YNEDT-02673; No of Pages 8 Nurse Education Today xxx (2014) xxx–xxx

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Factors influencing partnerships between higher education and healthcare Arja Häggman-Laitila a,⁎, Leena Rekola b a b

University of Eastern Finland, Kuopion kampus, PO Box 1627, FIN-70211 Kuopio, Finland Metropolia University of Applied Sciences, Tuhkolmankatu 10, FIN-00290 Helsinki, Finland

a r t i c l e

i n f o

Article history: Accepted 3 February 2014 Available online xxxx Keywords: Partnership Higher education Healthcare environment Influencing factors Change agents transcending boundaries Evaluation study

s u m m a r y Objective: The aim of this study was to describe the factors influencing partnerships between higher education and healthcare. Background: Partnerships have often been studied as organisations' internal processes or multi-professional team activities. However, there has been less research on the partnership as a phenomenon between organisations and, until now, the research has mainly focused on experiences in the US and the UK. Setting, Participants and Methods: The study was carried out in Finland. Staff from a university of applied sciences and a service unit for the elderly took part in nine focus group interviews (n = 39) and produced self-evaluations based on diaries (n = 13) and essays (n = 24). The data were analysed by qualitative content analysis. Results: The factors influencing partnerships were: a joint development target, agreeing on collaboration, providing resources for partnership, enhancing mutual understanding, sharing operational culture, commitment and participatory change management and communication. Conclusions: This study updates, and complements, previous reviews on factors influencing partnerships, by providing some new concepts and a new cultural perspective from Finland on a partnership between higher education and healthcare. The results provide information on factors that influence partnerships and develop and manage their sustainability. © 2014 Elsevier Ltd. All rights reserved.

Introduction Creating partnerships between higher education and clinical practice is an essential method for developing education, workplaces and society (Boland et al., 2010; Boyer et al., 2010; De Geest et al., 2010). Partnerships solve problems faced by organisations that cannot manage on their own and require new solutions (Boland et al., 2010; Boyer et al., 2010; De Geest et al., 2010). According to Engeström (2006), social challenges requiring partnerships tend to be initially difficult to identify and define. Furthermore, they are long-lasting, they get complicated quickly and their effects are far-reaching. Partnerships between higher education and healthcare have been implemented in the development of multi-professional and practical study units and teaching hospitals (e.g. De Bere, 2003; Conolly and Wilson, 2008) and have traditionally been restricted to clinical practice placements and thesis work (Tynjälä et al., 2003). Partnership has no commonly accepted definition. Casey's (2008) literature review suggests that a partnership can be defined based on the intensity of the implementation of decision-making. In such ⁎ Corresponding author. E-mail addresses: arja.haggman-laitila@uef.fi (A. Häggman-Laitila), leena.rekola@metropolia.fi (L. Rekola).

a case, a partnership can be described as collaborative, operational, contributory, consultative or phony. Partnerships characteristically involve decision-making that crosses organisational boundaries and creates interaction based on negotiation, mutual problem-solving and learning. A successfully implemented partnership requires clearly defined structures and processes that transcend organisational boundaries at strategic, tactical and operational levels. Intense interaction between individuals should also be considered (Engeström, 2006; Missal et al., 2010). A partnership creates added value to organisations and is profitable compared to its costs. Certain central features of partnerships, such as learning together or participatory change management, have often been studied as organisations' internal processes or multi-professional team activities, excluding partnership as a phenomenon occurring between organisations (Xyrichis and Lowton, 2008; Zwarenstein et al., 2009; Memhard, 2012). Establishing and maintaining partnerships is challenging, as only half of them are in operation after the first year (Corbin and Mittelmark, 2008; Boland et al., 2010). We need research information on factors influencing partnerships to develop, manage and maintain their sustainability. This study is part of a larger research project. The first phase was a systematic literature review, using the CINAHL, PubMed and ERIC databases (Häggman-Laitila and Rekola, 2011). This aimed to identify preliminary concept factors influencing partnerships and to identify good

http://dx.doi.org/10.1016/j.nedt.2014.02.001 0260-6917/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

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practice examples of partnerships between higher education and clinical practice. Literature Review According to the systematic literature review (Häggman-Laitila and Rekola, 2011), the factors influencing partnerships were: joint development targets and agreement on collaboration, providing partnership resources, commitment, mutual understanding and shared operational culture, participatory change management and communication (Fig. 1). A joint development target and agreement on collaboration are based on an envisioning process that aims to reach a mutual understanding of the needs of the partnership, its purpose and its future, as well as the benefits it will generate. It is important to identify the needs of both partners, noting that not all problems offered for collaboration require a partnership in order to be solved. Sometimes, agreeing on the goals for a partnership does not happen straight away. It becomes possible when collaboration advances and trust are established. The result of the envisioning process should be described thoroughly in an action plan (Caldwell et al., 2007; Horns et al., 2007; Levin et al., 2007; Livingood et al., 2007; Conolly and Wilson, 2008). The literature describes partnerships being established in two ways. It starts out as correspondence between two enthusiastic leaders (Horns et al., 2007; Levin et al., 2007; Conolly and Wilson, 2008) or it involves a large number of staff from the start (Conte et al., 2006; Munro and Russell, 2007). Both partners provide resources for the partnership, by allocating staff, material, time and management input. The allocation of resources should be realistic in relation to the goals and their implementation. It should also consider the dissemination of achieved results and the need for further resources after forming the partnership. In many cases, the introduction of collaboration was financed through external funding (Wildridge et al., 2004; Levin et al., 2007; Livingood et al., 2007; Conolly and Wilson, 2008). Factors preventing partnerships include: unwillingness or inability to cover the costs of collaboration, lack of management support and suitable clinical practice placements or supervisors for students, as well as the teachers' invisible role in clinical practice placements. It has been difficult to identify experts from workplaces who could teach in higher education, as they often lack pedagogical qualifications (Wildridge et al., 2004; Conte et al., 2006). Commitment to a partnership requires the visible participation of management, their support for those in development work and an activation process aimed at staff (Wildridge et al., 2004; Conte et al., 2006; Springer et al., 2006; Levin et al., 2007). Recognising that one partner is strong in an area where another partner is weak affirms commitment. We also need to be certain that the partner takes the development goals seriously and is genuinely committed to the same values (Levin et al., 2007). Partnership is promoted by mutual understanding and shared operational cultures. These include similar basic values and similarities in organisational structures, processes and work schedules. Previous experiences of collaboration and environmental factors, such as favourable political and social climates, also promote partnership (Wildridge et al., 2004; Caldwell et al., 2007; Levin et al., 2007; Munro and Russell, 2007). According to the literature, a negative attitude manifests itself as resistance, belief that the collaboration does not provide added value and stereotyped attitudes towards the other partner. Lack of shared understanding can be caused by issues like previous bad experiences of collaboration or inadequate evaluation on the benefits of the partnership. In addition, problems related to the division of power between partners, and lack of clarity about common goals, roles and agreements on the ownership of results, may lead to negative attitudes. Other causes can include inadequate understanding and documentation of an already existing collaboration network and lack of infrastructure over the financial year (Wildridge et al., 2004; Conte et al., 2006). Flexibility, sustainability of actions and trust are the most important operating principles underlying partnerships, with flexibility including the

ability to take risks that outweigh new ideas and being ready to change collaboration plans (Wildridge et al., 2004; Springer et al., 2006; Caldwell et al., 2007; Levin et al., 2007). Previous literature suggests that cultural differences between organisations may be caused by different operating paradigms or ideologies. These can manifest themselves, for example, as differences in staff policy. A partnership calls for staff development discussions to emphasise criteria typical of the partner organisation. Nurses should be encouraged to complete university degrees, whereas universities should place more value on the participation of staff in development projects (Wildridge et al., 2004; Conte et al., 2006; Horns et al., 2007). Partnerships are formed to find new solutions for demanding situations and the process calls for good change management skills. They are based on the balance of power and promoted by seeing change as an opportunity instead of a threat, readiness to explore new service possibilities and the ability to compromise on shared power. This process can be supported by utilising representation from partners' interest groups and service users in decisions. Lastly, the balance of power is promoted by having official rules, a collaboration plan, a contingency plan in case of conflict and effective methods of decision-making and sharing responsibility, which should be adhered to despite employee turnover. In addition to a detailed operating plan, full descriptions of the roles, tasks and responsibilities of the partners and participating employees are needed. The focus of leadership should be on processes and results, instead of obstacles, structures and input (Wildridge et al., 2004; Conte et al., 2006; Raines, 2006). Managing change within a partnership requires extensive and multifaceted participatory actions from staff, including joint responsibility for development work and ownership of mutual decisions. The partnership should be everyone's personal aim and it is important for staff to be dedicated. Staff should decide the rate at which development work progresses (Wildridge et al., 2004; Springer et al., 2006; Horns et al., 2007). A partnership becomes empowering if participants realise that, rather than losing their own identity, reciprocal sharing enables them to display their competence better (Raines, 2006). Describing benefits gained by partners' individual performances increases willingness to participate in the process. In order to bring about change, follow-ups, measurements and learning from feedback are required (Wildridge et al., 2004; Conte et al., 2006; Raines, 2006; Caldwell et al., 2007; Livingood et al., 2007). Regular and effective communication and dissemination of knowledge promote partnership and the changes it creates. The mission of communication is to strive for collaborative effort and convey a general view of the development of partnership. It underlines parallel and simultaneous communication, including shared messages in the partner organisations (Wildridge et al., 2004; Raines, 2006; Caldwell et al., 2007; Levin et al., 2007; Munro and Russell, 2007). Methods Aim of the Study and Research Questions The aim of this study was to describe the factors influencing partnerships between higher education and healthcare environments, based on the experiences of change agents of developing a partnership. The research questions were: 1. What kinds of factors influence partnerships between higher education and healthcare environments? 2. What identifiable characteristics of factors promote or prevent partnerships? Research Context in Finland and Implementation of the Study The study participants included staff from a university of applied sciences, offering degree programmes in nursing, healthcare and welfare,

Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

Main categories:

Promoting features

Influencing factors

Subcategories:

Preventing features

Target of development is worth the collaborative effort and benefit both partners, identified by involving a great number of staff * + Shared vision of partnership in future*+ Clear and realistic written action plan including agreements of goals, implementation and equal share of responsibilities and ownerships of results and products* +

Joint development target and agreement on collaboration

Partnership remains too abstract, disregards the practical needs of workplace+ Development target identified only by one partner or given by leaders+ Benefits only one partner*+ Rigid agreement, tight schedules+ Uncoordinated cooperation of simultaneous projects+

Allocating staff, material, time and management for collaboration*+ Expertice of staff, research and development competence+ Multiprofessional and multi-scientific collaboration+

Providing resources

Unwillingness or inability to cover the costs of partnership* Lack of management support or expert exchange*+ Lack of time to participate in common projects+ Shortage of staff+

Commitment of various levels of organizations, leaders, peers*+ Change agents’ and leaders’ example*+ Discussions to crystallize the shared willingness, meaningfulness and benefits of partnership*+ Belief on partnership*

Commitment

Lack of management support and involvement*+ Lack of support and involvement from peers*+ Loneliness and feelings of inadequancy+

Common language+ and similar value foundation*+ Similarities in organizational structures, processes and work schedules*+ Enough time to get know each other and to be together in tolerant atmosphere+ Identification of own expectations and inputs+ Flexibility, sustainability of actions and trust*+ Favorable political and social climate*

Mutual understanding and shared operational culture

Negative attitudes*+ Previous bad experiences* Inadequate evaluation of the benefits*+ Unclearly settled common goals*+ Unclear agreements of the ownership of results and products*+ Unclear roles and expectations*+ Lack of infrastructure*+

Balance of power and joint decisions, clear statements*+ A contingency plan in case of conflicts* Full descriptions of roles, tasks and shared responsibilities*+ Representation from partners’ interest groups* Strong and competent leadership*+ Adequate support to the operational management and follow up*+ Enhancement of staff’s participation and motivation, encouragement*+

Participatory change management and communication

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Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

Subcategories:

Differences in organizations’ decision-making, use of power, administrative structures and staff policy*+ Unclear leadership of partnership+ Focus on obstacles of partnership, structures and inputs* Differences in work schedules+ Unsynchronized changes in organizations+

Fig. 1. Main and subcategories of influencing factors of partnership. ⁎Described in literature review (Häggman-Laitila and Rekola, 2011); . +described by change agents. 3

57 pages 70 pages

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Spring 2009–autumn 2011

• Description of collaboration and its development (how has it been implemented, what is done differently now) • Nature of collaboration, what has happened, what is the basis for collaboration • Smoothness of collaboration and benefits

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Amount of data

Number of participants

The credibility of the study was increased by the participants, as they all had personal experience of the research topic. By the second phase interviews, the participants had worked together for a year. They knew each other and the interviewers (both authors) and felt comfortable in each other's company. During the first phase interviews, the change agents had only met a few times and did not really know each other. They needed to develop trust and courage to express their personal opinions on partnership, found the interview topics difficult to describe conceptually and had some difficulties understanding each other's expressions. The participants were provided with the interview themes and, during the second phase, they were also given the literature review (Häggman-Laitila and Rekola, 2011) and the results of the first phase to help them prepare for the second focus group interviews.

Schedule

Credibility and Limitations

Table 1 Description of data collection methods and their implementation.

Ethical Considerations Consent to carry out the research was obtained from the participating organisations. Participation was included in work tasks and was not voluntary. However, only volunteers took part in the interviews and in writing the diaries and essays. Change agents were told about the research at the beginning of the project and were given enough information on data collection and its different phases. They gave verbal consent for the interviews to be recorded and could withdraw from the process at any time. No personal information was collected.

Autumn 2011

Diaries

First phase: • Previous experiences of projects between UAS and the workplace, promoting and preventing features of partnership • Benefits of previous partnerships • Experiences of the on-going project • Vision of the future partnership • Expectations of the development of the partnership Second phase: • Means of development and implementation of partnership • Promoting and preventing features of partnership • Benefits of partnership • Evaluation of the development of one's own actions and understanding First phase spring and autumn 2009 Second phase autumn 2010 39, of which 20 participated in both phases, collaboration in first phase 7.5 months and 14 months in the second phase 188 pages (1.5 line spacing)

• Changes in job descriptions during the project • Developers of the workplace/developing teachers' tasks and evaluation of their implementation • Challenges met and competence needs • Received and required support • Changes in one's own expertise, career development and organisations • Faced promoting and preventing features of partnership • Benefits gained from the partnership

Focus group interviews

Themes

and staff from a service unit for the elderly. The organisations recruited nearly 70 change agents, transcending organisational boundaries to develop partnerships. Most of these change agents worked in the project part-time. Some performed strictly defined short-term tasks and others were involved throughout the project. The change agents' collaboration was realised in the planning and implementation of three subprojects focusing on the development of services for the elderly. These included patient safety, particularly in medical care, preventing errors, rehabilitation, discharge and home care. The common activities performed by the change agents were: sharing expertise of their own field and how their organisation operated, planning, coordinating and implementing changes in elderly care and reorganising student supervision and participating in teaching together. How these activities were implemented differed to some extent. Teachers were expected to provide more research knowledge and multifaceted expertise on the use of the wards than the elderly care change agents. They, in turn, focused more on the implementation of change and follow-up actions. The teachers also provided support on innovation and development of follow-up methods. The change agents took part in project meetings, small groups and workshops and worked in pairs to find new clinical practices. The study comprised 39 change agents, who worked as directors, development managers, principal lecturers, lecturers, physicians, head nurses, nurses, physiotherapists, occupational therapists and practical nurses. They had been in their present roles for an average of seven years (range: six months to 21 years). Less than half of them had previous experience of two to three joint ventures between the university and their department. The majority (36) were female and their average age was 45 years (range: 24–61 years). The data were collected through nine focus group interviews (Kruger and Casey, 2009) in two phases, as well as from diaries and essays written by the change agents. The themes for each data collection method are described in Table 1. Each focus group interview involved four to seven people, took approximately two hours and was conducted and recorded by two researchers. The second interview was based on the result analysis of the first interview and the systematic literature review. Change agents, who had worked in a project for more than 40 h a year, were asked to produce essays at the end of the project. The data were analysed by qualitative content analysis (Elo and Kyngäs, 2008).

Essays

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Data collection methods

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Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

A. Häggman-Laitila, L. Rekola / Nurse Education Today xxx (2014) xxx–xxx

The material they received provided the change agents with ideas that they could use to identify and reflect their own experiences and to analyse their own, and others', involvement in the development process of partnership. This material did not restrict the participants' expressions to those found in the literature, because the change agents also produced new concepts that described factors that promoted or prevented partnership (see Fig. 1). The fact that the participants were more familiar with each other in the second focus group interviews might have also increased their willingness to provide socially acceptable descriptions. Experiences of shared reality reduced this tendency. According to Kruger and Casey (2009), interviewees' experiences of the same research context increase the description of valid data and reduce the need to give socially acceptable replies. The advantage of group interviews, as opposed to individual interviews, includes receiving more versatile data and refreshing interviewees' memories. When they listen to others, interviewees share experiences they may not have identified in an individual interview (Kruger and Casey, 2009). It was possible to return the diaries or essays anonymously and it was not necessary for the responders to indicate the name of their organisation. The size of the group interviews proved appropriate. Finally, the validity of the data was increased by collecting the data in different phases of the development project. The relationship between the categories and the original data is indicated in this paper by using direct quotes, translated from Finnish, that enable the credible evaluation of the results. Each main category consisted of several subcategories. Based on these, it can be concluded that saturation was obtained. The results of the analysis were verified by the participants at workshops and seminars. The results were limited to those participating in the project and two organisations, although they were large in size. Results According to the change agents, the factors influencing partnership were the same as those found by the literature review (HäggmanLaitila and Rekola, 2011). However, their experiences of characteristics that promoted or prevented partnerships differed from the literature review to some extent and the study produced some new concepts (Fig. 1). Joint Development Target and Agreement on Collaboration The change agents noted that entering into a partnership was challenging if the development target was given by leaders but not jointly identified. They felt that partnership was an abstract notion and the expressions describing it were far removed from everyday work. Concrete plans on the joint development of elderly care helped them to adhere to partnership. “We have different basic tasks in our organisations and you have to find the common ground.” “Concreteness has promoted collaboration. These subprojects have been a good way to develop partnership, because concreteness enables you to become closer and understand each other's context.” According to the change agents, the vision for the partnership should result in an action plan covering each partner's perspective and include clear detailed descriptions of responsibilities and ownerships of results, as well as actual, realistic, scheduled and attainable goals. “Most collaboration is small-scale work between two people. But in a large project like this, there needs to be clear, written agreement on who is responsible and who does what…who owns the results, that's one thing people talk about throughout the project…The plan is good when there are clear areas of responsibility and roles, so that everyone

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knows what they are doing, in what amount of time and who is responsible for what.” Change agents stated that disregarding the practical needs of the workplace, and only paying attention to the interests of one partner, prevented forming a partnership. Building a partnership was not desirable if the development targets were not genuine problems that needed to be solved together. Problems also arose if one of the partners was unable to prepare for partnership. Provision of Resources into Partnership Change agents emphasised that both partners should prepare themselves for the partnership by providing resources that were negotiated in advance of the partnership being formed. Attention should be paid to the goals of partnership, the dissemination of achieved results and any needs identified during the partnership. Staff should be informed of decisions in good time. Change agents felt it was important to evaluate what suitable expertise was available for developing or implementing the partnership, by using multi-professional and multidisciplinary expertise and research and development competence as much as possible. “It has been a little awkward that, quite often when a partnership is offered, it has been requested and applied for. Then, when we try to enter into partnership, we are asked for resources and competence.” The change agents noticed that staff members did not have enough time to participate in projects, due to tight schedules or inconvenient meeting times. Uncoordinated collaboration was seen as a waste of resources, resulting in several simultaneous projects with several partners and leading to a shortage of staff to implement projects. This also applied to finding and using experts. Moreover, the project and cooperation competence of staff were not fully anticipated in advance. “There might not be this research and project competence, but that is exactly what they want from a university … predicting things early enough to be able to recruit people.” Commitment Change agents felt that it was vital for leaders to set an example and get involved and saw their own role as ensuring that their peers were committed to the partnership and providing information to the management. “It is essential that managers are involved. People then start acting and somehow get permission to do so.” “Those of us who are involved in the process have the partnership spirit, but how about staff members on the ward who are not involved yet? They must be a little amazed to see people show up there. The question is how to make the partnership visible to others, so that it becomes something we all can share. I suppose this is still challenging because of shift work and many substitutes ….” The change agents felt that they were put in a difficult position between the two partner organisations and their own management and having to carry out their own “fieldwork” at the same time. They frequently had to defend and justify the partnership, which increased the burden of the task. But it strengthened their commitment to the partnership. “Our workplace managers don't know what we're doing here at the end of the day … sometimes I feels I have to explain to my managers why I'm taking part in these meetings, even though I have been ordered to be here.”

Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

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“I talk about the importance of collaboration with the university and I particularly defend the work done in the university from a completely different point of view than before.” The change agents also emphasised the need for open discussion with representatives at various levels of the organisations, particularly management, in order to crystallise their shared willingness to work to the agreed plan. Similarly, they wanted to hear the management's opinion on the development work. The partnership was established at the level of the change agents and remained their responsibility throughout the process. According to the change agents, commitment was achieved by ownership in the other organisation and utilising the results in clinical practice. Mutual Understanding and Shared Operational Culture Joint meetings, gatherings and workshops in a tolerant atmosphere enabled change agents to acquaint themselves with each other at personal and organisational levels, develop mutual understanding and share operational culture. It was also important to find a common language, which proved challenging, especially at the beginning of the partnership. Meetings were arranged throughout the partner organisations, increasing the understanding of a partner's operating environment, and regular meetings with partners also brought colleagues closer together in a new way. However, the change agents were surprised at how much time it took for the partnership to develop. “I wanted all the results at once, but then realised that, in reality, the development does take time.” The change agents felt that the partners had the same basic values in terms of the shared operating environment, the development target and educational background. First and foremost, both organisations wanted to safeguard good patient care. “Our work is the shared value: we think what is best for the patient. Also, our education is quite homogenous. The ethical values originate from there and the moral values are uniform. For this reason, it is not difficult to work together.” It was also important to adopt a positive attitude towards the partnership and have realistic expectations. A partnership calls for reaching an understanding of what can be offered to the partner and expected from it, both at personal and organisational levels. “To gain understanding from both sides, to know what the university offers and wants, but also that we are able to share our views, what we want, what we might also provide later. But we still focus on the patient and the patient's interests.” The change agents detected differences in the operational cultures of specific employee groups. For example, hospital staff members thought teachers showed more innovation and tended to get more enthusiastic than hospital personnel. The work schedules in the organisations differed significantly from each other, which hindered arranging joint meetings and making plans. When it came to the operating principles underlying the partnership, flexibility, sustainability of actions and trust were considered the most important. “It was kind of building up trust in the beginning. In my opinion we have progressed a lot since then, have taken many steps, have gained mutual trust, and it is easy to approach one another.” Flexibility was conveyed in the voluntary interactions between the change agents and supported by their enthusiasm and creativity. Trust entailed openness and honesty, feeling able to disagree and

promote alternative ideas, equality, mutual appreciation and respect, the opportunity to enjoy the cooperation and the courage to receive feedback from the partner. The credibility and availability of those who promoted the partnership were also related to trust. They were also related to realising the significance of the partnership and the willingness to instil it as part of the operational culture. “At times, our thinking is not quite on the same level in this project. Maybe both perspectives are needed; they should be highlighted and combined. The main thing is that the expertise of both parties can be appreciated and utilised accordingly. Maybe I should not expect great innovation and good writing skills from clinical healthcare workers, but instead expect a perspective in clinical practice and the ability to adopt and apply matters there.” The operating principles were realised by the partners in the general working atmosphere and included in meeting protocols and in agreements on issues such as communication, job descriptions and the distribution of responsibilities, tasks and resources. Trust was established based on how the partners fulfilled their promises to deliver benefits through synergy and the expertise that they offered. People evaluated the other partner's approach to work by comparing it to their own expectations and trust was compromised when partners provided limited expertise and did not fully participate in the partnership. Building on the established expertise of the partners as much as possible was a general principle. Furthermore, equality was tested when both partners had the opportunity to get involved in the development processes of each other's basic tasks. The change agents said that transferring knowhow from the healthcare environment to develop teaching at the university was not as easy as switching know-how from the university to develop nursing at the hospital. Participatory Change Management and Communication The participants felt that the key to managing partnerships lay in the balance of power and joint decisions. “Some kind of balance in decisionmaking so that the partner does not dictate”. They wanted each organisation to provide clearly designated people responsible for the partnership as well as management partner pairs who had the power to make decisions in their own organisations. “Managers and immediate superiors needed similar project work to the change agents' subprojects in order to develop the leadership of the partnership”. The change agents emphasised that leaders must recognise each other's expertise in the partnership and delegate responsibility and tasks to ensure flexible participation. Achieving these actions together and securing the continuity of change despite staff turnover were important. They expected the management to show strong support and encouragement for development work, despite uncertainty, and to appreciate the solutions that were produced. If the partnership did not result in anything concrete, those involved in the process got tired and discouraged. Leaders were expected to follow up the progress and benefits of the partnership and share the findings with the staff. Change agents stated that, as the benefits of collaboration built up, the motivation for partnership increased. A partnership became empowering if that participants felt that they could learn from each other. “Each person has a chance to demonstrate their competence. The point is how to make them believe in themselves, use their creativity and work openly and genuinely toward a good common goal that has been set together.” “I have tried to worry less and increase my level of tolerance of uncertainty, which is needed in all major projects. To have the courage to make this journey together, despite not knowing what is in store for us. It is very important for me, as a developing teacher, to understand change and tolerate uncertainty, but I am able to see the far-reaching

Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

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significance of the issues at hand here, that is the primary goals of this project. It is important to clarify this constantly, so that the choices at subproject level are evaluated by utilising a certain framework.” The basic tasks and positions of the partner organisations were not similar in their administrative structures and networks, requiring, for example, different decision-making processes, operating models and electronic systems. This provided employees developing the partnership with novel administration, management and communication processes from the other organisation, which were difficult to perceive. Unsynchronised changes in organisations were an impediment to the partnership. “Just when we have had the change, it starts in the other organisation”. Decision-making was very different in various organisations, as were the attitudes to decision-making. What was a major decision in one organisation proved to be a small one in the other. “Here at the university we have a different pace … and fast action. We're focusing on one thing, education … and it might be easier for us to operate, whereas the city is a large entity where healthcare is only one fraction and it's just one element of all the decisions and then things don't happen as fast.” A written plan was an important communication tool, as it included agreement on the channels of communication, the people responsible for it and a schedule. Communication should be open, comprehensive enough to reach everyone involved and provide similar up-to-date messages to all partners. It played a major role in providing feedback and helped to build respect for other people, ensuring that they were taken seriously and looked after. Using modern means of communication promoted this. “Colleagues and other teachers at the university have expressed some concern about not having enough information about how to be involved and there is also some pressure around the actual benefits of all of this. How is it made visible at the university, what competence does it develop and how?” Discussion This study produced eight main categories that defined the factors that influence partnerships and each of these contained several features that promote and prevent partnerships (Fig. 1). The influencing factors included joint development targets and agreement on collaboration, providing resources, commitment, mutual understanding and shared operational culture, participatory change management and communication. Our study supports, updates and complements previous reviews by concentrating on factors that promote and prevent partnerships (cf. Dowling et al., 2004; Petch, 2012). In comparison to the review of earlier research (Häggman-Laitila and Rekola, 2011), it also provides some new concepts of the features that promote and prevent the influencing factors, a new cultural perspective that focuses on partnerships between higher education and the workplace and how Finnish organisations approached partnership. Until now, research has mainly focused on experiences in the US and the UK. The parallel results reinforce the significance of identified impact factors and they should be considered in nursing education and management. According to Corbin and Mittelmark (2008), the most important contribution to long-lasting partnership lies in the employees of organisations and how they interact. They strive to transcend organisational and professional boundaries and interpret their implementation (cf. Lamont and Molnar, 2002). Petch (2012) suggests that, at its core, partnership is a mental attitude and that employees identify factors that contribute to partnership from different standpoints. Therefore, promoting factors are identified based on aspects controlled by the organisations in a partnership, whereas preventing factors tend to be external and national challenges.

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Because of the short duration of the development project, the infrastructure supporting the partnership and the leadership efforts were studied less. However, they also form a vital part of partnerships (Cramer et al., 2006; Corbin and Mittelmark, 2008; Boland et al., 2010; Weiss et al., 2010). This subject matter still poses many research challenges. For example, overall satisfaction with partnerships and establishing control over partnership processes have only been studied and evaluated to a limited extent (Weiss et al., 2010). Nevertheless, they are significant factors that contribute to how committed staff are to partnerships. For example, employees' subjective experiences of benefits affirm commitment (Cramer et al., 2006). Gaining benefits is linked with the management of partnerships and administration as well as the interaction between partner organisations. Although international literature has described factors related to partnership processes, we lack critical analysis on the input, process and output factors and their interrelatedness. Little attention has been paid to the additional benefits that partnerships create for organisations (Dowling et al., 2004; Dickinson, 2006; Corbin and Mittelmark, 2008; Petch, 2012). In addition, there is very limited empirical research knowledge on the development phases of partnerships between organisations (Cramer et al., 2006). Lamont and Molnar (2002) note that the group partnerships that stand out are founded on social factors, such as professional education, competence and boundaries, as well as symbolic attributes related to concepts, knowledge foundation, interpretation strategies and cultures. In this study, the most important symbolic attributes were concepts describing the knowledge foundation and practices of the change agents' own professions, the learned culture of multi-professional collaboration and the interpretations of the vision and strategy of the change agents' own organisations. Transcending the organisational boundaries in relation to these symbolic attributes is a fundamental requirement for a partnership. On the one hand, transcending boundaries causes insecurity and regrouping and takes time, but, on the other hand, as the results of this study indicate, it deepens and consolidates the relationship with one's own group. The impact of symbolic attributes took the participants of this study by surprise. No-one had anticipated them or was prepared to deal with them. In the future, this should be considered before developing partnerships. Partnership is based on good communication between the representatives of organisations and requires a certain form and rules to function, as well as continuity irrespective of individual agents. Supporting interaction and polyphony lie at the core of a partnership (cf. also Dowling et al., 2004; Casey, 2008; Weiss et al., 2010; Petch, 2012). The realisation of polyphony is supported by communication and mutually agreed operating principles, with trust emerging as one of the most important factors in this study. Hence, a major challenge for future partnership research is to specify operating principles as well as to identify their implementation and support in the interaction processes. In particular, research should focus on the critical component of trust, to ensure success when developing a partnership.

Conclusions Creating partnerships between higher education and clinical practice will be an essential method for developing education, workplaces and society in the future. Based on the study, the following suggestions can be recommended for the development of partnerships. 1. By involving staff, identifying a joint development target, which benefits both partners. Formulating a clear and realistic written action plan in collaboration with partners including agreements of goals, implementation and equal share of responsibilities and ownerships of results and products. 2. Allocating staff, material, time and management for collaboration in advance. Paying sufficient attention to expertise.

Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001

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Please cite this article as: Häggman-Laitila, A., Rekola, L., Factors influencing partnerships between higher education and healthcare, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.001