Patterson, Davis G. PhD; Carline, Jan D. PhD
The past few years have seen a surge in the release of policy documents by numerous organizations and commissions that recognize the need for greater minority representation in health careers.1–4 All of these reports point to partnerships as a strategy for strengthening the educational pipeline. In this review we consider public school–university partnerships and the solutions they offer to the problem of minority underrepresentation in the health professions. We examine the elements of partnerships—the functioning of partner relationships, the problems they attempt to solve, and the interventions designed to solve these problems—with the purpose of discerning best partnership practices.
We identified literature through a PubMed database search using the terms “partnership,” “school,” and “health career/profession” and a library search using the terms “school,” “university,” and “partnership.” We supplemented the articles and books thus obtained by consulting their reference lists and other sources with which we were familiar, such as government, foundation, and research reports.
Our discussion thus draws from the literature on higher education–public school partnerships in general, and health professions partnerships in particular. We consider the social contexts that shape partnerships, including cultural clashes and available resources and constraints. We then look at stages of the partnership process: initiation, ongoing management, and institutionalization. Finally, we review strategies to improve minority student achievement—specific types of programmatic interventions—and best practices identified in the literature.
We make a distinction between “stand-alone” or independent programs versus those developed and implemented in partnership. Health professions schools may operate independent programs with minimal participation of public schools besides access to their students. Independent programs focus on individual students and may draw participants from more dispersed geographic areas.
In contrast, partnerships represent the maximum level of institutional commitment and involvement by both the health professions school and the public school system. Partnerships tend to work with a more narrowly defined population of students or teachers for extended or multiple exposures in individual schools, in a school district, or in several districts. Partnerships are multilateral and collaborative, and the menu from which they select strategies to improve K–12 education runs the gamut from the individual to the institutional level.
The Partnership Process: A Clash of Cultures
Partnerships are cooperative agreements between schools and community, business, and higher learning institutions to improve educational outcomes in K–12 education. A true partnership gives rise to a new culture with a set of norms, procedures, and relationships based on equality between members, rather than the hierarchy typical of educational organizations.5 This egalitarian framework engenders trust among parties that can lead to risk-taking and creative solutions. Creating a new entity with a new culture that has its own identity, distinct from the very organizations that created it, presents a host of challenges on multiple levels.
Divergent cultures and organizational imperatives mean that people in public schools and universities do not always see each other as part of the same pipeline, in a shared educational enterprise.5–13 School–university relationships may be loaded with the historical weight of past problems in working together.6,13 Public school personnel may feel threatened by outsiders or skeptical about what a university has to offer and how committed it is to long-term involvement; after all, programs come and go and funding is unstable.14 These tensions can lead to problems setting up partnerships, continuing distrust, and if not overcome, ultimately failure.
Teacher versus professor
Relative to public school teachers, university faculty have lighter teaching loads, more freedom in selecting teaching materials, smaller classes (or assistants for large lectures), and more flexible schedules.11 Their students are better prepared academically and less in need of behavior management. Peers and students typically evaluate college faculty; superiors evaluate public school teachers. Research and publication govern university faculty promotion; student performance is what counts for public school teachers. University faculty receive superior compensation and amenities compared with public school teachers. Despite the fact that public school and university faculty both teach, their daily experiences could not be more different.
One way to bridge this gap is to involve university faculty in serving K–12 students directly.15 This immersion provides higher education faculty a measure of credibility and a sense of the challenges that K–12 teachers face. However, because universities are not designed for providing direct services to public schools, faculty who understand and work well with K–12 teachers may be more effective at promoting systemic change, such as curriculum revision and teacher preparation.16,17
Because university administrators have greater autonomy and fiscal latitude, they can become frustrated when public school partners appear to lack creativity and flexibility.11,14 Leading a university tends to be a more reflective and participatory process, while public school principals are more likely to take charge and react. Exclusion from governance processes rankles college faculty, whereas public school teachers expect a more limited role in decision making. In addition, school boards exercise more “hands-on” control of policy implementation than do university trustees, who let administrators worry about the details.
These differences play out in the hiring of personnel to achieve partnership objectives.11,13 New approaches to teaching and learning often require new personnel with nontraditional credentials or experience. Higher education partners may feel frustration with public school bureaucracies and union regulations that restrict hiring, promotion, and transferring of key staff.13
Partnership Economies: Resources and Constraints
The scale of a project—how many institutions to involve, whether to work with schools or districts, which alliances to cultivate, how radically to attempt changing educational systems—involves a set of decisions that occur within the scope conditions set by the local community and state education environment. Several key resources and constraints shape partnership “economies,” from statewide policies and budgets, to local communities, to the characteristics of the partner institutions themselves.
Public school bureaucracy may either facilitate or circumscribe partnership activities.13 Fundamental school reform efforts are more likely than limited interventions to run up against state or district policies that restrict experimentation, unless backed by legislative mandates. Unions and other community pressures may further affect staffing choice and flexibility during partnership implementation.
Partnerships need to balance school-level change with the priorities of school boards and superintendents.10 A whole-district focus may involve decision-makers who are not active members of the partnership, but whose priorities can exert a strong influence. A school-level focus usually means working with principals and teachers in some schools but not others. Either strategy—casting a wide net or putting all one’s eggs in one basket—has pitfalls. Partnerships that focus intensively on certain schools can challenge the authority of district leaders and set up conflicts between partner and nonpartner schools over curricula, human resources, and operating policies.13 Thinking big increases the chances of discovering a successful formula for change in at least one school, but it also usually requires increased effort at higher levels in the district hierarchy, creating extra bureaucratic layers that can dilute the impact of partnership activities. Participants on the ground need to perceive signs of progress close to them.
Availability of resources
Partnership scale depends fundamentally on the amount of resources available. Spreading risk can overextend resources, while investing heavily in one school can either bring complete failure or provide the critical threshold of resources needed for success. The partnership’s leaders bring leverage and prestige commensurate with their positions, social capital resources that determine the scale of possible activity. When universities lead partnerships, their influence helps raise the partnership’s profile, attracting support locally and beyond.12
School characteristics such as size, grade level, and quality also condition partnership success. Small schools are easier to manage but may lack certain kinds of resources or services.12 Larger schools lend themselves to greater program specialization. The narrower focus of specialized subject teachers in secondary schools can mean that they are less concerned with school functioning overall than elementary school teachers.10 Systemic reforms may be easier to carry out at the elementary level. Secondary school interventions may be more successful if they target specific subjects or schools with innovative management structures that span subject disciplines and focus on the full school experience.
Some schools may not be strong enough to capitalize on partnership resources when pervasive poor administration and teaching require a more comprehensive solution.13,17 Engaging in triage may be unacceptable to some, but a partnership needs to assess realistically its own limitations and those of partner schools.
Partnership initiation—the identification of institutional interests, risks, benefits, and common goals—sets the stage for how partners will work together as their relationship develops.
Articulating institutional missions
School quality and integrity affect a school’s ability to articulate its needs and goals as a basis for undertaking commitments. An institution needs to have its own clear vision before it can develop a shared vision with others.13,17,18 At the same time, if successful, the partnership will reshape all of the constituents’ missions.
Identifying common goals and objectives
It is easy for partners to proclaim the goal of improving minority or at-risk student outcomes,5,6,13 but they must also negotiate ownership of the problem and the solutions. Failure to serve all constituents’ interests will make the partnership a burden to some rather than a resource.5,9 Identifying the specific contributions that each organization is willing to make will determine the scope and logic of the intervention model.5,6,8,13,19
The identification of partners, goals, and resources carries with it a number of dynamic tensions. Diverse constituents bring expanded resources but a wider range of interests to satisfy.6,10,13 Allowing each partner to focus on its highest priorities can yield opportunities for natural partnering to occur based on complementarity,7,17 instead of seeking the lowest common denominator. This means pleasing some of the members most of the time rather than trying to please all the members only a small part of the time. More radical systemic reforms are probably possible only when all partners are highly committed on multiple levels.15
When members cannot articulate common goals to themselves and others, they will fail to attract the support of external allies and lose their place in the state’s educational agenda to better-articulated priorities.10 At the same time, a loose collaboration where learning is occurring and structure is being developed requires flexibility and fine-tuning.5,13,20 In the early stages, carrying out joint activities may be more important than overly defined goals or structures.
Public school versus university stakeholders
Universities and public schools have different stakes in the partnership enterprise. In complex institutions, one set of stakeholders, the administration, may buy in, while another, the faculty, may not, and vice versa.6
Universities are concerned about improving the qualifications of their applicant pool and attracting more applicants through publicity. Partnerships may help universities accomplish both goals, but the costs may exceed perceived benefits from recruitment gains.11 Public universities, which are sensitive to broader constituencies than private ones, may reap public relations benefits from partnerships in areas where minority communities have adequate voice to influence policy.
Public K–12 schools have an even greater interest in responding to the demands of local constituents and state and federal mandates to improve student performance. A partnership, however, may be just one of several strategies available. Getting results matters in a high-stakes environment of heightened scrutiny or tightening budgets.6,20 On the other hand, too much success can mean loss of eligibility for “at-risk” funding from other sources.6 Well-intentioned universities seeking public school partners can fail to understand these risks of participation.
Some of the same factors affecting partnership initiation continue to matter long after it has been established. Running a functioning partnership also brings into play additional considerations.
While mutual trust and respect are critical, and equal power is ideal,5,6,9,12,13 true equality between public schools and universities may be elusive. They do not have the same interest or urgency in improving public schools, and it is unrealistic to expect both to commit equally to the same goals.10 Nevertheless, successful partnerships ignore power relations at their peril. A partnership’s chances for success depend on the structural bases of power—the rewards and punishments—that each institution has in relation to the others.6
Participatory governance structures that give each partner representation in important decisions and committees can promote greater equality.5,9 Open communication between partners fosters productive working relationships, and sharing information about progress toward goals also engenders project loyalty.9 Partnership collaborations require more process time than other types of organizations.9 In striving to ensure equal participation and power-sharing, partnerships must constantly balance democratic process with necessary action to produce results.
The administration of funds has both symbolic and practical implications for balancing partners’ interests. The partner who holds the purse strings must guard against real or perceived dominance that can alienate other partners.20 Joint control of resources among parties helps prevent power imbalances. Outside observers may attribute success or failure to the institution that receives the funds,6 often the university, yet public school personnel may be held responsible regardless,13 because their efforts are closer to student performance outcomes.
Teacher buy-in is essential: they can wield the ultimate “punishment power” by not cooperating or even undermining the work of more enthusiastic participants.6,17 Unless the partnership can offer clear benefits to teachers, universities can find themselves in a weaker power position. Universities need to cultivate relationships with public school administrators and teachers who can influence the opinions of other teachers. Engaging in “teacher bashing” is a clear sign that project directors are out of touch with teacher needs.6 University staff can promote trust through frequent interaction with teachers, guaranteeing them a voice in the partnership,10 and consultation with a teacher advisory committee.5 Higher education institutions that seek to change public schools must examine themselves and change the way they do business as well.
Public school and university partners need to consider parent, community, and corporate interests. School policies to encourage parental involvement and favorable parent–teacher relations provide a barometer of teacher openness to the involvement of others in the educational process.14,17 Likewise, community and corporate involvement are desirable, but care must be taken not to allow parents, community organizations, and businesses to set priorities. Educational institutions must ultimately live with whatever changes they make, and they should control policy and practice.12
Effective leadership is critical for establishing an agenda that inspires commitment and for carrying out planned activities. Partnership directors from higher education will enjoy more external clout and prestige. She or he needs a dean’s backing to deal with others who may have higher credentials, salaries, or other status.12
Being part of the higher education establishment is not sufficient. Leaders must know public schools and respect teachers.13,17 An effective leader is a “boundary spanner”—someone experienced enough in the various cultures of a partnership to move freely among them with enough credibility and understanding to negotiate and translate.6,9,17,20
Turnover among partnership leaders and council members creates one of the most significant barriers to partnership continuity, and if not handled correctly, can completely disrupt activities.5,13,14,17 Bringing new representatives on board entails socializing them to the partnership’s aims and operations. New blood may also change the partnership’s direction as recent entrants advocate their own visions and priorities. Dealing successfully with the problem of succession is a hallmark of institutionalization.13
Partnership Maturation and Institutionalization
While a good beginning with strong leadership is important, partnership continuity and institutionalization are more difficult to achieve.13 Commitment, energy, and focus naturally relax as a partnership ages, sometimes slowing momentum.5
The greatest difficulty of institutionalizing a partnership is its lack of authority over its member organizations; partnerships tend to remain peripheral, especially if not addressing key goals of partners.5,12 Partnership activities often take place outside of university academic departments and may be invisible to the core members of the institution. Even when academic departments effectively launch programs, only high-level university leadership can ensure long-term stability.9,14,16
The level of university commitment to a partnership will depend on its mission statement. A university should include the goal of diversity, informed by a notion of its obligation to provide community benefit, as an explicit part of its institutional mission.1,3,4 In successfully functioning partnerships, a university expects its faculty members to contribute time and resources.10 Top leadership commitment may also take the form of tenure and promotion credit for participating faculty. 5,7,10,12–14 Without these policies, partnership activities are less likely to become routinized in the university culture. In larger universities, the commitment of departmental chairpersons is of equal or greater importance than that of the dean.12
School superintendents also provide important leverage.12 Public school personnel who contribute to partnership success need recognition.13 Administrators must support personnel by providing release time to attend workshops and visit other schools, giving access to clerical support, and even helping to work around or bend the rules if necessary.21,22
Organizations must be willing to commit resources, which can take the form of funds, office space, or staff time.13 At least three to five years of seed funding may be necessary for a partnership to establish itself. Designing programs that can be supported by institutional discretionary funds saves valuable energy that would otherwise be expended searching for funds externally.16,19 School districts should be willing to commit funds to the enterprise to ensure long-term sustainability.5,12 Building political bases around a partnership is an effective strategy that can generate protest if the program is threatened. Such support can develop only if the partnership is perceived as central to member and community interests.6,12 Sustained commitment of resources by the university and public school system, along with partnership centrality to its members and the local community, are markers of institutionalization.
Health Professions Partnerships: Best Practices
Thus far we have been concerned with matters of partnership culture, form, and process. We now turn to the question of content: what can partnerships do, once established, to improve minority achievement?
In general, partnerships that successfully assist underrepresented minority students are consistently multidimensional, employing strategies to strengthen academic skills, ability to function in a campus environment, self-esteem, sense of purpose, and cultural awareness.5 Effective partnership strategies to achieve these objectives include parental support and involvement, earlier intervention, high expectations of students, hands-on learning and innovative teaching, addressing the entire pipeline rather than just one segment, strong project leadership, clear assessment and evaluation measures, year-round enrichment, career exposure, and long-term financial and community support.23
The following is a typology of programmatic options that are particularly relevant for minority progress toward health professions24,25:
▪ Academic enhancement: remediation or enrichment to strengthen students’ academic skills, particularly in math, science, communications, study skills, and test-taking
▪ Science and/or math instruction enrichment: a variety of more systemic changes, from improving teacher knowledge or pedagogy to curricular reform
▪ Career awareness and motivation: providing information about health careers and encouraging interest
▪ Mentoring: fostering long-term relationships between K–12 students and older students, faculty, or professionals in health care fields
▪ Research apprenticeship: placement of students in laboratories, generally for less time than mentorships and more targeted to developing research knowledge
▪ Reward incentives: scholarships or college admission preferences for successful program participation or other achievements
▪ Parent involvement: parent education about college and health career requirements
Career awareness and motivation interventions are the easiest to conduct, but research shows that minority interest in science and health careers already matches or exceeds that of whites.26,27 High school completion with rigorous preparation is the greatest need of underrepresented groups.2,28 For these reasons, efforts to increase minority representation in health careers should be directed primarily at academic and instructional enhancement—providing academic support to students, improving curriculum offerings, and improving teacher skills. Achieving academic gains is a difficult long-term challenge: partnership participants must resist the temptation to pursue the easier success of affecting career awareness and motivation at the expense of addressing learning, the most fundamental disparity.
The following list of best practices for improving minority achievement in the health professions is based on a review of successful programs by Grumbach and colleagues,25 supplemented by other relevant evidence:
▪ Interventions need to be intense and sustained. Stand-alone classes or short programs have limited or short-lived effects, particularly on “hard” academic measures.25 Longer, intensive programs, though expensive, are more effective in K–12 settings.26 Basic school reform—interventions that change the core functioning of schools and communities—is needed.
▪ Partners should carefully consider the scope and timing of interventions depending on the target health profession and the resources available.25 A well-targeted academic program for competitive college students can secure successful entry into medical school. Baccalaureate nursing programs should look back to high school. For long-term, resource-intensive, basic school reform, interventions must begin in elementary or middle school.
▪ Interventions need to address the community sociocultural context within which learning occurs and nonacademic barriers that can prevent academically capable students from progressing. The input of parents and other minority community members is crucial during program design and implementation.
▪ All partnering institutions should be chosen carefully for their suitability as partnership grantees or members. Universities with premedical or health science programs that serve minority students well are good candidates for partnerships with minority high schools.17,29 The response of health professions school administrators and faculty to both educational and health care needs of minority communities that they serve is another indicator of the commitment of health professions schools to minority health issues.29
Funding organizations should contemplate innovative approaches. For example, targeting community colleges, which are often overlooked, deserves careful consideration, given the relatively large number of underrepresented minority students who enter community colleges as opposed to four-year institutions.25 Organizations that have traditionally funded universities as the lead institutions might consider grants to public school systems, stipulating that they partner with the appropriate higher education institutions. This strategy ensures that the initiative comes from the place where change will be focused and helps solve the problem of public school buy-in. In all cases, recognizing there is no perfect partnership blueprint, funding organizations should provide concrete and sophisticated technical assistance in partnership development to all grantees.
Toward Better Evaluation
Now that the U.S. Supreme Court has affirmed that diversity can constitute a compelling interest in a university’s overall educational mission, partnership activities must be carefully crafted to serve legitimate ends, with activities and outcomes documented and evaluated to show program impacts.30 Strengthening confidence that resources are well spent is the only way to attract more resources to improve minority achievement. Funders should make rigorous evaluation a high priority by allocating funds exclusively for this purpose.5,6,13,23,25 A uniform set of data requirements across programs would help establish benchmarks and comparability across programs.25
Partners need to be committed to evaluation from the outset.5 Evaluation should occur alongside program design and implementation rather than afterward. Evaluations that do not show immediate gains should spur program modifications, not punitive withdrawal of funding. Unintended or “spin-off” impacts, such as community economic development and health improvement, also deserve to be documented.
Formative assessments of specific strategies and summative assessments of outcomes are fundamental, but the partnership process itself should also be the subject of evaluation. Most of what we know about partnerships comes from participants, but using third-party consultants can provide needed perspective and objectivity.9,13,20 Using a formal theoretical model to highlight partners’ various interests, resources, and problems also helps create a more objective understanding of partnership relationships and avoids casting blame on a particular party for a partnership’s difficulties.6
The Potential of Partnerships
Increasing the numbers of underrepresented minority health care providers is an important but complex challenge. Because the barriers to minority achievement are so formidable, partnerships are a necessary tool for pooling scarce resources to address the problem.10,29 Partnerships are also in keeping with the increasing involvement of medical schools and teaching hospitals in community outreach efforts.31
Programs that work with teachers and school systems rather than focusing exclusively on individual students can bring about lasting educational improvement. Faculty and administrators in health professions schools need to commit resources and develop new skills to engage effectively in partnership with public schools. The immediate beneficiaries of partnerships are public school curricula, administrators, teachers, and students, but successful partnerships can also lead to long-term transformations in health profession schools.
1 Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce, Institute of Medicine. In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: National Academies Press, 2004.
2 Council on Graduate Medical Education. Seventeenth Report: Minorities in Medicine: An Ethnic and Cultural Challenge for Physician Training. An Update. Rockville, MD: U.S. Dept. of Health and Human Services, Health Resources and Services Administration, 2005.
3 Gonzalez P, Stoll B. The Color of Medicine: Strategies for Increasing Diversity in the U.S. Physician Workforce. Boston: Community Catalyst, 2002.
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7 Curran-Everett D, Collins S, Hubert J, Pidick T. Science education partnership between the University of Colorado and a Denver high school. Acad Med. 1999;74:322–25.
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9 Erwin K, Blumenthal DS, Chapel T, Allwood LV. Building an academic-community partnership for increasing the representation of minorities in the health professions. J Health Care Poor Underserved. 2004;15:589–602.
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