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Fostering Academic-Clinical Research Partnerships

Albert, Nancy M., PhD, RN, CCNS, NE-BC; Chipps, Esther, PhD, RN, NEA-BC; Falkenberg Olson, Ann C., PhD, RN, FNP-BC, WHNP-BC; Hand, Linda Liu, PhD; Harmon, Michelle, PhD, RN; Heitschmidt, Mary G., PhD, RN, APN, CCRN; Klein, Colleen J., PhD, APRN, FNP-BC; Lefaiver, Cheryl, PhD, RN, CCRP; Wood, Teresa, PhD, RN, NEA-BC

JONA: The Journal of Nursing Administration: May 2019 - Volume 49 - Issue 5 - p 234–241
doi: 10.1097/NNA.0000000000000744
Articles
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Academic-clinical research partnerships can benefit academic and clinical partners when goals are clearly articulated and mutually determined and include increased research dissemination and lower research costs. This article explores the history of academic-clinical research partnerships and discusses the drivers of collaborative academic-clinical research relationships, resources from academia and clinical sites, and sustainability of collaborative partnerships. Through collaboration, academic-clinical partners can improve clinical outcomes and reduce healthcare costs.

Author Affiliations: Associate Chief Nursing Officer, Nursing Research and Innovation, Nursing Institute, Cleveland Clinic, Ohio; and Adjunct Professor (Dr Albert), Aalborg University, Denmark; Clinical Nurse Scientist, Associate Professor of Clinical Nursing (Dr Chipps), The Ohio State University Wexner Medical Center, The Ohio State University College of Nursing, Columbus; Nurse Research Scientist (Dr Falkenberg Olson), Gundersen Health System–Gundersen Medical Foundation, La Crosse, Wisconsin; Director (Dr Hand), Office for Nursing Research and Scholarship, University of Iowa; Nurse Education Specialist–Clinical/Academic Liaison (Dr Harmon), Nursing Development & Research–Henry Ford Macomb, Clinton Township, Michigan; Director of Clinical Research, Rush University Medical Center, Rush Oak Park, and Assistant Professor and Codirector (Dr Heitschmidt), Center for Clinical Research and Scholarship, College of Nursing, Rush University, Chicago; Education and Research Scientist (Dr Klein), Advanced Practice, OSF HealthCare, Peoria; and Director (Dr Lefaiver), Advocate Center for Pediatric Research, Oak Lawn, Illinois; Program Manager (Dr Wood), Nursing Research, Nursing Research and Excellence Department, OhioHealth, Columbus.

The authors declare no conflicts of interest.

Correspondence: Dr Albert, Cleveland Clinic, 9500 Euclid Ave, Mail Code J3-4, Cleveland, OH 44195 (albertn@ccf.org).

Academic-clinical (service or practice) nursing partnerships can be defined and organized in many ways. The American Association of Colleges of Nursing defined collaborative partnerships as official structural linkages between universities and clinical centers (most often hospital medical centers, but may involve community health, nursing homes, home care, wellness centers, etc) that had a shared vision for best practices.1,2 Highly structured partnerships had formal contracts, strategic plans, and financial arrangements. Moderately structured partnerships lacked highly structured components and clear management structures; instead, they were developed ad hoc to meet specific or situational needs.3 In a foundational article on academic-clinical partnerships, authors defined the academic-clinical partnerships as formal or informal arrangements between cooperating parties to advance mutual interests.4 Historically, the focus of academic-clinical partnerships was to improve patient care quality and safety, foster innovation, and provide student learning experiences; however, some authors found that faculty-clinical partnerships also had an unanticipated benefit of fostering research collaborations.5 Of 17 suggested outcome measures of individuals involved in effective partnerships, only 1 was directly and specifically research oriented: to increase research productivity.5

This writing team placed the terms academic-clinical, academic-practice and academic-service partnerships, and research in a PubMed title/abstract search in January 2018. Between 1999 and 2017, 87 references were identified, but only 19 articles had an academic-clinical research partnership focus. Of 68 references that were excluded, the term research was not used in the context of increasing research capacity; it was used to designate the type of article published, as an implication for next steps in advancing the topic of interest, as a descriptor of the need to increase research-based knowledge, or to describe a characteristic of a university within a partnership.

The paucity of academic-clinical research partnership publications reflects a potential gap in the promotion of evidence-based clinical practices. Research-based academic-clinical partnerships create connections between nursing research and clinical practice, increase overall nursing and multidisciplinary research production, increase generalizability of nursing research findings, and improve the strength and quality of nursing research designs and methods. Thus, the aims of this article are to describe the history of academic-clinical research partnerships and use a pragmatic view to discuss the catalysts, academia and clinical site resources, and their collaborative sustainability.

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Evidence for Academic-Clinical Research Partnerships

In De Geest and colleagues'3 systematic review of 114 publications on moderately or highly structured partnerships, 39% included research as a focus of the partnership. In Beal's5 integrative review of 110 articles, 8 included research partnerships that led to enhanced evidenced-based practices and grant funding and improved research conduct, dissemination, and translation/application of knowledge that improved nursing practice and patient outcomes. In a qualitative study aimed at identifying best practices of academic-clinical partnerships, doctorally prepared academic leaders and clinical nurse leaders (totaling 72 individuals) participated in 1-on-1 interviews and focus groups.6 One theme that characterized effective academic-clinical partnerships was the value to specific individuals involved in the partnership. Evidence-based practices, intellectual growth, and improved quality of care were valued by nurse executives and nurse managers, but deans did not verbalize these themes or any other theme that could be indirectly related to research.6 During interviews, nurse executive and nurse manager practice leaders made requests to academic partner leaders for research collaborations,6 reflecting their desire to enhance and ensure scholarly, evidence-based decision making by clinical nurses.

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History

Academic-clinical nursing partnerships are not a new phenomenon. Education and service alliances date back to the 17th century. A hospital-based training model that preceded the movement of nursing education to universities was predicated on the idea that service and education were symbiotic.7 As hospital programs closed, and nursing education moved into college/university settings, the divide between clinical service and education widened. As nursing faculty acquired more academic responsibilities associated with traditional university faculty roles, academic nursing education became more complex beyond just training nurses. Expectations for scholarship and clinical activities at the university level and within professional organizations increased. As a result, senior nursing faculty have become more immersed in research and scholarship activities outside their local service/clinical settings.8 Over time, as cultural differences grew between academics and practice, local collaborations were further limited, hampering the generation of new knowledge and evidence-based clinical practices that were needed to improve patient outcomes.9

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Catalysts

There are multiple catalysts of academic-clinical partnerships. In 1 report, a partnership was initiated by hospital leaders who sought an academic partner to provide research mentorship aimed at positively impacting nurses' skills, knowledge, and confidence to conduct research activities.10 In other reports, the partnership was a strategy to meet nursing research requirements for American Nursing Credentialing Center Magnet® designation.11,12 There has been an increase in academic leaders initiating partnerships with nurses in clinical settings, individually or as part of formal fellowship training programs that utilize an implementation (translational) science framework to enhance diffusion of research outcomes.13,14 Informal research partnerships include collaborations involving graduate nursing students who complete short-term clinical research practicum hours with hospital-based doctorate-prepared nurse scientists as part of research coursework or to meet final project/capstone project requirements to design, implement, and evaluate a clinical practice change.15,16 Academic-clinical research training partnerships allow for real-world clinical research and evidence-based practice experiences that may spark curiosity and interest in future clinical research, thereby increasing understanding of the relationship of clinical research and clinical outcomes.

The evidence-based practice movement and a heightened call to practice based on research evidence have fostered academic-clinical partnerships. When academic institutions collaborate with clinical partners, they will be more informed of current evidence-based practices and gaps in knowledge about patient needs. When input from clinical experts is infused throughout the research process, translation of research to practice is more successful.17 Academic and clinical partnerships strengthen the ability of academic nurse scientists to respond to funding initiatives that call for patient-centered research. It is expected that the clinical and translational science awards programs that are part of the National Center for Advancing Translational Sciences of the National Institutes of Health (a training opportunity to develop innovative solutions into interventions that benefit individual and public health) will enhance academic and clinical translational research partnerships at the bedside and in the community. As examples, the Cincinnati Partnership for Nursing Research evolved from the University of Cincinnati clinical and translational science awards program and connects academic and practice nurse researchers across Cincinnati,18 and the Duke Translational Nursing Institute involves Duke University School of Nursing and the Duke University Hospital health system.19 Other examples of published research collaboration arrangements are between the University of North Carolina at Chapel Hill School of Nursing and University of North Carolina Hospitals.20 East Carolina University School of Nursing and Pitt County Memorial Hospital,21 University of Pennsylvania and Penn Presbyterian Medical Center,22 and Queens Medical Center and University of Hawai'i at Mãnoa.23Table 1 provides strengths and gaps perceived by each partner and strategies that lead to building successful partnerships. Potential challenges that may inhibit success are also presented.15-23

Table 1

Table 1

In an integrative review of the literature on academic-clinical nursing partnerships, Beal5 provided evidence of variability in 3 areas: long-term partnership effectiveness, quality of patient outcomes, and building workforce sustainability. Thus, a driver of short- and long-term success might be to mutually design process and outcome performance measures that assess program effectiveness and partnership efficiencies. From a research perspective, outcomes of interest might be to assess the number of research publications in high-impact journals that are authored by academic and clinical partners, to assess cost-effectiveness of shared interorganizational research services or experiences or to assess the number of policies or procedures that were revised based on new-evidence derived from research implemented through the partnership. Further research involving an evaluation of partnership effectiveness in achieving research and financial outcomes is needed.7

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Balancing and Managing Resources

Facilitators of successful academic-clinical research partnerships can be used as a foundation for organizations when developing arrangements or when optimizing or calibrating collaboration features. When resources are correctly proportioned, both academic faculty and clinical research personnel should be able to achieve research and evidence-based practice outcome goals without excessive expenses.

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Benefits for Clinical Institutions

For clinical institutions that are not research intensive, an academic partner can provide access to resources endemic to academic settings, such as an expansive library system, discounted computer and statistical software, and faculty and staff with research expertise in study designs, survey development, and statistical and data support. Academic institutions typically have administrative staff dedicated to assist with grant proposal development, review and submission, manuscript development, editorial support, and institutional review board application processes. Academic partners may also provide access to funding sources and/or provide staff support for postaward administration and accounting. When one acute care hospital initiated an academic-clinical research partnership, nurses' research knowledge increased at 1 year compared with baseline, and research productivity increased by 33%24

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Benefits for Academic Partners

Many clinical partners are able to provide unique resources that benefit academic faculty. Academic faculty can gain valued hands-on experience by participating in collaborative multidisciplinary research as coinvestigators,25 serving on relevant committees/councils, and contributing to interorganizational innovation challenges. Because clinical partners have access to electronic medical records and databases with aggregated clinical patient quality, safety, satisfaction, and nurse engagement data, access to anonymous data may foster answers to research questions. When clinical research questions can be facilitated by clinical nurses who can document responses to variables or implement research interventions, costs of research can be dramatically reduced. Further, clinical nurses often have relationships with hospital-based equipment, supply, and device businesses. Business partners may support research initiatives,26 especially those using comparative effectiveness research designs or those assessing new product effectiveness. Finally, some hospitals create internal funding mechanisms to “buy out” nursing staff time. Some research grants support time to conduct research or to participate in research internship programs. Although dissimilar to academic institution models for protected research time, hospital-based funding mechanisms remove a consistently discussed barrier of lack of time for research.3,27 Ultimately, calibrating the scale and extent of academic-clinical partnerships to available resources for both partners is an important consideration when developing arrangements.28,29

Hospital-based nurse scientists can minimize barriers that academic faculty may experience; for example, credentialing, training, hospital institutional review board and research compliance office requirements, and contracts associated with data use.30 Hospital-based nurse scientists can support clinical nurses involved in academic-clinical research by negotiating agreements to use tools, negotiating research time, and providing mentorship in patient enrollment, data collection, data analysis interpretation, and internal and external dissemination of findings, including clarity in authorship arrangements.

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Sustainability of Partnership Arrangements

Academic-clinical partnerships may be easiest to initiate and sustain when both partners are able to achieve goals that are personally or professionally rewarding on an individual or institutional level. True collaboration is necessary to ensure that immediate and long-term goals are openly discussed, regularly reviewed and agreed upon. When goals are misaligned or non-stated goals become prioritized above stated goals, partnerships may fail, and trust between organizations or participants may be diminished. For example, if an academic partner seeks a clinical partner to conduct a specific research project, the clinical site needs to understand the goal. When enrollment and data collection end, the partnership may end without closure between partners. Clinical partners may not have perceived a benefit and may feel abandoned. If the academic partner spends time teaching clinical nurses about research processes, such as enrolling subjects, data collection, and data analysis goals, and then shares results and implications for practice in roundtable group discussions, clinical partner collaborators may perceive the partnership as productive, satisfying, and as having a natural ending.

Goals should be measured throughout the academic-clinical partnership experience and shared on a regular basis with stakeholders. Recognition of goal achievement, even small successes that involve research processes, is important.7,20,23,31 Agendas for project team meetings should include routine reporting of progress. Sustainability is enhanced when recognition of the partnership and goal achievement are visible. A 1-day or multiday nursing research conference, monthly grand rounds, or paper/electronic newsletters can be methods for internal and external visibility of the partnership, partner work/contributions/outcomes, and partner participants.

Once academic-clinical partnerships are established, they require energy and enthusiasm to sustain. Clearly communicated joint goals that are balanced between partnering organizations may be the driving force in sustainability. Figure 1 provides questions to consider regarding sustainability. Lack of regular communication between partners can hinder progression of goals and diminish the initial momentum. Regularly scheduled meetings can facilitate and maintain open, direct communication between stakeholders, ensure mutual decision making, promote reassessment of outcomes and current project status, and prompt clarification of new or changed partner expectations.32 Effective communication between partners facilitates an environment of mutual respect, which is the cornerstone that sustains collaborations.

Figure 1

Figure 1

Mutual respect within an academic-clinical partnership is predicated on understanding that each stakeholder has something to contribute to the relationship and that each partner possesses a level of knowledge and expertise that will be of benefit. Academic partners can provide faculty research mentorship, knowledge of scientific research, and access to large-grant funding. Clinical partners can provide clinical research mentorship and knowledge of clinical research processes within their setting (including patient recruitment, enrollment, and follow-up) and share unique insights about clinical practice, clinical research steps, or research issues.31

Extrinsic rewards derived from an academic-clinical partnership foster sustainability over time. Rewards of the collaborative should be apparent to both partners, including personnel engaged directly in the collaboration and by nurse leaders that the collaborating partners represent. For healthcare organizations, an important reward should be new knowledge of interventions or practice changes that, when implemented, improve patient outcomes,22 reduce healthcare costs, or improve nurse efficiencies. By building new mentoring relationships, clinical nurses may become eager to lead/participate in unit-based changes.33 Direct clinical nurse participation in changes promotes diffusion among colleagues and, ultimately, sustainability. When clinical nurses are treated as full collaborators by academic partners, they may be more open to personal and professional benefits of implementing research projects and assume principal or coinvestigator roles. The experience of full collaboration and the associated knowledge gained become a reward when nurses use it to attain clinical or professional advancement. For academic collaborators, partnering on individual studies becomes a reward in itself when patient access is expedited and data collection is completed in the desired time frame or without complications that require protocol amendments. Mentoring and collaborative relationships based on shared research projects build mutual trust and excitement, often leading to future (ongoing) research collaborations that are rewarding to both groups. Valuing and rewarding each stakeholder's contributions generate enthusiasm for the partnership and contribute to successful achievement of current goals and a desire to create new goals.

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Multisite Academic-Clinical Partnerships

With the shift toward value-based rather than volume-based healthcare, there is an increased focus on optimizing patient health and well-being and minimizing hospitalization and emergency care. Research questions are shifting to patient-reported outcomes, quality of life, and population health, which involve value perspectives that are important to nurse executives, patients, insurance companies, and government payers. Additionally, when clinical staff identify gaps in the healthcare literature and best practices are not evident, nurse leaders turn to nurse scientists for solutions. The results of both scenarios are that partnerships between academic faculty, hospital-based nurse scientists, and clinical nurses may be needed to implement robust clinically focused research that answers important questions across many institutions.

There is a growing need to build sustainable multisite research networks that include many academic-clinical partnerships. However, stakeholders involved in multisite research often have differing perspectives on the clinical problem or need being studied, research intervention methodologies, data collection, and interpretation of findings.30,34 For example, when acute care hospital nursing personnel participated in a multisite study, they encountered challenges surrounding coordinating center communications and methodological changes in data collection and analysis plans after research study startup.34 Discussion of differing perspectives may enhance the robustness of research studies and lead to results that are more generalizable and meaningful to a larger population. If academic-clinical partnerships extend beyond just 1 relationship, multicenter research designs can be used that produce larger sample sizes in less time. Further, when considering implications of research findings, having the perspectives of scientists and clinicians with different expertise can enhance the generalizability of findings.

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Implications for Nurse Executives

Academic-clinical research partnerships add depth to the nursing enterprise by promoting a culture that challenges the status quo. Nurse executives must contemplate new and challenging models of care that focus on client health optimization, reduction in hospitalization events, and high-quality clinical outcomes, while simultaneously controlling the escalating costs of healthcare delivery. Academic-clinical research partnerships provide an accessible forum for nurse executives to collaborate with nurse scientists on important questions that impact clinical and health services delivery model challenges. Further, when nurse executives promote clinical nurse–led research to their nursing staff, they are sharing the value they place in clinical nurses to be stakeholders in healthcare optimization, service transformation, and organizational innovation.

Once academic-clinical research partnerships are established, nurse executives are responsible for ensuring that clinical research environments have the right resources to be successful. Leaders must leverage financial and human resources and hold others accountable for engaging nurses in the conduct of research. Clinical nurses are valuable members of research teams as they often use pragmatic approaches that increase generalizability of findings. Nurse executives must consider implementation barriers of time away from staffing, apprehensiveness about research, and lack of access to research resources24 when strategic goals are to increase research capacity and productivity and promote optimal research outcomes.

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Conclusion

In the current healthcare climate, an academic-clinical research partnership is a resource to nurse executives and academic partners to enhance patient care while being mindful of resources. Managing complex relationships requires leadership among academic leaders, as well as nurse executives. To manage the challenges of the current healthcare environment, best evidence must incorporate high-quality research evidence when available, as well as innovative strategies that have been tested for efficaciousness and effectiveness. When academic-clinical research partnerships are developed based on shared goals that include advancing high-quality evidence-based nursing practices and using innovative research interventions, translation of research into practice may be enhanced. Notable benefits of shared resource utilization include nursing workforce professional development and clinical research application. On a personal level, participation in academic-clinical collaborations could promote nurse retention, professional development, and clinical advancement. When collaborators understand strategies for initiating partnerships and potential challenges with partnership development, they can better prevent or overcome adversity as well as sustain long-term success. Ultimately, high-quality patient-centered research that is completed within a partnership will drive improved patient outcomes.

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