In Search of the Evidence

Informing Academic-Practice Partnerships in Ambulatory Care

Stephanie Witwer, PhD, RN, NEA-BC, FAAN; Elizabeth Fritz, PhD, RN, NPDA-BC; Susan M. Antol, PhD, MS, RN; Stephanie Bilskis, MBA, BSN, RN, NEA-BC


Nurs Econ. 2022;40(3):146-155, 138. 

In This Article

Abstract and Introduction


This article describes findings from an extensive literature review and subject matter expert survey. Barriers to successful partnerships and strategies for success are highlighted, and examples from different types of successful partnerships are provided.


The 2010 Institute of Medicine's (IOM) (2011a) report, The Future of Nursing: Leading Change, Advancing Health, identified the pivotal role nurses should play in transforming and improving care. This report was published at a time of celebration for our country as insurance coverage was becoming available for 32 million more Americans (IOM, 2011a). Doors were opening for large numbers of people to receive preventive care, health and wellness services, and to help them manage chronic conditions. The report recommended ways to transform nurses' roles, responsibilities, and education. Changes were needed to meet the increased demand for care created by healthcare reform and to advance improvements in America's increasingly complex health system. Additional recommendations detailed opportunities for nurses in expanded roles to improve health outcomes and reduce costs by leading and implementing improved care delivery, payment models, and performance measures that demonstrate the contributions of nurses and ensure better quality care (IOM, 2011b).

Simultaneously, advances in health care and cost-reduction strategies associated with the Patient Protection and Affordable Care Act (2010) implementation led to increasingly complex patients being managed in ambulatory care settings. These forces were shifting care out of hospitals and into the community, increasing both the demand for primary care and elevating its role in achieving the quadruple aim (Josiah Macy Jr. Foundation, 2017). Focus on the Affordable Care Act and the Quadruple Aim (Bodenheimer & Sinsky, 2014) began reshaping care delivery through population-based reimbursement stressing prevention, quality, evidence-based clinical practice, and patient-centered care. Although nurses had the knowledge and skills to provide high quality, safe care in ambulatory care settings, a long-standing educational emphasis on hospital-based acute care left nurses ill prepared to assume roles in the community. Ironically, many ambulatory care settings either lacked registered nurses (RNs) or had not realized their full potential. Undaunted, the IOM called upon the nursing profession to reconceptualize the role of the nursing workforce, redesign education to meet changing needs, seek innovative care delivery solutions, and to attract and retain nurses across multiple settings. This was a big challenge – one that could not be accomplished independently by either academic or practice settings.

The Josiah Macy Jr. Foundation (2017) convened a group of healthcare and nursing leaders – including the American Academy of Ambulatory Care Nursing (AAACN) – and produced a report titled, Registered Nurses: Partners in Transforming Primary Care. The report proposed a new model for nurses as leaders of the team operationalizing the therapeutic plan and assuming increased responsibility for managing patient care. The vision was well-prepared RNs – in partnership with physicians, nurse practitioners, and other care team members – would teach and coach patients for behavior change, manage complex care teams, and coordinate care for these patients to achieve clinical and financial outcomes. To accomplish this, the current and future nursing workforce must be prepared to practice as members of primary care teams. However, the report cited evidence that existing faculty and the hospital-centric nursing workforce lacked adequate preparation for leadership and practice demands of ambulatory care roles. Recommendations encompassed redesign of nursing education and primary care practices to optimize the role of nurses, development of primary care expertise in nursing school faculty, and increased emphasis on interprofessional education and teamwork. The need to create partnerships with primary care practices – to develop and test expanded roles for RNs and provide experiential learning opportunities for RN students – were highlighted as key steps.

The American Association of Colleges of Nursing (AACN) (2019) published AACN's Vision for Academic Nursing which informed the AACN Essentials (2021). This vision championed a transition to competency-based education and assessment; development of consensus-derived, nationally recognized competencies; and creation of valid and reliable competency assessment methods. The white paper advocated for increased collaboration between education and practice through expanded and more formalized academic-practice partnerships (APPs) by adopting the Guiding Principles for Academic Practice Partnerships (AACN, 2012). However, these APP principles – and toolkit – stopped short of addressing the needs of ambulatory care practices and academic faculty charged with implementing high-level clinical placements in ambulatory care. Since this work began, The Future of Nursing 2020–2030 report (National Academy of Science, Engineering & Medicine, 2021) and The Essentials (AACN, 2021) were published, confirming the importance of developing APP guidelines to achieve competency-based education, and clarifying the workforce needs for ambulatory care. These reports clearly link a strengthened nursing workforce with achieving health equity. The first article in this series outlined the benefits, current state, and the changing landscape of APPs. This article describes findings from an extensive literature review and subject matter expert survey. Barriers to successful partnerships and strategies for success are highlighted. Examples from different types of successful partnerships are provided.