- Email: [email protected]
Evaluation of an academic service partnership using a strategic alliance framework
Available online at www.sciencedirect.com
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
www.nursingoutlook.org
Evaluation of an academic service partnership using a strategic alliance framework Teri A. Murray, PhD, APHN-BC, RN, FAANa,*, Dorothy C. James, PhD, RNCb a
b
School of Nursing, Saint Louis University, St. Louis, MO Center of Nursing Excellence, Mercy Hospital, St. Louis, MO
article info
abstract
Article history: Received 1 July 2011 Revised 9 October 2011 Accepted 13 October 2011 Online 16 December 2011
Strategic alliances involve the sharing of resources to achieve mutually relevant benefits and they are flexible ways to access resources outside of one’s own institution. The recent landmark report from the Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, called for academic and health care organizations to strategically align around the future registered nurse workforce to improve the quality and safety of patient care.1 The dedicated education unit (DEU) is one practical way for 2 entities to align so that students can learn to administer safe, quality care. Because DEUs have great potential, it is critical to evaluate the alignment between the academic and service partner for appropriate fit, mutual benefit, and long-term success. In this article, we analyze the effectiveness of the Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) DEU project, an alliance between a medical center and school of nursing, using the Single Alliance Key Success Model.
Keywords: Academic-service partnership Academic-practice partnership Practice-education partnership Strategic alliance Dedicated education unit Clinical education Undergraduate education
Cite this article: Murray, T. A., & James, D. C. (2012, AUGUST). Evaluation of an academic service partnership using a strategic alliance framework. Nursing Outlook, 60(4), E17-E22. doi:10.1016/ j.outlook.2011.10.004.
Strategic alliances involve the sharing, exchange, or codevelopment of resources to achieve mutually relevant benefits.2 These alliances provide access to complementary resources outside of one’s own institution and have been known to create synergy in times of scarce human and fiscal resources.3-5 Moreover, the alliances greatly enhance nursing education, practice, and research.6 The recent landmark report of the Institute of Medicine (IOM), The Future of Nursing: Leading Change, Advancing Health, expressed the need for academic and health care organizations to strategically align around the future registered nurse workforce to improve the quality and safety of patient care.1 The nursing community has also acknowledged that academic-service partnerships are needed to effectively
prepare an educated nursing workforce.7 Thus, there have been numerous calls to advance academic and service partnerships that improve the quality and safety of patient care.7-10 The dedicated education unit (DEU) is an innovative partnership between an academic and service entity that has been touted as a practical way to align education and practice so that students can learn to administer safe, quality care.11,12 In the DEU, staff nurses are integrated into the teaching/learning process as clinical instructors and/or preceptors, and school-based faculty members serve as coaches and provide guidance to the staff nurses.13 The key features of the DEU model are summarized in Table 1.13 The DEU constitutes a profound change in the clinical
* Corresponding author: Dr. Teri A. Murray, Saint Louis University, Dean & Associate Professor, School of Nursing, 3525 Caroline Mall, Suite 226, St. Louis, MO 63104. E-mail address: [email protected] (T.A. Murray). 0029-6554/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2011.10.004
e18
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Table 1 e Key Features of the Dedicated Education Unit (DEU) The hospital unit, as a living learning laboratory, becomes the teaching environment where practice and education intersects. The goal is to maximize student learning through the achievement of specific outcomes. The DEU is used primarily by one school of nursing. Expert staff nurses are integrated into the teaching/ learning process as clinical instructors and/or preceptors. The student is assigned to a staff nurse for the duration of the clinical rotation. School-based faculty members serve as coaches and provide guidance to the staff nurses in the teaching/ learning process. The academic and service partners are committed to work together to build an optimal practice environment for students and staff that is consistent with the unit’s goal for its patients and staff. Source: Moscato S, Miller J, Logsdon K, et al. Dedicated education unit: An innovative clinical partner education model. Nurs Outlook 2007;55:31-7.12
education process and has been shown to increase student and staff nurse satisfaction, benefit the academic partner through expanded educational capacity, and furnish the clinical partner with a recruitment pool of new graduates familiar with the faculty.1 It was with this understanding that the leadership of Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) partnered to establish a DEU to better facilitate students’ transition to practice and more deliberately integrate the staff nurse into the educational process.13,14 The key elements of the design and implementation of the MHSL-SLUSON DEU are presented in Table 2.14 Early outcomes from this academic-service partnership have yielded promising results in the following areas: student transition to practice, staff nurse integration into the clinical education process, and expanded educational capacity.14 The purpose of this article is to evaluate the MHSL-SLUSON academic-service partnership for its long-term success in fostering educational innovation and mutual benefit using the Single Alliance Key Success Model.
The Single Alliance Key Success Model The Single Alliance Key Success Model is based on alliance research and has 3 major components: formation, design, and management (Figure 1).15
Alliance Formation The formation phase describes the decision-making process involved when 2 entities contemplate whether to venture into a joint initiative. The selection
of an appropriate partner can be a critical factor in the success of the strategic alliance. Collaborative and strategic alliances are most effective when partners share vision, values, and goals.16 Shah and Swarminathan identified 3 attributes that have been positively associated with alliance success: complementarity, commitment, and compatibility.17 Complementarity is the extent to which one partner can bring the needed resource that the other partner lacks and is often the minimum requirement for the alliance.18 Commitment is the action taken by each partner to achieve the goals of the alliance and is critical for the long-term success of the partnership. Compatibility has to do with “organizational goodness of fit” between the partners.16,18 All 3 attributes are vital to partnership success, although some attributes may be more critical for success than others depending on the goals of the alliance.16
Alliance Design Alliance designs not only provide structure and direction, but also serve to formalize the strategic operations by clarifying expectations and responsibilities.18 In the Single Alliance Key Success Model, Kale and Singh identified 3 governance designs: equity-based (partners share equity); contractual (partners have clearly established rights, obligations, and outcomes); and/or relational (the partnership is based on the goodwill, trust, and reputation of each institution.16 Two of the 3 designsdequity-based and contractualdare designated as formal modes of governance, whereas the relational design, which is based on the trust and goodwill of the partners, is considered an informal model.19 The relational design can also be viewed as complementary to contractual or equity-based designs and is believed to enhance alliance success.16 In general, many strategic alliances are structured in a manner that includes elements of all 3 governance designs.
Alliance Management The ongoing management and coordination of the activity beyond the initial arrangement is critical to partnership success and sustainability. Partners use 3 methods to manage the coordination of activities during the postformation phase of the partnership: programming, hierarchy, and trust. Programming involves establishing clear operational guidelines with assigned tasks and responsibilities along with the timeline for implementation.16 Hierarchal management is a formalized decision-making body in the form of a governing board with an alliance manager to oversee all aspects of the partnership.16 The hierarchical structure allows a specific department to coordinate partnership-related activity within the organization. This provides a mechanism to institutionalize the partnership as well as to teach, share, codify, and document key phases of the partnership life cycle.3 Trust has 2 components: structural and behavioral. Within the structural component, it
e19
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Table 2 e The Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) Dedicated Education Unit Project Inputs Activities Outputs Outcomes Impact Human resources Administrators Faculty Clinicians Students Fiscal resources Orientation costs Productivity factors
Affiliation agreement Clinical unit identification Role orientation activities Preceptor selection process Preceptor orientation program Student orientation Administrative leadership orientation Preclinical preparation activities Clinical simulation activities Clinical unit review Establish a governance model Establish communication and decision-making model Evaluation
Partnership Mutuality of benefit Replicability Student Course/clinical completion of objectives Preceptor Orientation program completion Role enactment Faculty Role transition
is expected that a partner remain principled and not behave opportunistically. The behavioral component involves the degree of mutuality in reliability, integrity, relational capital, and relational risk.16
The MHSL-SLUSON DEU Project Formation Complementarity In the MHSL-SLUSON partnership, the complementarity was clearly demonstrated through the resources that each partner brought to the table. SLUSON contributed faculty with educational expertise in the teaching-learning processes, whereas MHSL contributed expert nurse clinicians actively engaged in clinical practice. The school and its faculty provided the “educational know-how,” and the medical center provided the clinical, learning laboratory.19 This complement of assets ensured that students were fully engaged in didactic learning and clinical practice.20 The partnership enabled both entities to leverage respective strengths and resources to enhance the clinical education process.21
Evaluation process Formative evaluation data Summative evaluation data Integration Degree of student integration into the clinical setting Degree of staff nurse integration into the clinical education of the student Degree of faculty role transition from teacher to coach
The extent the model facilitates the student’s transition to practice The extent the model expanded faculty and student capacity The extent the model can drive regulatory changes Model sustainability (human, fiscal, and partnership)
partner’s existing resources to cover the expenses associated with preceptor education for the staff nurses. Both entities fully understood that the partnership could realize results that neither entity could achieve separately.14 The School of Nursing expected to graduate students who had excellent and realistic clinical learning experiences and the medical center expected a pool of graduate nurses from which to recruit staff nurses. This shared vision and mutual expectation was fundamental to the success of the partnership.
Compatibility In terms of mission and values, the institutions were highly compatible. The partners were both Catholic institutions and sought excellence in the fulfillment of their respective corporate missions. The core values (faith and social justice; innovation; compassion; service; respect for human dignity; advocacy; and the improvement in the health and quality of life for individuals, families, and communities) were deeply embedded within each organization’s mission statement, and these values were clearly evident in the everyday work of both institutions. This cultural compatibility of the partners was critical to the success of the strategic alliance, because cultural and value clashes are 2 of the major reasons that some alliances fail.3
Commitment Commitment is reflected by the mutual investment of the human and fiscal resources necessary for partnership success. The MHSL-SLUSON partnership required commitment for the judicious use of each
Design The MHSL-SLUSON partnership was governed by the typical clinical affiliation contractual agreement
e20
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Figure 1 e A Single AlliancedKey Success Factors.
between an academic institution and a clinical entity. The agreement outlined the requirements for the placement of students at the clinical site, but there was no specific contractual agreement for the DEU. The initial leadership team, subsequently known as the partnership steering team (PST), guided the implementation phase and provided oversight of the DEU, once established. The PST enabled the active engagement of the service and academic partners in all aspects of the DEU. This connectivity, the interconnectedness between the 2 entities, allowed for the ongoing exchange of information affecting the partnership and for rapid and continuous adjustments in response to problems, issues, or concerns.7,22 According to D’Amour et al, the process of connectivity generally occurs through a governance structure or a designated committee. In the MHSL-SLUSON partnership, it occurred through the PST.19 The PST agreed upon a set of role expectations for the preceptor, the faculty, and the student that provided guidelines for the clinical learning experiences on the DEU. The relational MHSL-SLUSON DEU partnership design was based on self-enforcing governance, goodwill, and trust. Shaw & Swaminathan described trust in partnership design as the extent to which the academic and service partners demonstrate reliance on the other’s good will, expertise, capabilities, and judgments.18 A relational governance design is thought to enhance alliance success because the relational method allows partners to share tacit knowledge, exchange resources that are difficult to cost out, and respond to issues or concerns without limiting actions or responses to the content and language of a contract.16 Other alliance research cautions against this approach and advises the need for formalization to clarify partner responsibilities.23 Questions that should be addressed during this phase of the alliance include: (1) How does the action of one partner affect the other partner?16 (2) What information is critical to share with the partner?16 (3) What impact will changes in resources (human or fiscal) have
on the partnership?16 and (4) How will the partners continue to align resources to maximize the benefits of the partnership?16 Each of the 3 modes of postalliance management (programming, hierarchical, and/or trust) can be used to readily incorporate responses to the 4 questions in the postalliance management guidelines. In the programming method of management, responses to these questions would be incorporated in the operational guidelines. Hierarchical methods would include how to respond to these questions in the codification process. Trust, probably the most difficult to assess, would be handled through basic ethics, goodwill, and principled behavior.
Management The postimplementation management of the MHSLSLUSON partnership, now in its third year, continues to operate through a hybrid design. It is a partnership based on a relational design and governed by the PST. Although many of the original PST members have changed, the commitment to the DEU partnership remains strong. The Organization for Economic Cooperation and Development (OCED) warns that partnerships that involve the personal commitment of partner representatives are not as sustainable as partnerships that involve institutional commitment (ie, contractual), because a change in the institutional representative can affect the level of commitment of the organization.23 The MHSL-SLUSON academicservice partnership, established by 2 leaders interested in a transformative educational experience, maintains the characteristics of an effective partnership as defined by OCED: ownership, attentiveness, responsibility, voice, power, and influence.23
Discussion Dyer et al identified 4 dimensions to evaluate alliance effectiveness:
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
1. The extent to which the alliance met its objectives, 2. The extent to which the alliance enhanced each partner’s competitive position, 3. The extent to which the partners learned critical skills from each other, and 4. The level of harmony between the partners.3 Both partners agree the alliance has realized success on all 4 dimensions. The initial objective of the MHSLSLUSON partnership was to facilitate the students’ transition to practice and integrate the staff nurses into the learning process. As preceptors, the staff nurses were clearly integrated into the educational process, and based on the preceptor comments in the evaluation of the clinical experience, the preceptors felt the students were much more competent than their new graduate peers who had not experienced the DEU as part of the clinical education process. The DEU partnership model engaged the students as practitioners who integrated “thinking and doing” in a living laboratory, and learned the complexities of the system in a way that allowed reflection and proactive learning.23 This approach to learning is consistent with Benner and colleagues’ situated cognition or “thinking in action,” which is believed to be essential in clinical teaching to acquire, learn, and use nursing knowledge.24 Clinical evaluation data from the faculty, preceptors, and the students regarding the MHSL-SLUSON DEU project indicate that students gained the following: improved prioritization and delegation skills; better integration into the clinical unit as team members; increased opportunity to perform skills and procedures; increased confidence in the clinical environment; and increased levels of critical thinking, decision-making, and inquiry skills.14 Undoubtedly, the new graduates hired by MHSL had a competitive advantage over new graduates who had not worked on the DEU. SLUSON used the “new” transformational clinical model in its recruitment discussions with prospective students and faculty, and MHSL was able to hire new graduates who were familiar with the institution and its operations. The alliance provided each partner with the ability to leverage its respective strengths. In addition, the partners worked well together and were able to handle issues and concerns through the PST. The DEU model was mutually beneficial and increased the interconnectedness between academe and service. These partnership opportunities are paving the way for innovative and transformative collaboration in both the practice and academic environments.25 In terms of partnership sustainability, the partners continue to rely on the other’s goodwill and trustworthiness, which is consistent with the relational design of alliance management based on trust. Either partner can terminate the relationship, but at this point, both partners are committed to the alliance, and as long as there is mutual benefit, the partners are satisfied with the current design.
e21
Next Steps At the present time, the MHSL-SLUSON DEU partnership is one example of a strategic alliance that currently works for both partners. However, longitudinal study of the students who participated in the MHSL-SLUSON DEU is an area of future research. Equally critical is the need to analyze academic-service partnerships for success, sustainability, and replication. A recent survey suggested there was substantial untapped opportunity for hospitals and schools to collaborate on improving student competencies during the school-based clinical experience.26 In spite of the known limitations of isolated institutional activity, leaders remain challenged with how to establish strategic alliances and partnerships that offer mutual benefit.27 In evaluating innovations in nursing education, we must keep in mind that innovations may be difficult to evaluate. The very nature of innovation implies a process of trial and error with a necessary degree of experimentation. The complexity of the health care environment is such that a particular combination of needs, people, and problems may or may not occur on a routine basis for empirical evaluation. As Senge pointed out, with any innovation, “statistical measures may be disappointing, but if you’re actually involved, you may see that people are engaged and learning.on the brink of a breakthrough.incomplete or premature assessment may destroy learning or the innovation.we must avoid pulling up the radishes to see how they’re growing.”28 Yet the question remains: How do we move from existing educational practices to next practices? Nurse leaders should continually ask this question. Next practices are innovations that change existing paradigms and have the potential to significantly alter an entire field or practice.29 Leaders should assess whether one has the capacity for creativity and innovation and how he or she could create sustainable partnerships that align and leverage resources.9,30 The nursing community needs leaders who are undaunted by innovative practices and are willing to experiment to chart the course for transformative changes that lead to a well-qualified nursing workforce. Nursing leaders, as thoughtful strategists, can shape the future rather than respond to it.
references
1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing health. Washington, DC: The National Academies Press; 2011. 2. Gulati R. Does familiarity breed trust? The implications for repeated ties for contractual choice in alliances. Acad Manage J 1995;38:85-112. 3. Dyer JH, Kale P, Singh H. How to make strategic alliances work. MIT Sloan Management Review 2001;42:37-43.
e22
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
4. Murray TA, Schappe A, Kreienkamp DE, et al. A communitywide academic-service partnership to expand faculty and student capacity. J Nurs Educ 2010;49:295-300. 5. Murray TA. An academic-service partnership to expand capacity: What did we learn? J Cont Educ Nurs 2008;39:217-24. 6. Fralic MF. Hardwiring the “three-legged stool”: Nursing’s vital education/practice/research triad. J Prof Nurs 2004;20:281-4. 7. California Institute for Nursing & Health Care. Nursing education redesign for California: White paper and strategic action plan recommendations, 2008. Available at: http:// www.cinhc.org/wordpress/wp-content/uploads/2009/12/ 5_Nursing-Ed-Redesign.pdf. Accessed June 11, 2011. 8. Joynt J, Kimball B. Blowing open the bottleneck: Designing new approaches to increase nurse education capacity. White paper sponsored by the AARP, US Department of Labor, & Robert Wood Johnson Foundation; 2008. 9. American Association of Colleges of Nursing. AACN-AONE task force on academic-practice partnerships. Available at: www.aacn.nche.edu/about-aacn/committees-task-force/ aacn-aone-task-force-on-academic-practice-partnerships. Accessed June11, 2011. 10. Robert Wood Johnson Foundation. Charting nursing’s future: Reports on policies that can transform patient care. Available at: http://www.rwjf.org/files/publications/other/ nursingfuture4.pdf. Accessed June 11, 2011. 11. Mulready J, Kafel K, Bannister G, et al. Enhancing quality and safety competency development at the unit level: An initial evaluation of student learning and clinical teaching on dedicated education units. J Nurs Educ 2010;48:716-9. 12. Moscato S, Miller J, Logsdon K, et al. Dedicated education unit: An innovative clinical partner education model. Nurs Outlook 2007;55:31-7. 13. Murray TA, Crain C, Meyer G, et al. Building bridges: An innovative academic-service partnership. Nurs Outlook 2010; 58:252-60. 14. MacIntyre RC, Murray TA, Teel CS, et al. Five recommendations for prelicensure clinical nursing education. J Nurs Educ 2009;48:447-53. 15. Kale P, Singh H. Managing strategic alliances: What do we know now, and where do we go from here? Acad Manage Persp 2009;23:5-62. 16. Smith E, Tonges MC. The Carolina nursing experience: A service perspective on an academic-service partnership. J Prof Nurs 2004;20:305-9. 17. Shah R, Swaminathan V. Factors influencing partner selection in strategic alliances: The moderating role of
18.
19. 20.
21.
22.
23. 24.
25.
26.
27.
28. 29.
30.
alliance context. Strategic Management Journal 2008;29: 471-94. D’Amour D, Goulet L, Labadie J, et al. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Services Research 2008;8:188. Warner JR, Burton DA. The policy and politics of emerging academic-service partnerships. J Prof Nurs 2009;25:329-34. Donaldson SK, Fralic MF. Forging today’s practice-academic link: A new era of nursing leadership. Nurs Admin Q 2000;25: 95-101. Kirschling JM, Erickson JI. The STTI Practice-Academe Innovative Collaboration Award: Honoring innovation, partnership, and excellence. J Nurs Scholarsh 2010;42:286-94. Organization for Economic Co-operation and Development (OCED) Local Economic and Employment Development (LEED) Forum. Successful partnerships: A guide. Available at: http:// www.oecd.org/cfe/leed/forum/partnerships. Accessed June 11, 2011. Finkelman A, Kenner C. Educational and service partnerships: An example of global flattening. J Prof Nurs 2007;24:59-65. Benner P, Sutphen M, Leonard V, et al. Educating nurses: A call for radical transformation. San Francisco, CA: JosseyBass; 2010. Cartwright JC. Opportunities for practice and educational transformations through unlikely partnerships. J Nurs Educ 2010;49:243-4. The Advisory Board Company. Bridging the preparationpractice gap: volume I: Quantifying new graduate nurse improvement needs. Washington, DC: The Advisory Board Company; 2008. O’Neil E. The nursing shortage, by the numbers. Available at: http://www.rwjf.org/pr/product.jsp?id¼21037. Accessed on June 11, 2011. Senge P. The practice of innovation. Leader to Leader Journal 1998;9:16-22. Nidumolu R, Prahalad CK, Rangaswami MR. Why sustainability is now the key driver of innovation. Harvard Business Review 2009;87:56-64. Niederhauser V, MacIntyre RC, Garner C, et al. Transformational models of nursing across different care settings: Transformational partnerships in nursing education. In the Committee on the Robert Wood Johnson Initiative on the Future of Nursing at the Institute of Medicine; Institute of Medicine. The future of nursing: Leading change, advancing health. National Academies Press; 2010.
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
www.nursingoutlook.org
Evaluation of an academic service partnership using a strategic alliance framework Teri A. Murray, PhD, APHN-BC, RN, FAANa,*, Dorothy C. James, PhD, RNCb a
b
School of Nursing, Saint Louis University, St. Louis, MO Center of Nursing Excellence, Mercy Hospital, St. Louis, MO
article info
abstract
Article history: Received 1 July 2011 Revised 9 October 2011 Accepted 13 October 2011 Online 16 December 2011
Strategic alliances involve the sharing of resources to achieve mutually relevant benefits and they are flexible ways to access resources outside of one’s own institution. The recent landmark report from the Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, called for academic and health care organizations to strategically align around the future registered nurse workforce to improve the quality and safety of patient care.1 The dedicated education unit (DEU) is one practical way for 2 entities to align so that students can learn to administer safe, quality care. Because DEUs have great potential, it is critical to evaluate the alignment between the academic and service partner for appropriate fit, mutual benefit, and long-term success. In this article, we analyze the effectiveness of the Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) DEU project, an alliance between a medical center and school of nursing, using the Single Alliance Key Success Model.
Keywords: Academic-service partnership Academic-practice partnership Practice-education partnership Strategic alliance Dedicated education unit Clinical education Undergraduate education
Cite this article: Murray, T. A., & James, D. C. (2012, AUGUST). Evaluation of an academic service partnership using a strategic alliance framework. Nursing Outlook, 60(4), E17-E22. doi:10.1016/ j.outlook.2011.10.004.
Strategic alliances involve the sharing, exchange, or codevelopment of resources to achieve mutually relevant benefits.2 These alliances provide access to complementary resources outside of one’s own institution and have been known to create synergy in times of scarce human and fiscal resources.3-5 Moreover, the alliances greatly enhance nursing education, practice, and research.6 The recent landmark report of the Institute of Medicine (IOM), The Future of Nursing: Leading Change, Advancing Health, expressed the need for academic and health care organizations to strategically align around the future registered nurse workforce to improve the quality and safety of patient care.1 The nursing community has also acknowledged that academic-service partnerships are needed to effectively
prepare an educated nursing workforce.7 Thus, there have been numerous calls to advance academic and service partnerships that improve the quality and safety of patient care.7-10 The dedicated education unit (DEU) is an innovative partnership between an academic and service entity that has been touted as a practical way to align education and practice so that students can learn to administer safe, quality care.11,12 In the DEU, staff nurses are integrated into the teaching/learning process as clinical instructors and/or preceptors, and school-based faculty members serve as coaches and provide guidance to the staff nurses.13 The key features of the DEU model are summarized in Table 1.13 The DEU constitutes a profound change in the clinical
* Corresponding author: Dr. Teri A. Murray, Saint Louis University, Dean & Associate Professor, School of Nursing, 3525 Caroline Mall, Suite 226, St. Louis, MO 63104. E-mail address: [email protected] (T.A. Murray). 0029-6554/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2011.10.004
e18
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Table 1 e Key Features of the Dedicated Education Unit (DEU) The hospital unit, as a living learning laboratory, becomes the teaching environment where practice and education intersects. The goal is to maximize student learning through the achievement of specific outcomes. The DEU is used primarily by one school of nursing. Expert staff nurses are integrated into the teaching/ learning process as clinical instructors and/or preceptors. The student is assigned to a staff nurse for the duration of the clinical rotation. School-based faculty members serve as coaches and provide guidance to the staff nurses in the teaching/ learning process. The academic and service partners are committed to work together to build an optimal practice environment for students and staff that is consistent with the unit’s goal for its patients and staff. Source: Moscato S, Miller J, Logsdon K, et al. Dedicated education unit: An innovative clinical partner education model. Nurs Outlook 2007;55:31-7.12
education process and has been shown to increase student and staff nurse satisfaction, benefit the academic partner through expanded educational capacity, and furnish the clinical partner with a recruitment pool of new graduates familiar with the faculty.1 It was with this understanding that the leadership of Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) partnered to establish a DEU to better facilitate students’ transition to practice and more deliberately integrate the staff nurse into the educational process.13,14 The key elements of the design and implementation of the MHSL-SLUSON DEU are presented in Table 2.14 Early outcomes from this academic-service partnership have yielded promising results in the following areas: student transition to practice, staff nurse integration into the clinical education process, and expanded educational capacity.14 The purpose of this article is to evaluate the MHSL-SLUSON academic-service partnership for its long-term success in fostering educational innovation and mutual benefit using the Single Alliance Key Success Model.
The Single Alliance Key Success Model The Single Alliance Key Success Model is based on alliance research and has 3 major components: formation, design, and management (Figure 1).15
Alliance Formation The formation phase describes the decision-making process involved when 2 entities contemplate whether to venture into a joint initiative. The selection
of an appropriate partner can be a critical factor in the success of the strategic alliance. Collaborative and strategic alliances are most effective when partners share vision, values, and goals.16 Shah and Swarminathan identified 3 attributes that have been positively associated with alliance success: complementarity, commitment, and compatibility.17 Complementarity is the extent to which one partner can bring the needed resource that the other partner lacks and is often the minimum requirement for the alliance.18 Commitment is the action taken by each partner to achieve the goals of the alliance and is critical for the long-term success of the partnership. Compatibility has to do with “organizational goodness of fit” between the partners.16,18 All 3 attributes are vital to partnership success, although some attributes may be more critical for success than others depending on the goals of the alliance.16
Alliance Design Alliance designs not only provide structure and direction, but also serve to formalize the strategic operations by clarifying expectations and responsibilities.18 In the Single Alliance Key Success Model, Kale and Singh identified 3 governance designs: equity-based (partners share equity); contractual (partners have clearly established rights, obligations, and outcomes); and/or relational (the partnership is based on the goodwill, trust, and reputation of each institution.16 Two of the 3 designsdequity-based and contractualdare designated as formal modes of governance, whereas the relational design, which is based on the trust and goodwill of the partners, is considered an informal model.19 The relational design can also be viewed as complementary to contractual or equity-based designs and is believed to enhance alliance success.16 In general, many strategic alliances are structured in a manner that includes elements of all 3 governance designs.
Alliance Management The ongoing management and coordination of the activity beyond the initial arrangement is critical to partnership success and sustainability. Partners use 3 methods to manage the coordination of activities during the postformation phase of the partnership: programming, hierarchy, and trust. Programming involves establishing clear operational guidelines with assigned tasks and responsibilities along with the timeline for implementation.16 Hierarchal management is a formalized decision-making body in the form of a governing board with an alliance manager to oversee all aspects of the partnership.16 The hierarchical structure allows a specific department to coordinate partnership-related activity within the organization. This provides a mechanism to institutionalize the partnership as well as to teach, share, codify, and document key phases of the partnership life cycle.3 Trust has 2 components: structural and behavioral. Within the structural component, it
e19
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Table 2 e The Saint Louis University School of Nursing (SLUSON) and Mercy Hospital, St. Louis (MHSL) Dedicated Education Unit Project Inputs Activities Outputs Outcomes Impact Human resources Administrators Faculty Clinicians Students Fiscal resources Orientation costs Productivity factors
Affiliation agreement Clinical unit identification Role orientation activities Preceptor selection process Preceptor orientation program Student orientation Administrative leadership orientation Preclinical preparation activities Clinical simulation activities Clinical unit review Establish a governance model Establish communication and decision-making model Evaluation
Partnership Mutuality of benefit Replicability Student Course/clinical completion of objectives Preceptor Orientation program completion Role enactment Faculty Role transition
is expected that a partner remain principled and not behave opportunistically. The behavioral component involves the degree of mutuality in reliability, integrity, relational capital, and relational risk.16
The MHSL-SLUSON DEU Project Formation Complementarity In the MHSL-SLUSON partnership, the complementarity was clearly demonstrated through the resources that each partner brought to the table. SLUSON contributed faculty with educational expertise in the teaching-learning processes, whereas MHSL contributed expert nurse clinicians actively engaged in clinical practice. The school and its faculty provided the “educational know-how,” and the medical center provided the clinical, learning laboratory.19 This complement of assets ensured that students were fully engaged in didactic learning and clinical practice.20 The partnership enabled both entities to leverage respective strengths and resources to enhance the clinical education process.21
Evaluation process Formative evaluation data Summative evaluation data Integration Degree of student integration into the clinical setting Degree of staff nurse integration into the clinical education of the student Degree of faculty role transition from teacher to coach
The extent the model facilitates the student’s transition to practice The extent the model expanded faculty and student capacity The extent the model can drive regulatory changes Model sustainability (human, fiscal, and partnership)
partner’s existing resources to cover the expenses associated with preceptor education for the staff nurses. Both entities fully understood that the partnership could realize results that neither entity could achieve separately.14 The School of Nursing expected to graduate students who had excellent and realistic clinical learning experiences and the medical center expected a pool of graduate nurses from which to recruit staff nurses. This shared vision and mutual expectation was fundamental to the success of the partnership.
Compatibility In terms of mission and values, the institutions were highly compatible. The partners were both Catholic institutions and sought excellence in the fulfillment of their respective corporate missions. The core values (faith and social justice; innovation; compassion; service; respect for human dignity; advocacy; and the improvement in the health and quality of life for individuals, families, and communities) were deeply embedded within each organization’s mission statement, and these values were clearly evident in the everyday work of both institutions. This cultural compatibility of the partners was critical to the success of the strategic alliance, because cultural and value clashes are 2 of the major reasons that some alliances fail.3
Commitment Commitment is reflected by the mutual investment of the human and fiscal resources necessary for partnership success. The MHSL-SLUSON partnership required commitment for the judicious use of each
Design The MHSL-SLUSON partnership was governed by the typical clinical affiliation contractual agreement
e20
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
Figure 1 e A Single AlliancedKey Success Factors.
between an academic institution and a clinical entity. The agreement outlined the requirements for the placement of students at the clinical site, but there was no specific contractual agreement for the DEU. The initial leadership team, subsequently known as the partnership steering team (PST), guided the implementation phase and provided oversight of the DEU, once established. The PST enabled the active engagement of the service and academic partners in all aspects of the DEU. This connectivity, the interconnectedness between the 2 entities, allowed for the ongoing exchange of information affecting the partnership and for rapid and continuous adjustments in response to problems, issues, or concerns.7,22 According to D’Amour et al, the process of connectivity generally occurs through a governance structure or a designated committee. In the MHSL-SLUSON partnership, it occurred through the PST.19 The PST agreed upon a set of role expectations for the preceptor, the faculty, and the student that provided guidelines for the clinical learning experiences on the DEU. The relational MHSL-SLUSON DEU partnership design was based on self-enforcing governance, goodwill, and trust. Shaw & Swaminathan described trust in partnership design as the extent to which the academic and service partners demonstrate reliance on the other’s good will, expertise, capabilities, and judgments.18 A relational governance design is thought to enhance alliance success because the relational method allows partners to share tacit knowledge, exchange resources that are difficult to cost out, and respond to issues or concerns without limiting actions or responses to the content and language of a contract.16 Other alliance research cautions against this approach and advises the need for formalization to clarify partner responsibilities.23 Questions that should be addressed during this phase of the alliance include: (1) How does the action of one partner affect the other partner?16 (2) What information is critical to share with the partner?16 (3) What impact will changes in resources (human or fiscal) have
on the partnership?16 and (4) How will the partners continue to align resources to maximize the benefits of the partnership?16 Each of the 3 modes of postalliance management (programming, hierarchical, and/or trust) can be used to readily incorporate responses to the 4 questions in the postalliance management guidelines. In the programming method of management, responses to these questions would be incorporated in the operational guidelines. Hierarchical methods would include how to respond to these questions in the codification process. Trust, probably the most difficult to assess, would be handled through basic ethics, goodwill, and principled behavior.
Management The postimplementation management of the MHSLSLUSON partnership, now in its third year, continues to operate through a hybrid design. It is a partnership based on a relational design and governed by the PST. Although many of the original PST members have changed, the commitment to the DEU partnership remains strong. The Organization for Economic Cooperation and Development (OCED) warns that partnerships that involve the personal commitment of partner representatives are not as sustainable as partnerships that involve institutional commitment (ie, contractual), because a change in the institutional representative can affect the level of commitment of the organization.23 The MHSL-SLUSON academicservice partnership, established by 2 leaders interested in a transformative educational experience, maintains the characteristics of an effective partnership as defined by OCED: ownership, attentiveness, responsibility, voice, power, and influence.23
Discussion Dyer et al identified 4 dimensions to evaluate alliance effectiveness:
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
1. The extent to which the alliance met its objectives, 2. The extent to which the alliance enhanced each partner’s competitive position, 3. The extent to which the partners learned critical skills from each other, and 4. The level of harmony between the partners.3 Both partners agree the alliance has realized success on all 4 dimensions. The initial objective of the MHSLSLUSON partnership was to facilitate the students’ transition to practice and integrate the staff nurses into the learning process. As preceptors, the staff nurses were clearly integrated into the educational process, and based on the preceptor comments in the evaluation of the clinical experience, the preceptors felt the students were much more competent than their new graduate peers who had not experienced the DEU as part of the clinical education process. The DEU partnership model engaged the students as practitioners who integrated “thinking and doing” in a living laboratory, and learned the complexities of the system in a way that allowed reflection and proactive learning.23 This approach to learning is consistent with Benner and colleagues’ situated cognition or “thinking in action,” which is believed to be essential in clinical teaching to acquire, learn, and use nursing knowledge.24 Clinical evaluation data from the faculty, preceptors, and the students regarding the MHSL-SLUSON DEU project indicate that students gained the following: improved prioritization and delegation skills; better integration into the clinical unit as team members; increased opportunity to perform skills and procedures; increased confidence in the clinical environment; and increased levels of critical thinking, decision-making, and inquiry skills.14 Undoubtedly, the new graduates hired by MHSL had a competitive advantage over new graduates who had not worked on the DEU. SLUSON used the “new” transformational clinical model in its recruitment discussions with prospective students and faculty, and MHSL was able to hire new graduates who were familiar with the institution and its operations. The alliance provided each partner with the ability to leverage its respective strengths. In addition, the partners worked well together and were able to handle issues and concerns through the PST. The DEU model was mutually beneficial and increased the interconnectedness between academe and service. These partnership opportunities are paving the way for innovative and transformative collaboration in both the practice and academic environments.25 In terms of partnership sustainability, the partners continue to rely on the other’s goodwill and trustworthiness, which is consistent with the relational design of alliance management based on trust. Either partner can terminate the relationship, but at this point, both partners are committed to the alliance, and as long as there is mutual benefit, the partners are satisfied with the current design.
e21
Next Steps At the present time, the MHSL-SLUSON DEU partnership is one example of a strategic alliance that currently works for both partners. However, longitudinal study of the students who participated in the MHSL-SLUSON DEU is an area of future research. Equally critical is the need to analyze academic-service partnerships for success, sustainability, and replication. A recent survey suggested there was substantial untapped opportunity for hospitals and schools to collaborate on improving student competencies during the school-based clinical experience.26 In spite of the known limitations of isolated institutional activity, leaders remain challenged with how to establish strategic alliances and partnerships that offer mutual benefit.27 In evaluating innovations in nursing education, we must keep in mind that innovations may be difficult to evaluate. The very nature of innovation implies a process of trial and error with a necessary degree of experimentation. The complexity of the health care environment is such that a particular combination of needs, people, and problems may or may not occur on a routine basis for empirical evaluation. As Senge pointed out, with any innovation, “statistical measures may be disappointing, but if you’re actually involved, you may see that people are engaged and learning.on the brink of a breakthrough.incomplete or premature assessment may destroy learning or the innovation.we must avoid pulling up the radishes to see how they’re growing.”28 Yet the question remains: How do we move from existing educational practices to next practices? Nurse leaders should continually ask this question. Next practices are innovations that change existing paradigms and have the potential to significantly alter an entire field or practice.29 Leaders should assess whether one has the capacity for creativity and innovation and how he or she could create sustainable partnerships that align and leverage resources.9,30 The nursing community needs leaders who are undaunted by innovative practices and are willing to experiment to chart the course for transformative changes that lead to a well-qualified nursing workforce. Nursing leaders, as thoughtful strategists, can shape the future rather than respond to it.
references
1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing health. Washington, DC: The National Academies Press; 2011. 2. Gulati R. Does familiarity breed trust? The implications for repeated ties for contractual choice in alliances. Acad Manage J 1995;38:85-112. 3. Dyer JH, Kale P, Singh H. How to make strategic alliances work. MIT Sloan Management Review 2001;42:37-43.
e22
N u r s O u t l o o k 6 0 ( 2 0 1 2 ) e 1 7 ee 2 2
4. Murray TA, Schappe A, Kreienkamp DE, et al. A communitywide academic-service partnership to expand faculty and student capacity. J Nurs Educ 2010;49:295-300. 5. Murray TA. An academic-service partnership to expand capacity: What did we learn? J Cont Educ Nurs 2008;39:217-24. 6. Fralic MF. Hardwiring the “three-legged stool”: Nursing’s vital education/practice/research triad. J Prof Nurs 2004;20:281-4. 7. California Institute for Nursing & Health Care. Nursing education redesign for California: White paper and strategic action plan recommendations, 2008. Available at: http:// www.cinhc.org/wordpress/wp-content/uploads/2009/12/ 5_Nursing-Ed-Redesign.pdf. Accessed June 11, 2011. 8. Joynt J, Kimball B. Blowing open the bottleneck: Designing new approaches to increase nurse education capacity. White paper sponsored by the AARP, US Department of Labor, & Robert Wood Johnson Foundation; 2008. 9. American Association of Colleges of Nursing. AACN-AONE task force on academic-practice partnerships. Available at: www.aacn.nche.edu/about-aacn/committees-task-force/ aacn-aone-task-force-on-academic-practice-partnerships. Accessed June11, 2011. 10. Robert Wood Johnson Foundation. Charting nursing’s future: Reports on policies that can transform patient care. Available at: http://www.rwjf.org/files/publications/other/ nursingfuture4.pdf. Accessed June 11, 2011. 11. Mulready J, Kafel K, Bannister G, et al. Enhancing quality and safety competency development at the unit level: An initial evaluation of student learning and clinical teaching on dedicated education units. J Nurs Educ 2010;48:716-9. 12. Moscato S, Miller J, Logsdon K, et al. Dedicated education unit: An innovative clinical partner education model. Nurs Outlook 2007;55:31-7. 13. Murray TA, Crain C, Meyer G, et al. Building bridges: An innovative academic-service partnership. Nurs Outlook 2010; 58:252-60. 14. MacIntyre RC, Murray TA, Teel CS, et al. Five recommendations for prelicensure clinical nursing education. J Nurs Educ 2009;48:447-53. 15. Kale P, Singh H. Managing strategic alliances: What do we know now, and where do we go from here? Acad Manage Persp 2009;23:5-62. 16. Smith E, Tonges MC. The Carolina nursing experience: A service perspective on an academic-service partnership. J Prof Nurs 2004;20:305-9. 17. Shah R, Swaminathan V. Factors influencing partner selection in strategic alliances: The moderating role of
18.
19. 20.
21.
22.
23. 24.
25.
26.
27.
28. 29.
30.
alliance context. Strategic Management Journal 2008;29: 471-94. D’Amour D, Goulet L, Labadie J, et al. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Services Research 2008;8:188. Warner JR, Burton DA. The policy and politics of emerging academic-service partnerships. J Prof Nurs 2009;25:329-34. Donaldson SK, Fralic MF. Forging today’s practice-academic link: A new era of nursing leadership. Nurs Admin Q 2000;25: 95-101. Kirschling JM, Erickson JI. The STTI Practice-Academe Innovative Collaboration Award: Honoring innovation, partnership, and excellence. J Nurs Scholarsh 2010;42:286-94. Organization for Economic Co-operation and Development (OCED) Local Economic and Employment Development (LEED) Forum. Successful partnerships: A guide. Available at: http:// www.oecd.org/cfe/leed/forum/partnerships. Accessed June 11, 2011. Finkelman A, Kenner C. Educational and service partnerships: An example of global flattening. J Prof Nurs 2007;24:59-65. Benner P, Sutphen M, Leonard V, et al. Educating nurses: A call for radical transformation. San Francisco, CA: JosseyBass; 2010. Cartwright JC. Opportunities for practice and educational transformations through unlikely partnerships. J Nurs Educ 2010;49:243-4. The Advisory Board Company. Bridging the preparationpractice gap: volume I: Quantifying new graduate nurse improvement needs. Washington, DC: The Advisory Board Company; 2008. O’Neil E. The nursing shortage, by the numbers. Available at: http://www.rwjf.org/pr/product.jsp?id¼21037. Accessed on June 11, 2011. Senge P. The practice of innovation. Leader to Leader Journal 1998;9:16-22. Nidumolu R, Prahalad CK, Rangaswami MR. Why sustainability is now the key driver of innovation. Harvard Business Review 2009;87:56-64. Niederhauser V, MacIntyre RC, Garner C, et al. Transformational models of nursing across different care settings: Transformational partnerships in nursing education. In the Committee on the Robert Wood Johnson Initiative on the Future of Nursing at the Institute of Medicine; Institute of Medicine. The future of nursing: Leading change, advancing health. National Academies Press; 2010.