Building Capacity through University Hospital and University School of Nursing Partnerships

The immediate need to expand enrollment to ensure an increasing supply of baccalaureate prepared nurses is the challenge schools and hospitals face. Because the decline in enrollments has led to such a severe shortage, schools of nursing must expand enrollment capacity to begin to "catch up" for lost production (AACN, 2000). The ability to expand enrollment and increase capacity in schools of nursing is dependent on a) adequate numbers of nursing faculty with the appropriate clinical preparation, b) adequate access to quality placements for clinical learning experiences, c) adequate classroom and laboratory space, d) adequate or improved faculty salaries, e) adequate state budgets, and f) adequate numbers of science and general education courses available in the university to accommodate increased enrollments in nursing. 

The longer-range challenge to expanding baccalaureate nursing enrollments and increasing graduations is to engage in a process to improve practice environments and create satisfying professional career opportunities. In 2002 AACN published the Hallmarks of Professional Practice, a guide to help new graduates select employment settings where their education and potential are recognized and used. This document also serves as a guide for institutions seeking to improve recruitment and retention of nurses who enter their institutions. 

Issues of workplace redesign and improvement were addressed extensively in several recent reports on the nursing shortage (American Nurses' Association, 2002; American Hospital Association, 2002; Association of Academic Health Centers, 2002; Joint Commission on the Accreditation of Healthcare Organizations, 2002; Robert Wood Johnson Foundation, 2002; University of Illinois, 2001). Central themes consistently emerge from these reports including: a) the nature of the work of nursing, b) workplace and culture factors, c) recruitment and retention, d) need to support nursing education, and e) system development and policy issues. Strategies for collaboration between practice and education are recommended. There is general agreement that short-term solutions cannot correct the underlying problems affecting the nursing shortage. The specific recommendations in these reports and examples will be helpful to university hospitals and schools of nursing that collaborate in a partnership model.

The complexity of the capacity problem and urgent need for change provide a leadership opportunity for university health centers. University hospitals and university schools of nursing are in a unique position to be part of the short-term and long-term resolutions of the capacity problem. Changes are required to attract bright, college-bound students into the profession and offer them satisfying career paths. The task force concluded that effective solutions must go beyond "quick fix" approaches and address the core issues in the nursing profession today: the professional image of nursing, characteristics of the workplace, the relationship of education to practice, and the recognition of education in employment decisions and benefits. 

Several obvious factors support the development of strategic alliances between university schools of nursing and university hospitals. First, university hospitals and university schools of nursing exist in an environment where education is valued and preparation of the next generation of health providers is a priority goal. Second, university schools of nursing prepare nurses with baccalaureate and higher degrees, the educational product desired by university hospitals. A survey of chief nursing officers at university hospitals conducted by UHC found a strong preference for hiring nurses prepared at the baccalaureate level. Third, university hospitals are the main teaching site for health professions education in the university health center and have the potential to model professional nursing practice. In spite of these obvious commonalities there is often a lack of formalized partnerships between university hospitals and university schools of nursing.

The overall aim of a partnership model is to use the unique position of university health centers to support and implement best practices in nursing education and practice. The task force identified the following goals to guide university health center nursing partnerships. 

1. Collaborate to recruit, retain, and expand enrollment of students in baccalaureate programs in nursing.
2. Achieve the recommended balance in nursing workforce in university hospitals by educational preparation, i.e., 60% BSN, 40% ADN (National Advisory Council on Nursing Education and Practice, 1995).
3. Ensure a professional transition for baccalaureate graduates through a structured residency model.
4. Ensure a professional work environment that supports the development of best practices in clinical practice and education.
5. Provide differential entry level nursing salaries based on educational preparation and a career pathway that recognizes education and its relationship to practice.
6. Identify model(s) that are sustainable in and portable to other settings. 

Short-term Solutions. To respond to the urgent, immediate need for baccalaureate prepared nurses, the task force endorsed the following short-term solutions as viable and attainable by immediate partnership efforts. 

Recruitment and Retention. Successful recruitment of talented students to baccalaureate nursing programs will depend on their perception of nursing as a viable career choice where education is recognized, career advancement is possible, and work environments foster the Hallmarks of Professional Practice (AACN, 2002). Successful retention of students currently enrolled in BSN programs will ensure graduation. 

• Target new student populations (e.g., men, second-degree students, and undecided college students). 
• Provide tuition support and incentives to enter baccalaureate nursing programs through collaborative efforts between university hospitals and schools of nursing. 
• Prevent barriers to admission for all qualified applicants (e.g., encourage regional referral to schools with open spaces for qualified applicants not admitted due to space limitations). 
• Communicate through media the specific message about the value of learning in a university hospital setting. Create marketing strategies that demonstrate partnership efforts between university hospitals and schools of nursing. 
• Eliminate barriers to progression of students in the nursing program (e.g., financial support and personal and professional support through advising, mentoring, and educational case management). 
• Ensure stimulating and satisfying clinical learning experiences in university hospital settings. 

Create New Programs & Accelerate Progression 

• Explore time-acceleration to graduation of existing BSN programs. 
• Explore time-accelerated program options that are attractive to potential students and will quickly increase the number of graduations from existing programs. 
• Create new program options attractive to new populations of students (e.g., second-degree programs, master's entry programs). 

Share Faculty & Increase Access to Clinical Experiences. Establish integrated clinical partnerships that combine best practices in education and clinical practice and result in an improved working and clinical learning environment. 

• Expand faculty capacity by sharing clinical faculty and/or funding additional faculty positions. 
• Design clinical learning experiences that accommodate increased numbers of students and use of clinical space (e.g., preceptors). 
• Collaboratively evaluate ways to increase access to clinical experiences through creative scheduling and preference given to baccalaureate nursing programs. 
• Establish linkages and share expertise between university schools of nursing practice centers and university hospitals. 

Redesign Learning - Technology and Simulations. Explore uses of technology to expand the ability to deliver instruction, redesign learning, and enhance clinical learning experiences (e.g., simulations, distance education). Increase the use of technology and clinical simulations as a way to increase the capacity to teach more students. 

• Increase access to nursing education programs through development of distance education technologies. 
• Increase use of Patient Simulators and Standardized Patients as clinical learning enhancements and ways to expand learning opportunities. 
• Explore technological systems to support the clinical practice of nursing and improvement of care system. 

Long-Term Solutions. To ensure a well-educated future workforce it is essential to address the core issues and problems that create barriers to recruiting, educating, and retaining baccalaureate nurses. 

Create reimbursement and career ladder systems that recognize and support educational preparation at the baccalaureate level. 

• Differential pay for educational preparation. 
• Clear advancement pathways for professional nurses. 

Establish Consortia for Leadership in Practice, Education, and Research. Leadership partnerships in university health centers with integrated models of practice, education and research lead to improved patient care outcomes, improved educational outcomes, and nursing research for evidence-based practice. These consortia models will provide ongoing leadership for sustained improvement of the nursing workplace in university hospitals. These consortia working together to create curriculum and learning experiences will result in a graduate better able to make the transition to the workplace. An example of successful consortia is the UCSF Stanford Center for Innovation and Research in Patient Care, which combines efforts from UCSF Medical Center, UCSF School of Nursing, and the Departments of Nursing at Stanford and Packard. 

Create new funding mechanisms to support nursing education. University hospitals and schools of nursing continue to seek federal funding to support sustained high quality nursing education in university hospitals. Partnerships work together to share faculty in the clinical setting to allow for increased salaries and increased numbers of faculty.

Short-Term Approaches. Recent surveys of AACN membership and summary data from states that are addressing the capacity issue show that activity is underway to implement short-term solutions to the problem. Schools of nursing in university health centers responding to an informal AACN survey (2002) identified the most frequent partnership as funding from the hospital to support faculty, clinical teaching assistants and student scholarships (e.g., University of Arkansas, University of Alabama-Birmingham, University of California-San Francisco, University of Florida, University of Texas-Houston, West Virginia University, University of Virginia). Many schools reported that these partnerships had been in place for years and were now strengthened because of the nursing shortage. The University of Tennessee-Knoxville receives financial support for doctoral students who then teach undergraduate students at the hospital. Other partnerships reported were exchanges aimed at strengthening the educational capacity of the clinical environment. For example, Emory University conducts a Clinical Preceptor Institute, a Clinical Teaching Institute, and informal opportunities for hospital and school of nursing partners to network. Another example is the University of Washington's collaboration with the University of Washington Medical Center wherein the medical center offers an experienced staff nurse the opportunity to take a sabbatical as a clinical instructor of BSN students. The medical center continues to pay the nurse's salary and benefits by rewarding and ultimately retaining a valued staff member. The AACN Issue Bulletin:Using Strategic Partnerships to Expand Nursing Education Programs (October 2002) provides many additional examples of partnerships and creative approaches to expanding capacity. 

A comprehensive look at academic/hospital partnerships in California indicates that almost all programs have teamed with one or more hospitals to share costs, faculty, and clinical facilities to expand the capacity to produce nurses with baccalaureate degrees. A three-year plan for expected enrollments in California baccalaureate nursing programs anticipates the admission of approximately 200-250 additional nursing students per year with the support of these partnerships. While this analysis includes schools outside of university health centers, it provides an example of the scope of change possible when partnerships are pervasive. 

In the state of Texas, significant funding was appropriated by the state legislature in 2001 to provide support through 2003 to schools of nursing and partnerships to increase the supply of nurses. Support of baccalaureate programs and Health Science Center programs was based on actual increases in student credit hours and full time student equivalents. The University of Texas-Houston participates in the Greater Houston Partnership and the Worksource Collaborative, which unites business leaders, hospital chief executive officers and chief nursing officers, and deans of nursing, to address issues around the nursing shortage, including faculty shortages. This partnership coordinates the needs of schools and clinical agencies to match clinical faculty from the hospitals with the needs of the schools. The aim of this partnership is to double the number of baccalaureate graduates. 

Another approach to seeking new populations of nursing students is the focused recruitment of men into the profession. The nursing workforce is approximately 90% female and is often neglected as a career choice by men. There is a general effort to increase diversity in the profession, which is extremely important in making it an attractive choice for young college-bound individuals. The University of Texas-Houston has focused on recruiting men into nursing and is experiencing success in this area. As a result of focus groups with male students and practicing nurses, recruitment brochures and advising were revised and the school has increased its enrollment of male students. AACN also conducted a membership survey on the status of accelerated programs in schools of nursing (2002). In the last decade, accelerated programs in nursing have tripled from 31 in 1990 to 90 in 2002 and another 24 are in the planning and development stages. These accelerated programs are primarily second degree to BSN, but some are accelerated to the Master's degree. These accelerated programs for students seeking a second degree are highly valued as a way to bring a new population of well-educated students into the profession. Hospitals and other employers are eager to partner with schools to prepare these students. The accelerated second-degree program at the University of Louisville is a partnership with the University of Louisville Hospital to gain tuition support for students, exclusive access to hospital clinical settings, and support for faculty positions. In addition, the University of North Carolina (UNC) - Chapel Hill began an accelerated second-degree BSN program when the UNC Hospital helped fund support faculty during the program planning and development year, and provide scholarships to enable students to complete the program. In return, the students sign contracts to work at UNC Hospital after graduation. 

Long-Term Approaches. To address the longer range issues related to the nursing shortage AACN has established task forces to study a) the characteristics of professional nursing working environments (Hallmarks of Professional Practice), b) issues surrounding education of nurses and regulatory practices (Task Force on Education and Regulation), and c) issues related to the shortage of nursing faculty (Task Force on Future Faculty). It is essential that a comprehensive analysis of issues occur in order to establish a future course that will result in positive outcomes in both numbers of nurses and quality of professional preparation for nursing practice. 

The University of Iowa College of Nursing and University of Iowa Hospital & Clinics is one university school of nursing and hospital partnership that is addressing the long term issues of the nursing shortage while continuing to apply short - term approaches. The University of Iowa is an excellent example of how a partnership can achieve multiple objectives related to strengthening the workplace and working environment and increasing the immediate supply through capacity building and recruitment. The collaboration between practice and education has resulted in "The University of Iowa Nursing Collaboratory" (Dreher, Everett, & Hartwig, 2001). The purpose of the collaboratory is to facilitate collaboration in the domains of practice, education, research, and informatics. In addition, A Professional Practice Model of Care Delivery (Dreher & Everett, 2002) was built by the Department of Nursing and the College of Nursing. It differentiates job descriptions, performance indicators, and levels of practice according to educational preparation. The College of Nursing also has initiated a new educational program to attract second-degree students into an accelerated program. The new program is a Professional Masters, which was accepted as a mechanism to increase the supply of nurses for the state of Iowa (Dreher, 2001). The College of Nursing is also expanding its efforts to recruit and retain men into nursing and has produced a recruitment brochure that includes visual and content messages appropriate to the population. 

Another example is the long-standing collaboration with the university hospital and the college of nursing at the University of Cincinnati to develop and implement an institute for nursing research. As a result of the collaboration, the college has access to an ideal setting to implement faculty managed research programs, and the hospital gains research expertise needed for its active evidence-based nursing practice program. This collaborative initiative has also resulted in increased income to the hospital and increased hospital support for college nursing faculty. AACN Issue Bulletin: Using Strategic Partnerships to Expand Nursing Education Programs (October 2002)

Since the task force joined to discuss the nursing shortage and solutions for university health centers, there has been massive national interest in this issue. Multiple reports, several state legislative initiatives and new federal legislation (Nurse Reinvestment Act) have created an environment supportive of change. All initiatives acknowledge the long-term nature of the current nursing shortage and there is amazing agreement about the need to facilitate access to education programs, improve the work environment, conditions of employment, and career potential for those individuals seeking careers in nursing. The challenge to build capacity in schools of nursing continues. To increase interest in faculty careers, increase faculty salaries, and increase resources for schools turning away students, university health centers have a unique opportunity to establish partnerships with their schools of nursing. These partnerships can support increased enrollment while working to assure changes in the hospital workplace that will promote retention and satisfaction. The primary recommendation of this task force is for university health center schools of nursing and hospitals to assume leadership in forging partnerships to ensure a well-educated and highly functional nursing workforce.

• American Association of Colleges of Nursing. (2000). Issue Bulletin: Amid nursing shortages, schools employ strategies to boost enrollment. 
• American Association of Colleges of Nursing. (2002). Hallmarks of the professional nursing practice environment. Washington, D.C.: American Association of Colleges of Nursing.
• American Association of Colleges of Nursing. (2002a). Membership survey on education practice partnerships (unpublished). 
• American Association of Colleges of Nursing. (2002b). Issue Bulletin: Accelerated programs: The fast-track to careers in nursing. 
• American Association of Colleges of Nursing. (2002c). Issue Bulletin: Using strategic partnerships to expand nursing education programs. 
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• Dreher, M., Hartwig, S.M. (2001). The University of Iowa nursing collaboratory: A partnership for creative education and practice. Journal of Professional Nursing, 17 (3) pp:114-20. 
• Dreher, M., Everett, L. (August, 2002). University of Iowa professional practice model. 
• Dreher, M. (2001). Special initiative to expand the nursing workforce in the state of Iowa. 
• Joint Commission on the Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Chicago, Illinois. 
• Kimball, B.K., O'Neill, E. (2002). Health care's human crisis: The American nursing shortage. Princeton, N.J.: The Robert Wood Johnson Foundation. 
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• University of Illinois Nursing Institute (2001). Who will care for each of us? America's coming health care labor crisis. Chicago, Ill.

Copyright 2003 held jointly by the American Association of Colleges of Nursing and the University HealthSystem Consortium. All rights reserved. Permission to copy and distribute are given by the publisher.