexibility, and commitment. Because people comprise the organizations and systems, we will focus primarily on the organization and system changes. We believe these changes will provide a solid foundation for future work.

Organizations Two key organizations were instrumental in developing and sustaining the academic–practice partnership within our South Central Texas nursing community: the Nurse Executive Forum (NEF) and the Greater San Antonio Healthcare Foundation (GSAHF). A third organization, the Texas Team, has provided synergy and perspective to advance the local work to a state level. The respective contributions of each will be discussed, as will the evolution of each organization over the last 3 years. Within each, significant leadership changes occurred. Yet, the clear mission and goals of each sustained the organization changes.

Nurse Executive Forum Since 2005, the nursing community in San Antonio, TX, had a solid tradition of working together through the NEF created by the Greater San Antonio Hospital Council under the auspices of the GSAHF. The NEF provided a neutral home and forum to discuss and strategize nursing issues impacting the future of nursing in South Texas. The NEF brought together the chief nursing officers of the public and private sector hospitals and the nursing leadership from academia, including the deans of all the area nursing schools. Having all the players at the table at the outset of any initiative facilitated completion of projects and success in addressing issues identified. The first issue the NEF tackled was the lack of communication in the clinical agencies concerning nursing students' abilities. Staff nurses did not know the experience or competency level of the students assigned to their units. A consistent, standardized mechanism of communication and documentation was needed to facilitate student education and the delivery of patient care. Through the NEF collaboration between the health care systems and academia, the Clinical Passport was created. This is a pocket card that students carry which outlines the competencies they achieved through clinical practica. More precisely, it listed skills such as hand hygiene, asepsis, and medication administration, among others, that could be shared with staff nurses. This clinical passport is a simple example of how productive conversations in a nonthreatening collaborative atmosphere allowed for tangible results. Through

projects such as the development of the clinical passport, academic centers and agencies were no longer viewing each other as competitors but as partners solving the issues facing nursing in South Central Texas. The next project was based on the Texas Center for Nursing Workforce Studies' report on the magnitude of the nursing shortage in Texas. The numbers were alarming. Significant numbers of qualified nursing school applicants were refused admission (Figure 1). The primary reason for denied admission was insufficient faculty. In addition, it was predicted that almost 75% of existing faculty will either retire or be eligible to retire in the next 15 years. Furthermore, an estimated 25,000 RN nursing workforce shortfall is predicted for Texas by 2020 (see Figure 2). When we first started our work together, there were two baccalaureate (BSN), two associate degree in nursing (ADN), and one diploma program represented. This changed over time so that there are now three BSN and three ADN programs. All have turned away qualified students because of lack of faculty resources and student placement opportunities. The five major health care systems, both private and public, have all expanded, resulting in an increased demand for RNs. Mindful of these trends in workforce needs, another member of the NEF, who was also serving as the president of the Texas Nurses Association, presented a proposal to expand capacity of the clinical experience. The pressing question was: “given these data, how can we maximize existing teaching resources and expand the clinical education of our future nurses?” Creating three task forces within the NEF was the first step; each task force focused on a different element of the problem. The three areas were the following: (a) how and when nursing students are placed in the clinical setting, (b) consideration of modification of the clinical education models, and (c) identification of the existing clinical placement paradigm and strategies to modify the archetype. All task forces involved members from the academic and the clinical setting, thus increasing the likelihood of success in all strategies. As groups met during this exploration stage, it was determined that a fourth task force was necessary: (d) refilling the nursing faculty pipeline. Nursing faculty positions will always be a necessity, and insuring that there are available resources in 2020 to educate the next cohort of nurses is paramount to meeting the health care needs of the citizens of South Central Texas. Table 1 outlines each of the initial task force-specific responsibilities. In hindsight, these were very ambitious goals. Recognizing how each task force's work was related to the others' and building on its history of collaboration, the NEF committed to establishing the South Texas Acts for Nursing Development (STAND) project. The first draft of this proposed project was prepared by a graduate student in the nursing administration master of science in nursing program at the University of Texas Health Science Center at San Antonio. Through collaboration with nursing leaders of the six schools of nursing and five

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Figure 1. Texas Qualified Applicants Not Admitted (QANA) in Professional Nursing Programs, 2005–2010. Source: Texas Center for Nursing Workforce Studies. Student Admission, Enrollment and Graduation Trends in Professional Nursing Programs. April 2011. www.dshs. state.tx.us/chs/cnws/default.shtm.

major health systems via the NEF, commitment to this initiative was obtained. The initial STAND project was envisioned to maximize the current educational resources and plan for the future by grooming more nurses to be faculty. The major expected outcome was to build and maintain a substantial educational infrastructure in the San Antonio area.

All of this initial task force groundwork laid the solid foundation for the submission of the STAND project proposal that was eventually approved as a PIN collaboration in 2008. The NEF had a solid history of commitment to partnerships and solving community issues collaboratively and collectively, which were key prerequisites for PIN applicants. The “parent” organization of the NEF, the Greater San Antonio Hospital

Figure 2. Texas Professional Nursing Graduates Needed for Supply to Meet Demand, 2005–2020. Source: Texas Center for Nursing Workforce Studies. The Supply of and Demand for Registered Nurses and Nurse Graduates in Texas. November 1, 2006. www.dshs.state.tx. us/chs/cnws/default.shtm.

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Table 1. Original NEF Task Force Responsibilities • Preceptor model task force ◦ Collaborate among educators and practice leaders to develop a new clinical model for student nurse clinical education in San Antonio based on the successful use of the certified preceptor model being used in other regions ◦ Create an online preceptor training program accessible across the region and acceptable to the schools of nursing and clinical agencies • Automation of clinical placement task force ◦ Mechanize clinical placement with a simplified computer system recognizing that clinical agencies availability ◦ Focus on a Web-based computerized student placement program that makes it easier to manage the traditional cohort clinical group and/or the preceptor model of clinical student education and will be built on the strategies designed in the preceptor task force and the traditions task force to optimize clinical education • Traditions task force ◦ Identify traditions, rules, and possible barriers that could limit the success of maximizing resources and identify strategies that will make change successful in the clinical agencies and the schools of nursing • Faculty pipeline task force ◦ Create a mentoring program for new faculty members. Being able to share the experiences of years of teaching and mentor the novice faculty are as important as educating our next graduating class of RNs. Preceptors from the clinical sites would be the first group recruited for the Nurse Scholar Program, followed by nurses interested in enhancing their area of expertise to include clinical teaching ◦ An actuarial of faculty to include possible retirement dates will be maintained to aid in forecasting needs and target recruitment for certain specialties in addition to general nursing faculty ◦ A Nurse Scholar Program would offer funding to support the education of the next generation of educators, at the master's and doctorate level

Council's Foundation, submitted the grant proposal to extend the work of its NEF.

Greater San Antonio Healthcare Foundation The PIN program's vision of creating unique community partnerships to address workforce issues paralleled the approach of the Greater San Antonio Hospital Council. Many projects in the South Texas community require broad-based community support and equanimity among its participants, resulting in the Hospital Council's accepting the role as the neutral “organizational home” and the Foundation acting as the catalyst for building relationships. In 1996, the GSAHF was created as a 501(c) (3) private foundation to fund charitable, scientific, and educational activities to improve the health of the people of South Texas. The Greater San Antonio Hospital Council (Hospital Council) was the sole member of the GSAHF, which represented more than 120 hospitals and health care-related institutions throughout the 23 counties of South Central Texas. The chief executive officers of these hospitals participated in the leadership of the Hospital Council, represented by a 12-member board of directors. Thus, the Hospital Council served as the South Texas regional leadership roundtable for discussion and action on health care issues of common concern. The Hospital Council's strategic plan consisted of five goals: (a) advocacy and education for key stakeholders; (b) addressing health care workforce issues; (c) raising awareness of unintended consequences of violating the Emergency Medical Treatment and Active Labor Act; (d) improving access and funding for un/underinsured care; and (e) maintaining and enhancing the Hospital Council's value to its members.

Nursing workforce, for a decade, was a priority for the Hospital Council. The Bexar County Commissioners Court and the Mayor of San Antonio looked to the Hospital Council to facilitate a San Antonio Health Care Summit in 2001 to address pressing health care issues facing the San Antonio and South Texas community. This summit resulted in the creation of the Health Professional Resources Task Force. The task force, led by the Hospital Council, addressed the nursing shortage in San Antonio and South Texas through community and hospital partnerships. The outcome was to reduce the nursing shortage by raising funds to address the nursing faculty shortage, thus making it possible to increase enrollment in nursing schools. Specifically, the Nursing Faculty Funding Program, administered by the GSAHF in 2003–2005, raised more than $300,000 from community stakeholders after the Methodist Healthcare Ministries pledged a matching challenge grant. The outcomes of this initiative demonstrated a 58% increase in nursing graduates and displayed a commitment by the hospital and business communities to make nursing a priority. In addition, the Hospital Council had strong experience with evaluation of the programs it facilitated and was fortunate to have access to consultants within Workforce Solutions Alamo to assist with this function. For example, during the 2003–2004 Nurse Faculty Funding Program, a noted consultant conducted the program evaluation. The three metrics evaluated were (a) the community's ability to raise funds, (b) funds allocated as outlined, and (c) whether increased faculty resulted in an increase in nursing graduates. Evaluation demonstrated the Council's success. However, once the funding ended, so did the increased funding for faculty. The Texas Higher Education

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Coordinating Board has subsequently taken a lead with the Texas Team project and secured $54 million for the Professional Nursing Shortage Reduction Program. This program incentivized enrollment growth, retention, and graduation of entry-level RNs throughout the state for a 2-year funding period. The STAND proposal was submitted by the Healthcare Foundation in partnership with 10 others, including the four major health systems, the county commissioner's court, Workforce Solutions Alamo, and other smaller health care providers. It was successfully reviewed, and PIN funding was secured in the fall of 2008. The PIN project focused on three goals that evolved from the initial work of the NEF task forces: (a) identify barriers to clinical placement of nursing students and use an electronic clinical placement tracking system; (b) address modification of clinical education and develop a preceptor model of clinical education; and (c) enhance the pipeline for nursing faculty. The STAND committee, a subcommittee of NEF, continued to provide oversight and guidance for the project. A project director was identified, who was never able to fully commit to the project and who ultimately left the project, leaving the president of the Hospital Council as acting director. Despite this firm foundation, the PIN project work moved slowly. A year into the project, the board of directors of the Hospital Council disbanded the Council, leaving the San Antonio Health Foundation to focus solely on workforce issues, specifically the PIN project. The disruption leading to this major organizational change diverted energy from the program. The STAND committee, which was just getting a toehold as the advisory board for the PIN grant, had been struggling to establish an identity and role in the project and essentially disbanded at this time. Personnel changes also precluded progress. Over the course of the project, chief nurse executives in four of the five major hospital systems changed. The initial project director was replaced by the former vice president of the Hospital Council, whose primary responsibilities were to the Hospital Foundation. Although turnover among the clinical liaisons on both the academic and practice end was not tracked, it was high during the grant period. Fortunately, the academic side provided more stability, as five of the six deans of the nursing schools remained in place. Interestingly, no changes occurred in the clinical education process with this initiative. In spite of the multiple personnel changes and challenges, work has progressed toward the first goal and in spring 2011, the electronic placement software was used for placing students from each of the San Antonio Nursing Schools into each of the participating clinical agencies.

Texas Team At the state level, in 2008 a formal network of regions was established for Texas to encourage regional collaboration in addressing the nursing shortage. The Texas Team Addressing Nursing Education Capacity was appointed by the governor to continue the statewide efforts

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addressing the nursing shortage in response to a call to action by the Center to Champion Nursing in America in 2008. Charged with developing a sustainable plan for workforce development, one strategy was to organize the nursing education programs into regions. Regions could address unique local issues more effectively in a state with the size and diversity of Texas. The south region spread from San Antonio to the border of South Texas and included 19 schools. The 7 schools in San Antonio joined 12 other schools located in Beeville, Brownsville, Corpus Christi, Laredo, McAllen, Uvalde, and Victoria. The distance between San Antonio and Brownsville is 269 miles, with average distances between major cities in the Texas lower Rio Grande Valley of around 160 miles. Because this area is so diverse, the unique needs of the area varied, and pockets of collaboration, the southern region as defined by the Texas Team proposed a needs assessment as a project for the Texas Team initiative. We collaborated on a grant proposal to conduct a comprehensive needs assessment to develop strategic directions. However, we were not funded. Despite lack of funding, the south region educational programs came together in the fall of 2008 and held one gathering in Corpus Christi to identify common issues, conduct a needs assessment, and craft a strategic direction for the south region's work. It became clear that although members would value the ability to share resources, the distances and wide disparity in institutional resources would be a deterrent. The major goals identified by the group were to develop a communication strategy, share faculty development resources regarding simulation, and study the possibility of a regional network of online programs. A regional faculty development conference is planned for June 2011. The schools in San Antonio and in Corpus Christi had already established academic–practice partnership networks and used the impetus of the Texas Team to continue and refine those networks. One of the specific goals of the Texas Team initiative was to advance the use of a computer clinical placement system. This goal supported our efforts in developing the system for South Central Texas.

Systems Clinical Placement System Changes Given the multiplicity of people and organizational changes, the computerized clinical placement system became the core tangible focus of the STAND project. The existing paradigm for nursing clinical education had been in place in San Antonio for almost 40 years. It was handled exclusively by four liaisons from the academic end. Placements were based largely on academic need rather than resources available on the clinical side. The system was entirely paper-and-pencil and based largely on past commitments and personal contacts. Although this model had served the community well for many years, it did not represent a true partnership between the academic and clinical sides. The hospital systems were not involved in creating the best match with existing staff and nursing students; at the same time, the

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hospitals were not committing the resources to place the students. With the recent growth in San Antonio and its health care systems, the educational liaisons were not always informed about changes in the delivery system or modifications in existing units. It was clearly time to create a new model and realign the clinical placement system. Many other communities had already adopted a computerized placement system. Such a system would allow all liaisons—both academic and clinical—to view the placements and availability in all participating facilities. After significant deliberation, San Antonio selected StudentMax as the system of choice. The technical aspects of the project, computerized placement and modification of how clinical education is practiced, were the simple issues. Changing the behavior patterns and the value system that had developed around a generation of existing practices has been extremely difficult. Only after much debate, for example, the STAND committee and the NEF approved a set of rules for requesting and procuring placements. The goal was not to do more with less, but to do the work differently. This culture change provides the opportunity for the region to come together to accept a different approach to how, when, and where nursing students will be educated in the clinical setting. After 2 years of discussion, the StudentMax system has been implemented. A number of lessons were learned through the process, including the following:

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1. The clinical liaison committee that used to meet

at least two to three times a year increased the frequency of face-to-face meetings, as well as telephone conferences with the StudentMax software developer. The learning curve for the software was steep, particularly for the clinical agencies who had been less involved with the traditional placement processes. Without the strong leadership of a director, communication between clinical facilities and schools was more difficult, particularly when it came to making decisions about the rules for engaging with the electronic placement system. However, the liaison group persisted, learned the system, and ultimately was able to successfully place students using the software. Future endeavors will address process improvement and begin to identify new placement opportunities and new roles for each of the clinical and academic partners. 2. A director for StudentMax was never hired

because of the inadequate salary budgeted for the position. A director with an adequate salary and competent leadership skills needs to be hired, quickly. That position will facilitate the continued work of the liaison group. 3. Although there have been numerous implementation issues, StudentMax is up and run-

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ning. Most partners are committed to keeping it running; they recognize that a paper-andpencil process is not an option in today's complex environment. They are generally optimistic about resolving the problems and knowing that it will, with time, be a valuable asset to the community. Implementation of StudentMax has required the clinical facilities to become more engaged in the clinical placement of students in their facilities, since the clinical facilities are required to approve all placements once the data entry person has put them in. This means a stronger partnership—and commitment— between the academic and clinical sides in the educational process. All schools and all clinical facilities are not using StudentMax, so the expected increase in clinical placements has not yet occurred. The new director will be instrumental in getting all the schools and clinical facilities to participate in StudentMax and in contributing to its sustainability. The expected increase in clinical time availability has also not yet occurred. Because the current system information is based on past precedent, it was grounded in the academic calendar. Thus, many schools requested that placements start and end with the formal semester beginning and end and not with the actual time students would be performing clinical work. With time, the StudentMax entries will reflect real clinical needs, which should free clinical time in the health care facilities. Another group from the NEF had been tasked to address the second STAND goal, preceptorship models. That group stopped meeting in 2010 after identifying multiple barriers to this pedagogical model and losing key members of the group. One of the primary barriers for preceptorship model is the lack of baccalaureateprepared nurses in the San Antonio workforce. The particular goal was likely too specific. However, other approaches to clinical education are being investigated. Future endeavors should begin to assess the efficacy of other innovative approaches to clinical education. As noted above, the clinical liaisons have articulated a need to continue face-to-face meetings on a regular basis. Clinical liaisons feel that the inevitable questions and conflicts that will arise even with the StudentMax system can best be solved by colleagues— individuals who have had personal relationships and commitments.

Organizational System Changes Greater San Antonio Healthcare Foundation The project's long-term sustainability has been a goal throughout the entire program. Licensure costs for the

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StudentMax software have been covered by one of the initial program partners (Workforce Solutions Alamo), but it has become clear that maintaining the StudentMax system requires a project director and data entry staff. As the PIN project entered its final year, the hospital executives who constituted the board of the Healthcare Foundation felt that the project and the community would be best served by a nurse-driven organization. Because the PIN project was the Foundation's only initiative, the hospital executives decided to resign from the board, transfer the foundation's assets, and elect members of the STAND committee to the new board. The current GSAHF board, then, is governed by nursing leaders who are drawn equally from the academic and practice sides. The informal executive nursing leader partnership created in 2005 by the NEF has now been institutionalized in a formal 501(c) (3) foundation. Board members of the transformed Healthcare Foundation must now turn their energies to creating a business plan that sustains the StudentMax system and allows for future work on the original NEF and STAND project goals. The initial focus of StudentMax sustainability remains, although the board members are mindful of the faculty pipeline needs and creating public private resources to achieve our initial goals. Specifically, the new board of directors of the San Antonio Healthcare Foundation has concluded that the sustainability of StudentMax will require the hiring of a director who has good leadership skills and works well with the community at large. This director will work with schools and clinical facilities to ensure funding for StudentMax and fluid communication between educators and clinical facilities. This director will be responsible for the data entry person in charge of inputting all the students into the StudentMax. Although the future of the StudentMax project has not yet been fully defined, the sustainability of a computerized entry system has strong support from both the academic partners and the clinical systems being served. Although implementation challenges remain, a cultural shift is underway that should serve to strengthen the

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relationship between the academic and clinical participants and help create a true partnership in the education of the future nursing workforce.

Nurse Executive Forum With the dissolution of the Hospital Council, discussions began at the NEF as to the benefits and risks of transitioning into a new chapter of the Texas Organization of Nurse Executives (TONE). After serious deliberation, drafting of bylaws, and consultation with the TONE, the NEF voted to transition into a South Texas chapter of the TONE. Specific goals for implementing a chapter of TONE included creating a broader forum to expand collaboration among nurse managers, faculty, and executives in practice and education and providing a broad nursing leadership to impact quality and safety and for the development of nursing managers, faculty, and executives. Being part of a national association, being cognizant of the need for grooming the next generation of leaders, and being more inclusive were drivers of our decision to create a chapter. It will also allow local nursing leaders to draw on the resources of a state and national network of nurse executives and still focus on the issues impacting the local community. The newly reconstructed San Antonio Healthcare Foundation will maintain the executive nurse collaboration in practice and education. We should note that significant progress has been made during the past 3 years with increased enrollment and graduation of RN students among the San Antonio nursing schools despite the organization, people, and system changes. Figure 3 provides the latest data from the Texas Center for Nursing Workforce Studies. Notable is the fact that despite these increases in enrollment and graduation in basic RN preparation, faculty vacancy rates continue to increase (Figure 4). We are doing more with less. With impending retirements within the next 5 years, this will be a key priority. We also continue to turn away significant numbers of qualified applicants despite our increased capacity. We achieved this progress through cooperation, communication, and collaboration.

Figure 3. San Antonio 2008–2010. Enrollments, graduations, Qualified Applicants Not Admitted (QANA). Source: Texas Center for Nursing Workforce Studies, Center for Health Statistics, Texas Department of State Health Services

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Figure 4. Number of vacant faculty FTEs in San Antonio, 2008–2010. Source: Texas Center for Nursing Workforce Studies, Center for Health Statistics, Texas Department of State Health Services.

Lessons Learned Five key lessons in this journey reaffirmed much in the literature. The first lesson is that change is inevitable. We experienced and managed change in organizations, people, and systems. Sustaining change is the leadership challenge in this age of complexity. Leading emergence, which is identifying disequilibrium conditions, amplifying actions, recombining aggregates, and instituting stabilizing feedback will be the necessary skill set for nurse leaders (Goldstein, Hazy, & Lichtenstein, 2010). The second lesson is that leadership matters at all levels. Clinical liaisons, nurse managers, nurse executives, nurse educators, and hospital executives all participated in moving beyond their own walls of their own institutions toward the common goals (Hesselbein, 2002). Communication among all partners and developing consensus for common strategies to address issues are key for forward movement of the academic–practice partnership (McKay & Hewlett, 2009). Succession planning is vital, as we experienced multiple personnel changes at all levels. The timing of the succession is the most critical factor effecting forward progress. Having active task forces, involving many individuals at multiple levels, and allowing talent to emerge from within greatly assisted in continuing our progress toward our goals. We discovered with the lesson “persistence toward established goals is necessary” that perseverance is essential. It was the one attribute that prepared us to succeed no matter what challenges were presented. In fact, we learned sometimes that one must go slow to move fast. McBride (2010, p. 15) states, “perseverance isn't a stylish elegant quality, but it is the one that matters in the long run.” The last lesson is that relationships are the glue to creating the successful academic–practice partnerships. With time, trust and respect were earned (Barger & Das, 2004). There is no replacement for spending the necessary time for relationship development. The time commitment cannot be overemphasized. Open communication and frequent communication in a variety of forums allowed for the relationships to evolve and develop. In summary, the South Central Texas leadership journey for nursing reflects the dynamics of changing organizations, people, and systems. The pace of change, turnover in nursing leaders and organizations, and

growth in the demand for health services and quality outcomes were both challenges and drivers of the needed change. The lessons learned were invaluable and create the opportunity to continue to contribute to the development of South Central Texas health care.

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