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

Background The nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year. Methods We conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement. Results We emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care. Conclusions Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.


Background
In a business context, strategic alliances may be conceptualized as formal or informal collaborative relationships between parties who come together to achieve a common goal while remaining separate organizations [1]. In the nursing profession, strategic alliances are typically created between an academic partner or nursing school and a practice partner, usually an inpatient healthcare facility, that are geographically proximate to each other. The potential benefits of such alliances, or ? academicpractice partnerships,? may include increased capacity for students to matriculate into nursing programs [2] and the ability to better prepare nursing students to meet the demands of the practice setting [3]. Medicine has benefited from such academic-practice partnerships for decades, but nursing is comparatively new to the academic-practice partnership model [4].
The Department of Veterans Affairs (VA), as a major employer of nurses and other healthcare professionals, has an abiding interest in clinician education, and, while not an educational institution itself, does make its facilities available for clinical instruction. Moreover, for disciplines such as medicine, VA has been a major employer of clinical teaching staff and an active participant in shaping clinical experiences. VA recently extended this academic-practice partnership framework to nursing education on a pilot basis. In 2007, the VA Offices of Academic Affiliations and Nursing Services established the VA Nursing Academy (VANA), a five-year, $60 million pilot program, to address the nursing and nurse faculty shortage occurring both within VA and the nation by providing pilot funding for 15 strategic partnerships to be established between competitively selected VA facilities and nearby nursing schools nationwide [5]. The VANA partnership model was designed to develop strong, mutually beneficial relationships between participating nursing schools and VA facilities by (1) expanding educational faculty through career development, (2) increasing student enrollments, (3) cultivating educational and practice innovations, and (4) increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education. In addition, the VANA model was designed to allow for substantial local variation in its structure and application. This approach afforded each partnership with the ability to adapt the program to meet local contextual needs and demands, and also permitted significant experimentation to ascertain the relative success of various approaches.
The nursing profession is currently exploring how such arrangements may be most effectively operationalized to maximize the potential benefits for each partner and for the field. The nursing literature provides many examples of partnerships that include one nursing school and one or more practice partners, but the evidence for the success of these partnerships is poor [6]. Many of these articles describe the development and nature of the partnership model, but collectively they provide little empirical evidence to guide organizational decision-makers when they seek to design new partnerships or modify existing ones [7][8][9][10][11][12][13][14]. Recent recommendations from a task force established by the American Association of Colleges of Nursing (AACN) and the American Organization of Nurse Executives (AONE) on academic-practice partnerships [15] provide some guideposts for such partnerships, but they are guiding principles rather than recommended practices for their implementation.
With five years of funding for fifteen partnerships, VANA provided an oppportunity to increase the evidence base on the implementation effectiveness of partnerships. Towards this end, the VA funded a six-year, multidimensional evaluation of the VANA program. As part of this evaluation, the evaluation team sought to identify specific indicators of successes and challenges that characterized VANA partnerships during the ? start-up phase? of each partnership. This article proposes a framework of critical features that have emerged from our qualitative data analysis during an examination of the first year, or ? Launch Year,? of each partnership. In so doing, we propose certain features as early, evidencebased indicators of progress toward achieving desired outcomes, and provide practical, real-world details that extend the guiding principles in the aforementioned AACN-AONE report. These findings, drawn from a comparative analysis of partnership development at 15 sites from across the United States, provide critical insight into effective approaches for structuring and implementing academic-clinical partnerships in nursing.
This article addresses the following two research questions: 1. What implementation activities and goal-specific outputs were associated with a successful launch? 2. What program inputs and contextual factors also were associated with a successful launch?

Methods
This formative evaluation [16] was designed to qualitatively analyze data collected using in-person interviews and focus groups from 364 key informants involved in implementing these 15 partnerships. As Figure 1 illustrates, an ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement. Data collection included 142 in-person interviews with faculty and administrators during prescheduled site visits to each locale and 23 focus groups with nursing staff and students. Each site was visited one time within the first 18 months of joining the VANA pilot. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. Both the interviews and the focus groups included open-ended questions concerning the general background of the institutions and their motivation to participate in VANA, various structural and operational aspects of the partnership, opinions about the potential effectiveness and possible impacts of VANA on the respondent and their organization, and perceptions regarding the effectiveness of VANA in improving the VA? s ability to recruit new graduates. Each interview lasted approximately 60 to 90 minutes; the focus groups were typically 60 minutes. Two to four doctorallyprepared investigators were present at each interview or focus group session with one investigator serving as the primary interviewer, and the other(s) keeping detailed field notes, verifying observations, and ensuring that all key topics were covered [17]. All interviews and focus groups were audiotaped. Participants were informed that data was kept confidential and anonymous. Verbal informed consent for participation was obtained from participants. This study was approved by the Institutional Review Board of the VA Greater Los Angeles Healthcare System.
The research team used a structured tool, derived from the interview guide and the team? s collective expertise and ongoing experience, to organize and analyze the interview and focus group data. Directly after each site visit, the investigators who participated in the interviews met and debriefed each other using this tool to capture impressions and comments in a timely manner. Investigators often referred to their field notes during this process. Recordings, notes and transcriptions were used to settle disagreements until consensus was reached for each question in the analysis tool.
Our qualitative analyses focused on identifying the essential elements of program progress during the Launch Year. We defined progress as achieving the programmatic goals designated for VANA by VA. For each goal, we identified two categories of elements that influenced success: implementation activities undertaken by the program organizers and outputs or near term products (often predetermined by the VANA grant).
We searched for variability within each element that would indicate a spectrum of progress ranging from ? proceeding well according to plan? (i.e. successful) to ? addressing impediments and therefore lagging behind schedule? (i.e. challenged). Operational definitions for each theme and element, and observed indicators of success were collectively drawn from the data. Disagreements among the analysts were settled by consensus. Note that the indicators under each of the domains are not structured to strictly parallel each other; the data are presented in this manner to limit the size of the tables. Thus, the presence or absence of a particular indicator generally characterizes whether a partnership may be considered successful or challenged within that domain.
When analyzing these implementation activities and outputs critical to successful launch, it should be noted that the initial inputs into the program and the program? s environmental context also influenced the partnership? s launch. We applied a similar qualitative approach to analyzing these elements, with progress being defined as achieving programmatic goals more generally, rather than specifically for each goal.

Results
Tables 1, 2, 3, 4 and 5 present the critical implementation activities and outputs that were associated with a successful  Adjust faculty workloads as needed • New faculty coped with teaching assignments with ease and enthusiasm • Clinical groups had over 10 students • Clinical group size (i.e., typically 8? 10 students or less) allowed for adequate student interactions with faculty • New faculty had no access to information on teaching tips (e.g., grading care plans efficiently) that would have prevented them from feeling overwhelmed with workload • Faculty were paid for all hours worked or received ? comp time? for grading at home • Support was provided for faculty who needed more assistance in coping with workload during Launch Year • VA-based faculty were re-assigned to old clinical, administrative, or educational responsibilities in VA when classes were not in session • During breaks, VA-based faculty worked on ancillary programs such as curriculum development, both at the VA and nursing school • VA-based faculty, who held full-time VA positions, had no vacation breaks at the end of terms as did the school-based faculty Integrate faculty into partnering environment • VANA faculty group was very cohesive and supportive of each other, regardless of where they were based (i.e., VA or school) • Among partnership members, there existed a lack of awareness of each other? s responsibilities and contributions • VA-based faculty become involved in nursing school committees where their clinical expertise is welcomed (e.g., in curriculum development) • Clinical Expertise of VA-based faculty is not recognized or utilized by the members of the partnering institution • Nursing school-based faculty become involved in VA committees, particularly EBP • Faculty felt that they had two masters (i.e., were beholden to the demands of both the nursing school and the VAMC) • VA-based faculty were engaged in university activities depending on interests and role requirements • VA-based faculty perceived that their contributions were highly valued by nursing school colleagues

Goal 1: increasing faculty positions
As shown in Table 1, the data from the interviews and focus groups with the leaders, faculty, students, and nursing staff involved in the fifteen partnerships suggested that the following activities were critical to achieving first year progress toward the goal of increasing faculty positions: For each activity, the indicators of success and challenge illustrate the variation in performance of the activities that ranged from ? proceeding well according to plan? to ? addressing impediments and therefore lagging behind schedule.? • Turnover often due to discontent resulting from unrealistic expectations about the role and its associated workload • High levels of faculty dissatisfaction measured in VNEP surveys

Operationalize proposed innovations
• Sufficient office space was provided for faculty to prepare for clinical sessions, grade assignments and meet with students • There was a lack of dedicated office space for VANA faculty at either institution • Computer access and email accounts were provided to all partnership personnel at both the VAMC and the nursing school • Ad hoc availability of non-private space at the VAMC was often the only option for faculty to meet with students • Meeting space was provided for partnership personnel to conduct regularly held partnership meetings • Only limited or inconvenient access to email accounts was provided • Necessary instructional resources (e.g., textbooks and other teaching materials) were provided to faculty • Only limited parking was available at one or both locales, which made commuting between institutions difficult

Initiate proposed innovations
• Program launch at the beginning of the first academic year was well-planned and staged from time of grant notification • There were significant deviations from the proposed launch schedule by the end of year one • Program launch process mostly kept to schedule delineated in partnership? s proposal • Limited evidence of proposed innovations being implemented by end of first year, often due to the continuing distraction of coping with unforeseen logistical barriers since launch (e.g., faculty and/or leadership turnover) • Nontraditional care areas of the VAMC (e.g., ambulatory mental health clinics) were used for some clinical placements • Clinical experiences often included home health or outpatient clinics that focused on care continuity and the whole patient (e.g., co-morbid conditions, social situations) • Neither partner seemed to recognize unique clinical teaching opportunities available within the VAMC (e.g., use of mental health units) • Presence of VANA program facilitated creation of or bolstered existing VA student nurse apprenticeship programs (e.g., pre-baccalaureate residency, other VA programs) • DEU-style learning units were developed specifically for VANA clinical placements • Scope of student experiences was increased on some units, particularly where clinical faculty was well-known to nursing staff as a colleague • Simulation Lab resources and use, often at both facilities, were expanded to enhance VANA student learning • Curricular content, both didactic and simulation, was infused with veteran-specific content and case studies Collaborate on research and quality improvement initiatives • At least one of the program directors has strong research background and expertise We found that the scope of the faculty role varied widely amongst partnerships. Depending on the program structure, the distribution of full-time equivalents [FTEs] ranged from a full (1.0) FTE to less than half (e.g., 0.3 FTE) dedicated to the VANA faculty role. In situations where the dedicated FTE was below 0.5 FTE, commitment on the part of the faculty to the VANA program seemed diminished. Recognition of the need to provide faculty with ? protected time? from teaching to engage in other activities such as faculty meetings, committee work, and patient care (for those needing to maintain their license as advanced practice registered nurses) suggested higher satisfaction rates on the part of the VANA faculty, particularly among those who were new to the faculty role.
With the emphasis on using expert clinicians who often had limited teaching experience as faculty, those partnerships who recognized early on the need to invest in developing these faculty had increased satisfaction of VANA faculty and decreased turnover during the first year. Furthermore, recognition of workload-life balance was a challenge for many partnerships. Oftentimes, the natural breaks in the school calendar (e.g., late December) that traditional faculty receive were not available to VAbased faculty because of their clinical responsibilities at the VA facility, thus not providing them with adequate respite between terms. Issues around traditional working hours for hospital-based staff versus the more flexible hours of traditional nursing school faculty often resulted in work overload issues for faculty. Involve nursing staff in planning • VA-based faculty (i.e., staff nurses hired into faculty positions) highly integrated into workflow on units where students were placed • Unit nursing staff as a whole not enthusiastic about having VANA students placed there • VA-based faculty highly engaged in all aspects of clinical teaching (e.g., preceptor training, DEU implementation) • Presence of VANA students seen by unit staff as an increased workload burden and interruption to workflow • VANA faculty activated to develop their careers (e.g., furthering own education, gaining broad teaching experience) • Unit staff not willing to participate in VANA-related activities, such as EBP projects   Facilitate intraorganizational operation • Presence of a program champion, a firm and ardent believer in the program, who is able to achieve the buyin from within the leadership and faculty necessary for the program to develop

Perceived benefits by all stakeholders
All key stakeholders perceive at least some benefit from VANA participation, such as: Few stakeholders perceive any benefit from VANA participation, such as: University: University: • Opportunity for expanded curriculum (new course/subject matter; addition of veteran and VA-specific content) • Increased student enrollments and faculty positions not commensurate with level of perceived benefits Multiple challenges were noted around merging the organizational cultures of VA and university partners. Faculty from both sides viewed the other partner as a large, bureaucratic organization that created a number of difficulties around time-keeping for faculty. Universitybased faculty with academic experience uniformly described their academic culture as providing more flexibility than the VA in terms of where and when work is completed. Some VA employees expressed concern that this more lax approach to time-keeping with their university partner had the potential to limit accountability. Table 1 also shows that the critical outputs of year one efforts towards increasing faculty were:

Faculty hiring quota met by end of Launch Year Faculty satisfied with new roles
The successful expansion of nursing faculty and student enrollments was prescribed by the VANA grant (i.e. five faculty FTEs, either VA-or nursing school-based, per 20 additional students enrolled into the designated baccalaureate program over baseline), with a goal of hiring faculty first from the local VA facility, in order to encourage retention of clinically expert nursing staff within the VA system. Challenged programs often were unable to meet the hiring quota. When hiring quotas designated by the grant were not met by the end of the first academic year, it was generally due to a lack of qualified candidates in the local area. At some sites, the full quota was not filled during the initial year.
Satisfaction was measured primarily via faculty surveys, which looked at leadership support, mentorship, availability of teaching resources, and workload, among other issues. High dissatisfaction and turnover of faculty resulted primarily from unrealistic expectations in the first year of the partnership about the role and its associated workload.

Goal 2: increasing student enrollment
As shown in Table 2, our qualitative analysis suggested that two implementation activities during the Launch Year were critical to progress towards this goal:

Generated interest in VA clinical placements amongst students Placed students on VA facility units
The number of additional matriculating students was prescribed by the VANA grant in direct relation to the expansion of VANA faculty as indicated above. In rare cases, enrolling the target number of new students was not achieved, possibly due to a drop in applicants secondary to the poor state of the economy or the inability of the nursing school to accommodate that number of new students into coursework when new faculty were not yet recruited. Even if the increase in student enrollments was accomplished the first year, some partnerships encountered logistical problems related either to delays caused by complex hiring processes or difficulties transferring funds to the university to pay for nursing school-based positions.
Some VANA programs created cohorts of students who went to the VA facility for all of their clinical rotations (except pediatrics and obstetrics). Other programs chose to send most of their students to the VA for at least one clinical rotation. In both situations, efforts were made to take advantage of the unique opportunities of the VA, such as mental health and community health placements, in order to enrich the student experience. VA employment policies, like those of many practice Table 5 Critical elements: implementation activities and outputs for promoting collaboration (Continued) • Decreased concern about finding clinical placement slots VA: • Appreciation of clinical expertise of VA-based VANA faculty • No value seen in increasing career opportunities for expert nurses VA: • Students: Negative VA experiences negatively impact student impressions of VA • Increased unit staff and patient exposure to BSNprepared students Veteran patients: • Improved retention of current nursing staff, especially those with valuable experience and clinical expertise Students: • Increased awareness of veteran-specific needs • Increased awareness of employment opportunities at the VA Veteran patients: • Appreciation of interactions with VANA students, especially those with military background institutions, were often cumbersome and could significantly delay placement of students onto units. Having processes in place prior to the start of the semester as well as adequate resources to process and orient the students allowed students to start their rotations within an appropriate time frame. Two outputs appeared critical to this goal: Increased undergraduate student enrollment Increased student satisfaction with participation Prior to VANA, students? opinion of the quality of VA clinical rotations was often poor. After experiencing VA through VANA, students consistently reported high rates of satisfaction in surveys regarding their VA clinical rotations. Survey data will be reported elsewhere. A primary disappointment was the lack of job opportunities available at the participating VA facilities. Table 3 shows the implementation activities that emerged from interviews and focus groups as critical to first year progress towards the goal of curricular innovations:

Operationalized proposed innovations Initiated proposed innovations Collaborated on research and quality improvement initiatives Refined program components as needed
Examples of innovative programs that were launched during the first year of operation included enhanced use of simulation learning, ? embedding? VANA faculty members on certain units as expert resources even when they were not accompanied by students [18], designated educational units (DEUs), and evidence-based projects (EBPs) conducted collaboratively with students and unit staff. [5] Since most innovations often focused on aspects of the faculty role, providing resources for faculty to conduct their business was crucial. Office space, space for conducting regular VANA meetings, email accounts, textbooks for courses taught, and parking were resources that successful programs had in place at or near the start of the program. Implementing innovations as detailed in the partnerships? proposals often lagged behind the proposed schedule at challenged sites. Successful innovations were implemented as planned despite challenges along the way.
Successful partnerships typically foresaw opportunities for combined scholarly activities that optimized available expertise and were built into the strategic plan from the beginning. EBP projects often became the focus of such collaboration, likely because these quality improvement projects could be better integrated into the educational curriculum and therefore were easier to initiate. Potential opportunities for shared research often centered on the expertise of a single person who had a track record of such work; as the development of research studies typically requires more than one year, it is not surprising that initial efforts aimed at fostering collaborative research focused on persons with significant pre-existing experience in research. Plans of this nature were frequently delayed by unanticipated Launch Year logistics, where challenged sites either delayed the implementation of such plans or did not develop them during the initial year.
Three outputs emerged as critical to this goal: Increased stakeholder satisfaction with participation Increased evidence-based care Perceived improvements in nursing care quality Early on, new nursing students were not always welcomed by staff or patients, either because some VA facilities had not recently, or only infrequently, hosted baccalaureate students and accordingly did not know what to expect from them, or because some older staff nurses were reluctant to take on the role of preceptor. However, at successful sites unit nurses and, especially patients, were delighted and often enthusiastic about the clinical rotations and were impressed by the high caliber of the VANA students.
In successful partnerships, VANA afforded the VA partner with the opportunity to gain the benefit of faculty knowledge and experience to develop programs designed to foster the spread of evidence-based nursing care (e.g., development of a ? wish-list? of programs where faculty choose to provide their expertise, bringing in nationally prominent visiting scholars to lecture at the VA partner). The partnerships? efforts at joint research activities were limited in the Launch Year, likely because they were trumped by the logistics of program implementation. Where they existed, research collaborations benefited from the existence of VANA (e.g., development of a joint VA-university research position) resources.

Goal 4: increasing recruitment and retention
Two activities appeared to be important to progressing towards the goal of increasing recruitment and retentsion: Identified VA units to be used for VANA placements Involved nursing staff in planning Each of these activities were implemented with varying degress of success, as illustrated by the indicators of success and challenge presented in Table 5.
On some units, VA nurses served as role models or mentors for students as they sought to learn more about the nature of nursing practice and in what area they wished to practice. One partnership underscored this role by assigning formal mentors for students. Mentoring was reported as valuable both to the students and the nursing staff who served as mentors. Some respondents noted that by significantly increasing the length of time that the students were at a single clinical institution, students were more likely to view themselves as part of a team and were able to take on advanced responsibilities because they had a more detailed understanding of that institution. A few respondents noted that the opportunity for students to observe VA nurses in a variety of roles, including managerial positions, provided students with broader ideas for how their nursing careers could develop within VA. Challenged sites were characterized by staff resistance to having students, unwillingness by staff to engage in EBP-related activities, or over-reliance on staff for bedside teaching because of large clinical groups.
Outputs of the efforts to launch recruitment and retention included the following:

Increased stakeholder satisfaction with participation Benefits of VANA participation realized
Unit nurses were the primary benefactors of VANA student and faculty presence because of a variety of factors. Oftentimes, we were told that staff prepared for students? questions by refreshing their own knowledge and occasionally sought the expertise of the VANA faculty to do so. Clinical innovations implemented at some sites (e.g., DEUs, embedding faculty as unit staff ) activated staff in ways not seen prior to the partnership launch. We frequently heard anecdotes about observed improvements in care quality. Sites where staff continued to perceive student placements as burdensome were considered to be challenged. Realized benefits of VANA participation included the provision of career opportunities for expert VANA nurses who wished to teach, wellqualified graduates seeking work at the VAMC, and a much improved reputation for the VA as a high quality and competitive clinical rotation.

Goal 5: promoting collaboration
An underlying VANA goal was to promote collaboration between the academic and practice partners in order to build a strong, mutually beneficial relationship. A number of activities were important to achieve this goal ( Formal and regular meetings that included the VANA faculty allowed for the development of a strong cohesive group of faculty who could rely on each other for support and encouragement. When these meetings included leadership from both organizations, and where leadership encouraged participation in committee meetings from both institutions, faculty perceived that their expertise was more highly valued by the partnering organization. Barriers arose when one or the other program director did not regularly attend the meetings, or if faculty felt that they were beholden to incongruent demands from both organizations. Shared decisionmaking and trust marked those partnerships considered to be successful.
Other innovations, while strongly encouraged, were not requirements of the grant. These new activities could focus on clinical care, administrative practices, research, or education. Programs that received VANA funding generally proposed realistic and robust innovations, although challenged programs often had to delay the implementation of these activities due to logistical barriers created by partnerships that did not have pre-existing clinical placement agreements with their VA partner and thus were not fully aware of the demands associated with such arrangements. Similar challenges were also created by difficulties in the timely backfilling of clinical and managerial responsibilities of those VA nurses who took faculty positions. Even successful programs occasionally experienced delays in launching proposed innovations because of the short length of time between the notification of grant funding and the beginning of the academic year. Examples of innovative programs that were launched during the first year of operation included enhanced simulation learning, embedding VANA faculty members on certain units as expert resource staff even when they were not accompanied by students, DEUs, and EBP projects conducted collaboratively with students and unit staff.
Overt attempts made to market the VANA partnership within each organization and within the community were viewed as a positive indicator of a partnership that was proud of its work. Pride and strong program identity were weak or absent at challenged sites.
Culture clashes and administrative difficulties were frequently encountered across all programs. Such hurdles, often unforeseen, were either dealt with efficiently without interrupting launch implementation, or were met with poorly coordinated problem-solving or a lack of necessary involvement from organizational leadership.
The consistency of core people in the partnership, particularly in the leadership ? quadrad? (i.e. Dean, VA Nurse Executive, both Program Directors), was markedly emblematic of successful programs. In particular, having key personnel who took part in conceptualizing the program and writing the proposal remain associated with the program throughout the launch phase had greater value for maintaining morale and overcoming administrative and other challenges. Early turnover in faculty was viewed as highly disruptive to these nascent programs. Where small fragments of FTEs were assigned to VANA faculty roles, turnover was higher.
The following outputs emerged as critical to this goal: Local recognition for VANA program VA and academic partner co-authored publications Perceived benefits by all stakeholders Events held within VAs and the larger nursing community were common. Knowledge of the VANA program was poor outside of the direct participants in the partnership at challenged sites.
Drafting manuscripts describing unique aspects of certain VANA-supported activities started early at successful sites, whereas sites that were still struggling to overcome logistical problems in their first year, such as delays in faculty hiring, were challenged to meet the terms of the grant and unable to develop scholarly products related to the partnership.
Benefits of VANA program involvement were recognized at all levels of stakeholders at successful sites. In particular, the value of adding content regarding veteran care to the nursing curriculum (most commonly as vignettes in the simulation learning settings) and the positive feedback from veteran patients who received care from the students were notable. Discussions about the value of VANA were infrequent at sites, especially at sites where VA-based VANA faculty were poorly integrated into the nursing school environment and where unit staff at the VAMC were resistant to having students on their unit.

Initial program inputs and environmental context
The types of resources invested in the individual programs were similar across all partnerships. Some of the model? s inputs were anticipated in the original grant, including the funds to hire new faculty, but others were added to the framework as they emerged from the data. As shown in Table 6, important inputs included: Leadership participation in proposal development Collegiality between future partnership members (often based on prior work together) Relationship of partnership leaders with the VA Central Office Funds from VANA grant to support faculty salaries a Participation in proposal development was an important indicator of a stakeholder? s level of buy-in to the partnership? s mission, and seemed to be predictive of a sustained commitment to VANA throughout the Launch Year. It may also have assured full consideration of operational issues that had to be addressed in the ramp-up of the program, and led to a speedier and smoother implementation process.
Pre-existing relationships between leaders showed a commitment to the program between professionals who had worked together in the past. When such a relationship existed, it suggested a higher level of communication between partners, which not only facilitated informal, ad hoc contacts during the critical developmental phase of the nascent partnership, but also formed the basis for formal If partnership leaders were known to VANA directors in the VA Office of Academic Affiliations prior to receiving the VANA grant, that familiarity seemed to facilitate informal and therefore timely communication with that Program Office, and appeared to be especially beneficial when the partners confronted logistical barriers. Challenging problems were dealt with earlier when a Program Director or Dean, for example, felt comfortable contacting a colleague from the ? third-party? VA Program Office to seek advice or assistance. Leaders in partnerships that did not have that relationship either looked to the partnership network for advice or attempted to cope with problems amongst themselves.
The primary input of the VANA program was funding provided specifically for the expansion of nursing faculty and baccalaureate students, conducted on a graduated basis. New faculty FTE were appointed based on a fixed ratio of new faculty FTE to additional nursing students enrolled over baseline prior to the start of VANA at the partnering nursing school. The prescribed ratios increased according to enrollment guidelines established in the pilot program, and decreased again in the final year of the program as the pilot neared its end.
Additionally, a number of important environmental features appeared to meaningfully impact a partnership? s operation. For example, the economic downturn factored significantly in all cases, but with widely varying impacts on local programs. In some instances where the academic partner was a state-supported institution, the VANA grant provided key funding for struggling nursing schools. In general, balancing the needs of both partners was well managed in most cases. The most common contextual features that we found were: Local competition for undergraduate clinical placement sites between nursing schools Local availability of qualified faculty candidates Effect of the local economy on employment If several schools of nursing, including baccalaureate and community college programs, existed within a particular locale, we frequently observed competition for clinical placement slots. Commitment to partnering with VA through the VANA grant sometimes pre-empted such agreements where they had previously existed. Despite the demand for clinical places, we also observed that many VA facilities became clinical placements sites for their nursing school partners for the first time.
The search for clinically expert, masters-prepared VA nurses who wanted to develop themselves as educators was easiest where there was a plentiful supply of nurses with master? s degrees in the surrounding community. We most commonly observed that VANA faculty positions were offered to qualified VA nurses. However, in locales with a short supply of those nurses, VA facility leadership was often reluctant to release these valuable employees out of concern that the facility would be unable to backfill their positions. Filling the first year hiring quota was often delayed as partnerships were forced to search outside the immediate area for qualified applicants. In turn, this often delayed the program? s launch.
We found that local economic conditions impacted the VANA program in several ways. The most apparent effect was the (temporary) absence of a nursing shortage and the resulting lack of demand for new nurses. In general, the economic downturn since 2007 has altered the dynamics of the nursing shortage and, as such, there were fewer opportunities for VANA graduates to seek VA employment, especially in urban areas where the competition for jobs was most intense. As the economy recovers, it is anticipated that demand for new nurses will increase [19], but until that happens, fulfilling this aim of the VANA pilot program was not considered feasible. Hiring freezes and delayed retirements across VA facilities were common. In at least a third of the partnerships, VANA graduates who entered a nursing program with the idea that they would find work opportunities at a VA facility, were frequently disappointed to find few or no job openings.

Discussion
In this systematic evaluation of a nationwide academicpractice partnership program conducted during the VANA program? s Launch Year, we identified indicators of both successful and challenged launches. These indicators are the results of our observations obtained during the launch of the 15 ongoing academic-practice partnerships that were established between nursing schools and proximally-located VA medical centers. VANA? s nationwide breadth combined with the variation in the structure of each individual VANA partnership, allows this study to provide more generalizable information on academicpractice partnerships than prior studies that have been limited to small samples in single locations [6].
Five key themes emerge from this analysis. First, interorganizational collaboration (? teamwork? ) is a critical factor in enabling these partnerships to be successful. Such collaboration would include teamwork between direct and indirect participants across partnering institutions regarding specific issues, strategies, and decisions. Factors that facilitate building strong collaboration include prior working relationships and personal contact between leaders of the partnering organizations (often borne from preexisting clinical education relationships), a sense of equal participation and equitable burden on partners, clear and realistic expectations of the benefits and responsibilities of each party, and building ongoing and frequent opportunities for formal and informal communication between program participants at all levels. These processes were challenged when leaders failed to commit the time and effort to establish and maintain the collaboration, when informal communications were weak, when formal meetings and communications were sporadic or limited, and when commitments such as achieving enrollment targets or providing clinical instructors or preceptors were not fully met. In the VANA program, developing a proposal for funding from VA provided a vehicle for defining how the collaboration would be structured and time to consider issues before implementation began. In other contexts, where no such external mechanisms exist, the experience of the VANA sites suggests that formal, intensive planning processes will be invaluable to successful implementation.
Second, major challenges to creating the partnerships arose not just from blending different cultures, but also from having to integrate activities across divergent organizational processes and constraints. In the VANA context, for example, time keeping requirements and expectations about working on site for those working directly for the VA facility (as opposed to those working at schools of nursing) clashed with the nursing school? s expectations about time commitments across and between semesters. Similarly, nursing faculty expected greater flexibility to prepare for classes and grade assignments off-campus. Not all these challenges were anticipated during the planning stages, and sites differed in the speed with which these challenges were identified and addressed. In the VANA program, subsequent cohorts learned from earlier cohorts and better anticipated these challenges. The issues of operational integration identified in Table 1 should be expanded and extended to examine the experience of non-VA partnerships to see whether they differ from what we observed.
Third, there are specific challenges associated with identifying and recruiting nurses in clinical settings to take on faculty roles in a timely fashion, expanding the number of students recruited to programs when additional faculty are made available, and scheduling clinical and didactic courses. In the VANA program, these challenges were common across a number of sites. In some cases, these challenges proved daunting and substantially weakened the partners? commitment to the success of the partnership. Expectations about ramp-up time need to be realistic, and operational problems should be closely and continually reviewed on a joint basis by partnership leadership.
Fourth, expectations for these partnerships extended beyond merely building faculty or increasing the number of students and included such activities as using nursing school faculty to improve the use of EBP in clinical settings or increasing the use of simulation-based learning for in-service training of nursing staff. Oftentimes, planning for these activities and how they would be implemented was much less well developed than were the plans for expanding clinical and didactic education. Implementation was thus more inconsistent. Partnership planning and management need to be more explicit and detailed about how these components of a partnership are to be implemented. Nevertheless, based on the partnerships that we observed, it would appear that such efforts are better aimed at implementation after the Launch Year in a sequential planning and development process. Our findings contain lessons that can be applied to these efforts. Moreover, this theme suggests that academicpractice partnerships may be an effective means to achieve the full involvement of nurses in efforts to improve practice environments and outcomes of care as called for by the Rob Wood Johnson Foundation Initiative on the Future of Nursing in its 2011 report [20].
Finally, the immediate drivers for the VANA initiative ? a critical nursing shortage, the desire of the VA to address it by adding clinical nursing faculty, and VA? s goal of increasing nursing student interest in employment at VA facilities ? have been tempered by the economic downturn and the temporary easing of the nursing shortage. Nonetheless, partnerships are long term commitments for both clinical sites and nursing schools. Partners need to find ways to build stable relationships based on long-term interests and commitments even as they adjust to short-term changes in the supply and demand for nursing care.
The present study focuses on the critical elements of a successful academic-practice partnership launch, as informed by three successive annual cohorts. As the partnerships continued to evolve after the first year, it became evident that, as expected, partnerships responded in various ways to the identified challenges. Therefore, while we believe that the launch year is critical to a program? s eventual success, it should be recognized that partnerships evolve over time by confronting existing challenges and responding to new challenges. For VANA, this organic process benefited from interactions between the partnerships and also from the involvement of VA Headquarters personnel. Future studies will examine the growth of the partnerships and address the long-term effectiveness, efficiency, and sustainability of the VANA program.
The AACN-AONE Task Force on Academic-Practice Partnerships recommended a number of principles to guide such partnerships. These principles include collaborative relationships, mutual respect and trust, and shared knowledge, as well commitments to maximizing the potential of all nurses, effectively transitioning them into practice, highlighting their academic achievements, redesigning practice environments, and analyzing the needs of the nursing workforce [15]. While aligned with these principles, our findings suggest more specific implementation strategies for launching academic-practice partnerships. The critical implementation activities and outputs that emerged from our research provide a more basic level of operational guidance for implementing such partnerships, although some, such as those critical for promoting collaboration (Table 5), directly address a Task Force principle (collaborative relationships) as well.
While the framework we present can serve as a guide to best practices for establishing academic-practice partnerships [6,21,22], some limitations to our study should be acknowledged. First, each of the domains that influence partnership performance includes observations from our site visits that we believe delineate whether a partnership? s performance can be characterized as successful or challenged. The indicators of relative success of a partnership in a particular domain are based on our actual observations and not necessarily indicative of ultimate success in the latter stages of partnership development. Second, each of the domains represents different influences on performance and should be considered independently. In other words, partnerships could be viewed as successful or challenged in one or more of these domains, but when all of the domains are considered together, the overall partnership could still be considered to have largely met VANA? s programmatic goals overall. Finally, all of the studied partnerships include only VA as the practice partner. Thus, our results may not generalize to other practice partners due to dissimilarities of VA healthcare institutions compared to others in the same communities.
Although our evaluation examined academic-practice partnerships within nursing, it is likely that our framework would be applicable to academic-practice partnerships that involve other clinical practitioners. Future work should examine whether this Critical Elements approach is applicable to partnerships that include other types of healthcare professionals.

Conclusion
Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. This can be a daunting task. Furthermore, understanding how these partnerships emerge, and are nurtured and challenged also requires adopting a conceptual model in which partnerships can evolve over time as they learn from experience and attempt to address operational challenges. The experience of the VANA sites in implementing academicclinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. The findings provide practicable, actionable guidance on strategies for successfully launching academic-practice partnerships in nursing. By paying attention to the critical implementation activities and outputs identified here, decision-makers will be able to make better informed decisions about how to structure an academic-practice partnership for greatest success during the critically important initial year of the partnership? s creation.
Endnote a Full details of the grant requirements of the VANA partnership model are described in Bowman et al., [5].