Partners Investing in Nursing’s Future · The complexity and involvement of the communities and number of partnerships increased with each PIN cohort. Evaluation Concept 1: Expand

Partners Investing in Nursing’s Future

Final Evaluation Report: PIN 1-5 Cohorts

National Evaluators: Linda Norman, DSN, Sherril Gelmon, DrPH and

Katharine Ryan, MPH Vanderbilt University and Portland State University

June 2014

TABLE OF CONTENTS Page EXECUTIVE SUMMARY i I. OVERVIEW OF PIN 1 A. PIN Program Background 1 B. PIN 1-5 Partnerships 6 C. Changing Context of Nursing and Health Care 10 II. KEY THEMES AND PROMISING PRACTICES 10 A. Partnership Development, Management, and Sustainability 11 B. Nursing and Philanthropy Collaborations 13 C. Specific Accomplishments 15 D. Consistent Challenges 28 E. Nursing Workforce Development 29 F. Impact on, and Role of, Philanthropy 32 G. PIN 1-5 Projects Compared to 2011 IOM “Future of Nursing” Priorities 35 III. FRAMEWORK FOR EVALUATION OF PIN 1-5 39 A. Conceptual Framework 39 B. Stakeholder Perspectives 47 C. Sources of Evidence 47 1. Partnership Reports 47

2. End of Funding Surveys 48 3. End of Funding Interviews 49

4. Annual Evaluation Reports 49 D. Overview of Survey Respondents 50 IV. THEMATIC EVALUATION BY CORE EVALUATION CONCEPTS 53 A. Expand Philanthropy’s Role in Local and Regional Nursing Workforce Development 53

1. Funder Perspectives 53 2. Nursing Leader Perspectives 58 3. Building Relationships Among Community Partners 60

B. Advance Nursing Workforce Solutions in Local and Regional Communities 61 1. Faculty Development and/or Educational Infrastructure 62 2. Leadership and/or Collaboration 65 3. Diversity, Recruitment and Retention 66 4. Geriatrics and Long-Term Care 68

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5. Public Health 70 6. Changing Priorities 70

C. Grow and Enhance Partnerships to Address Local and Regional Nursing Workforce Issues 71

1. Creating the Partnership 72 2. Expanding/Enhancing the Partnership 73 3. Partnership Effectiveness 73 4. Partnership Operations 75 5. Synergy 78

D. Create Sustainable Solutions for Local and Regional Nursing Workforce Development 81 1. Leadership 82 2. Funding 83 3. Relationships 86

E. Value of Participating in PIN Program to Develop Nursing Workforce Solutions 87 1. Participating in a National Initiative 87 2. Developing a Local Strategy 89 3. Creating New Relationships 90 4. Articulating New Insights 90 5. Operational Observations 92

F. Value of Support Provided by the National PIN Program Office 94 1. Utilization and Satisfaction 94 2. Creation and Support of the PIN Community 95 3. Evaluation Consultation 97 4. Strategic Coaching and Facilitation 98 5. Communications Support 99

V. DISSEMINATION 90 VI. CONCLUSIONS 100 Appendix 1: Previous PIN Partners’ Participation in RWJF Projects 105 Appendix 2: Bibliography for Partnership Survey Development 107

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Executive Summary, PIN 1-5 Evaluation Report

Partners Investing in Nursing’s Future (PIN) was a collaborative partnership between the Robert Wood Johnson Foundation (RWJF) and the Northwest Health Foundation (NWHF) to invest in partnerships of local and regional grantmaking foundations working with nursing leaders to encourage sustainable nursing workforce solutions. The purpose of the program was to:

Support innovative and collaborative projects that address local nursing workforce issues; Leverage the interest and capacity of local and regional foundations to invest in nursing

workforce development; Establish a new model of partnership between foundations and nurse leaders to ensure the

success of the programmatic goals and objectives. The PIN program used an annual matching grants program to provide grants to local funders to address nursing workforce issues. PIN 1-5 supported 50 partnerships in five annual cohorts beginning in 2006; these were located in 37 states and the Pacific island territories. Each partnership received up to $250,000 for two to three year projects, matched with equivalent if not greater local resources. The PIN program invested nearly $10.7 million from RWJF funding in the local partnerships, leveraging an additional $13.7 million in local and regional funding. Approximately 230 funders and 440 community partners were involved in PIN 1-5. Key Findings This executive summary presents key themes across the fifty partnerships, synthesized by the national evaluation team in consultation with the PIN program staff. The full evaluation report is available from the PIN Program Office. The conclusions below are organized by the six concepts that have framed the evaluation of the PIN 1-5 cohorts for the past eight years. Collectively, the PIN partnerships made a significant impact on nursing workforce issues in their region. Since the partnerships were developed as strategies to address local issues related to the nursing workforce, each had a unique focus based on local needs. The complexity and involvement of the communities and number of partnerships increased with each PIN cohort. Evaluation Concept 1: Expand Philanthropy’s Role in Nursing Workforce Development The goal of the PIN initiative was to expand philanthropy’s role in local and regional nursing workforce development. Each of the PIN projects was successful in achieving this goal to some extent. Participation in PIN changed how many foundations approached community engagement and partnerships. The role of the foundation evolved to be a convener, facilitator, and champion for a specific issue, creating a “safe place” for organizations to come together to solve a community problem, even those that typically were competitors. Foundations were able to identify and engage partners from business and government, in addition to those involved in health care issues, many of whom were new players not typically approached by nursing for

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problem-solving. The nursing partners consistently indicated that the collaborations with multiple community agencies were a key factor in the success of the PIN project activities. The PIN program required the local or regional foundation or other funder to be the lead partner in the effort to develop sustainable nursing workforce solutions. This was a creative and innovative approach to increasing the amount of engagement by a traditionally passive funding community. This structure enabled the funding leader to involve other organizations that were not usual collaborators for the nursing profession. As a result, PIN enhanced foundations’ knowledge of the contributions that the nursing workforce makes to health care delivery within the community, and established the importance of a well-prepared nursing workforce to the local economy. Many foundations expanded their activities to become more engaged in other community issues as a result of participation in PIN. The foundations’ roles as “grantee” allowed them to become a catalyst for others to invest in the nursing workforce, leading to new collaborations within their regions and more involvement in varied health and community issues. An overwhelming theme expressed by the nursing partners was a greater understanding of the strategic work of foundations, and the importance of linking with those who have a mission and priorities that are consistent with a specific initiative. Both the nursing partners the foundation partners learned about the importance of including multiple partners from outside of health care, even when working on a health-specific issue. Working with the foundations in the PIN initiative changed the way many of the nursing partners approached other grant-related activities. Both the nursing and foundation partners reported a heightened awareness of the importance of evaluation. Many foundations changed their evaluation processes to utilize a conceptual framework approach that was consistent with the evaluation methods of the PIN initiative. They described a new appreciation for reporting outcomes and impact in addition to participation in the grant activities. Partner relationships matured during participation in PIN, and they were able to build new ways to work together and pursue new opportunities. Evaluation Concept 2: Advance Local and Regional Nursing Workforce Solutions Each of the PIN partnerships was unique; a common observation was: “When you’ve seen one PIN partnership, you’ve seen one PIN partnership.” Each of the projects was able to engage their target community to focus on strategies to address specific nursing-related needs in the local area. As a result, the purpose and approaches were very individualized. The value of working as a local partnership allowed PIN partners to address issues that were of importance to the community instead of having to tailor their grant activities to a national priority, as with many other workforce-related grant programs. The strategy of the PIN partnerships for approaching nursing workforce issues can serve as a model for other communities that could be generalized to other health care workforce issues. While the major purpose of PIN was to advance nursing workforce solutions in local and regional communities, an important aspect that each of the 50 partnerships communicated was the importance of community involvement in the issues of nursing workforce and the need to spend part of their time educating others about the specific issues of their area. Just as nursing partners learned about the workings of the foundation community, the community partners developed a better understanding of the issues associated with the nursing shortage.

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Funders developed a greater appreciation for the complexities of the nursing discipline and the issues surrounding expanding and enhancing the workforce. They consistently emphasized that they learned new information about the critical role that nurses play in improving the health status of a community and its relationship to the economy of the community. Evaluation Concept 3: Grow and Enhance Local and Regional Partnerships The PIN initiative was successful in developing a model of how local and regional partnerships can come together to address issues that no one else is working on and create synergy across multiple sectors of a community to begin communication and problem-solving. An important outcome of most of the PIN partnerships was the development of new models and methods of partners working together to bridge their respective interests and priorities. Many indicated that engaging “less traditional partners” enhanced the effectiveness of the project and expanded the impact within the community or region. However, several PIN partnerships indicated at the end of their funded project that they had missed an opportunity of developing a substantial relationship with the business community. The PIN partnerships developed goals, responded to relevant views and priorities, implemented locally relevant strategies, responded to needs and issues, identified new and creative problem-solving strategies, and evaluated progress and impact. Some important lessons learned addressed the need to carefully choose partners who were aligned with the goals of the project; more partners did not necessarily enhance the impact of the project. Almost all of the partnerships emphasized the need to pay attention to the organizational structure of the partnership, and allow sufficient time for the partners to get to know each other. Close relationships among the partners were an essential factor in the success of the PIN projects. Another key factor in growing and enhancing partnerships was the ability to establish mechanisms to address and overcome challenges and differences among the partners. Multiple commitments of the partners and changes in leadership created difficulties and delayed progress when they occurred. Partnerships needed to establish methods to address these issues when they surfaced. The complexity and involvement of the communities and number of partnerships increased with each PIN cohort. Successive PIN cohorts increasingly engaged workforce boards and other agencies, due in part to learning from earlier PIN partnerships. These new networks focusing on health workforce development helped to expand the influence of the PIN project and enhanced success in engaging other partners. Most of the partnerships indicated that, where their initial project was focused on a local or regional issue, by the end of the funded project they had seeded statewide interest and, for some, involvement in broader nursing workforce issues. Evaluation Concept 4: Create Sustainable Solutions for Nursing Workforce Development The PIN partnerships were similar to other grant-related initiatives, in that some continued beyond the funding and some ended. One of the biggest issues to sustainability was finding ongoing funding to support the work beyond the RWJF funding period. Most of the partnerships ultimately recognized the need to begin to plan for sustainability at the beginning of the project, rather than waiting until the project was well advanced in its work. Some of the most successful efforts in sustainability were those that were able to integrate the project activities into the work of a partner organization. Others were able to develop a fee structure to support their ongoing work or garner support from other external agencies.

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The majority of partnership leaders indicated that setting up the organizational structure was the most important part of the initial activities of the partnership and took a significant amount of time. Almost all of the partnerships indicated that it was necessary to pay attention to developing the partnerships, determining the right people to invite to participate, and establishing the structure and procedures to conduct the work of the PIN project within the first few months of the project. These early efforts provided the basis for ongoing sustainable relationships. Each of the partnerships indicated the importance of community involvement and education in the issues of nursing workforce. Just as nursing partners learned about the workings of the foundations, the community partners developed a better understanding of the issues associated with the nursing shortage. Engagement of community partners was a key to success in most areas. Through partnerships, new relationships were developed, knowledge about community programs increased, and awareness about the issues increased. Most participants saw few drawbacks to participating in the partnership other than the diversion of time and resources away from other priorities. Nonetheless, the benefits greatly exceeded any drawbacks experienced. A key outcome of most of the PIN partnerships was the continuation of the relationships among the partners. Even for those where the work of the project ended with the conclusion of the PIN funding, the partners often continued to work together on nursing workforce related issues or other health care workforce issues. Evaluation Concept 5: Demonstrate Value of Participation in a National Program Each of the PIN partnerships articulated the importance that participating in a national program had on the success and recognition of the project. It enhanced their ability to attract and engage partners in their work. The association with a Robert Wood Johnson Foundation project raised the profile and importance of the project at the local level. Many partners give considerable credit to RWJF and NWHF for the conceptualization, design and logic of the PIN program. The organization of PIN facilitated the partnerships to establish new networks of contacts and a process to share information with others who were working on similar problems. Both nursing and foundation partners highlighted that they had developed new contacts that led to participation in other organizational activities. The national grantee meetings created an opportunity to learn from others while they were engaged in the partnership activities and to utilize new strategies in their projects. Many commented that the connections that they made through PIN would be continued as they continue to work on other workforce initiatives in their communities and regions. PIN was a catalyst to start many of the projects that became PIN partnerships, and the partnerships were a necessary step to begin addressing nursing workforce issues. The work of the PIN partnerships has been integrated into the new developments launched as a result of the IOM report on The Future of Nursing and the creation of state action coalitions. Active PIN partnerships in many states have been the stimulus to help launch, and in some cases partially fund, these coalitions.

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Evaluation Concept 6: Clarify Value of Support Provided By the National Program Office The PIN national program office received considerable praise from the partnerships. The helpfulness and responsiveness of the staff were regularly cited. The ability to have questions answered and resources identified by available and knowledgeable staff in a timely way enhanced the progress and success of the projects. The partnerships indicated that they benefited from the multiple resources provided by the program office and the PIN website, as well as the connections to others who were working on similar issues. All of the partnerships expressed the value of the PIN community as a resource during their project and extended after the projects were completed. Efforts for Continuing Attention Despite the successes of the PIN partnerships, many participants identified specific issues that continue to need attention beyond the PIN initiative. These include the continuing need to:

Create leadership development initiatives for the nursing workforce. Increase diversity within the nursing workforce. Enhance emphasis on nursing’s role in community-based and primary care delivery,

particularly as part of health systems reform. Recognize the value of increasing the educational level of nurses and understanding how

career progression contributes to enhanced patient care outcomes and health care quality. Continue to prepare the nursing workforce to meet the needs of an aging population.

Concluding Observations Given that the PIN project’s success relied upon development of personal relationships and effective partnerships, it is appropriate to conclude with a synthesis of partners’ viewpoints on their experiences of the PIN project:

1. The time was right to work on nursing workforce issues. 2. The level of commitment among the PIN partners was high, partners were dedicated to

this project, and organizations benefited from being part of this work. 3. Participants in the PIN partnership knew and understood the goals for the PIN project. 4. People involved in PIN partnerships trusted one another, communicated openly, and were

willing to consider various approaches to their work and compromise when necessary. 5. The organizations involved in the PIN partnership were the “right” cross-section with an

interest in what they were trying to accomplish. 6. Partners were able to adapt to changing conditions that affected their collective work, and

keep up with the work necessary to coordinate all the elements of their project. 7. Celebration of achievements was an important element in working together. 8. What individuals were trying to accomplish within PIN would have been difficult for any

single organization to do by itself. PIN was successful in meeting the goal of enhancing the nursing workforce through the creation of partnerships among funders and nursing organizations. PIN projects have made a significant impact on nursing workforce issues in their region. PIN can serve as a model for communities to bring partners together to create local solutions and have a national impact on important issues. For further information, visit www.partnersinnursing.org.

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Partners Investing in Nursing’s Future Final Evaluation Report, PIN 1-5 Cohorts

Linda Norman, Sherril Gelmon and Katharine Ryan National Evaluation Team

I. OVERVIEW OF PARTNERS INVESTING IN NURSING’S FUTURE A. PIN Program Background Partners Investing in Nursing’s Future (PIN) was a collaborative partnership between the Robert Wood Johnson Foundation (RWJF) and the Northwest Health Foundation (NWHF) to invest in partnerships with local and regional grantmaking foundations to encourage sustainable nursing workforce solutions. This partnership sought to spur local grantmaking foundations to act as catalysts in developing comprehensive strategies that would be vital to a stable, adequate nursing workforce. Bringing philanthropic leaders together with nurses to develop new relationships, share knowledge, and generate innovative projects was a major goal of this program, both locally and nationally. The two lead foundations recognized that addressing the long-term and systemic issues of nursing workforce development required collaboration among local, regional and national philanthropies, as well as other allies. An underlying precept of the program was the importance of encouraging nurses to be active leaders in the development of sustainable solutions in their local communities. The PIN 1-5 program supported 50 partnerships in five annual cohorts beginning in 2006 (the PIN 6 cohort is beyond the scope of this evaluation). Ten partnerships were funded in each of 2006, 2008, and 2009; in 2007, eleven were funded; and in 2010, nine were funded. The funds were initially granted for a two-year period; many partnerships received no-cost extensions to continue their PIN-supported work into a third year. The 50 partnerships are listed by cohort, funding dates, primary funding partner, location and project title in Table 1. These PIN partnerships have implemented innovative strategic efforts to enhance the contributions of nurses in 37 states and the American Pacific island territories. The PIN program invested nearly $10.7 million from RWJF funding in the local partnerships, leveraging an additional $13.7 million in local and regional funding. Approximately 230 funders and 440 community partners were involved in PIN 1-5. The PIN 6 cohort adds additional partnerships, partners, and dollars invested; however, PIN 6 had a different scope, and its evaluation was conducted and will be reported separately.

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Table 1: PIN 1-5 Partnerships

Cohort and Dates

PIN Primary Funding Partner Location Project Title

PIN 1 2006-2009

Blue Cross Blue Shield of Michigan Foundation

Michigan Nursing for Life: RN Career Transition Program

PIN 1 2006-2010

The Colorado Health Foundation Colorado The Clinical Placement Inventory and Matching System and the Leadership for Resilience: Nursing Retention Project

PIN 1 2006-2009

Community Foundation of the Eastern Shore, Inc.

Maryland Partners in Nursing – Community Foundation of the Eastern Shore: Nursing Careers Support Initiative

PIN 1 2006-2008

Irene E. & George A. Davis Foundation Massachusetts Collaborating for the Advancement of Nursing Opportunities (CANDO)

PIN 1 2006-2009

Dreyfus Health Foundation of the Rogosin Institute

Mississippi Minority Nurse Mentoring in the Mississippi Delta

PIN 1 2006-2009

HMSA (Hawaii Medical Service Association) Foundation

Hawaii Hawaii Partners in Nursing: Recruitment and Retention in Long-Term Care

PIN 1 2006-2009

Mississippi Hospital Association Health, Research & Education Foundation

Mississippi Mississippi Critical Nursing Faculty Shortage Initiative

PIN 1 2006-2010

Rasmuson Foundation Alaska Recruitment and Retention of Alaskan Natives into Nursing Rural Generalist Preceptor Program Development

PIN 1 2006-2009

St. James Healthcare Foundation Montana Academy for Advanced Nursing Workforce Solutions

PIN 1 2006-2009

Ventura County Community Foundation California Ventura Nursing Legacy Project

PIN 2 2007-2010

Community Foundation of Middle Tennessee

Tennessee The Nursing Crisis in Tennessee: Building Capacity through Collaboration

PIN 2 2007-2010

Con Alma Health Foundation New Mexico Project Diversity: Develop/Increase the Voice of Ethnic, Racial Students through Youth

PIN 2 2007-2010

Dakota Medical Foundation North Dakota North Dakota Nursing Career Lattice Consortium Project

PIN 2 2007-2010

Faye McBeath Foundation Wisconsin Raising the Bar: Redesigning Community and Public Health Nursing in Wisconsin

PIN 2 2007-2010

Illinois Prairie Community Foundation Illinois Partners in Nursing of Central Illinois

PIN 2 2007-2010

Midland Area Community Foundation Michigan Foundations Underwriting Nursing Development (FUND)

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PIN 2 2007-2010

Mt. Sinai Health Care Foundation Ohio North East Ohio Nursing Faculty Corps

PIN 2 2007-2010

Oklahoma Hospital Education Research Foundation Trust

Oklahoma Using Advanced Technology to Develop Nurse Leaders

PIN 2 2007-2010

Pitt Memorial Hospital Foundation North Carolina PRN: Partners for Rural Nursing in Eastern North Carolina

PIN 2 2007-2010

Richmond Memorial Health Foundation Virginia Central Virginia Nurse Leadership Institute

PIN 2 2007-2010

Wolslager Foundation/Project ARRIBA Texas Lifting Hispanic Nurses Across the Border

PIN 3 2008-2011

American State Bank Texas West Texas Alliance for Simulation Application and Partnerships

PIN 3 2008-2011

Daisy Marquis Jones Foundation New York Nurses as Leaders in Long-Term Care: Building Competencies and Commitment

PIN 3 2008-2011

Dimmer Family Foundation Washington Comprehensive Gerontologic Education Partnership (CGEP)

PIN 3 2008-2011

Friends of the College of the Marshall Islands Foundation, Inc.

US Affiliated Pacific Islands

Building Nursing Capacity and Enhancing Patient Care in the US Affiliated Pacific Island (USAPI) Jurisdictions

PIN 3 2008-2011

Greater San Antonio Healthcare Foundation

Texas South Texas Acts for Nursing Development (S.T.A.N.D.)

PIN 3 2008-2011

Health Care Foundation of Greater Kansas City

Missouri Bi-State Nursing Innovation Workforce Center

PIN 3 2008-2011

Jonas Center for Nursing Excellence New York, North Carolina

A Multi-Regional Model to Increase the Number of Baccalaureate Nurses in the U.S. (RIBN)

PIN 3 2008-2011

Oregon Community Foundation Oregon Nurturing Cultural Competence in Nursing

PIN 3 2008-2010

San Francisco Foundation California Immigrant Nurse Refresher Program

PIN 3 2008-2011

Wyoming Community Foundation Wyoming Nursing Workforce Project of Wyoming

PIN 4 2009-2012

West Central Initiative Minnesota Building Faculty Capacity in Geriatric Nursing for Central Minnesota

PIN 4 2009-2011

The Greater Kanawha Valley Foundation West Virginia West Virginia Nursing Leadership Institute: Team Leadership Development Program

PIN 4 2009-2012

Arkansas Community Foundation Arkansas Planning for Workforce Development in Geriatric and Long-Term Care in Arkansas

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PIN 4 2009-2011

The Blue Foundation for a Healthy Florida, Inc.

Florida Promoting the Use of Simulation Technology in Florida Nurse Education

PIN 4 2009-2012

Community Foundation for the Land of Lincoln (formerly The Sangamon County Community Foundation)

Illinois Central Illinois Nursing Initiative [CINI]: Expanding Capacity and Educational Articulation for Rapid Nursing Workforce Development

PIN 4 2009-2012

The Community Foundation of the Great River Bend

Iowa Pathways and Perceptions: A Life Span Model for Nursing Work Force Development

PIN 4 2009-2012

Tufts Health Plan Foundation, Inc. Massachusetts, Rhode Island,

New Hampshire

Creativity and Connections: Building a Regional Nursing Education Framework

PIN 4 2009-2012

Hinds Community College Development Foundation

Mississippi Mississippi Geriatric Dedicated Education Unit Initiative

PIN 4 2009-2012

Vetter Foundation Nebraska Nebraska Geriatric Nursing Quality Improvement

PIN 4 2009-2012

John T. Vucurevich Foundation South Dakota Education Service Partners Program [ESPP]: Prepare and Retain

PIN 5 2010-2013

Bingham Foundation Maine Maine Partners in Education and Practice

PIN 5 2010-2013

Caring for Colorado Foundation Colorado Care and Career Transitions: Innovations in Home Health Care, The Missing Link

PIN 5 2010-2013

The Cleveland Foundation Ohio Online Nursing Education for Nontraditional Faculty

PIN 5 2010-2013

Community Foundation of Southeast Michigan

Michigan Leading Towards Tomorrow

PIN 5 2010-2013

Dakota Medical Foundation North Dakota North Dakota Partners in Nursing Gerontology Consortium Project

PIN 5 2010-2013

Endowment for Health New Hampshire New Hampshire Nursing Diversity Pipeline

PIN 5 2010-2013

The Horizon Foundation for New Jersey New Jersey Nursing Academic Resource Center of New Jersey

PIN 5 2010-2012

Humboldt Area Foundation California Humboldt Bay Regional Simulation Center

PIN 5 2010-2013

Texoma Health Foundation Texas, Oklahoma

Nursing Advancement and Leadership Project

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The purpose of the PIN 1-5 program was to: Support innovative and collaborative projects that address local nursing workforce issues; Leverage the interest and capacity of local and regional foundations to invest in nursing

workforce development; Establish a new model of partnership between foundations and nurse leaders to ensure the

success of the programmatic goals and objectives. RWJF and NWHF defined the outcomes of the overall PIN program in three major areas:

1. Expanding the capacity of local foundations to: Address nursing issues that are particularly relevant to their local community. Become engaged grantmakers, advancing the profession of nursing through

collaborative partnerships, not just in financially supporting individual projects. Develop collaborative partnerships and networks between local and regional funders

to address these and other issues important to health. Institutionalize and sustain projects after PIN funding has ended. Create a nationwide network of private philanthropy dedicated to supporting

innovative and comprehensive activities that promote the nursing profession. 2. Enhancing the nursing profession by:

Promoting nationwide public interest in the profession of nursing. Increasing the visibility of the challenges of the nursing workforce and relationship of

nurses to quality of care. Increasing understanding of nursing/health care workforce issues in local and regional

areas. Linking and integrating existing and new activities into a comprehensive approach to

nursing issues that reflects the overall vision for the profession, not the isolated objectives of a single activity or entity.

3. Creating a shared learning environment between NWHF and RWJF that will: Build and evaluate a new model of partnership between a local foundation (NWHF)

and a national foundation (RWJF) through this effort. Foster learning and innovation among all partnership participants (NWHF and RWJF

staff; local/regional foundations, nursing leadership, project staff, etc.). Explore new strategies for NWHF and RWJF to address nursing issues, individually

and collaboratively, in the future. Disseminate lessons learned from both a comprehensive evaluation of the partnership

and by promoting the activities of the grantee partners.

NWHF served as the host foundation for PIN, coordinating and managing the activities of the grant program, awarding grants, serving as a conduit between local foundations and RWJF, providing technical assistance and strategic coaching, developing opportunities for partners to collaborate, and promoting the program to philanthropic, nursing, and other partners. This report summarizes the findings of the evaluation of the PIN 1-5 partnership cohorts, as synthesized by the national evaluation team in consultation with the PIN National Program Office. The multi-year national evaluation was conducted by Linda Norman, DSN (Dean of Nursing, Vanderbilt University) and Sherril Gelmon, DrPH (Professor of Public Health, Portland State University), assisted by Katharine Ryan, MPH, formerly of Portland State.

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B. PIN 1-5 Partnerships The PIN program strategy was an annual matching grants program that teamed the resources of the RWJF with the innovative vision and programmatic skills of the NWHF to provide grants to local funders that addressed the concerns of the nursing profession in their communities. Each PIN 1-5 partnership received up to $250,000 for two to three year projects; these funds were matched with local resources, at least equivalent to if not greater than the RWJF funding.

A unique quality of PIN was providing funding directly to local grantmaking foundations to coordinate projects and programs developed in collaboration with nursing leaders and other community partners, instead of funding the nursing organizations or others at the implementation level. Foundations were encouraged to develop funding partnerships with other organizations to support sustainable investment in nursing workforce projects.

The annual request for PIN partnership proposals defined program subject areas for the year; many proposals addressed more than of these areas:

Faculty Development and Educational Infrastructure: Bolstering the nursing educational infrastructure by developing, recruiting and retaining qualified nursing faculty and by redesigning the educational system to meet the needs of the 21st century.

Diversity: Increasing the racial, ethnic and gender diversity of the nursing workforce to improve access to care for patients, provide greater patient choice and satisfaction, and improve patient-nurse communication.

Collaboration and Leadership: Supporting effective, targeted professional development for nurses in all practice settings to hone their skills to work collaboratively and to foster new leaders for the nursing profession.

Geriatrics and Long-Term Care: Increasing the number, developing the competencies, and improving recruitment and retention of nurses to work with and treat the growing elderly population.

Public Health: Supporting strategies that address the shortage of public health nurses to aid in preventing illness, injury or disability, and promote and maintain the public’s health.

Recruitment and Retention (a topic for the PIN 1 (2006) cohort only): Enhancing recruitment and retention of nurses across care settings, including identifying organizational factors that support excellent practice and working conditions.

A summary of program subject areas for the PIN 1-5 partnerships is presented in Table 2 below. The most frequently addressed topic was educational infrastructure (34 partnerships) followed by faculty development (23 partnerships), highlighting the emphasis on addressing various elements of nursing education as a focus of workforce development. Another 19 partnerships addressed collaboration and leadership; 16 worked on topics related to diversity; and 15 focused on issues related to geriatrics and long-term care. Recruitment and retention was an explicit topic in the request for proposals only for PIN 1, and seven of those partnerships addressed this topic. Only one PIN partnership specifically focused on public health and the nursing workforce. Forty-three of the 50 partnerships framed their proposals and their subsequent work to address more than one of the PIN subject areas. “Primary Care” was a topic for the PIN 5 (2010) cohort only, but none of the funded PIN 5 partnerships addressed this topic.

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Table 2: PIN 1-5 Partnerships – PIN Program Subject Areas

Education Infra-

structure

Geriatrics and Long-Term Care

Faculty Develop-

ment

Diversity Collabor- ation and

Leadership

Public Health

Recruitment and Retention (2006 only)

Blue Cross Blue Shield of Michigan Foundation (Michigan) (PIN 1)

X X X

The Colorado Health Foundation (Colorado) (PIN 1) X X Community Foundation of the Eastern Shore, Inc. (Maryland) (PIN 1)

X X X

Irene E. & George A. Davis Foundation (Massachusetts) (PIN 1)

X X

Dreyfus Health Foundation of the Rogosin Institute (New York/Mississippi) (PIN 1)

X X

HMSA (Hawaii Medical Service Association) Foundation (Hawaii) (PIN 1)

X X

Mississippi Hospital Association Health, Research & Education Foundation (Mississippi) (PIN 1)

X X

Rasmuson Foundation (Alaska) (PIN 1) X X X St. James Healthcare Foundation (Montana) (PIN 1) X X Ventura County Community Foundation (California) (PIN 1)

X X

Community Foundation of Middle Tennessee (Tennessee) (PIN 2)

X X X

Con Alma Health Foundation (New Mexico) (PIN 2) X Dakota Medical Foundation (North Dakota) (PIN 2) X X Faye McBeath Foundation (Wisconsin) (PIN 2) X X Illinois Prairie Community Foundation (Illinois) (PIN 2)

X X X

Midland Area Community Foundation (Michigan) (PIN 2)

X X

Mt. Sinai Health Care Foundation (Ohio) (PIN 2) X X Oklahoma Hospital Education Research Foundation Trust (Oklahoma) (PIN 2)

X X

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Education Infra-

structure


Faculty Develop-

ment

Diversity Collabor-ation and

Leadership

Public Health


Pitt Memorial Hospital Foundation (North Carolina) (PIN 2)

X

Richmond Memorial Health Foundation (Virginia) (PIN 2)

X

Wolslager Foundation/ Project ARRIBA (Texas) (PIN 2)

X X

American State Bank (Texas) (PIN 3) X X Daisy Marquis Jones Foundation (New York) (PIN 3)

X X X

The Dimmer Family Foundation (Washington) (PIN 3)

X X

Friends of the College of the Marshall Islands Foundation, Inc. (US Affiliated Pacific Islands) (PIN 3)

X X X

Greater San Antonio Healthcare Foundation (Texas) (PIN 3)

X X

Health Care Foundation of Greater Kansas City (Missouri) (PIN 3)

X

Jonas Center for Nursing Excellence (New York and North Carolina) (PIN 3)

X X X X

The Oregon Community Foundation (Oregon) (PIN 3)

X

The San Francisco Foundation (California) (PIN 3) X Wyoming Community Foundation (Wyoming) (PIN 3)

X X

Arkansas Community Foundation (Arkansas) (PIN 4)

X

The Blue Foundation for a Healthy Florida, Inc. (Florida) (PIN 4)

X X X

Community Foundation of the Great River Bend (Iowa) (PIN 4)

X X

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Education Infra-

structure


Faculty Develop-

ment

Diversity Collabor-ation and

Leadership

Public Health


Community Foundation for the Land of Lincoln (Formerly The Sangamon County Community Foundation) (Illinois) (PIN 4)

X X X X

The Greater Kanawha Valley Foundation (West Virginia) (PIN 4)

X

Hinds Community College Development Foundation (Mississippi) (PIN 4)

X X X

Tufts Health Plan Foundation, Inc. (Massachusetts) (PIN 4)

X X X

West Central Initiative (Minnesota) (PIN 4)

X X X

Vetter Foundation (Nebraska) (PIN 4) X X X John T. Vucurevich Foundation (South Dakota) (PIN 4)

X X X

Bingham Foundation (Maine) (PIN 5) X X Caring for Colorado Foundation (Colorado) (PIN 5)

X X

The Cleveland Foundation (Ohio) (PIN 5) X X Community Foundation of Southeast Michigan (Michigan) (PIN 5)

X X X

Dakota Medical Foundation (North Dakota) (PIN 5)

X X X X

Endowment for Health (New Hampshire) (PIN 5) X X X The Horizon Foundation for New Jersey (New Jersey) (PIN 5)

X X X

Humboldt Area Foundation (California) (PIN 5) X X Texoma Health Foundation (Texas/Oklahoma) (PIN 5)

X X X

TOTALS by subject area 34 15 23 16 19 1 7

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C. Changing Context of Nursing and Health Care Since the PIN program was launched in 2006, there have been changes in the national context of nursing and health care in general that have had an impact on the PIN projects. The downturn of the economy in 2008 was perhaps the most significant change in terms of its direct impact on project funding and sources for sustained funding. Almost all of the partnerships reported that they had more difficulty in implementing the project activities and engaging partners because of the partners’ at times urgent needs to reorient organizational goals. The earlier predictions about the impending nursing shortage shifted during the time of the PIN 1-5 projects as well, as a result of the economic downturn. Fewer nurses left employment, nurses employed part-time moved into full-time positions, and many nurses delayed retirement. While these actions may have only delayed the nursing shortage, they made it harder for the projects to garner support as many of the communities were not experiencing the full impact of the nursing workforce shortage as had been predicted prior to the beginning of PIN. Simultaneous to the economic downturn, multiple other factors were affecting the US health care system. These are described well by Susan Hassmiller of RWJF in her Health Affairs article entitled “RWJF’s Investment in Nursing to Strengthen the Health of Individuals, Families, and Communities” (2013, 32 (11) 2051-2055):

“Health care costs were quickly rising to an unsustainable level and threatened to cripple family budgets and the economy. The graying of America accelerated, with people living longer but with more complex chronic diseases and extensive care needs. The United States grew more diverse, making the imperative to deliver culturally appropriate care even more urgent. In this climate, Congress passed the Affordable Care Act (ACA) in 2010, not only raising the prospect—and the promise—that millions more people would gain insurance coverage and enter the health care system, but also politicizing the health care debate like never before.”

During this time, nursing education saw a significant increase in enrollment in basic nursing programs, particularly at the baccalaureate level, reflecting a national initiative to increase the number of nursing graduates (to anticipate the expected nursing shortage) complemented by increased numbers of applications. Concurrently, faculty were aging, and nursing education leaders recognized the need to develop more potential nursing faculty with relevant credentials and expertise, both in academic and clinical settings. As well, during this time educational programs collectively worked to increase their emphasis on cultural competence and diversity, reflecting both the changing US population and the need for a comparably diverse nursing workforce. Finally, within health care delivery organizations, there was an increasing awareness of the importance of development of nurse leaders, and their roles in leading the changes needed to respond to health reform as well as their influence in recruiting and retaining nurses within their organizations. II. KEY THEMES AND PROMISING PRACTICES The findings across the fifty PIN 1-5 partnerships can be summarized in terms of seven areas of key themes and promising practices that reflect the evaluation framework (described subsequently). These are: partnership development, management and sustainability; nursing and philanthropy collaborations; specific accomplishments; consistent challenges; nursing workforce

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development; impact on, and role of, philanthropy; and comparison with the IOM Future of Nursing priorities. A. Partnership Development, Management, and Sustainability The structure of the PIN program brought together groups that were not usual collaborators. Both nursing and foundation partners consistently commented about the value of the learning that they gained from each other and connections made to other groups. This was particularly true for the nurses, and for some funders, when working with partners outside of direct health services delivery, such as Area Health Education Centers (AHEC), Department of Labor, or a chamber of commerce. Requiring the foundation to be the lead partner allowed for more creativity than traditional grantmaking to only nursing organizations. PIN partners reported a positive experience in learning how many participants shared the same goals and how, through PIN, they could establish a consensus to work on priorities for local action. Until PIN brought them together to directly work on their shared priorities, they had not been able to do so. This experience led to partnerships developing an effective collaboration model that facilitated further participation of major partners. In many cases, the convening foundations became the “safe place” and served as a convener for groups to work together, breaking down barriers to collaboration among organizations that may compete in other areas. The partnerships that were most successful in building community collaboratives were those that fully engaged the funding and community partners, as well as nursing leaders. Partnerships that gave attention to partnership development at the beginning of the project helped to accelerate activities and diminish problems as the work progressed. A PIN funder commented: “It’s been an amazing opportunity to work more closely with our partners. As a result of working together we have been able to develop deeper relationships with individuals and with organizations.” A PIN nursing lead stated: “Many of our funders weren’t aware of what was going on in the nursing workforce. There was a great concern we wouldn’t have the next generation in faculty. I think we brought awareness to funders about needing the next generation. With everyone on board we were able to continue to bring awareness to what’s happening in nursing education. We have a lot of health care funders, but not necessarily keyed into nursing. They learned funders need to be aware of the issue, and being part of the project they recognized we needed to be doing a better job of making that issue visible.” An important aspect of participating in the PIN initiative cited by the PIN nursing partners was the development of partnerships in their communities and states with foundations and partners that had never worked together. Many of the PIN partnerships cited developing new partnerships as one of the top accomplishments of their PIN projects. Some of the partnership descriptions included:

“The nursing leaders now know the local foundations and introduce [the foundation] to other segments of the health care community. The next time there’s a partnership opportunity, they’ll be more willing to work with us because of this experience.”

“There were collaborations established [among] health care organizations in our state that had never worked together before.”

“True partnerships between schools of nursing and health care agencies to better educate the nursing workforce now exist.”

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“The program made many strides in gaining many different partners/donors/sponsors who are all passionate about health care.”

One of the lessons learned repeatedly was that a defined structure for project and partnership management had to be addressed at the beginning of the work. One partner expressed that if they were starting over: “We would be more vocal and be out there seeking new partners earlier.” Initial face-to-face meetings were important, and regular contact and information-sharing with partners were strategies that kept the partnership connected and moving forward. Conference calls could be used once the partners became familiar with each other and developed trust. For the partnerships that worked across regions, periodic face-to-face meetings helped to sustain the relationships and further the work. Where such meetings could be convened in conjunction with another event, there was greater likelihood of high participation. One nursing partner emphasized the importance of communication by saying: “Look at how you communicate your progress and ongoing work. We are finding out now that we thought people were fully aware of the outcomes of the PIN project, but some were not as aware as we thought.” A survey respondent observed: “Dealing with philanthropic organizations can be both extremely rewarding and at the same time frustrating. The funding which was received through the PIN Program allowed us to develop a program that would never have been started otherwise. The program was extremely successful; however the ability to continue the program relied upon the ability to garner funds from other local and regional foundations, a task which proved to be very frustrating.” Throughout the PIN program, sustainability has been a key strategy. A PIN funding partner commented: “The private partner was a great contribution. The development of the partnership the way it looks now will be able to create a new entity or forum; investing the new dollars to be able to continue the partnership is all new and we will be leveraging additional projects.” Most, if not all, PIN funders do not have the intention of funding the work developed during PIN on a long-term sustaining basis, but the experiences of collaborating during PIN often helped to identify leverage opportunities for support that would enable the partnership’s work to continue. PIN partnerships across all five cohorts noted that participating in a project with RWJF and NWHF was valuable in bringing credibility and visibility to their work. The investment from RWJF and NWHF gave local funders the financial edge to implement their partnerships in ways that facilitated success from the beginning. At the same time, many partners commented that participating in the PIN partnership was much more work than they had anticipated, but it gave them opportunities for “deep and powerful” work. There was broad expression of the partners’ appreciation of the opportunity presented by PIN, and the support of RWJF and NWHF. Many funders made a comment such as: “We have to thank RWJF and Northwest Health Foundation for getting this going; there is no way to thank them enough for this model. It is unique and everyone knew this work needed to happen, but this gave us a way to do it. The national scope meant it was going on everywhere and learning from each other has been so important.” The partners were asked to rank priority issues related to the nursing workforce in terms of the past, the present, and the future. Their answers reflect both their experiences in a changing environment but also their increased knowledge about nursing workforce issues; in many cases, their views of future issues may influence their future work as a partnership. Diversity and

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geriatrics were ranked highest as the future priorities by PIN respondents across all of the cohorts, followed by educational infrastructure and retention. Collaboration and leadership, and primary care, were the next highest ranked overall. Nursing respondents across the five cohorts ranked geriatrics and educational infrastructure highest as future priorities, whereas funders ranked retention and diversity. Rankings for primary care as a future priority area jumped substantially in importance over the five PIN cohorts, perhaps reflecting the current environment of health reform and increased attention to primary care. These results demonstrate changes in perspective on the most important and relevant issues while also reflecting accomplishments made by partnerships in addressing key concerns. More detail on these responses is presented in Section IV.B.6: Changing Priorities. B. Nursing and Philanthropy Collaborations From the beginning of PIN, participants have commented on the new insights they have gained about working with philanthropy (for those not from philanthropy) and working with nursing (for those not from nursing). Both funding and nursing partners identified lessons learned from working with the other. The lessons nursing learned from working with philanthropy fit within two key categories: recognizing how collaborations can address broader community needs, and identifying/understanding the needs and roles of funders. Many funders came to the table wanting to address community problems, and this affected how nursing partners saw their issues as fitting within a larger picture. This elevated the importance of collaboration and communication across partners and issues as a potential avenue for finding solutions. In working with nursing, funders gained a better understanding of workforce issues from both academic and provider perspectives. Many recognized the value and importance of nursing within the health care field and the value in developing leadership, confidence and trust in nurses to fulfill key roles. Several funders acknowledged new insights into the role of nursing in health care agencies as both patient care providers and facilitators of change in health care delivery. A PIN lead funder observed: “Nursing as a field and nurses in particular are underestimated and underappreciated and a lot of people have no idea of what’s going on in this work; they’ve been flying under the radar for many years. I don’t want to trivialize it but I think nursing as a profession has been put off to the side and there is this hard feeling and for some there’s a chip on the shoulder that makes perfect logical sense. So, we’ve learned about that but we also at the same time learned about nurses’ continuing willingness to be good partners and be part of teams and do what needs to be done in spite of all the challenges.” Funders also recognized that work with nursing could seed interests and opportunities with other health professions, but at the same time acknowledged that they could not necessarily limit their support to one health profession. In a time of health systems reform, funders in the later cohorts in particular have commented on insights about roles for nurses, such as: “We think about whether we have an adequate capacity to meet the need that we had before the Medicaid expansion; now more people are insured, and I’ve learned a lot about the role nursing can play in that, and should play. We have more appreciation for it than we did before.” A PIN nursing partner commented: “Bringing awareness to the business community of health care, in particular nursing, was important. The business community needs to know that we need to invest in nursing and nursing education. We’re able to tap into their constituents, and their board members are CEO’s of hospitals or other health care organizations. They were also

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helpful with the fundraising connection, and if there was something that came up in government related to nursing they could be our advocate. They represent the community, and they might not know a lot about health care.” Survey respondents were asked an open-ended question about new insights they had gained that will be relevant in their future work on nursing or other topics. Responses about nursing from funders across the cohorts included:

“We made a lot of valuable connections within the nursing world that we are able to call on for training and field trips for the high school students in our program interested in studying nursing.”

“Nursing school leaders need to be committed to change for change to happen.” “The aging of American nursing faculty and the lack of nursing faculty diversity are

issues of paramount importance.” “Working with nursing gave us insight into ways to be more effective now and in future

work with health care providers. Our organization obtained insights into issues and solutions involving health care. It showed the value of working with a variety of partners.”

“You’ve got the problem of some folks who are resistant to change; it doesn’t matter if it’s good for everyone else or the patients, there’s just some self-interest that you could align to any field. It’s complex and in some sectors immovable, so while this is not unique to nursing, I observe it among the nurses. I think there’s enough folks out there post-IOM who get the need to change, and with what our collaborators are doing I see hope.”

“We gained awareness of the deep-rooted challenges facing nursing as a field (nurses vs. doctors; few nurses in leadership roles; complicated education and degree tier system). These will be important to helping us in this work in the future.”

“I have a fuller understanding regarding the relevance of the viewpoints and interests of all involved stakeholders in the projects to be developed and funded.”

“[This work] continues to reinforce the importance of communication and relationships amongst partners; a foundation cannot do this without nursing and nursing cannot do this without the foundation.”

Responses about philanthropy from PIN nursing participants included the following:

“We developed new partnerships and synergies with local funders and educational institutions.”

“The perspective of funders is important when planning new projects and proposals -- it is important to develop relationships with funders who may have an interest in nursing workforce or other nursing issues.”

“Be open to the possibilities of funding partners. Think big and don't be afraid to ask.” “[We] learned to view the work from the funder perspective … understanding how to

emphasize the return on investment, aligning goals with foundation funding priorities, and techniques of reporting progress.”

“I see that the project needs to have clearly defined goals and a measurable outcome from the onset. There needs to be someone who has the time to be an accountable lead.”

“Our foundation leader was insightful and passionate about making an impact on the nursing workforce situation in the state.”

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“Gained an appreciation of the broad scope that philanthropy funds and the commitment to future health issues for local and national communities.”

“Appreciation for the range of resources they contribute, and their capacity to utilize external resources.”

“Reporting is key to keeping funding partners aware of progress.” “I learned A LOT during the last 3 years about working with funders, and was able to

develop great relationships with foundations and donors that are helping to sustain our work beyond the PIN funding.”

“For this project we had multiple funders and multiple in-kind contributors, really providing a different financial approach and commitment. This has really helped us to collaborate at a higher level. The financial investment made a difference.”

“It was challenging to develop and sustain the partnership with our local funding source. They appeared to feel the need to "own" the project, and did not appear comfortable being an equal partner at the planning table.”

“The foundation's goals and objectives must be kept in view. Finding a funding partner that your project will help them meet their goals is essential.”

“The funders want to see results and outcomes. They are eager to help. They want their contributions to attract other funders.”

“We have learned what is important to philanthropic organizations and ways to approach them. Some organizations have incredible connections to possible sources for innovative ideas. We have learned the importance of being able to ‘sell’ the ideas so they are understandable and appeal to funders.”

These quotes reinforce the findings reported in this report, and offer rich illustrations of the impact of PIN in the personal words of PIN partnership participants. C. Specific Accomplishments Table 3 summarizes examples of accomplishments of the PIN 1-5 cohorts. The table is presented by cohort, and summarizes the major activities and outcomes/impact for each partnership. Throughout the narrative of this report, examples from the partnerships are highlighted. More detail about specific partnership accomplishments may be found on the PIN program website (www.partnersinnursing.org) or from the PIN program office. Some of the activities were targeted to a local or regional issue related to enhancing the nursing workforce. Other partnerships focused on improving nursing education within a geographic region. Still others addressed statewide issues and created structures to support improving the nursing workforce by equipping nurses with competencies (such as in leadership) and/or skills for health care delivery (for example, in a focused area such as geriatrics). More complete descriptions of specific partnership activities may be found in individual partnership reports and on the PIN website.

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Table 3: Accomplishments of PIN 1-5 Partnerships

PIN 1 Partnerships Activities Outcome/Impact Blue Cross Blue Shield of Michigan Foundation (Michigan) (PIN 1)

10 modules developed for an RN Transition course to retain experienced nurses from acute care in the nursing professions

Preceptor training module developed Held two Health Care Leadership Forums

33 nurses participated 162 participants, many from other organizations, used

preceptor development modules 73 people participated from 58 organizations in forums

The Colorado Health Foundation (Colorado) (PIN 1)

Leadership development fellowship created to decrease turnover

Implemented statewide clinical placement system to increase access for nursing education programs

23 participants in fellowship program Additional clinical sites located; able to accurately assess the

value of each placement site for use

Community Foundation of the Eastern Shore, Inc. (Maryland) (PIN 1)

Mentoring program for nurses in 1st year of employment

Created leadership development program Developed program to increase number of nurses

with advanced degrees Hospitals and state higher education community

collaborated to establish a clinical educator role

17 participated, increased the retention rate of new nurses in the profession

200 participants attended 13 enrolled in BSN and MSN programs 3 new nursing faculty roles were created

Irene E. & George A. Davis Foundation (Massachusetts) (PIN 1)

Developed five year strategic plan to restructure nursing education

Created CNA/LPN pathway Developed economic model (ROI) outlining impact

of nursing shortage

Articulation plan accepted for ASN/BSN or area institutions 10 BSN enrolled in MSN/PhD 8 Latino nurses participated Made business case for funding nursing education

Dreyfus Health Foundation of the Rogosin Institute (New York/ Mississippi) (PIN 1)

Developed Student Support System for BSN program

Established leadership forum for Mississippi Delta hospital nurses

Retention rate in nursing program increased from 50-80% NCLEX pass rate increased Success for nurse managers in area to encourage retention of

nurses in Mississippi Delta

HMSA (Hawaii Medical Service Association) Foundation (Hawaii) (PIN 1)

Developed collaboration between LTC agencies and schools of nursing to increase number of students placed in LTC

In-service programs presented in LTC agencies to increase staff knowledge about geriatrics

Developed leadership preceptor program in LTC

Nursing programs and LTC agencies partnered to increase availability of LTC clinical experiences; 271 students placed in LTC agencies

8 sessions presented with excellent staff ratings 12 RN’s completed leadership program; decreased turnover

in staff

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PIN 1 Partnerships Activities Outcome/Impact

Mississippi Hospital Association Health, Research & Education Foundation (Mississippi) (PIN 1)

Created survey of organizational culture within schools of nursing

Developed on-line teaching tools for faculty development

Nationwide dissemination of survey instrument On-line modules for new faculty to transition from clinical

role to faculty role, available nationwide Mississippi legislature increased faculty salaries by $12,000

Rasmuson Foundation (Alaska) (PIN 1)

Recruited Alaska Natives for Bethel AAS program Developed Rural Generalist Nurse Competencies for

new nurses

5 Native Alaskan students graduated and employed in Bethel community, 3 of whom are fluent Yup’ik speakers

Nursing program expanded to another rural area 7 clinical agencies using competencies

St. James Healthcare Foundation (Montana) (PIN 1)

Developed academy for nursing students to better prepare for nursing positions

34 students completed the program

Ventura County Community Foundation (California) (PIN 1)

Developed and held Priority Nursing Issues: Nursing Symposium

Conducted 3 county-wide summits

153 people attended symposium Increased community awareness of nursing issues


Community Foundation of Middle Tennessee (Tennessee) (PIN 2)

Expanded online placement system statewide Offered two simulation workshops and developed

Simulation Alliance Nurse Manager workshops offered Free continuing education series for faculty

development on use of simulations Developed role of Clinical Teaching Associate for

staff nurses to assist nursing faculty members

24,898 placements acquired for nursing students Increased use of simulation in schools of nursing (from out

of the box to implementation) 231 participants, excellent ratings Developed program available on-line nationally Utilized in one hospital in Tennessee

Con Alma Health Foundation (New Mexico) (PIN 2)

Developed academic readiness program for students to succeed in academic work and be prepared for nursing coursework

Nurse mentoring program to link interested high school students with practicing nurse

183 students (63 high school, 120 middle school) participated

44 high school students completed the program 41 nurses recruited as mentors

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PIN 2 Partnerships Activities Outcome/Impact Dakota Medical Foundation (North Dakota) (PIN 2)

Developed articulation process for students to progress from ADN to BSN

Created strategies to increase number of MSN prepared nurses

Conducted Nursing Capacity Summit, attended by education, labor, commerce, regulatory agency, foundation and health care representatives

Developed Nurse Educator Academy

Enrollment in LPN, ADN, and BSN programs increased as a result of the articulation processes

Number of students enrolled in the MSN programs increased by 1000%

State legislature awarded $500,00 to support simulation > 250 participants each year in Academy

Faye McBeath Foundation (Wisconsin) (PIN 2)

Designed competencies for public health nursing (PHN)

Redesigned education in PHN for nursing schools Created Wisconsin Center for Nursing Scholars

program

Adoption and implementation of a standardized public health curriculum in all nursing programs across the state

17 Nursing Scholars from 5 schools of nursing participated in public health clinical rotations

Illinois Prairie Community Foundation (Illinois) (PIN 2)

Coordinated $140,000 assistance for nursing students in accelerated BSN to PhD programs

Developed intergenerational project to introduce students to long-term care

Increased students’ ability to attend the nursing program Increased the number of students pursuing a PhD in Nursing

in the region Increased LTC experience within the nursing program

Midland Area Community Foundation (Michigan) (PIN 2)

Revised/changed role description to support staff nurses to include teaching nursing students as a part of their staff nurse role

12 practice scholars who had been staff nurses finished the MSN, and were employed and teaching in a nursing program following graduation

Mt. Sinai Health Care Foundation (Ohio) (PIN 2)

Developed presentation about nursing education for staff nurses

Created Nurse Faculty Academy

211 staff nurses attended nursing education presentations 151 participants in the Nurse Faculty Academy

Oklahoma Hospital Education Research Foundation Trust (Oklahoma) (PIN 2)

Developed and delivered distance learning leadership modules in three rural areas

Scholarships to become nurse educators

10 on-line modules developed. Employers reported an increase in effectiveness of teamwork

10 BSN prepared faculty received scholarships for MSN studies

Pitt Memorial Hospital Foundation (North Carolina) (PIN 2)

Established East Carolina Center for Nursing Leadership

Increased enrollment in MSN in leadership concentration

Increased RN-BSN-MSN enrollment

Center created Rural Nurse Councils in 4 counties, 30 participants

Enrollment increased from 6 to 70 in MSN programs Enrollment increased from 82 to 117 in RN-BSN-MSN

programs

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PIN 2 Partnerships Activities Outcome/Impact Richmond Memorial Health Foundation (Virginia) (PIN 2)

Created Virginia Nursing Leadership Institute 79 nurses participated in leadership institute Employers rated the training as highly effective Institute expanded to be offered statewide

Wolslager Foundation/ Project ARRIBA (Texas) (PIN 2)

Developed program to facilitate success of Hispanic nursing students from low social economic status

124 students recruited to nursing programs in El Paso 294 students in retention program (95% retention) NCLEX pass rate of participating students increased to 95%


American State Bank (Texas) (PIN 3)

Provided 20+ simulation workshops for local nursing professionals in 15+ institutions in Texas

Developed a central database to house a scenarios and simulation library

Uploaded 14 simulation case scenarios to a website to share with other agencies

Created a nonprofit organization to oversee ongoing simulation activities

Workshop participants developed competencies in writing simulation case scenarios

Created a collaborative atmosphere for nursing schools and all other health occupations

Improved the assessment and critical thinking skills of nurses who participated in the workshops

Number of website inquiries increased from 322 in January 2010 to 1,591 in January 2011

Daisy Marquis Jones Foundation (New York) (PIN 3)

Conducted 12 focus groups in the 5 Senior Health Alliance of Greater Rochester (SHAGR) nursing homes

Developed an executive leadership program for Directors of Nursing (DON) and Assistant Directors of Nursing (ADON) based on focus group findings

Provided a training program to 3 cohorts of nurse managers, supervisors, and care coordinators

12 DON/ADONs participated in executive leadership program

37 nurses completed “Nurse as Leader in Long-Term Care” program


Created longitudinal geriatric clinical experiences for all BSN students

Established 11 new clinical sites with a gerontological focus

Developed 15 workshops on elder care health issues Awarded 14 scholarships to students to advance

their gerontological expertise

Students gained expertise in providing holistic, patient-centered care to older adults

Documented a reduced readmission rate for clients with heart failure to below 7% over a three-year period

80% of students experienced an increase in knowledge skills and confidence in elder care

Increased interest among students for a career in elder care

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PIN 3 Partnerships Activities Outcome/Impact Friends of the College of the Marshall Islands Foundation, Inc. (US Affiliated Pacific Islands) (PIN 3)

Addressed the faculty development needs of the 7 member nations in the United States Affiliated Pacific Islands (USAPI) jurisdiction

Developed nursing leadership’s skills in using Elluminate, a web conferencing tool

Implemented faculty development program on use of technologies

Purchased pediatric and adult simulation mannequins for case scenario trainings

Established a well-functioning network, which has increased capacity for nursing faculty development, student nurse mentoring, and partnering between academic and hospital sectors

Served as a catalyst for nurses to begin to increase their capacity as educators with new resources, strategies, partners, connections, and tools

Expanded local and regional workforce development collaborations across the socio-political parameters of the Pacific


Implemented an electronic student placement system (StudentMAX).

Developed a simulation lab at San Antonio College and University of Texas Health Science Center

Established the Nurse Executive Forum (NEF), a nurse-directed organization

22 of San Antonio’s 23 acute care hospitals participated in the matching system

1,357 new student placements were made in these hospitals Nurse Executive Forum (NEF) evolved into a chapter of the

American Organization for Nurse Executives


Developed the Nursing Innovation Center, a bi-state nursing workforce center

Created the Clinical Scene Investigator (CSI) Academy, an academy that aims to train staff nurses’ in improving patient care

Instituted Work Environment Assessments (WEA) at 3 hospitals

Developed the Nursing Innovation Conference

The Nursing Innovation Center developed the capacity to respond to regional nursing issues

Held 9 didactic sessions of the CSI Academy 23 CSIs from 7 different hospitals completed the Academy Improved both leadership and project implementation, skills

of CSI nurses as well as their confidence 180 individuals attended Nursing Innovation Conference


Developed a program model that encouraged nurses with Associate Degrees in Nursing (AND) to pursue a pathway toward a Baccalaureate of Science in Nursing (BSN)

Successfully merged nursing programs from New York and North Carolina; created dual enrollment system

24 students invited to join the first class in Fall 2011 Increased communication and collaborations among faculty

and administrators of different educational programs

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PIN 3 Partnerships Activities Outcome/Impact The Oregon Community Foundation (Oregon) (PIN 3)

Provided grant funding to 13 projects at schools of nursing, hospitals, community agencies, and nonprofits

Identified promising practices related to improving cultural competence in nursing based on individual projects

Developed training activities that fostered growth in cultural competence including a video and booklet

Developed a website that provided a directory of cultural competence resources

Nursing leaders at hospitals involved with the program now see the impact of cultural competence training on their staff

Community partners created training programs that helped employees to become more culturally competent

Engaged nurses from a wide variety of practice settings into the discussion of cultural competence issues

Incorporated cultural competence ideas into simulations, coursework, and evaluations by community partners

85 participants attended a Cultural Competence in Nursing conference

The San Francisco Foundation (California) (PIN 3)

Implemented 3 cycles of RN Refresher program and 1 cycle of LVN Refresher program to train foreign-trained nurses for entry into the U.S. health care workforce

84 foreign-trained nurses from 22 countries participated 93% completed training; 96% became licensed nurses 44% placement in nursing positions; average wage

$32.79/hour Wyoming Community Foundation (Wyoming) (PIN 3)

Developed systems to increase recruitment, training, and retention rates of LTC nurses

Established the nursing workforce center, the Wyoming Center for Nursing and Health Care Partnership (WCNHCP), and a website

Partnered with Wyoming Area Health Education Center to provide summer camp for high school students to expose them to health care careers

Developed a media campaign targeted to middle school students

Completed 5 recruitment and retention pilot projects Growth in the amount of training and outreach for nurses Website averaged 150 visitors per month Co-sponsored an annual nursing summit; 10 participants 38 students attended the summer camp cosponsored with

the Wyoming AHEC



Developed a three hour undergraduate course, “Introduction to Gerontology” offered to CNAs, LPNs, and RNs employed in LTC agencies

Secured funding from USDA to create a learning lab in 6 nursing homes; 2 were equipped with tele-health equipment to offer the gerontology course on-line to LTC employees

106 LTC employees completed the course (CNAs, LPNs, RNs)

Recruited 200 long-term care employees (CNAs, LPNs, RNs), who expressed an interest in pursuing RN licensure or advanced nursing degree

Increased the potential student numbers to over 350 through the “Introduction to Gerontology” course

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PIN 4 Partnerships Activities Outcome/Impact The Blue Foundation for a Healthy Florida, Inc. (Florida) (PIN 4)

Created the Florida Healthcare Simulation Alliance with virtual simulation center, simulation library, and coordination of regional simulation activities

Developed a white paper on the current status of the use of simulation technology in nursing education

Hosted policy/strategic summit on simulation

Increased the awareness and enthusiasm of students regarding the importance of simulation technology

500 respondents completed the survey regarding current state of simulation training and utility in Florida

140 participants attend the “simulation” summit to inform Florida on future use of simulation technology in nursing education


Offered 2 Clinical Nursing Faculty Preparation seminars

Organized a continuing education event to address concerns about nurses working with students in a clinical learning capacity, which affects availability of clinical sites

Created plan to address clinical placement barriers

15 students participated in Clinical Nursing faculty Preparation seminar

Obtained $20,000 local grant for creation of model to expand community based clinical nursing placements


Designed an ADN-BSN Mentoring program Partnered to plan a Faculty Open House and Faculty

Academy in Springfield Launched a weekend associate’s degree program Hired a Diversity Caseworker/Coordinator Partnered with Sam’s Club to establish a pre-

CNA/CNA program; generated a CNA scholarship. Held regional Clinical Faculty Academy Began the process of beginning an ADN-MSN

program and a Masters Hybrid at Benedictine University at Springfield

Registered 6 minority students and mentors into the ADN-BSN mentoring program.

Produced a better understanding of the types of barrier and challenges that exist in the nursing field

Graduated the first cohort of the Lincoln Land Community College Weekend ADN program, and placed 10 new RNs in the community

20 participants in the Diversity in Nursing program Graduated 12 new CNAs, 6 of whom will further nursing

education into LPN or ADN coursework


Developed a year-long training program to enhance team leadership and team effectiveness skills for nurses

Developed a Partners Advisory Board for alumni of the training program

11 cohort teams comprised of 44 nurses completed the training program

Teams completed an improvement project within their hospital addressing staffing system, patient satisfaction, nurse residency program, staff retention

Successfully engaged partners, current participants, and alumni about the value of the program

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PIN 4 Partnerships Activities Outcome/Impact Hinds Community College Development Foundation (Mississippi) (PIN 4)

Established the MS Geriatric Dedicated Education Unit (DEU) in response to the nursing shortage

Created and sustained partnerships between hospital/health care facilities and schools of nursing to facilitate development of the DEU

Implemented the Clinical Facilitator training online

Identified 5 project sites to implement a DEU providing care to a large number of geriatric patient’s hospitals

Trained 50 Clinical Facilitators from 5 hospitals Trained faculty on the implementation of DEUs from 4

schools of nursing


Established a multi-stakeholder regional collaborative to oversee three state (MA-NH-RI) coordinating councils responsible for implementing the project’s major components

Integrated Nurse of the Future Competency into curriculum redesign for nursing programs in three state areas to facilitate seamless transition between ADN to BSN programs

Increased the number and diversity of faculty through scholarship support for individuals committed to teaching

Increased the availability of clinical placements through the utilization of the computerized Centralized Clinical Placement Systems

Competency model adopted in all programs in the three-state area

Dual admission process implemented in one school; RN-BSN curriculum pathway was revised in one school

5 programs in RI created a common bridge course to facilitate students moving from ADN to BSN.

Created 19 new faculty positions, all currently teaching; 37 new faculty members are in the pipeline.

Created a total of 56 scholarship awards across three states (MA-NH-RI)

Over 800 new placements sites were identified in the three-state area.

West Central Initiative (Minnesota) (PIN 4)

Created a collective vision within the 10 schools of nursing in the region to ensure that all graduates are competent to care for older adults

Organized summer institute for nursing students to increase interest and enthusiasm in employment in an area focusing on care of the older adult

Created the Doctoral Technical Assistance Workshop for nurses to help them with the application process for doctoral program.

Partner SONs created plan to institutionalize geriatric curriculum, including intentional geriatric clinical experiences in a variety of settings 40+ persons attended two doctoral information sessions

Increased number of nursing faculty partners enrolled in Facilitated Learning to Advance Geriatrics program

4 nurses applied/accepted into doctoral nursing programs with geriatric emphasis; intend to teach in a Central Minnesota school of nursing

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PIN 4 Partnerships Activities Outcome/Impact Vetter Foundation (Nebraska) (PIN 4)

Developed and implemented a Gerontological Nurse Certification course

Developed and implemented a Nurse Executive Certification course

Formed a Geriatric Nurse Leadership Academy for Long-Term Care Nurses

Created a Best Practices in Long-Term Administration document

88 nurses completed Gerontological Nurse Certification course

60 nurses completed Nurse Executive Certification courses 83% of nurses in certification courses attained ANCC

gerontological nursing certification 100% of nurses who participated in the certification courses

attained AALTCN certification American Healthcare Association assumed sponsorship of

the gerontology preparation course; income from the course offerings will sustain the project beyond funding

LTC agencies reported enhanced ability to recruit RNs John T. Vucurevich Foundation (South Dakota) (PIN 4)

Developed and implemented Education Service Partnership (ESP) Program to train nurses to become Clinical Partners to supervise students

Integrated the concepts of the ESP program into a Dedicated Education Unit (DEU)

Developed and implemented the Registered Nurse Residency (RNR) Program

Educated 182 nursing students using the Clinical Partner model

Students who participated in the ESP project score higher in 6 nursing competencies than peers

99 new graduates from 4 cohorts of the RNR program. Increased retention rate to 99%


Bingham Foundation (Maine) (PIN 5)

Developed and defined Maine Nursing Core Competencies for ADN and BSN programs

Piloted Nurse Preceptor Training program Utilized Massachusetts Centralized Nursing

Clinical Placement System to increase clinical placement opportunities in Maine

Funded micro-grants to spur innovative initiatives to address competency gaps within nurses

All 14 of Maine’s nursing programs have committed to adopting the Maine Nursing Core Competencies

4 nursing programs formally adopted and fully integrated the Maine Nursing Core Competencies

51 participants enrolled in the Nurse Preceptor Training program

13 nursing schools participated in the Centralized Nursing Clinical Placement System training sessions, as well as 24 health care organizations

17 $1000 micro-grants were funded that addressed various competency areas such as patient-centered care and geriatrics

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PIN 5 Partnerships Activities Outcome/Impact Caring for Colorado Foundation (Colorado) (PIN 5)

Developed the Home Healthcare Collaborative (HHC) Recruiting Sphere Tool & Training Process

Created the Leadership Development & Coaches program with Capstones

Implemented the Competency-based New Hire Orientation program

Developed Home Health Preceptor Training program

Created Competency-based Modules for Experienced Nurses to enhance nursing skills

80 participants enrolled in the Leadership Development & Coaches program

Developed home health orientation to 51 new nurses Provided 6 month leadership coaching courses Trained 15 Subject Matter Experts for item-writing for

confidence based learning modules Trained 4 Subject Matter Experts to be Facilitators for

Simulation in Home Care Partnered with 5 Schools of Nursing to implement Home

Health curriculum The Cleveland Foundation (Ohio) (PIN 5)

Developed an online teacher training module entitled “Methods of Online Education” targeting masters-prepared nurses working outside of academia who were interested in teaching and traditional nurse educators for training

Produced online teaching competence

16 traditional nurse educators enrolled in the first online training education course; 12 completed it

91 non-traditional and traditional nurse educators participated in the second online training education course, which was held at 4 different locations

Community Foundation of Southeast Michigan (Michigan) (PIN 5)

Purchased and adapted leadership curriculum from the California Institute for Nursing and Healthcare

Piloted an educational leadership program for nurse leaders entitled “Leading Toward Tomorrow”

Increased the leadership capability of current and aspiring nurses

Improved retention of nurses in diverse care settings

Held 3 cohorts of leadership program for nurse leaders 136 individuals attended the educational leadership program Exceeded original targeted enrollee number goal by 136% 88% of the leadership program participants indicated that

they were very likely to refer other leaders to the program

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PIN 5 Partnerships Activities Outcome/Impact Dakota Medical Foundation (North Dakota) (PIN 5)

Provided financial stipends to faculty members to attend the “Facilitated Learning to Advance Geriatrics (FLAG)” training program

Distributed stipends to practicing nurses to assist them with obtaining gerontology certification

Sponsored Adventures In Nursing to motivate high school students from diverse backgrounds to pursing gerontology based nursing careers

Created Adopt-A-Grandparent Toolkit to change youth perceptions of the elderly

Created the Summer Nurse Camp Edventure, an immersive summer experience for students to job shadow nurses in health systems in North Dakota

9 faculty members received a stipend award to attend FLAG 9 practice nurses received stipends of $500 to obtain their

gerontology certification 30 4th and 5th graders attended the Adventures In Nursing

event 12 rural junior and senior high students attended the Summer

Nurse Camp Edventure Hosted the Adventures in Nursing and the Summer Nurse

Camp for 2 consecutive summers and planning for a third summer

Endowment for Health (New Hampshire) (PIN 5)

Developed the Afterschool Nursing Program and Nursing Quest Camp to enhance high school student’s interest in nursing careers

Established a curriculum for the Nursing School Pre-Orientation program

Created/merged Minority Nursing Student Support Program (MNSSP) and Nursing School Pre-Orientation program, to provide current nursing students and practicing nurses with support and networking opportunities

Targeted future nurse educators to encourage educational advancement as a practicing nurse

114 individuals began the Afterschool Nursing Program, and 100 completed the program

3 introductory and 2 advanced sessions were held within the Afterschool Nursing Program

4 students who participated in the Afterschool Nursing Program were admitted to nursing school

232 students participated in the Nursing Quest Camp Held 3 sessions of the Nursing School Pre-Orientation

program with 15 students in attendance 89 people signed up for the MNSSP mailing list 3 nursing scholars were awarded scholarships to help obtain

advanced degrees in nursing The Horizon Foundation for New Jersey (New Jersey) (PIN 5)

Created the Academic Resource Center of New Jersey (ARC)

Utilized an educational tool MyCompLab (MCL) to enhance academic writing ability for masters level nursing students

Expanded the use of the MCL tool to PhD level nursing students

1,900 students registered to participate in ARC and utilized the MCL tool

87% of the nursing schools (N=11) in New Jersey with an MSN program utilized the ARC over the course of the three year program

90 faculty have integrated and/or required MCL usage within 106 courses

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PIN 5 Partnerships Activities Outcome/Impact Humboldt Area Foundation (California) (PIN 5)

Held clinical training and educational support curriculum courses at the College of the Redwoods and Humboldt State University through the Humboldt Bay Regional Simulation Center (HBRSC)

Incorporated patient safety goals and local risk management into simulation scenarios through training courses

Created partnerships of regional users that will ensure the long-term sustainability of the HBRSC

Offered a “Train-the-Trainer” program in a three day workshop conference for health instructors

Over 800 participants in the HBRSC training courses, including nurses, respiratory therapists, paramedics, and health professions students

72% of Sim Center course attendees indicated that simulation was a valuable experience

15 community nurses attended an Initiative on the Future of Nursing report and recommendations

53 healthcare providers have become simulation experts through the Sim Center

90 programmed simulation scenarios were purchased and adapted for the Sim Center usage

50 nursing and allied health instructors and staff were trained in the use of mannequins and scenarios through the HBRSC “Train-the-Trainer” program

Texoma Health Foundation (Texas/ Oklahoma) (PIN 5)

Conducted needs assessment to identify highest educational needs and priorities in the two states

Planned a virtual classroom network to increase the skills of nurses in north Texas and south central Oklahoma

Developed a website dedicated to maintaining educational curriculum (TexomaNursing.org)

Identified 6 core concepts and competencies to plan and implement the mission of the program

Partnered with 11 organizations and associations to accomplish the program goals

Awarded $60,016 in additional funding to help sustain the project after the PIN funding period

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D. Consistent Challenges Most of the challenges related to PIN were focused on the process of collaboration. Common issues centered around changes in leaders and membership of the partner organizations, bureaucracy of organizations, scheduling of partners for meetings, engaging partners at the specific times needed during the project, and securing funding for sustainability. Many partners indicated that the partnership work was more time-consuming than expected, and that partnership plans included more activities than could feasibly be accomplished in the timeframe available. A PIN lead funder stated: “Everything takes longer than you think it does. It’s hard work to get together. Relationship building and collaboration take longer than I like. I’m more of an action person but I have to respect the process.” Differences among organizational cultures, such as between health care agencies and nursing education programs, were mentioned by many of the PIN 1-3 partnerships; this was reported less in the PIN 4 and 5 cohorts. Enhancing communication among the partners was a challenge for all cohorts. Learning about the unique personalities of not only the organizations but also the individual partners presented challenges in initiating the work and keeping the partnership moving. Almost all of the partnerships cited the need to designate a project director near the initiation of the partnership as an essential element. For those partnerships that had wide geographic areas, the travel time to get people together periodically posed a continuing obstacle. One lead funder observed: “The part that was more time consuming, not difficult but a bit of a surprise, was that there was a lot of information that I needed to be sure got to all the partners. It was sometimes weekly, or every other day at the beginning. The convening sometimes was a little more than we anticipated -- it was a learning process, a surprise. BUT over time the project leadership helped pull everything together and people wanted to be part of the team and make things happen. So the investment of my time was worth it.” All five cohorts identified the negative impact of the economic recession as a challenge. The uncertainty of the economic climate and instability of health care funding affected partnerships’ abilities to secure additional funds and/or in-kind services to support project activities and sustain longer-term initiatives. One lead funder stated: “After getting through the recession, keeping our local funding streams stabilized and maintaining active participation from the partner organizations was a challenge. A question at the evaluation meeting was whether there was a need for a more formalized partnership -- MOUs or something that would identify each institution’s commitment to the collaborative. This community can feel like that’s not something we need because we have longstanding relationships and if we have someone’s word, then that’s what they’ll do. But when the economy shifts so dramatically and organizations aren’t able to give what they thought, that’s where those MOUs could have been really helpful with participation in the collaborative and ensuring feedback from the partners on grant reports or the evaluation strategy or other program expectations.” Another challenge identified consistently was the diversity of interests and focus among the partner organizations, which in many cases delayed progress towards the PIN project goals. More time was required in the beginning of the partnership to develop a shared vision and cohesive approach to the PIN partnership than was expected by most partners. While the diversity was a benefit in terms of ensuring broad representation of stakeholder interests, it also in some cases became a larger issue than had been anticipated, and was eventually resolved. As

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well, some partnerships had to work to shape a project that would be of relevant scale for the size of community, within the time and resources available for the PIN project. While lofty goals were certainly inspirational for many partnerships, the reality of two years of funding, and in some cases two years of organizational commitment, meant that goals needed to be refocused to local realities. Despite these challenges, every partnership identified accomplishments (as summarized above in Table 3) and all made definite contributions in their local community to address nursing workforce issues by the time they concluded their funded work. E. Nursing Workforce Development The work of multiple PIN partnerships raised awareness, particularly among nursing and health care leaders, of the role of workforce development agencies as a local or regional partner for addressing nursing workforce issues. In many communities it was unusual (prior to PIN) to invite a representative of a workforce investment board, the state Department of Labor, or a regional economic development office to participate in a project such as this. Yet many partnerships found that these individuals became key players in developing effective local strategies, and in some cases identified channels for new resources and/or funding programs from state or national sources. In all PIN cohorts, partnerships were linked to a developing or established state nursing workforce center, and these centers were credited with helping to accelerate relationships across labor and workforce agencies. Most often, these organizations were new collaborators for the partnerships. The Davis Foundation (PIN 1) partnership worked closely with the Regional Economic Board in Massachusetts. Illinois Prairie Community Foundation (PIN 2) worked with their local workforce investment board. The San Francisco Foundation (PIN 3) was instrumental in the creation of the Bay Area Workforce Funding Collaborative that included Jewish Vocational Services and the Regional Health Occupations Resource Center, as well as a representative of the local County Supervisor. A PIN funder observed: “Our PIN partnership highlighted to our non-nursing and business community that success begets success. The business community loved hearing about the success we were having with such a respected national foundation and the feedback we were getting was that we were going in the right direction. We kept telling our business community that, but it was nice to have an outside source making the same observation, which became obvious by being a part of PIN.” Another opportunity identified by some of the partnerships was working with the local AHEC. For those that linked with the AHECs, it became an important relationship in developing long-term workforce development strategies. Many of the PIN 1-3 partnerships collaborated with workforce development agencies and/or local Departments of Labor (or equivalent). These collaborations were especially important for recruitment into the nursing workforce and expanding enrollment in educational programs. The emphasis of workforce development in PIN 4 and 5 was directed to nurses already in the workplace. As a result, there was less collaboration with these outside agencies than in the first three PIN cohorts, which may have limited options to develop outreach strategies.

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A clear challenge for workforce development was creating programs that were accessible to the target populations, which was a particular issue in the partnerships that served rural areas or covered large geographic regions. PIN partnerships such as those in Alaska (PIN 1), the American Pacific Islands (PIN 3), Wyoming (PIN 3), or multi-state collaboratives as in New England (PIN 4) faced such challenges. As one PIN funder commented: “It was really difficult getting people to sign up and come to some of the trainings. In rural areas, you know these little agencies are struggling to survive and who knows how many of them really will survive. So getting people to leave work for training was a real challenge. It might be better to have trainings done on-site rather than expecting people to travel.” These comments were also reflected by some partners in contexts where there was perceived competition or hierarchy between acute and long-term care, as well as with home health, in terms of credentials for entry to the workforce, salary rates, and prestige. In many communities, a deficit with regard to workforce development was the ability to more actively engage the business community in the PIN partnership. When business or labor became involved in PIN, this often resulted from strategic discussions emphasizing the fact that nursing will touch everyone in the context of personal and family health issues, and thus business and government should have vested interests in advancing the nursing workforce and keeping the population healthy. This was often the compelling case made by PIN leaders to invite these community leaders in to this work. A few partnerships involved leaders from the Chamber of Commerce (or equivalent) but in most communities this was a missed opportunity. A few partnerships were housed in or closely affiliated with the local Chamber of Commerce, which provided effective connections to the business community. A funding partner commented: “We didn’t understand how difficult it was to get all of the folks who were very academic to understand the benefits of integrating business, whether the Chamber of Commerce or working with corporate funders. It was a lesson that collaborations can work as long as you’re willing to listen up front to the interests and needs and work to bridge the different perspectives.” PIN created an opportunity for the nursing community to be creative in developing key strategies to address issues relative to the nursing shortage. The structure of PIN allowed for nursing partners to tailor initiatives to their local level rather than meet other regional or national areas of interest as specified in a defined call for proposals from a funding agency. While it is difficult to generalize about the impact of the projects on the profession, because they were directed to local issues, several key themes emerged. PIN focused local community attention on the issues affected by the nursing shortage and the factors associated with the nursing shortage. Educating community leaders (businesses, chambers of commerce, health care agencies, governmental agencies) about the value of nursing to the community, the economic impact of quality nursing and nursing education were major examples of the impact on the nursing profession. Some of the best practices for nursing workforce development identified include: engagement of health care organizations to partner with schools of nursing to support nursing

staff to pursue advanced nursing degrees while continuing employment to ultimately enable them to serve as clinical faculty;

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development of an economic model to assess the contribution of nursing to the community, which provided a business case for the value of nursing and nursing education;

establishment of regional institutes/alliances to meet the needs of the nursing workforce and nursing education (including partners from multiple nursing organizations, educational programs, health care agencies, and governmental entities) to create policies and services such as educational articulation agreements, nursing leadership initiatives, simulation training programs, and proposed legislation to increase nursing salaries;

creation of specific training programs targeted to a need (such as geriatrics or home health care) that would advance the nursing workforce; and

development of competency models and curricula for educational progression and professional development (primarily ADN to BSN).

The first PIN cohort was the only one that had a specific focus area on recruitment into the nursing profession. Some of those partnerships were able to delve into the “real” issues of recruitment by testing strategies that could facilitate interest and success in nursing programs. Some of the best practices in this area were creating the structures and supports for people to be successful in preparing for, and succeeding in, nursing programs. Local surveys assessed interest in nursing faculty positions, provided information about the number of people who might be available to serve as faculty, and also identified the reasons why nurses with advanced degrees were not interested in faculty positions. Identifying the effect of low salaries as a factor in attracting people into faculty positions was illuminating. A particularly important outcome within one state was advocacy to effect legislative policy change that resulted in increased faculty salaries for all nursing faculty. Many of the PIN partnerships addressed strategies toward increasing the interest in nursing careers of specific groups, such as those from minority and disadvantaged backgrounds. The PIN partnerships were able to provide models that can be utilized by others to increase the interest and success of target groups in nursing from basic to graduate nursing education. In some areas, scholarships were most needed and models were developed to help students find access to financial resources. Delineating models of specific social support structures needed for students to succeed was a significant contribution to the nursing profession, particularly for those from disadvantaged backgrounds or remote rural areas. The immediate outcome in the communities was the increase in the number of students from disadvantaged backgrounds who entered and graduated as nurses. These models demonstrate how to facilitate success in nursing program for special populations. One important contribution was the exploration of the economic impact of the leadership development programs in order to understand their effect on improving patient care outcomes. While the focus of the leadership development academies/institutes was to enhance the ability of the nurse leaders, some projects were able to document cost savings that resulted from improved patient care outcomes and reduction in nurse turnover rates. This was shown both in acute care and long-term care agencies, going beyond the traditional nursing leadership outcomes that typically only target leadership skills and development of the individual nurse. The strategies that expanded the scope of the projects to the regional area and coordinated the assets of the schools of nursing as service providers to the health care agencies were essential elements that fostered the sustainability of the leadership institutes/academies beyond the PIN funding period, and added to the economic impact of these programs.

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An important contribution from several of the partnerships related to improving the delivery of geriatric services. The specific projects that addressed geriatrics increased participants’ knowledge base about caring for the elderly across delivery systems and settings, improved nurses confidence, self-assurance, mastery of skills, decision-making and competency, equipping them to provide better patient care in future. Associated leadership development activities helped the participating nurses to become positioned to assume leadership roles in their health care organizations. PIN formalized relationships among nursing organizations that in many cases have continued to grow and expand to include other organizations as a direct result of involvement in PIN. However, a concern expressed by some relates to the number of nursing organizations; one PIN funder commented: “I get lost with the number of associations related to nursing, there are so many voices and they’re all speaking on behalf of nurses and I would really hope the nurses will be able to better align their voices -- that means they have to simplify the message. I’ve learned how diverse the nursing workforce is, but as a consequence the nursing voice is also diverse and I think it loses some of its power and authority.” As health care reform was implemented, comments from one of the PIN leaders highlighted health systems transformation as a context for framing their insights from participation in PIN. “Now that we better understand some of the implications of health reform, we are more aware of the national priorities in terms of leadership and nurses getting more advanced degrees and all those types of things – we would not have known these had we not participated in PIN. So, now when we’re meeting with organizations, we’re able to ask questions that are at least reminding folks that as a funder we are aware of those priorities and that they are important to us as well.” PIN also helped to develop or expand networks among nursing leaders. Survey respondents consistently commented on new opportunities to advise nursing groups in other regions or states, and also to collaborate with state nursing centers and regional nursing alliances. All of the PIN partnerships reported an expansion of connections with a range of health care agencies, clinical units, educational organizations and/or service organizations, reflecting a breadth of strategic relationships developed as a result of the PIN partnerships. Collectively, the PIN partnerships have had a substantial impact on nursing and its future. F. Impact on, and Role of, Philanthropy The PIN initiative quickly began to show an impact on philanthropy. It created a unique model that funders could use for other areas of their work, since the focus of the work was directed toward partnership development and collaboration in the foreground with the strategies to address the nursing shortage in the background. Funders in many cases were required to modify their traditional roles as exclusively a grantor, and become engaged in relationships where they had more active involvement in project work, and committed substantial time to the multiple mechanics of partnership recruitment, development and ongoing maintenance and nurturing. Many lead funders across the PIN cohorts observed that this work had transformed their individual organizations to be more collaborative in a wide range of activities, and to seek partnerships for initiatives where previously they may have attempted to work alone. Some funders initially saw PIN as exclusively a nursing project, but over time recognized that the community-wide relationships necessary to be successful went far beyond nursing. In many

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communities, funders observed that this had already changed the dynamics of community leader interactions. As a result, there are some early changes in organizational culture, including evidence of foundation board changes with members showing greater interest in broad social issues beyond defined funding priorities, and demonstrating eagerness to collaborate and become more involved on behalf of the foundation. This reflected new insights into how formal collaborations work, illustrating participation and new dynamics of power-sharing among multiple community stakeholders, as well as moving foundations into community leadership roles in a similar way to the history of NWHF in Oregon. Throughout PIN, more local foundations were recognized for leadership roles in their local communities and regions. This broader involvement across the community resulted in several of the participating foundations articulating strategies to leverage as many resources as possible by conceptualizing projects across local, regional and statewide levels with multiple stakeholders involved. Again, this was a change for many foundations, which traditionally had operated very independently within their defined scope of operations and funding. One funder commented: “Our nursing community is sophisticated, committed, and patient. It was inspiring to be part of a group that is truly focused on long term goals. The primary lesson for us is to take a complex issue down to its key leverage points and focus energy in just those areas. You cannot please every stakeholder but if everyone agrees on the key leverage points, they will remain engaged.” A PIN funder reported: “We now have an extensive network of nursing educators all working on the same strategy. As a foundation, we are going to reach out to other health professions including physical therapy and first responders to see how they are using these educational strategies. We are still trying to figure out how to reach medical education, and to work in interprofessional training, but we can build on the network established through PIN.” The experience of PIN influenced the funding priorities and roles of many of the participating funders. One PIN funder observed: “Our foundation is in the process of looking at our investment plan and realigning what we do. We will definitely be looking at more workforce development but it will be in a way that the community is integrated -- the pharmacists, the nurses, and so on -- to improve either the community or a specific area.” Some funding partners found the experience, including the requirements and expectations, to be very familiar based on prior experiences with RWJF or other funding agencies, while for some the experience of being the “grantee” was new and at times challenging. Meeting the expectations for reporting and accountability was not the norm for some funders, and several commented on being “on the receiving end” of such expectations of accountability as a recipient, rather than as the funder. This was particularly true for those foundations that had a history of being in the funding role and in PIN were asked to report to NWHF, which for some funders initially raised issues of power; these were resolved once concerns were clarified in the context of accountability for expenditure of RWJF funds. Such power issues dissipated quickly, and all of the lead funders expressed positive sentiments towards their working relationships with the leaders of RWJF and NWHF with whom they collaborated during PIN. A PIN lead funder offered this observation: “In future, for projects that are going to have a longer run, we’re going to gather people together to have some conversations around project leadership and shared leadership. Specifically, how are we going to make decisions, how are we

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going to manage conflict in a way that’s beneficial for all partners? Something we were reminded of is that too often we as funders are used to having the final say in things and the final decision point in terms of we’re bringing money to the table and so our voice is heard differently and I don’t think that’s something as funders that we like to talk about very often. We like to think of ourselves as constantly holding up a quality of all partners but I think there’s still that spoken or unspoken tendency for folks to acquiesce to funders. PIN helped us remember that we need to continue to do work around insuring that if we’re really going to be partners with community organizations and individuals, then we need to be true partners and not partners that are more equal than others.” Some examples of how funders summarized their experiences include these key insights:

“Having a strong lead organization is critical, and to have that coordination function played by a high performing organization that understands how to work across sectors with multiple stakeholders and is a good implementer themselves is key. … It reinforces … the importance of strong organizations that can deliver. You can have a capacity building strategy for those smaller organizations, but to take on something like this you really need an organization to support it.”

“I think PIN accomplished the underlying goals in terms of engaging foundations in addressing nursing workforce issue, at a local level. You have these large national foundations that want to do this work and it takes local solutions, so you got more local foundations involved. I do think it was effective at that.”

“We’re very proud that PIN thought enough of the project and our community to fund it and that the people who spearheaded the concept were absolutely dynamite leaders -- passionate, caring, very goal-oriented. It made it easier for the rest of us to understand where they were going -- and then we got there!”

“Being put back in the grantee role reminded me of some of the barriers for grantees that we have with our regular grantees and how I might do things differently with them; it was like “I feel your pain.” … I’ve been a grantee before, so it was a really good refresher for me to be in that role and to share some of those challenges with other foundation staff about what we expect of our grantees and what that really means and what the barriers are for them in doing that.“

“The PIN program leaders emphasized creating models that we can share with other people. Even though our PIN project focused in our state, we created models that we can implement in other areas and we are already doing this. PIN emphasizes taking what you learn, making it better, and sharing with others. That is unique to this program!”

Several funders reported that they changed their approach to, and valuing of, systematic evaluation as a result of their experiences in PIN. Many adopted elements of the PIN evaluation strategy, and built upon the experiences of NWHF in integrating evaluation as a systematic and ongoing part of project work from the beginning of funding. For many funders, this was a welcome element in terms of helping them to focus on the effectiveness of their grantmaking, and to raise the level of accountability of funding recipients. One PIN lead funder commented: “We now understand how to work from our strategic goals as a framework for evaluation. One of the best components of PIN was the organization for collection and analysis of data, and then taking that and putting it to practical usage -- feeding the results back to a large group of people and using them to shape how we’re going to work together in a structured way to move forward.” A PIN funder observed: “We would never have done some of the analysis we did if

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there had not been such a robust evaluation expectation. Some of the elements were really fleshed out because of that, so the requirement to have a foundation be the lead and then have to report on the evaluation was a real benefit for us.” The funders were able to use the example of NWHF and RWJF and their collective commitment to evaluation and use of evidence for decision-making and planning to develop longer-term local strategies to modify local practices, and build evaluation into ongoing funding activities and programmatic initiatives. A PIN funder commented: “I really respect this funding strategy. As a result, when the [state] nursing coalition was set up, we stepped forward and are funding it for the third year in a row. We gave them the overhead to get started.” Funders recognized the value of being recognized and selected by a major national foundation for a very limited program, and the leverage that gave them locally and regionally. A PIN funder commented: “The commitment to the partnership that is being supported through grants like PIN was impressive. RWJF funds a number of projects and collaboratives where their expectation is there’s a deep level of commitment on the part of all the funders. While I believe we have that and had it from the beginning, partners need to take a considerable look and have some conversations about the level of commitment from each group that is going to be going after these grants. There’s the opportunity to use grants as a catalyst for deeper collaboration as long as the partnership all agrees that’s what the grant can do. If there’s not that agreement and understanding it gets challenging when some understand the deeper commitment but others feel like it’s grant requirements you have to check off … having more people that feel there’s a lot of value in being able to participate and go through all the pieces the grant requires, and not just see it as funders wanting to make grantees jump through hoops.” In addition, the creation of a network of a range of kinds of foundations across the country, and the new connections and opportunities for information exchange and potential collaborations, were a major benefit for many funders, and they indicated that these connections will also have a long-standing impact on their work locally as well as regionally and nationally. G. PIN 1-5 Projects Compared to 2011 IOM “Future of Nursing” Priorities In October 2010, the Institute of Medicine released its report entitled The Future of Nursing: Leading Change, Advancing Health. This report was the result of a two-year study of the nursing workforce, funded by the Robert Wood Johnson Foundation. The IOM study called for a major transformation of nursing, recognizing that since nursing is the largest segment of the health care workforce, any changes in nursing will have a major impact on meeting the needs of the United States population and improving its health status. The IOM report emphasized four key messages (as stated on the IOM website, www.iom.edu):

Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved

education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health care professionals, in

redesigning health care in the United States. Effective workforce planning and policy making require better data collection and

information infrastructure.

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This IOM national initiative occurred simultaneously with the implementation and conclusion of local PIN project work. The developmental work to create the proposals for all of the PIN 1-5 projects was completed prior to the release of the IOM report. Most of the PIN 1 and 2 projects had completed their funded work by that time, and PIN 3 and 4 projects were in the implementation or completion phases. PIN 5 proposals were submitted in the spring of 2010, so even these projects were already defined and structured prior to the release of the IOM report. Only the PIN 6 projects (beyond the scope of this report) were directly shaped by, and responsive to, the IOM recommendations. While the PIN projects predated the IOM report, nonetheless there is some congruence between the PIN areas of focus and the IOM strategic directions, given that both initiatives have overall goals of enhancing the future nursing workforce. Table 4 maps the major emphases of the PIN 1-5 projects with the IOM recommendations. As can be seen in this table, the greatest overlap of PIN project focus and the IOM recommendations is with lifelong learning, increasing baccalaureate preparation and leadership – all of which were explicit in the PIN program subject areas. While all of the IOM recommendations are clearly important, this table does reveal the differing emphasis between the initiatives.

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Table 4: PIN 1-5 Projects Compared to 2011 IOM “Future of Nursing” Priorities

IOM 1 Scope

of Practice

IOM 2 Models of Care

IOM 3 Resid-ency

IOM 4 Increase

BSN

IOM 5 Increase Doctoral

IOM 6 Lifelong Learning

IOM 7 Leader-

ship

IOM 8 Research

on Workforce

Blue Cross Blue Shield of Michigan Foundation (PIN 1) X X The Colorado Health Foundation (PIN 1) X Community Foundation of the Eastern Shore, Inc. (PIN 1) X X X X Irene E. & George A. Davis Foundation (PIN 1) X X Dreyfus Health Foundation of the Rogosin Institute (PIN 1) X X HMSA (Hawaii Medical Service Association) Foundation (PIN 1) X X Mississippi Hospital Association Health, Research & Education Foundation (PIN 1)

X

Rasmuson Foundation (PIN 1) X St. James Healthcare Foundation (PIN 1) X Ventura County Community Foundation (PIN 1) X Community Foundation of Middle Tennessee (PIN 2) X X X Con Alma Health Foundation (PIN 2) X Dakota Medical Foundation (PIN 2) X Faye McBeath Foundation (PIN 2) X Illinois Prairie Community Foundation (PIN 2) X X Midland Area Community Foundation (PIN 2) X Mt. Sinai Health Care Foundation (PIN 2) X Oklahoma Hospital Education Research Foundation Trust (PIN 2) X X Pitt Memorial Hospital Foundation (PIN 2) X X X Richmond Memorial Health Foundation (PIN 2) X Wolslager Foundation/Project ARRIBA (PIN 2) American State Bank (Texas) (PIN 3) X Daisy Marquis Jones Foundation (New York) (PIN 3) X X The Dimmer Family Foundation (Washington) (PIN 3) X Friends of the College of the Marshall Islands Foundation, Inc. (US Affiliated Pacific Islands) (PIN 3)

X X

Greater San Antonio Healthcare Foundation (Texas) (PIN 3) X Health Care Foundation of Greater Kansas City (Missouri) (PIN 3)

X X

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IOM 1 Scope

of Practice

IOM 2 Models of Care

IOM 3 Resid-ency

IOM 4 Increase

BSN

IOM 5 Increase Doctoral

IOM 6 Lifelong Learning

IOM 7 Leader-

ship

IOM 8 Research

on Workforce


X

The Oregon Community Foundation (PIN 3) X The San Francisco Foundation (PIN 3) (California) X Wyoming Community Foundation (PIN 3) X Arkansas Community Foundation (Arkansas) (PIN 4) X The Blue Foundation for a Healthy Florida, Inc. (Florida) (PIN 4) X Community Foundation of the Great River Bend (Iowa) (PIN 4) X Community Foundation for the Land of Lincoln (Formerly The Sangamon County Community Foundation) (Illinois) (PIN 4)

X X

The Greater Kanawha Valley Foundation (West Virginia) (PIN 4) X X Hinds Community College Development Foundation (Mississippi) (PIN 4)

X X

Tufts Health Plan Foundation, Inc. (Massachusetts) (PIN 4) X X West Central Initiative (Minnesota) (PIN 4) X X Vetter Foundation (Nebraska) (PIN 4) X X John T. Vucurevich Foundation (South Dakota) (PIN 4) X Bingham Foundation (Maine) (PIN 5) X X Caring for Colorado Foundation (Colorado) (PIN 5) X X X The Cleveland Foundation (Ohio) (PIN 5) X Community Foundation of Southeast Michigan (Michigan) (PIN 5)

X

Dakota Medical Foundation (North Dakota) (PIN 5) X Endowment for Health (New Hampshire) (PIN 5) The Horizon Foundation for New Jersey (New Jersey) (PIN 5) X Humboldt Area Foundation (California) (PIN 5) X Texoma Health Foundation (Texas/Oklahoma) (PIN 5) X Number of PIN Partnerships 0 4 4 14 4 27 18 2

39

III. FRAMEWORK FOR EVALUATION OF PIN 1-5 A. Conceptual Framework The PIN program relied upon an evaluation framework that was developed and finalized through discussions among the evaluation team and the PIN program staff (Figure 1). The framework articulates the core concepts, relevant indicators, and associated methods of data collection. The first iteration of the framework was agreed upon by PIN program staff and the evaluation team in 2006. It was revised in April 2007, and a further revision was made in 2010, which remained in place for the remainder of the evaluation. A summary of the evaluation framework is presented in Figure 1 (following). The indicators and related methods were selected based upon a comprehensive review of the literature on partnerships and partnership evaluation. A list of relevant citations has been provided in previous annual reports, and is included in Appendix 2. The core elements in the evaluation framework are six concepts, which respond to the question “What are the major areas addressed by the PIN program?” The concepts are high level and broad, and span the entire scope of the PIN program (i.e., multiple partnerships over multiple cohorts reflecting multiple perspectives). They form the foundation for the evaluation and the subsequent reporting of results. The six concepts are:

Expand philanthropy’s role in local and regional nursing workforce development. Advance nursing workforce solutions in local and regional communities. Grow and enhance partnerships to address local and regional nursing workforce

issues. Create sustainable solutions for local and regional nursing workforce development. Demonstrate the value of participating in PIN program to develop nursing workforce

solutions. Clarify value of support provided by national PIN program office.

For each concept there are multiple key indicators, which articulate what can be measured or observed in order to support the core concepts. The indicators each relate to a specific concept, are defined as important issues to understand, and can either be measured (via quantitative data collection strategies) or observed (via qualitative data collection strategies). Indicators may be very specific (e.g. number of partners) or broad (e.g. communication strategies). Where the indicators are broad, the indicator is supported by multiple sources of evidence. Evidence is collected for each indicator by at least one method, but there may be multiple questions across multiple methods that provide evidence on individual indicators. The evidence is then aggregated across methods, using the indicators and concepts as an organizing framework for synthesis and presentation of findings. Each PIN 1-5 partnership addressed the evaluation concepts. Since each partnership focused on its own locally relevant topic, the depth of coverage of the evaluation concepts was not necessarily equal across all sites. Table 5 illustrates the extent of evidence of these six concepts for each of the 50 partnerships, assessed as extensive, moderate and limited.

40

Figure 1: PIN 1-5 Evaluation Conceptual Framework The PIN 1-5 evaluation is built upon the following framework: I. Core Concepts: What are the major areas this program addresses? We have revised the original framework and have now agreed upon six core concepts. These are high level and broad, and span the entire scope of the PIN program (ie multiple partnerships over multiple cohorts reflecting multiple perspectives). They form the foundations of the evaluation and the subsequent reporting of results. For each concept there are multiple indicators. II. Key Indicators: What can we observe or measure to generate evidence? The indicators all relate to a specific concept, and are defined as important items that we want to know and can either be measured (via quantitative data collection strategies) or observed (via qualitative data collection strategies). Indicators may be very specific (e.g. number of partners) or broad (e.g. communication strategies); where broad, the indicator is operationalized via multiple questions. There may be multiple questions across multiple methods that provide evidence on individual indicators. III. Methods: How will we collect the evidence? and Sources: From whom or where will we obtain this information? The following reports and data collection strategies provide the evidence for the evaluation:

Brief 1st interim narrative report (due 6 months after start of project) – abbreviated format at end of first six months of funding period - project status, partnership status and technical assistance needs. Standardized report protocol for all partnerships; usually prepared by project manager, ideally with consultation with relevant stakeholders

Annual report (12 months); 2nd interim (18 months); 3rd interim (if project extension) – more comprehensive report every six months following; standardized report protocol for all partnerships; usually prepared by project manager, ideally with consultation with relevant stakeholders

Final report packet: Final Narrative report (within one month of grant conclusion; standardized report protocol for all partnerships; usually

prepared by project manager, ideally with consultation with relevant stakeholders) Executive Summaries (6 one page executive summaries for each concept summarizing accomplishments over partnership

funding period; single page per concept; lead author/contact person for each summary identified) Final Bibliography, Grant Products and Financial Report

Partnership surveys: an anonymous, web-based survey to be sent to all identified participants in the partnership within one month of funding end-date; project managers will be asked to provide list of participants and contact information as one deliverable with their final project narrative; common survey format but with some variations for funding lead, nursing lead, and other partners (ie three formats)

Interviews with lead funding partner and lead nursing partner: conducted by telephone using a standardized interview protocol

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Core Concepts Key Indicators

Expand philanthropy’s role in local and regional nursing workforce development

Transformative change Lessons learned from PIN applied to other nursing workforce development work Lessons learned from PIN applied to other community activities Commitment to long-term engagement in nursing and related workforce issues

Advance nursing workforce solutions in local and regional communities

Specific project outcomes (intended and unintended) Lessons learned (project) Project impact on target audience(s)

Grow and enhance partnerships to address local and regional nursing workforce issues

Establishment, evolution and experience of partnership Partnership management and maintenance Facilitators and barriers of effective working partnerships Impact of partnership on local and regional nursing workforce issues

Create sustainable solutions for local and regional nursing workforce development

Continued funding and investment of resources Leverage of partnership for other activities Sustainability of partnership Replication or expansion of project

Demonstrate value of participating in PIN program to developing nursing workforce solutions

Local and regional impact of PIN project Benefits of participation in national network for nursing leaders, foundation leaders,

other partners New connections and opportunities identified

Clarify value of support provided by national PIN program office

Effectiveness of program management (partner and staff perspectives) Impact of financial resources Adequacy of technical assistance (includes GYMR, evaluation team and other)

Revised January 2010; Based upon 2006 original, and revised April 2007. The complete evaluation conceptual framework may be found in earlier annual reports, or obtained from the PIN Program Office.

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Table 5: PIN 1-5 Partnerships – Evidence of Core Evaluation Concepts from Evaluation Framework Evidence rated as: E=Extensive; M=Moderate; L=Limited

Eval. 1: Philanthropy’s

Role in Nursing Workforce

Eval. 2: Nursing

Workforce Solutions

Eval. 3: Grow and Enhance

Partnerships

Eval. 4: Sustainable Workforce Solutions

Eval. 5: Value of National Program

Eval. 6: Support of Program Office

Blue Cross Blue Shield of Michigan Foundation (PIN 1)

E E M E E E

The Colorado Health Foundation (PIN 1) M M M L E E Community Foundation of the Eastern Shore, Inc. (PIN 1)

M M M L M E

Irene E. & George A. Davis Foundation (PIN 1) E E E E E E Dreyfus Health Foundation of the Rogosin Institute (PIN 1)

E E M E E E

HMSA (Hawaii Medical Service Association) Foundation (PIN 1)

M M E L M E

Mississippi Hospital Association Health, Research & Education Foundation (PIN 1)

E E E E E E

Rasmuson Foundation (PIN 1) E M E M E E St. James Healthcare Foundation (PIN 1) M L L L L E Ventura County Community Foundation (PIN 1) E M E L M E Community Foundation of Middle Tennessee (PIN 2)

E M E E E E

Con Alma Health Foundation (PIN 2) E M E E E E Dakota Medical Foundation (PIN 2) M E M M L E Faye McBeath Foundation (PIN 2) E M E M E E Illinois Prairie Community Foundation (PIN 2) E M M L E E Midland Area Community Foundation (PIN 2) M M M L M E Mt. Sinai Health Care Foundation (PIN 2) M M M L M E Oklahoma Hospital Education Research Foundation Trust (PIN 2)

M M M L M E

43



Eval. 2: Nursing

Workforce Solutions


Partnerships




Pitt Memorial Hospital Foundation (PIN 2) E E E E E E Richmond Memorial Health Foundation (Virginia) (PIN 2)

E E E E E E

Wolslager Foundation/Project ARRIBA (Texas) (PIN 2)

L E E E L E

American State Bank (Texas) (PIN 3) E M E E E E Daisy Marquis Jones Foundation (New York) (PIN 3)

M M E M M E


M E M E E E

Friends of the College of the Marshall Islands Foundation, Inc. (US Affiliated Pacific Islands) (PIN 3)

M E E E E E


M M M L M E


E E E E M E


E E E E E E

The Oregon Community Foundation (Oregon) (PIN 3)

M M E M E E

The San Francisco Foundation (California) (PIN 3) M E E L M E Wyoming Community Foundation (Wyoming) (PIN 3)

E E E E E E


M E E E E E

The Blue Foundation for a Healthy Florida, Inc. (Florida) (PIN 4)

E E E E E E

44



Eval. 2: Nursing

Workforce Solutions


Partnerships





M M M M M E


M E E M M E


M M M M M E

Hinds Community College Development Foundation (Mississippi) (PIN 4)

M E E E E E


E E E E E E

West Central Initiative (Minnesota) (PIN 4) M M M L M E Vetter Foundation (Nebraska) (PIN 4) E E E E E E John T. Vucurevich Foundation (South Dakota) (PIN 4)

M M L L L E

Bingham Foundation (Maine) (PIN 5) M M E L M E Caring for Colorado Foundation (Colorado) (PIN 5) E E E E E E The Cleveland Foundation (Ohio) (PIN 5) M L L L L E Community Foundation of Southeast Michigan (Michigan) (PIN 5)

E E E E E E

Dakota Medical Foundation (North Dakota) (PIN 5)

M M M L M E

Endowment for Health (New Hampshire) (PIN 5) E M M L M E The Horizon Foundation for New Jersey (New Jersey) (PIN 5)

E M M L M E

Humboldt Area Foundation (California) (PIN 5) M M E L M E Texoma Health Foundation (Texas/Oklahoma) (PIN 5)

E M E L M E

45

Each year the evaluation team conducted a variety of activities, determined by the scope of the annual program emphasis. This included attending annual grantee meetings, conducting evaluation accountability workshops for new PIN partners annually, making site visits to each of the 50 PIN partnerships at the end of year one of funding, conducting final individual interviews with each of the 50 partnership nursing and funding leaders, surveying partnership participants, reviewing semi-annual and final reports for each partnership, consultation with program staff and the PIN 6 evaluator, dissemination, preparing annual reports, and attending other special meetings. A summary of these activities is presented in Table 6 below.

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Table 6: Evaluation Team Activities by Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 Annual grantee meeting

November, Portland, OR

October, Charleston, SC

October, Carlsbad, CA

October, Couer d’Alene, ID

December, Washington, DC

October, Albuquerque, NM

September, Portland, OR

May, New Orleans, LA

Evaluation accounta-bility workshop

October, Charleston, SC

October, Carlsbad, CA

September, Couer d’Alene, ID

October, Chicago, IL

Site visits 10 - PIN 1 11 - PIN 2 9 - PIN 3 11 - PIN 3 & 4 9 - PIN 5 End of program interviews

41 - PIN 1 & 2 20 - PIN 3 19 - PIN 4 16 - PIN 5

End of program surveys

90 - PIN 1 236 - PIN 2

186 - PIN 3 172 - PIN 4 208 - PIN 5

Review of project reports

PIN 1 PIN 1 & 2 PIN 1, 2 & 3

PIN 1, 2, 3 & 4

PIN 3, 4 & 5 PIN 4 & 5 PIN 5

Annual evaluation report

PIN 1 & 2 PIN 1 & 2 (Revised)

PIN 3 PIN 4 PIN 5 PIN 1-5

Consulta-tions

Program staff

Program staff

Program staff

Program staff

Program staff Program staff PIN 6 evaluator

Program staff PIN 6 evaluator



Other NAC Meeting; Survey of PIN 1 applicants

NAC Meeting

NAC Meeting

Evaluation Meeting, Savannah, GA, February

Legacy Program meeting, Princeton, December

Planning for final PIN meeting

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B. Stakeholder Perspectives The PIN program relied upon collaborative partnerships of multiple stakeholders; it was important in designing the evaluation to invite input from all of the key individuals. For each partnership, there was a designated lead from the applicant funder, as well as a designated lead representing the nursing perspective. In some cases, the “nursing” representative was the project director who spoke on behalf of the project as a whole. Each partnership was organized somewhat differently, so not all stakeholders were evident in every partnership. For example, in some partnerships the funding or nursing partner lead played the project director role, while in other partnerships a project director was hired outside of the foundation/nursing organizations. In many of the partnerships, there were multiple other participants including funding organizations, nursing, and other groups (such as health care providers, workforce development, departments of labor, nursing workforce centers, education, etc.). This report captures unique perspectives (as described in the next section on sources of evidence), while also reporting the collective partnership experience as appropriate. C. Sources of Evidence There were four primary sources of evidence for the evaluation: regular reports developed and submitted every six months by each PIN partnership to the national office, as well as a final project report; an end of funding survey sent to all partners identified by each PIN partnership; end of funding interviews conducted with the lead funding and nursing partners for each partnership; and four annual reports submitted by the national evaluation team to the PIN program office (each of which was accompanied by an executive summary). Each of these sources was structured using a consistent format that was developed from the core concepts and related indicators in the PIN 1-5 evaluation framework. The evaluation team developed a unique survey instrument and an interview protocol for the end-of-funding evaluation, accompanying communications and consent-related documents; all documentation was submitted to the PSU Human Subjects Research Review Committee for institutional review board approval (initial HSRRC approval #101400, July 2, 2010). This approval was updated annually and is current through July 2014. 1. Partnership Reports Each partnership submitted semi-annual reports to the PIN program office and the national evaluation team using a standardized report format. A comprehensive final report (also with a standardized format) was the final written reporting requirement. All semi-annual and final reports were reviewed as part of the analysis for the annual reports prepared by the PIN national evaluation team. No particular partner/member was expected to complete the reports. The PIN staff encouraged partnerships to engage in a collaborative process for report-writing but this was not mandated. In general, most reporting appeared to be completed by local project directors and/or the funding/nursing leads. These reports and the accompanying attachments provided a rich array of insights and observations.

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2. End of Funding Surveys A unique survey was developed, based upon existing survey instruments identified through a review of the published and grey literature (see Appendix 2 for the bibliography). The survey was developed by the evaluation team, in consultation with PIN program staff. The final survey (available upon request from the national evaluators) included questions addressing:

The respondent’s role in the local PIN partnership, Philanthropy’s role in local and regional nursing workforce development, Local and regional nursing workforce solutions, Partnerships to address local and regional nursing workforce issues, Creating sustainable solutions for nursing workforce development, Value of participating in PIN, and Support provided by the PIN staff.

A slightly modified survey was created for funding partners to focus specific questions on the role of the funding partner. Other questions were framed so that non-funding partners were asked about insights from working with philanthropy, and non-nursing partners were asked about insights from working with nursing. In their final reports, each partnership was asked to submit names and contact information for each member of their partnership (funders, nursing, other); thus the end-of-funding survey population was defined by the partnership leaders. This provided an opportunity to gather insights from a range of stakeholder perspectives beyond the designated program leaders. After each partnership submitted its final report, an email invitation was sent to all potential survey respondents from a PIN email that was recognizable to most of the partnership participants ([email protected]). The voluntary nature of the survey was emphasized. To encourage responses and ensure anonymity of the respondent pool, all elements of survey consent were described in the email, a hotlink to the web-based survey was embedded in the email, and no additional consent form was used. The surveys were administered from Portland State University using Qualtrics (a survey software package supported by PSU). This software minimizes identifiers that can be linked to respondents. Several strategies for safeguarding records and participant identities were used (related to data retrieval, password protection for data access, use of unique identifiers, and aggregation of responses for reporting) and there was no risk of disclosure of individual responses in a way that could compromise a respondent. In the early cohorts, partnerships finished their funded work at different times due to contract extensions; beginning with PIN 3, two fixed dates per year were established for project completion and submission of final reports. Within one month of submission of the final report, the end-of-funding survey was administered to the lists of partners, with two reminders at approximately three-week intervals. In each case the invitation to the survey and all subsequent reminders were sent in emails from either the former PIN Program Director (Judith Woodruff) or the former PIN Deputy Program Director (Jennifer Fuller). Survey responses reported here are for all PIN 5 partnerships. All survey responses were downloaded from Qualtrics and exported into Excel files. More detailed analysis of quantitative responses was conducted using SPSS. Only Dr. Gelmon and her research assistant had access to the raw data responses.

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3. End of Funding Interviews An interview protocol was developed, building upon the survey instrument and focusing on questions that would draw out the unique perspectives of the funding and nursing leads for each PIN partnership. This protocol was reviewed and approved by the PIN project team, and is covered by the same Institutional Review Board approval as the survey (described above). Drs. Norman and Gelmon each worked with specific PIN partnerships through a site visit and periodic consultations; they conducted the interviews with the nursing and funding leads for these partnerships since they already had established relationships with the leads. Within a few weeks of a partnership submitting its final report, an introductory email was sent by either Dr. Norman or Dr. Gelmon to each of the nursing and funding leads for the partnership, inviting them to participate in a private interview that would follow a structured format and last up to one hour. The interviewees were asked to respond by email indicating their agreement to participate in the interview; this served as their consent to participate. The script for the interviews also reviewed the consent elements, and advised participants that the interview would be digitally recorded to facilitate subsequent transcription of their comments. Interviewees gave their consent to be recorded, and were advised that only the interviewer (Dr. Norman or Dr. Gelmon) and their respective research assistant would listen to the recordings, and transcribe and synthesize the comments. Most interviews were completed within two months of the submission of a partnership’s final report.

The interviews were considered low risk for human subjects participation, with the only possible risk identified as the potential violation of confidentiality that could inadvertently occur in release of information that was linked to an individual. Interviewees were asked to identify any comments that they did not wish repeated, and were also asked whether there were any comments for which they did not mind personal attribution. The reporting of interview findings ensured blinding of comments, and individual attribution was made only when the individual had given specific permission. The interviews provided an opportunity for in-depth conversations with both the nursing and funding leads, each of whom provided important leadership to each partnership but may not have been able to express some of their perspectives in a personal way through the written reports. Interviews were conducted with 96 nursing and foundation leads. In some cases, two interviews were conducted at the request of the key contact (usually when there had been a staff or leadership transition). At least one interview was conducted with each partnership. 4. Annual Evaluation Reports The national evaluation team prepared four comprehensive annual reports that were submitted to the PIN national program office. A single report was prepared for the PIN 1 and 2 cohorts, and annual reports were prepared for each of the PIN 3, 4 and 5 cohorts. The PIN program team reviewed each report, offered editorial comments, and the evaluators prepared a final report that was then accepted by the program staff. An executive summary for each report was prepared; as well, aggregate executive summaries that covered PIN 1-3 and PIN 1-4 were also prepared. All of these reports are available from the PIN program office.

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D. Overview of Survey Respondents The survey responses give a broad set of perspectives on the experiences of being part of a local PIN partnership as well as part of the national program, and help to understand the impact of the PIN program. The number of partners (funders, nursing and other community stakeholders) identified at each of the PIN sites varied from three to 57. This range reflects not only the scope of the individual PIN partnerships, but their individual interpretation of individuals to invite to the survey. Table 7 below provides detailed information on the end-of-funding survey launch and the number of partners identified by each partnership to be contacted for the survey.

Table 7: Partnership Survey Population

PIN Cohort Number of Partners Contacted

PIN 1 90 PIN 2 236 PIN 3 186 PIN 4 172 PIN 5 208 Total 892

The survey responses across the five PIN cohorts included 76 nursing respondents, 55 funding partners, and 53 other respondents, for a total of 184 responses or a 21% response rate. In some cases, these partners were very closely involved with the PIN project. In other cases, PIN partnerships provided an extensive list of individuals involved in their partnership. The evaluators received a number of emails from those receiving the survey invitation questioning why they had been invited – often revealing that while an individual might have been very involved with the local partnership, they had no or little understanding of, or connection to, the national PIN initiative and thus chose not to respond to the national survey. This lack of connection to the national initiative, as well as a lack of name recognition of PIN, may explain the low response rates. The breakdown of respondents by year is listed in Table 8, below. The previous annual reports presented data for survey responses for individual PIN cohorts; the results that follow are the aggregate across all five cohorts.

Table 8: Survey Respondents by Year

Nursing Partners

Funding Partners

Other Partners All Partners

PIN Cohort N % N % N % N % 2006 (PIN 1) 13 42% 10 32% 8 26% 31 100 % 2007 (PIN 2) 19 49% 12 31% 8 21% 39 100 % 2008 PIN 3) 15 41% 12 32% 10 27% 37 100 % 2009 (PIN 4) 17 35% 13 27% 19 39% 49 100 % 2010 (PIN 5) 12 43% 8 29% 8 29% 28 100 %

(may not sum to 100% due to rounding)

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Some of the results that follow are analyzed by the total number of nursing, funding and other partners that responded to the survey. Table 9 presents the results with percentage response for each category, as compared to the presentation by year in Table 8 above.

Table 9: Survey Respondents by Type of Partner

Nursing Partners

Funding Partners

Other Partners

PIN Cohort N % N % N % 2006 (PIN 1) 13 17% 10 18% 8 15% 2007 (PIN 2) 19 25% 12 22% 8 15% 2008 PIN 3) 15 20% 12 22% 10 19% 2009 (PIN 4) 17 22% 13 24% 19 36% 2010 (PIN 5) 12 16% 8 15% 8 15% Total 76 100% 55 100% 53 100%

(may not sum to 100% due to rounding) The organizational affiliation of survey respondents is shown in Table 10 below. Fifty respondents (27%) were lead foundation or funding partners; over forty percent (N=77) were nursing partners. The other respondents were primarily health organization partners (13%, N=23).

Table 10: Primary Organizational Affiliation

Organizational Affiliation N % Nursing partner 77 42% Lead foundation (applicant) 28 15% Health organization partner 23 13% Foundation partner (funding) 22 12% Work force/labor partner 8 4% Foundation partner (non-funding) 4 2% Business partner 2 1% Other partner 20 11% Total 184 100%

The greatest number of survey respondents indicated that their primary organizational role (see Table 11) was as a program director or senior administrator (23%, N=42). The next largest group was nursing education leaders (dean, program director or administrator) (20%, N=37); another 14% (N=26) were senior executives with the title of CEO/Executive Director/President. Another 14% (N=25) were project coordinators/program officers/mid-level administrators, and 10% of respondents were nursing faculty (N=19). Workplace-based nurses were represented by respondents in nurse executive/leadership roles (7%, N=7) and only three respondents (2%) were in roles as nursing staff or in service delivery.

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Table 11: Primary Organizational Role in PIN Partnership

Primary Organizational Role N % Program director/senior administrator 42 23% Nursing education dean/program director/administrator 37 20% CEO/Executive Director/President 26 14% Project coordinator/program officer/mid-level administrator 25 14% Nursing faculty member 19 10% Nurse executive/leadership 13 7% Nursing staff/service delivery 3 2% Other 19 10% Total 184 100%

(may not sum to 100% due to rounding) In terms of their role in the PIN partnership, the largest number of respondents indicated their primary role was as a member of a partnership working group (34%, N=62), followed by PIN project manager (21%, N=39). The next most frequent response was from members of a partnership advisory group (16%; N=29). As shown in Table 12 below, a small number of respondents indicated their primary role as PIN evaluator, fiscal oversight, project staff, or as a community champion to recruit additional funders, with very few respondents who were community champions to recruit additional nursing partners or played a role in communications/public relations. These results may reflect who actually responded to the survey, rather than the actual participants in the PIN partnerships.

Table 12: Primary Individual Role in PIN Partnership

Nursing Partners

Funding Partners

Other Partners All

Primary Individual Role N % N % N % N % Member of a partnership working group 30 39% 16 29% 16 30% 62 34% PIN project manager 19 25% 14 25% 6 11% 39 21% Member of a partnership advisory group 10 13% 7 13% 12 23% 29 16% PIN evaluator 2 3% 0 0% 8 15% 10 5% Fiscal oversight 2 3% 5 9% 1 2% 8 4% Project staff 3 4% 1 2% 2 4% 6 3% Community champion to recruit additional funders 0 0% 4 7% 1 2% 5 3% Community champion to recruit additional nursing partners 1 1% 0 0% 1 2% 2 1% Communications/public relations staff 1 1% 0 0% 0 0% 1 1% Other 8 11% 8 15% 6 11% 22 12% Total 76 100% 55 100% 16 100% 184 100%

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Some of the analyses that are reported here were analyzed by the type of PIN partner (funding, nursing, other), by PIN cohort, or by subject area. In the survey, respondents indicated their perception of the subject areas of their PIN partnership (which may have been more broadly defined by the individual respondent than in the project proposal); since the survey was anonymous, these could not be cross-checked with the proposal. Respondents could indicate multiple subject areas. As a result, for some analyses the five subject areas that crossed all PIN cohorts were used as the framework for analysis; the respondent breakdown is shown in Table 13 below.

Table 13: PIN Partnership Subject Area

Subject Area N % Education Infrastructure 71 25% Collaboration and Leadership 66 24% Faculty Development 63 22% Geriatrics and Long-Term Care 46 16% Diversity 35 13% Total 281 100%

IV. THEMATIC EVALUATION BY CORE EVALUATION CONCEPTS This section provides a detailed discussion of the findings across the 50 PIN partnerships from the various reports, surveys and interviews, and is organized around the PIN evaluation framework and its six core concepts. The findings in the subsequent sections reflect survey responses from participants in all 50 of the PIN partnerships, and interviews with the funding and nursing leaders of these 50 partnerships. Some examples of specific partnership accomplishments are also highlighted; these are referred to by the name of the primary foundation for brevity (project names and other identifying information were presented previously in Table 1). A. Expand Philanthropy’s Role in Local and Regional Nursing Workforce Development To understand the findings related to this concept, it was important to separate the perspectives of the funding and nursing leaders. The findings reported here first present the funder perspectives (from the surveys and the interviews), which reflect insights from philanthropy about the role of philanthropy. The nursing leader perspectives are then presented, drawing primarily upon the interviews with each partnership’s nurse leader. Finally, perspectives that draw across all partners (including non-nursing or funding, who were invited to respond to the anonymous survey) are presented. 1. Funder Perspectives Throughout the PIN program one of the most striking findings from all of the evidence collected has been the set of responses related to changing, expanding and/or enhancing philanthropy’s role with respect to workforce development – particularly related to nursing but sometimes expanding to other professions, and with varying emphasis on local and/or regional strategies. Since PIN has a particular emphasis on engaging philanthropy more extensively in such issues, this report provides considerable detail on these findings.

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The PIN program required the foundation or funding partner to serve as the applicant for the grant and became the grantee partner. The purpose of this structure was to determine if the funder would change their strategies by: (1) becoming more engaged in the nursing workforce issue; (2) changing grantmaking procedures to reflect personal experience with the process and grantmaker power dynamic; (3) continuing or increasing investment in the nursing workforce issue regardless of the presence of the PIN grant. The experiences of the funders varied depending on whether they were a solo funder or were one of many funding partners, largely linked to foundation size and the availability of other potential sources (a function of community size in many cases). A PIN lead funder commented on their experience in this way: “You know we had to write grant reports as a funder. It was really a nice reminder to feel what it is like to be an applicant and then a grantee. For me that was a good thing -- for a funder to experience once in a while and to remember that the responsibilities of that role can seem burdensome. They weren’t with PIN, but it was a good experience just from that perspective as a funder.” Another PIN lead funder had a similar comment: “What was obviously different was that we became a grantee from PIN. We were suddenly in the position of many of our grantees, which is having to be responsible to a funder, write regular reports, be attentive to any kind of directives or requests for information from PIN, come to annual meetings. That was a difference for us. A PIN lead funder stated: “It really forced the foundation to take on a leadership role and it really put us with a seat at the table. It also allowed us to really serve as the facilitator which we were doing before but not around nursing and it was very limited, so PIN really sort of catapulted us to do more.” As a result of participation in the PIN partnership, funders across all five cohorts consistently indicated that they were more likely to see themselves as more than a grantmaker, identifying themselves as leaders, conveners, and participants. Beyond these key roles, funders felt they became more engaged in community issues including seeing themselves as a catalyst for social change, a leader or expert responsible for bringing together key players to solve community problems, a dissemination point for information about nursing workforce issues, and a central player in policy and advocacy. Prior to PIN, approximately one quarter (N=8) of the lead funding partners responding to the survey had regularly funded projects related to nursing, and approximately half (N=16) had occasionally funded such projects. Twenty-one of the 29 lead funding partners (72%) who responded to the survey indicated that their foundation was now more engaged in community issues as a result of participation in PIN. One funder stated: “One of the advantages that we have now as a convener or collaborator is we know the players across the region. We’re bringing them to the table to address an issue in the area – multiple communities coming together including the educators and health care providers who sometimes are competitors. We now have that relationship of trust and understanding and expertise.” Another funder commented: “As a community foundation we understand the importance of convening to what we’ve done for a long time. I think our participation in PIN has helped us to look at the relationship management component with a renewed sense of importance. I’m thinking of bringing partners together early to talk not just

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about the project but to talk about the project logistics. PIN really did a great job of helping us look deeper at the importance of communication within these relationships and how communication can really impact the partners independently and collectively and also how it can really impact the work.” Another PIN lead funder stated: “What worked well was we were a neutral convener to bring the partners together and we were able to provide a lot of in-kind that would have cost another organization to put together. We’re a hands-on grantmaker, so that wasn’t a complete shift for us. What we underestimated was how much staff time it was going to take. We leveraged a lot of in-kind resources which actually exceeded the dollars we put on the table for the initiative.” Yet another funder observed the following: “We’re now so much more aware and in acknowledgement of the roles nurses play in our community. The healthcare workforce is one of the largest so it’s always been something we’ve been connected with. Now we’re thinking about how to be better partners with nurse leaders in the work we do. Where’s the nursing voice in a dialogue? Is it a situation where nurse leadership would really help the coalition/partnership advance thinking in how to deal with particular issues?” One third of all of the PIN 1-5 lead funder respondents indicated that they have changed their approaches to grantmaking as a result of PIN. In the individual interviews with lead funders, many more of the funders commented that, as a result of their experiences in PIN, they had modified their grantmaking processes including collaborating more with other funders, educating their Boards about critical needs in the community, and modifying application forms. Many funders from PIN 1-5 have indicated an increased likelihood to fund process/planning grants to support infrastructure and broader health workforce issues, rather than just specific programs. PIN funders across the cohorts have identified such changes in these ways:

“The foundation will be looking more at results-oriented programs with our funding where before we would have questioned it. Now we look at projects that build individuals or teams that have a way to benefit the community.”

“We have followed the ‘matching’ grant model and require partnership and matching on all of our organization's grant making.”

“We’re using some of the practices we got from PIN and working with RWJ and NWHF, as we’re now starting to work with community partners and saying we’re going to give you some money, what do the partnerships look like, how will you grant money out, what deliverables will you get back to us, what are the agreements with the funds we’re offering.”

“We are convening more activities and events.” “The flexibility given to us as a grantee and the way it allowed us to innovate and build

on our learning encouraged me to be more flexible with my foundation's grantees.” Some funders in each cohort have indicated that they have increased their investment in nursing. This has been reflected in a shift towards making grants related specifically to nursing and to greater involvement in nursing in general. Funders who were already working on nursing issues were, in general, able to continue this work as a result of PIN. Some funders indicated they may change some of their funding in the future to focus more on process and planning

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grants, infrastructure grants, and workforce-related grants. PIN lead funders offered these specific comments on changes in their grant-making strategies:

earlier engagement with potential partners; focusing on organizational partners and not just individuals; ensuring key leadership is fully engaged and on board from the beginning; and recognition that grant-writing is just the first step.

Funders identified an increased knowledge regarding nursing workforce issues and potential solutions as a result of the partnerships. Funding partners learned a great amount about the nursing profession in general, and about workforce issues specifically. For many, working closely with the nursing leads changed how they think and talk about nursing issues within their organizations and with others. The perspective of funders regarding the nursing workforce issues was well summarized by one individual saying: “It takes a very special person to be engaged in this field. You have to be knowledgeable, compassionate and good under pressure.” Many funders realized the importance of nursing, stating:

“If we’re going to get health care and public health right in this country, nurses have to be at the center of it, not just a strategy.”

“It was very helpful for our foundation -- we would go to meetings with workforce training people and learn so much about new educational practices,”

“I have realized how critical nurses are to the quality and safety of patient care, and how central they are to the delivery of care.”

“It made us far more aware of nursing programs, changes in nursing, the national focus on increasing nurse preparation and the important roles nurses play in our community.”

“I’ve become much more sensitive to the level of training and expertise nurses have.” “Nurses are very industrious and task-oriented. They get things done quickly, because

they know they won’t have time later. They get things done and that’s refreshing.”

Funders also acknowledged their lack of familiarity with health care contexts and terminology. One PIN lead funder stated: “When we started there was a lot of health care terminology that most of us weren’t familiar with, so learning how to converse with each other so we were all on the same page took some time. That collaboration opened lines of communication so everyone was on a level playing field.” In a similar vein, another funder observed: “Within health care, they seem to live in a world of their own. For PIN, they had to reach outside and the community had to understand why they live in the world they do. Through the collaboration of different partners, those of us not in the health professions became more comfortable with the conversation as time went along.” A PIN lead funder commented on the broad perspective necessary to engage in workforce development: “There are not just individual entities doing the workforce development, but there are systems and it’s almost like ecosystems. It’s not just education partners, or it’s not just non-profit health systems or individual health care organizations or non-profits, but there’s a landscape -- an ecosystem -- working to impact the overall outcomes. It requires complexity and PIN really helped us understand more of the landscape and how the players fit together with the national goals and what others were trying to do in terms of changing the landscape longitudinally. So now we have really a deeper sense of the overall ecosystem, the national goals, and how we can align with our local needs but also with national goals.”

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The PIN proposal asked funders to place themselves on a continuum consisting of three categories. At the end of their PIN funding, most of the foundations indicated that they had either maintained their level of investment and engagement in nursing; 21 lead funders indicated a constant place on the funding continuum, and another 23 indicated they had increased their overall commitment along the continuum to a place of greater focus on nursing issues. One PIN funder specifically acknowledged an additional $60,000 investment “to help to sustain the project as it moves forward.” Funders commented on their level of investment in nursing but also reflected upon the multiple priorities facing the funders, and the fact that many of them are choosing to invest across a range of health professions and health issues, rather than focusing only on nursing. More detail about the assessment of position on the funding continuum may be found in Section IV.D, Sustainable Solutions. The funding structure prescribed by PIN that required funders to act as the lead applicant was seen as successful and achievable. Navigating the process as a grantee provided an opportunity for many funders to change their processes for grant applicants. Funders in each of the completed cohorts have commented on this; a PIN lead funder stated: “It reminded us as a funding organization what it’s like to be a grantee so all the joy and excitement of receiving a grant and all the challenges and headaches of the reporting and budgeting and all of the management types of things. It was an opportunity for us to review our own practices and think about what requirements we have for our own grantees in exchange for the grants that our foundation makes.” Although there was some discomfort initially for some funders with this approach, many found innovative ways to administer and manage the funds they received, and this forced them to work with a number of new organizations and individuals. Many funders had previous experience with matching requirements. For the PIN program, they saw the match as an opportunity to work with other funders and organizations to ensure local support for the partnership, and to start building local ownership of the partnership. Foundations that were accustomed to writing grant applications and receiving funding found it an easy model to follow. For some foundations (generally the smaller ones) this was a new role; some found it helpful while others were somewhat resistant initially, because they were not used to being in the “grantee” role. Many funders commented on the benefits of the matching strategy. A PIN funder said: “We were able to extend dollars greater than any of the funding partners would have on our own. Without the national dollars, we probably would not have funded this project to the extent that we did, so it encouraged our foundation to go further than we would have for this particular project. Leverage was also important to us and to our partner funders.” Other PIN funders commented:

“There were private dollars that were put on the table that would not have been secured otherwise… Anytime you have a match you’ve got ownership.”

“It’s a smart model for getting things done because it makes like a lot easier to get sufficient funding.”

“The model worked very well. RWJF came up with a winner -- it engaged foundations into an area they didn’t know a lot about, where they’re not sophisticated, and now we are more educated about nursing funding.”

“We would not have applied if we did not have the incentive for the match dollars.”

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“We appreciated coming to the table as partners from the beginning and bringing matching gifts; that at least mobilized others around us to bring something to the partnership and financial [resources].”

One PIN lead funder commented: “There were some challenges in just having to [seek the match] and hope that we were inviting them into something that was going to be meaningful and that did fit with their funding priorities.” The same funder went on to add: “It was nice to have that impetus to have them get involved in the project from the beginning. We have a pretty collegial relationship with the other foundations that were the primary match providers that I had to bring to the table. So that it’s not all that unusual that we talk to one another about joining together on projects. But the others would never have been at that table had we not had that match requirement.” A unique aspect of PIN was the diversity of types of funders who were accepted as lead funders in PIN 1-5. Some foundations were the lead on two PIN grants, so the data below reflect fewer than 50 foundations. Based on information provided by the PIN program office, lead funders included:

14 community foundations; 9 private independent foundations; 6 conversion foundations; 5 public charity/grant-making foundations; 5 family foundations; 3 Blue Cross Blue Shield foundations; 2 hospital foundations; 2 statewide hospital foundations; 1 global health foundation; and 1 bank.

2. Nursing Leader Perspectives The nursing leaders’ responses regarding this concept about philanthropy were uniform in one conclusion: Nursing leaders indicated that the most substantial area of learning from the PIN project was about “how philanthropy works.” Many had worked extensively with a range of funders, but had never developed detailed insights about the realities of philanthropic work. A nursing leader stated: “I have come to appreciate that they have a different perspective on the work they do, looking more broadly, working in a particular area or project to develop an idea, from a different paradigm than I’m used to. I’ve come to respect the ideas that they have because a lot of their ideas made our project better and would not have happened if we didn’t have that relationship of the partnership.” All of the nurse leaders interviewed indicated that they now had a better understanding of foundation operations including how to approach foundations for funding, the importance of matching a request to the foundation’s mission, strategies for framing the request for funding, and choosing foundations that had a good fit with the specific community need related to nursing workforce issues. A nursing leader observed: “Our understanding of the foundation has deepened, both of its organization and how it works. In the last two years they’ve undergone all kinds of changes. Understanding how they set their priorities and the different levels of involvement they have in the community was wonderful to know and understand.” Another

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nursing leader stated: “This work really asked us to understand what our funders cared about and who our funders were and what they represented.” Similarly, another nursing leader observed: “I hadn’t really worked with philanthropy before. We nurses are used to working in our health care silos and the funders require different care than some of the folks we normally work with. Stepping out of that comfort zone and learning to work with them will be valuable in the future.” Almost all nursing leaders indicated that they had to learn how to communicate the business case of the project. They had to “learn a new language” of funders to be able to convey the nature of the project. One stated: “One of the things I have learned from some of the training and some of the work in PIN is we need to be able to communicate in a voice and a manner that is applicable to a broader group of people.” Several of the nurse leaders indicated that they had to discover the amount of involvement that the funder wanted to give related to the projects. Some funders wanted to be very engaged, while others chose to limit their involvement. A key learning expressed by more of the early PIN nurse leaders was about the nature of the relationship with a funder. Having a previous long-term relationship does not ensure that there will be continued funding if the mission of the foundation changes. One nurse leader stated, “Knowing someone who is a funder and a friend doesn’t mean that they will be a long term funder.” Another nurse partner expressed: “I learned that there are a lot of things that foundations think about that I never would have had on my radar.” Almost all of the nursing leaders indicated that they developed a clearer understanding of the necessity of reporting the impact of the project, not just the activities that they were doing. The importance of reporting evaluation results, including the progress toward sustainability was mentioned by many of the nurse leaders. Every nursing leader indicated that their relationship with the major funding partner matured during the partnership. With the assistance of their PIN foundation partner, nursing leaders were able to develop interactions with other funders, and some were able to secure additional grant funding for this and other projects, as well as engaging more funders for the PIN-related work. They also found that they had to translate the “language of nursing” to the foundation. Almost all of the nursing leaders reported that they learned how to educate foundations about nursing issues in the local area and indicated that their work in PIN helped them to expand their work to other initiatives, and to work with statewide and/or national funders. A nurse partner cohort gave this example: “Because of PIN, we developed a relationship with workforce services and received almost $3.5 million for our work.” A nursing leader commented: “Our funding partners participated in some of the days where the participants present a project and both commented on how impressed they were with the work they were doing. It’s given us a chance to showcase the work of nurses to people who don’t really have an in-depth idea and that’s been really helpful. They’ve gone on to fund other nursing projects and I think it helped give them a better understanding of nursing.” A consistent new learning articulated by the nurse leaders related to the networking that the funders were able to negotiate to open doors to other agencies and funders. They emphasized that funders were able to frame the message of the PIN project to be understood by other funders. Foundations could convene groups that had not worked together before or that had difficulty, and

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they became the neutral ground. Nurse leaders also learned that foundations have access to volunteers who can help with project implementation. Similarly, just as the funders found that nursing and health care have their own language, the nursing partners learned that funders also have their own type of communication: “They talk to each other differently than we talk to them.” 3. Building Relationships Among Community Partners Funding, nursing and other partners identified new connections with other funders as a result of work in the PIN partnership. Most partners established new connections with local and regional funders, but fewer formed new relationships with national funders. Over half of the PIN partners (56%, N=103) indicated they now have new connections with local or regional foundations. Among the non-funders, two thirds (N=72) indicated they had established such local or regional connections. Nearly half of the PIN funding partners (N=27) responding to the survey indicated that they had new relationships with national foundations as a result of their participation in PIN, and one-fifth (N=29) of the non-funding partners indicated this as well. In the interviews, both funding and nursing partners identified new connections with other funders as a result of work in PIN. A key result of the partnerships was the close, personal relationships developed among funding and nursing representatives. These relationships established a level of accountability and openness among key partnership leaders, facilitating conversations and discussions that they reported likely would not have happened in other grantor/grantee relationships and thus were key in achieving the outcomes of PIN. The necessity of close working ties resulted in a shift of the types of relationships, expanding the levels of participation beyond the typical connection between CEOs of the funding agency and the funded organization. As one nurse leader stated: “The CEOs of the participating agencies now show up and participate, and we have a critical mass of leaders who are speaking the same language and can collaborate effectively.” As an example, in Michigan, both nursing and funding leaders had worked together in a PIN 1 partnership, and while there were new players in the PIN 5 partnership, the established relationships from PIN 1 helped to accelerate the creation of the new partnership. In Mississippi (PIN 1 and 4), many of the partners already had long-standing relationships before PIN, which accelerated their ability to develop an application to PIN. In several PIN partnerships, organizations that had previously been competitors became collaborators around the PIN focus. The organizations knew each other, but the PIN partnership created a new focus for their work, which was accelerated based upon their collective histories. A PIN funder commented that: “building relationships between nurses and funders and working closely with the funders is the key element to success.” Another PIN funder observed: “Because of the power of our work together as a group, we are now working on coming up with an annual report to the community. We want to be able to leverage that, starting with an annual community report and then having a Nursing Leadership Forum in our community. That’s a definite change as a result of this project.” A PIN nursing partner said: “The relationships were already there, but because of the PIN grant and working toward common goals, we strengthened the relationships for everyone.”

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The PIN partnerships regularly demonstrated that relationships between funders and nursing partners influenced the continuation, expansion, and development of projects beyond PIN-supported efforts. These included expanding the work to include other disciplines, collaborating for programmatic evaluation, and developing partnerships with other organizations. Many of the PIN 1-4 partnerships applied for PIN 6 funding, some of which were successful, and used that support to expand or refocus the work conducted previously through PIN. PIN 5 partnerships were not eligible to apply for PIN 6 funding, but many built upon their work in other areas, such as in New Hampshire (PIN 5) where the PIN partnership contributed to a state-level Health Equity Partnership, and the PIN team also received technical assistance funding through the Harvard Culture Insight Project to establish a learning collaborative on developing cultural competency and effectiveness. As a result of their work in PIN, workforce diversity was raised as an issue to the New Hampshire state primary workforce commission. B. Advance Nursing Workforce Solutions in Local and Regional Communities Overall, the PIN partnerships made an impact on advancing nursing workforce solutions at the local level and that PIN program participation facilitated the ability to address important issues. A lead funder commented: “The workforce angle was something I did not spend enough time thinking through before. In a community where unemployment is high and educational preparation is not always as good as it can be, it is clear that a nursing degree can improve the lives of some students, so if we can find a way to create a pipeline that will keep people going.” Another funder said: “We are now so much smarter and sensitive to nursing issues. I can go to a conference and meet folks from a nursing school and I can talk to them because I know what’s on their minds.” Another funder made the following comment about the funder serving as the grantee for a nursing-focused project: “What I really appreciated about the PIN approach with the community foundation serving as a grant grantee versus the nursing lead, is that if the focus had been on the nursing lead then the feel of the project would have been money going to nursing to provide a service. That wouldn’t have had the same important benefit of bringing a community together around the nursing issue. Because the grant went to a foundation, we were able to preserve more of a focus on community, on workforce development strategies in the community bringing many partners together, making more linkages among employers, educators, and other intermediaries in workforce development.” For some partnerships, PIN provided an impetus for the necessary early planning steps to address nursing workforce concerns. PIN provided important opportunities to bring together relevant partners (business, health care, lawmakers, funders, regulators) and gather the necessary information for seeking out possible solutions and strategies. The work conducted through PIN was seen as applicable to other workforce issues related to nursing and within other professions. A lead funder commented: “Prior to PIN, our [rural] community foundation had never tried to work with the [urban] university, and we did not know what resources existed there. We’d never exchanged resources with a bureaucracy as big as the university, and it was very complicated, but we came to work together even across those differences of size and operating practices.” At the conceptual level many partners felt their efforts were addressing issues in the community that no one else was working on, and their partnership played an important part in meeting specific needs within the local and state health care communities. These perspectives are best

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summarized by these quotes from PIN partnership participants: “We put the nursing shortage on the map in a formal and forceful way” and “I think we were able to elevate the issue and its importance/implications for the economic and health vitality of the region.” The PIN 1 and 2 cohorts placed more emphasis on efforts to increase the enrollment in nursing programs whereas PIN 3 emphasized enhancing the nursing workforce and building educational capacity. The focus of the majority of the partnerships in PIN 4 and 5 emphasized building educational infrastructure and creating faculty development initiatives, with several emphasizing geriatrics/long-term care and/or collaboration/leadership For many funders, PIN helped not only to establish new relationships but also to better understand nursing workforce issues. One funder commented: “I certainly now know a lot more players in the state in the nursing field than I ever did. I now understand their challenges a bit more, particularly in the practice setting around maintenance in the workforce and the problems with new grads and how they adapt to work settings. I was not previously aware of the turnover that happens in certain sectors, and the fluidity of nurses who move in and out of the workforce depending on the economy.” In the last two cohorts, there was a shift in emphasis from attracting people to the nursing workforce to addressing those already in the nursing workforce (at various levels of preparation) and preparing them for the workplace needs in specific settings. These perspectives are best summarized by these quotes from PIN partnership participants:

“We were able to prepare more people for nursing leadership roles.” “We helped the home health care industry by helping nurses to develop the competencies

for work in home health agencies.” “We made an economic difference … for our community and for our patients.”

1. Faculty Development and/or Educational Infrastructure Several strategies were pursued by partnerships to develop capacity for faculty in multiple roles, conduct faculty development, and expand educational infrastructure. In PIN 1 and 2, the major focus of the faculty development and educational infrastructure was on increasing the interest in faculty roles, increasing the number of people enrolled in masters or doctoral programs or creating opportunities for collaborations with health care agencies to involve staff nurses in expanding clinical education capabilities. In PIN 3 and 4, and in some of the PIN 5 sites, partnerships emphasized the educational needs of faculty related to new teaching strategies, such as the use of simulations in nursing and health professions education, preparation for teaching in distance education, and strategies to improve the writing skills of graduate nursing students. The focus of many of the PIN 5 partnerships was on providing educational programs for practicing nurses, rather than on programs in schools of nursing as seen in previous cohorts. Some partnerships focused on special topics such as preparation for roles in home health care or geriatrics, and the educational needs of practicing nurses. Several of the partnerships conducted campaigns within their communities to increase awareness of the need for nursing faculty and the effect that the faculty shortage had on the nursing shortage. One of the unique tactics used was the development of a forum for community leaders including businesses, health care agencies, legislators, funding agencies, regulatory agencies, and commerce to learn about the impact of the nursing shortage and how the lack of well-prepared faculty is a key element in providing a solution. All sites using this strategy

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reported an increased awareness of the issues and appreciation of the importance of creating a pipeline for faculty development. The Mississippi Hospital Association Health, Research and Education Foundation (PIN 1) was able to convince legislators that low salaries were a key element in attracting nurses into faculty roles. In one of their reports they included: “The success of the public service campaign was measured by the Mississippi Legislature raising nursing faculty salaries by $12,000 and providing funds for a simulation study.” In the PIN 1-4 cohorts, a focus area was increasing the number of masters and doctorally prepared nurses able to teach in schools of nursing. The Dakota Medical Foundation (PIN 5) specifically addressed this area by targeting efforts to enable nurses from diverse backgrounds to pursue graduate study. Some of the strategies developed by the partnerships that proved effective were:

Creating new pathways for hospital/school partnerships to prepare staff nurses as clinical faculty to expand enrollments and clinical capacity for schools of nursing;

Providing scholarships to staff nurses to pursue advanced degrees; Creating policy changes and articulation agreements to facilitate ASN graduates to

pursue BSN and MSN programs of study; and Creating educational support systems such as assistance with writing skills, making

application to nursing programs, social support to support students while enrolled in the programs of study.

Creating collaborations among nursing schools and others within PIN 1-4 focused on initiating policy changes to develop similar courses and accept common pre-requisites to enhance the articulation between the levels of nursing education. Some partnerships were able to facilitate a dual admission process for students to enroll in the ADN and BSN program simultaneously (such as the Jonas Foundation, PIN 3). Another partnership was able to develop an associate to masters degree articulation process (Pitt Memorial Foundation, PIN 2). Several PIN partnerships built upon the experience of the NWHF-funded Oregon nursing collaboration among associate degree and baccalaureate nursing programs (OCNE) and were able to adapt those lessons to their local context. Some examples of their accomplishments were:

Creation and acceptance an articulation plan for ADN/BSN and area institutions in Western Massachusetts (Davis Foundation, PIN 1);

Development of an articulation process for students to progress from ADN to BSN (Dakota Medical Foundation, PIN 2);

Establishment of a statewide curriculum articulation initiative in Wyoming between community colleges and the University of Wyoming (PIN 3); and

Implementation of articulation models between the community colleges of western North Carolina and Western North Carolina University, and also between community colleges and Hunter College in New York City (Jonas Foundation, PIN 3).

Other partnerships developed statewide or regional activities to initiate policy changes. For example, the Bingham Foundation (PIN 5) partnership developed a common core competency model for nursing education programs to increase the number of baccalaureate prepared nurses. The purpose of this initiative was similar to previous PIN projects that facilitated a seamless transition between associate and baccalaureate degree nursing programs. The Tufts Health Plan sponsored partnership in New England (PIN 4) established a regional collaborative that spanned

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educational institutions in three states to integrate the “Nurse of the Future Competency Model”, assisting nursing students ability to progress from ADN to BSN. A unique collaboration between Community Foundation for the Land of Lincoln PIN 4 partnership and a local Sam’s Club created a Certified Nursing Assistant Program, including pre-CNA preparation, to increase the number of people who would be able to progress to LPN or ADN programs. The McBeath Foundation (PIN 2) created a public health, competency-based nursing curriculum that involved nursing schools across the state of Wisconsin. Most of the collaborations among nursing schools in the PIN 5 partnerships focused on special topics (home health, geriatrics, use of simulations) that resulted in common curriculum changes. All of the PIN 5 partnerships were able to engage educational partners in their projects. Some were localized partnerships, while others were statewide. The Horizon Foundation of New Jersey partnership (PIN 5) was able to engage 87% of the graduate nursing programs in the state to utilize their writing program. Faculty development activities were focused on preparing nurse educators and staff nurses for new models of clinical education and practice, both in academic programs and health care agencies. Most frequently, the partnerships sponsored workshops in the form of faculty academies or continuing education programs to enhance both faculty and staff nurse competencies in strategies to enhance clinical education of nurses and students. The programs ranged from concentrated continuing education programs that were delivered in a face-to-face manner, to creating on-line clinical educator training programs and development of simulation case scenarios. The Community Foundation of Middle Tennessee (PIN 2) created the Clinical Teaching Associates program to prepare staff nurses to assist faculty members in clinical teaching by assuming precepting roles. The Midland Area Community Foundation in Michigan (PIN 2), the Vucurevich Foundation in South Dakota (PIN 4), and the Hinds Community College Development Foundation in Mississippi (PIN 4) all created similar programs to enhance the capacity of staff nurses to serve as preceptors and expand the number of students who faculty are able to supervise. In the PIN 5 partnerships the focus was more on preparing staff nurses for specific areas, such as home healthcare or the use of simulation to increase competency. For example, the Caring for Colorado Foundation (PIN 5) developed simulations for faculty development related to home health care that could be utilized by health care agencies and schools of nursing. Several partnerships developed simulation centers, such as The Blue Foundation for a Healthy Florida (PIN 4), American State Bank (PIN 3), and Humboldt Area Foundation (PIN 5). Each of these partnerships was able to establish a strong network to support high technology training so that many people could benefit from participating in the simulation process. Several of the partnerships were located in rural areas, which created a challenge for ensuring current competence with advances in technology. The Humboldt Area Foundation project helped people in the community to accept that they did not have to fall behind in training and development just because they chose to live in a rural area. The leaders of this PIN partnership observed that the work of PIN helped the local community to see the direct benefits and value of simulation. In each of these projects it was also important for the nursing schools and clinical agencies to be able to develop simulation capability as part of their academic curriculum in order to maintain

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standards for the faculty and the students. This ensured that participating nursing schools were viewed as locally competitive and able to attract faculty and students to the nursing program. 2. Leadership and/or Collaboration In each of the PIN cohorts several PIN partnerships created leadership programs for nurses in both acute and long-term care with a primary focus of to grow the next generation of nursing leaders and to improve nurse retention. Each partnership focusing in this area increased the number of nurses developed for leadership roles. Most reported large numbers who attended leadership workshops and a substantial number of people who completed leadership programs. Some of the partnerships created programs for staff nurses while others focused on new nurse managers, still others on transition programs for new nurse executives. The Community Foundation of Southeast Michigan (PIN 5) developed a program for new nurse managers in acute care and long-term care agencies. The program was so successful that an additional session was added, increasing the total enrollment to 136 -- 100% above projections. A side benefit of the project was the development of a nurse honor guard that would attend the wake or funeral of a nurse to honor their colleague. The Caring for Colorado Foundation partnership (PIN 5) created a unique learning program that targeted frontline nurse leaders to support their transition to a leadership role and a coaching program for nurse executives to be able to foster leader development in their institutions. As a result of the leadership course, six participants have enrolled in masters programs, recognizing the need for higher education in their roles. For those that provided leadership workshops, the attendance and reach of the programs was substantial with ranges of attendance from 180 in local areas to statewide initiatives such as the Wyoming Annual Nursing Summit (PIN 3). One of the unique leadership development initiatives was the Clinical Scene Investigator Academy in Kansas City (PIN 3), which provided training for nurses from seven different hospitals to learn about improving patient care. They reported that: “the combined CSI cohort saved their institutions an estimated $2.5 million over the 16 month period.” The needs of the geographic areas determined the focus and spread of the leadership program. Some of the collaborations that developed as the partnerships initiated their activities led to more comprehensive structures across geographic regions, with multiple agencies addressing nursing issues in their area. For instance, in Virginia (PIN 2), the initial leadership development program was formatted for distance learning to disseminate it statewide. In other areas, such as Oklahoma (PIN 2) and North Carolina (PIN 2), the need for leadership development was most critical in rural and remote areas. The Bingham Foundation (PIN 5) established a core competency model that was adopted by all schools of nursing in Maine to increase the number of BSN prepared nurses in the state. In addition, they identified the need for additional clinical placements in order to be able to expand enrollment and began utilizing a Centralized Clinical Placement System from a previous PIN partnership. Working across states was sometimes a challenge, as seen in the Cleveland Foundation (PIN 5) partnership, which experienced challenges in the delivery of its online education program because of state higher education policies that may prohibit an institution from utilizing faculty from another state. Another challenge across states occurs when students who reside in one state enroll in a program offered by an institution in another state, leading to questions about in-state or out-of-state fee structures.

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Various types of leadership development programs were initiated ranging from one-time workshops to in-depth programs. Some programs were specific to long-term care agencies, and there were reports of reducing the RN and LPN turnover rates. While the decrease in turnover rate cannot be completely attributed to the PIN activities, there was a demonstrable difference noted by the partnerships (such as HMSA, PIN 1; Colorado Health Foundation, PIN 1; and Daisy Marquis Jones Foundation, PIN 3). In-service programs were also developed for long-term care agencies. One of the lessons learned was that long-term care staff have difficulty in attending courses that are off-site, therefore the partnerships needed to provide in-services to the staff at their own location. While computer-based programs made the education accessible, staff still reported that they did not have time within their day to attend the programs. Leadership development programs focused on the acute care sector were able to attract a significant number of nurses, nurse managers, and nurse executives. Programs such as those created by the Greater Kanawha Foundation (PIN 4), the Richmond Memorial Health Foundation (PIN 2), and the Oklahoma PIN partnership (PIN 2) demonstrated the value of such effort. A frequent comment on the impact of these workshops/programs was that they changed the nurses’ viewpoint of nursing care and empowered nurses to make changes. The Pitt Memorial Hospital Foundation (PIN 2) developed a unique leadership program to reach nurses in remote rural locations. A major outcome of the leadership initiatives was that it gave the PIN partnership more visibility in the community, attracted attention and gave it more influence. Some described it as “putting them on the map” while others indicated that it helped to move the foundation to a different level. A funder had the following observation about nursing practice and hospital management: “One thing that was surprising was how incredibly challenging it was to get nurses to have time to come and participate and be learners [in the simulation training]. Another piece was the fact that our hospitals don’t have more training and development in their budget to support the ongoing professional development of their staff. That was something that was unknown previously to those of us at the foundation and will help us in future in targeting hospitals and clinics to figure out how to prioritize things like simulation or other opportunities for staff to get ongoing training. Part of why it’s so challenging is that organizations don’t have time for their staff to go out and participate!” Another lead funder reflected on the role of nursing in health reform, commenting: “It feels like our region could benefit from a unified nursing association to be able to support nurses being at decision-making tables, especially looking at how our community is preparing to implement health care reform. The issue of nursing leadership and moving nurses into positions of leadership in a variety of health and wellness arenas is something I look forward to doing and that we’re more conscious of because of our work in PIN.” 3. Diversity, Recruitment and Retention Recruitment of people into the nursing profession was a priority issue for the first two PIN cohorts, but fewer of the PIN 3-5 partnerships focused on increasing interest in nursing as a career and retaining students in the nursing programs. For example, the Rasmuson Foundation (PIN 1) partnership recruited five rural Native Alaskan students from a remote area to complete the Associate Degree in Nursing program; they were then employed in their home community This was the first time that indigenous nurses who could speak the same language as

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their patients were employed in health care agencies in their home area. While the number of students was not large, the strategies developed provided a model for others in Alaska to utilize to meet the needs of rural areas. They were able to determine the specific support services needed to assist the rural minority students to be successful in an educational program. The Dreyfus Foundation project (PIN 1) in rural Mississippi also developed successful strategies to increase the retention of nursing students in the BSN program. Several partnerships focused their recruitment efforts on creating strategies to engage and develop people from the Certified Nursing Assistant level to become LPNs or RNs (Davis Foundation, PIN 1; Arkansas Community Foundation, PIN 4; and Community Foundation for the Land of Lincoln, PIN 4). A unique strategy developed by the Community Foundation of the Land of Lincoln (PIN 4) was linking with a local Sam’s Club to establish a pre-CNA and CNA program to attract people into nursing while facilitating their movement into LPN programs. A challenge for some new nurses is being well-prepared for the realities of the role of the nurse in the health care system. The Vucurevich Foundation in South Dakota (PIN 4) created a residency program for new nurses to mentor them through their first year of nursing practice. The Community Foundation of the Eastern Shore in Maryland (PIN 1) created a mentorship program that paired new nursing graduates with experienced nurses who helped guide them through their early practice experiences. The Pacific PIN partnership (Friends of the College of Marshal Islands, PIN 3) found that the salary level for nurses was not sufficient to attract people into the profession. They were able to propose legislation to establish a minimum level of nursing salaries. Diversity of the workforce was directly addressed by at least two partnerships in each cohort. Some focused on increasing the racial and ethnic diversity of nursing while others developed programs for rural areas. Retaining minority students in nursing programs was a common problem that was addressed by several of the projects. The Wolslager Foundation partnership (PIN 2) created a case management system for Hispanic nursing students to assist them with not only academic support but also social supports so that they could graduate in a timely manner and become employed. The Community Foundation for the Land of Lincoln partnership (PIN 4) hired a Diversity Case worked to assist minority students with success strategies. The St. James Healthcare Foundation in Montana (PIN 1) developed a summer academy for nursing students that helped develop skills and identify challenges they might encounter in order to better prepare them for their future nursing positions. The Dakota Medical Foundation (PIN 5) created an “Adventures in Nursing” program for 3rd and 4th grade students to introduce them to the role of nursing, and a Summer Nurse Camp “Edventures” program for high school juniors and seniors. A unique focus of these programs was that they targeted students from rural areas. The New Hampshire Endowment for Health partnership (PIN 5) developed a comprehensive set of programs for high school students, nursing students, practicing nurses, and future nurse educators from diverse backgrounds with the purpose to attract, support and retain them in nursing. A unique feature of this project was the establishment of connections to STEM (Science, Technology, Engineering, and Mathematics) programs, building synergies from the pipeline development for high school students with another key educational initiative.

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Several partnerships targeted students early in the academic career pipeline, such as focusing on elementary school children or early high school students. For example, the Con Alma partnership in New Mexico (PIN 2) developed programs for middle and high school students who came from disadvantaged backgrounds. They provided assistance to enhance the students’ ability to be successful in high school in order to qualify for entry into nursing programs. One of the funders commented: “The pipeline concept took us a while to solidify and work out. Ultimately it resonated with people -- working upstream as well as meeting people where they are, no matter where that is on the pipeline. I could see the application of that in other health fields.” A PIN lead funder made this observation: “I didn’t anticipate the need to help the institutions of higher learning understand that teaching cultural competency and being culturally competent are not the same thing. We had to sometimes help the institutions to ask themselves tough questions -- do they have to deal with this issue because they don’t have any minority students, and then why don’t they? Those conversations around cultural competency and academic institutions began at the nursing program level, but we helped in some cases to bump them up to institution-wide conversations.” A unique approach to increasing the number of nurses for the workforce and increasing the diversity of the workforce was the San Francisco Foundation (PIN 3) which created a refresher course for immigrant nurses from 22 countries who would be able to qualify for RN or LPN licensure in the US. This project was able to recruit 88 participants and facilitated placement of 33 nurses. Unfortunately, because of the economic downturn, they were not able to place all of the graduates. Only one PIN project focused specifically on increasing cultural competence of nurses. The Oregon Community Foundation (PIN 3) created a grant funding initiative and awarded 13 grants to schools of nursing, hospitals, community agencies, and nonprofit agencies to develop cultural competency training programs for nurses and other health care workers. A PIN partner observed: “We had many debates and dialogues that put on the table the variety of points of view people had. The academic institutions were honest about the fact that their programs are competitive so they can get the great students, and they acknowledged some inherent prejudice that minority students were possibly going to be at a lower capacity. Thinking about diversifying their student population was possibly going to lower the quality of their students. I think we opened their eyes a little. We didn’t bust it open like we could have, but we started the conversation.” 4. Geriatrics and Long-Term Care The partnerships that addressed geriatrics found a common theme: long-term care agencies have high staff education needs with few resources to meet these needs and are very complex organizations. Most of the partnerships that addressed geriatrics focused on providing education services for those employed in long-term care or leadership development programs for nurses in long term care. There were a few projects that developed clinical rotations or curricula to improve registered nurse education programs.

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Two partnerships developed a regional/statewide approach to their work. The Dakota Medical Foundation (PIN 5) partnered with the North Dakota State University Nursing Student Association to initiate a program for fourth, fifth, and sixth grade students in rural areas to utilize an “Adopt a Grandparent” toolkit to help change the perception of elders in the community and identify career paths related to caring for the elderly. The partnership also created a job shadowing experience for high school juniors to learn about nursing and health systems that provide care for the elderly (long-term care, public health, and other health systems). The Dakota partnership sent faculty to the faculty development program offered through the Hartford Foundation Facilitated Learning to Advance Geriatrics (FLAG). Similarly, the West Central Initiative (PIN 4) created a partnership of 10 nursing schools to increase faculty expertise in geriatrics and also utilized the FLAG program. Another creative approach to increase the competency of nurses in care of the elderly was the Bingham Foundation (PIN 5) awarded 17 micro grants of $1,000 each to spur initiatives to address nurse competency gaps. Two partnerships created unique approaches for clinical education in geriatrics. The Hinds Community College Foundation (PIN 4) developed a Dedicated Education Unit in one of their affiliated hospitals for geriatric care. The Dimmer Foundation partnership with Pacific Lutheran University (PIN 3) placed students in the community to care for older adults with chronic health problems for a two-year period. An unanticipated benefit of this longitudinal relationship between the nursing students and older adults was a reduction in hospital readmission rates to 7%. The Hawaii Medical Service Association partnership (PIN 1) also created a clinical rotation in geriatrics and found that both the long-term care agencies and the faculty needed to make specific preparations in order for the clinical experience to be valued by the students. The Caring for Colorado Foundation (PIN 5) utilized a unique approach to improving care of the elders through a collaboration among home health agencies, schools of nursing, and community educators. This was demonstrated by the inclusion of content on “transitions of care” that was specific to elderly populations in the materials that were developed. Several partnerships addressed the needs of nurses working in long-term care to enhance their leadership skills. The Daisy Marquis Jones Foundation (PIN 3) developed nursing leadership workshops for nurse managers and leaders employed in long-term care agencies within the region that resulted in improvements in care at each site. The Community Foundation of Southeast Michigan partnership (PIN 5) had a goal to recruit nurses who worked in long-term care settings to participate in the leadership development activities developed and offered by the partnership. Unfortunately, there were many challenges in that these nurses could not be given release time from their settings to attend the leadership program. This highlighted an organizational barrier inherent in the long-term care industry where the number of RNs employed in each institution is small, staff coverage is difficult when even one nurse is absent for an educational program, and staff nurses may not be compensated for time taken to attend a professional development program. The Arkansas Community Foundation project (PIN 4) found similar issues. They developed on-line courses for CNAs, LPNs, and RNs in long-term care agencies but found that it was difficult for the staff to participate in the courses because of lack of access to computers. They were able to secure funding from the USDA to equip six nursing homes with a learning laboratory so that the staff could take the courses at the employment site.

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Several funders involved with projects connected to long-term care commented on the challenges “to engage long-term care organizations in attending to the importance of professional development for their nursing staff. … The barriers to professional training in those institutions are tremendous.” Similarly, a nursing leader observed: “It’s very difficult to get the leadership from LTC to support the program monetarily and to release that person to come to the settings. It’s a big cultural difference in how they view nursing and its contribution and the value seen in other organizations. We’ve done much better with hospice and home care, than with long-term care.” 5. Public Health Only one partnership focused on issues related to public health. The Faye McBeath Foundation partnership (PIN 2) created a collaboration among public health agencies and five nursing education programs in the Wisconsin region, and developed a public health capstone experience for nurse scholars. The partners reviewed the BSN curricula and determined gaps when compared to regional public health competencies. The goal was to increase the number of nurses employed in public health agencies. The most important outcome of this project was the adoption and implementation of a standardized public health curriculum in all nursing programs within the state. 6. Changing Priorities Respondents to the survey were asked to rank a list of nursing workforce issues by priority before PIN, at present, and for the future. The detailed responses by respondent group regarding these priority rankings of nursing workforce issues are presented in Table 14 below, aggregated across all five cohorts (the numbers by cohort are too small to report disaggregated numbers). The issues are presented in rank order based upon aggregate responses for the future. The nursing partners rank all of the issues as important for the present (at least 75%) and the future (greater than 90% for future importance). The one exception is primary care, which only 64% of the nursing partners rank as important for the present, but 95% rank it as important for the future, reflecting the current shift to emphasize primary care as part of health reform and health systems transformation. Funding partners indicated that the top priority for the future is retention, closely followed by educational infrastructure and diversity, and then by public health. They gave high rankings (over 70%) to all of the other topics. In contrast, the “other” respondents ranked geriatrics, collaboration and leadership, retention and diversity as the top priorities for the future, with all other topics receiving at least 80% from this group.

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Table 14: Nursing Workforce Issues, Priority Ranking by PIN Respondents (% ranking each issue)

Nursing Partners Funding Partners Other Partners

Workforce Issue Before

PIN Present Future Before

PIN Present Future Before

PIN Present Future

Diversity 85% 85% 95% 84% 76% 84% 87% 81% 91% Geriatrics and Long-Term Care 81% 89% 99% 65% 78% 78% 75% 81% 92% Educational Infrastructure 74% 89% 96% 82% 76% 84% 81% 79% 85%

Retention 90% 89% 92% 87% 87% 85% 85% 81% 91%

Public Health 68% 77% 93% 73% 64% 82% 74% 77% 85% Collaboration and Leadership 84% 92% 93% 80% 78% 76% 83% 85% 91%

Primary Care 58% 64% 95% 53% 71% 75% 64% 72% 81% Faculty Development 85% 97% 95% 91% 82% 73% 87% 83% 83%

A summary of these results for all respondents is presented in Table 15 below. Two topics presented together indicates a tied score. The variations in rankings across cohorts do not reveal any clear trends. These overall rankings may be useful when considering funding of future nurse workforce initiatives (although again the results may be skewed based upon those who chose to respond to the survey).

Table 15: Nursing Workforce Issues, Priority Ranking

Past Currently Future Retention/ Faculty development

Faculty development Diversity/ Geriatrics

Diversity Retention Educational infrastructure/ Retention

Collaboration and leadership Collaboration and leadership Public health/ Collaboration and leadership

Educational infrastructure Geriatrics Primary care Geriatrics Educational infrastructure Faculty development

C. Grow and Enhance Partnerships to Address Local and Regional Nursing Workforce Issues Together, partners developed goals, responded to relevant views and priorities, implemented locally relevant strategies, responded to needs and issues, identified new and creative problem-solving strategies, and evaluated progress and impact. Partnerships and collaborations were seen as a necessary framework given the scope and nature of the issues at hand. Some of the challenges to working as partners included the time and cost of working with other organizations, managing partners as they entered and left the partnership, and establishing working contracts or membership agreements.

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1. Creating the Partnership Achieving a balance in involving the appropriate players was identified by many partners as both a challenge and a positive experience. Selecting partners presented challenges in terms of representing appropriate interests but also ensuring organizational cultures were compatible, the dynamics of individuals and groups were manageable, and work could be done to build and maintain successful relationships. While many of the partners indicated that funders and health care organizations in their community had a history of working together, they indicated there were many opportunities for increased partnerships among these groups and to increase in the involvement of less traditional partners. The diverse organizational affiliations of the partners who responded to the survey were presented previously in Table 10. A PIN lead funder commented on their experience in this way: “A difference was having a partner who was also a grantee, so we started to develop a new relationship that was not foundation and grantee, but partner as well. We had an excellent working relationship, we collaborated on every step, we co-led meetings, we sent out communications from both our organizations, we were actively involved in advocacy discussions. It worked very well.” Several PIN partnerships established or further developed linkages with their local or regional AHEC to spread the work of the project over a wider geographic area. One PIN partner shared this comment: “The AHEC has a long history of workforce diversity training and cultural competency so that helped us to figure out how to support the different pieces of the educational pipeline. They pushed us to stretch and do more than we initially proposed.” Other partnerships included a state nursing workforce center, and in general observed that these centers helped to facilitate connections across the many stakeholders in nursing workforce development. A nursing leader commented: “I think my role with the workforce center gave us entree into a lot of different camps quite easily. We didn’t have to prove anything, since we’re a known entity. I think that is a big plus.” A PIN nursing leader commented: “We learned to use different strategies for the pace of helping people develop collaborative opportunities. This group had a lot of competition between the players that we hadn’t seen in other groups that we had worked with before, probably because we chose groups that had already started that process a little bit different. Being a little bit more respectful around the change process that partners have to go through as they develop to the levels of collaboration was necessary, since it just doesn’t happen quickly. Having patience for how each organization fits into that and yet still holding them accountable to the process and the commitment they made up front was essential.” A PIN funder offered this observation about creating a partnership for this project: “Some people were thinking this was such a radical approach to grantmaking. It’s not; it’s sensible and intelligent and strategic. What I would do in future with each of the funders, and everybody involved, would be to say where do you see your role, what do you need, what can and can’t you do. That would help us to move forward more efficiently.” Another PIN lead funder stated: “The partnership depends on how you get people around the table, because although they may be competitors they share some common interests and challenges and that can be the glue that holds things together. In community work all the time you’re trying to bring together coalitions or groups of organizations. Finding the common

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ground is key, and that’s not a new lesson but it’s a good reminder. Trying to do a collaborative effort is really challenging and you have to be willing to adjust your sense of what the pace should be and maybe even what the direction should be, but if you can keep clear about where you’re trying to go and what the individual entities can contribute and can gain from it I think you can make some progress.” Some partners said they would have involved other partners earlier in the process; they developed insights about opportunities for other appropriate kinds of partners from hearing the experiences of other PIN partnerships. Each of the PIN 2-5 cohorts was able to learn from the partnerships in the previous cohorts, and had the benefit of observing the program in action before applying, thus giving them longer lead-time for assembling and developing the partnership for the initial proposal. As the PIN program continued, the partnership base became even more stable in many communities, since some sites applied more than once before being successful in obtaining funding, yet continued to work together once the application process was initiated. 2. Expanding/Enhancing the Partnership After the initial partnership was established, new partners were often added to meet specific objectives that may have been part of the initial proposal or were recognized as needs once the partnership began its work. Most of the PIN partnerships were based largely upon participation of funders, nursing academic programs, and hospitals/health systems. In the early cohorts, partners were sometimes added after project launch to expand the scope and interests of the partnership as a whole; in the later cohorts, few partners were added after project launch, likely because these partnerships began their funded work with more partners at the table. This reflects program-wide learning across the five cohorts, and encouragement by PIN program staff during the application process to bring key players to the partnership from the outset. Some funders observed that they could be more effective in their communities by expanding beyond nursing, but that their nursing partners wanted (or expected) the focus to stay on nursing. As one funder stated: “From a funding perspective, we saw great potential for expanding the program to include not just nurses but also pharmacy, medical students, phlebotomists -- all sorts of folks working within the medical arena to build cohorts and understanding of cross function in ways that would have been really interesting. This was a difference we had with our nursing partners.” By the end of their funding from PIN, many of the partnership leaders indicated that in future, they would pay more attention to evaluation earlier in projects, and also would engage the funders and other partners earlier in the partnership planning process. Several PIN partners were very explicit that they wished that they had started work on sustainability much earlier in their funded work; this may have been prompted by the content at later PIN annual meetings on this topic and additional technical assistance provided. Funders expressed similar sentiments related to project initiation, organization and management. 3. Partnership Effectiveness A key to success for each PIN partnership throughout the program was effectiveness. Survey participants responded to a number of questions derived from the literature on effective

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partnerships, in particular in terms of composition and collaboration; detailed responses are presented to highlight those areas where the partners felt their partnerships were most effective. Survey respondents were asked a series of questions about the collaborations and partnerships established through working together on PIN. Over 90% of the PIN end-of-funding survey respondents agreed or strongly agreed with the following statements:

The time was right to work on nursing workforce issues. The people involved in our PIN partnership represented a cross-section of those who

have an interest in what we were trying to accomplish. What we were trying to accomplish within PIN would have been difficult for any single

organization to do by itself. Communication among PIN partners happened in both formal meetings and informally. The PIN partners were dedicated to this project. My organization benefited from being part of the PIN partnership. The organizations involved in the PIN partnership were the “right” organizations to

address our issues. Between 80 and 89% of respondents agreed or strongly agreed with the following statements:

Participants in the PIN partnership knew and understood our goals for the PIN project. Partners were willing to consider different approaches to our work. We were able to adapt to changing conditions that affected our collective work. The level of commitment among the PIN partners was high. Members of the PIN partnership were willing to compromise on important aspects of

work. We had opportunities to engage multiple individuals from the partner organizations in

various aspects of our work. Members of the partnership communicated openly with each other. People involved in our PIN partnership trusted one another. We were able to keep up with the work necessary to coordinate all the elements of our

project. These statements speak collectively to the creation of effective partnerships with clear lines of communication, active participation, and appropriate roles for participants. The only responses that received less than 80% agreement related to a clear process for making decisions within the partnership, and a history of collaboration in the community. One funding partner had this observation: “I found that the collaboration did well because there was not an overabundance of rules and the ones that were there were logical, such as making sure money is going to what it’s supposed to. It was equally about what you accomplished as how did the process work. I learned that if you’re going to have a collaboration you’ve got to spend an enormous amount of time on process. I knew that we had to spend a lot of time doing that, but the culture of PIN invited and forced you to do that. You couldn’t just gloss over the things that weren’t working.”

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Partners described a number of roles they played in the partnership; the greatest number were either members of a partnership working or advisory group, or PIN project managers. These were previously presented in Table 12: Primary Individual Role in PIN Partnership. A concern related to partnership effectiveness was often identified when there were geographic barriers and dispersion among partners. In the early cohorts, the geography of working across the state of Alaska (PIN 1) or the Pacific Islands (PIN 3) posed a substantial challenge that required creative problem-solving but was usual practice in these regions. Similar barriers were identified even if the geographic spread was within one state such as in Colorado (PIN 1 and 5), Wyoming (PIN 3), New Hampshire (PIN 5), or North Dakota (PIN 2) where the state is predominantly rural and people assume there will be geographic challenges. Regardless of distance, when partnerships attempt to work across geographic regions or states, it became apparent that the key to success was identifying operational structures that would work for the participants – whether through use of videoconferencing capacities or telephone conferencing, through in person meetings, or through some combination of strategies that met the needs of the participants. This was the experience in partnerships such as the multi-state collaboration hosted by the Tufts Health Plan project (PIN 4). A mix of strategies generally seemed to work best, combining periodic in-person meetings with other communication formats. One nurse leader commented: “We had thought we would use a lot of electronic and internet systems for communication and networking ... and what we found in these small rural communities was that they want to meet in the flesh even if it takes you three hours to drive there, as they rarely get an opportunity to step outside the walls of their institution to collaborate with nurses that are in different organizations to address issues.” 4. Partnership Operations The partnership literature also emphasizes details of operations as important factors related to partnership success. Responses by PIN participants to the survey supported an understanding of partnership operations. Eighty percent or more of the survey respondents agreed or strongly agreed with the following statements:

The partnership made very good use of partners’ in-kind contributions (skills, expertise, connections, and information).

We had access to the information and the expertise we needed to do our work. The partnership made very good use of partners’ financial contributions. The partnership made very good use of partners’ time.

Between 70 and 79% of respondents agreed or strongly agreed with the following statements:

Each member of our partnership contributed to the best of their ability (time, in-kind, effort, resources, etc.).

Power was shared equitably among the partners. We had adequate staff to do our work. We had clear decision-making procedures. We established ground rules and norms for how we worked together. We had clearly articulated lines of authority. We had clearly articulated roles and responsibilities.

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In PIN 1 and 2, all of the statements on operations received at least 70% agreement from survey respondents. In PIN 4 most of the statements about effective operations achieved levels of agreement in the 80% range, and in PIN 5, all statements except one achieved at least 70% agreement. PIN 3 reported somewhat lower satisfaction with partnership operations. In the PIN 3, 4 and 5 cohorts, none of the responses on partnership operations achieved over 90% agreement (agree or strongly agree), in contrast to the responses from PIN 1 and 2. It is not clear exactly what is behind the variation in these responses, but they may reflect a lack of clarity about partnership operations, the timeframe of these partnerships, or a non-representative group of respondents. In all five cohorts of PIN partnerships, respondents indicated that frequent face-to-face meetings, email, or conference calls were essential elements that kept the partnership working, especially when working across geographically dispersed partners. Many used newsletters to keep partners and other communities of interest up to date with the PIN activities; there were no data reported to indicate how successful this strategy was in keeping partners engaged in the project activities. In their final report, one partnership cited that “key strategies to success were communication, trust, tolerance, and time.” A PIN funding partner describe various strategies for effective partnership operations: “It helped us remember the importance of in-person meetings as well as written communication and that it’s not as effective to simply send out an email newsletter or to communicate with people electronically but meeting in person is important. We realized the importance of breaking bread and having those working lunch or dinner meetings that were really a worthwhile experience in that it helped the partners connect as human beings as well as project partners. I think that is something funders can lose sight of sometimes when we get too stuck in our heads with projects and activities versus the people that are involved.” A PIN lead funding partner commented on the lessons learned by being actively involved in the partnership’s work: “We try not to bug our grantees enormously and get involved unless we are really invited in to some of the day-to-day operations. We trust them and work with them as needed but we’re not at the table many times in the way that we were with PIN and that was great. It was a really good learning experience for me because I got to sit with the collaborative and I spent a lot of time in conversation with [our project manager] and I saw some of the challenges in a way that I may have read about in a report but wouldn’t have experienced.” A PIN nursing partner said: “What I learned is that getting collaboration from individuals is not the same as getting those individuals to bring the project to the front of their organizations.” Another nursing partner stated: “Having the true partnership and the ability to have that foundation person be the person that actually sets the stage with the entire partnership at a different level was important, otherwise you don’t get the work done.” A PIN partner described lessons learned from PIN that will be used in future community collaborations in this way: “We do a lot of collaborative work locally and working in this partnership further assisted us with lessons learned in working in a deep collaborative way and the importance of having input and buy-in from the core partnership groups about program goals, objectives, and business planning. We already knew this but PIN reaffirmed how much more powerful our coalition can be if we come together and utilize all the different talents and expertise within a partnership to make sure our partnership can be as effective and sustainable

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as possible. There are a number of partnership related things that we know, but it was really good practice to think deeply about why certain things work.” Some partnerships convened advisory councils. A PIN funding partner commented: “The advisory group worked well in supporting our projects. Often unless there’s an action they can hang their hats on, it’s hard to advise but they worked very well in connecting our on-the-ground work to other things. They were good for volunteers, information, facilities. We could bring their expertise to other projects. I learned from the advisory group how you can do this well and keep people engaged, but not be beholden to them -- they’re advising but not governing.” Funding partners across the five cohorts offered the insights listed below:

“Partners really need to see and be satisfied with their role in the collaborative and what they were getting out of it.”

“We did not spend enough time early on discussing the process and how we’re going to navigate the relationship. We just kind of jumped into the project work.”

“We underestimated the amount of time it would take to manage and administer both the grant logistics and also the project partnerships and relationships.”

“When you are working in a partnership, the communication issues are important, making the project meaningful for all and having everyone get a win.”

“We underestimated the planning time and activities that needed to go into it. We thought we had it all together, everyone was on the same page, no one was negative, but we underestimated how much work we should have done in pre-planning.”

“Take it slow. Make sure you have the right people at the table.” “Different work styles and different professional cultures were challenges we had to

figure out.” “There was definitely no way the work we were doing could have been completed in 2

years. We were really optimistic and it all seemed doable but when you work with a partnership everything gets slowed down and that’s good sometimes, not everything has to be at the speed of light.”

Issues of adequate staffing to do the work of the partnership were often raised by partners. As one PIN funding partner stated: “For our program one of the biggest challenges was operating based on a collaborative model because so much of the business planning and follow through was the responsibility of our steering committee members. It made it challenging for the program manager to feel she had a clear direction on day-to-day issues. She was the manager but wasn’t operating at the executive level, so when there were decisions she needed to go to steering committee members for. It would have been helpful to have resources for another staff person to do the business outreach and keep the steering committee going, allowing the manager to focus on operational issues.” Although challenges described above are inherent in partnership projects, a number of beneficial outcomes related to the collaborative approach were identified including:

a greater impact as a result of working together; mutual benefit for all partners; establishing ongoing networks and projects; and the ability to share skills, information, strategies and specializations across partners.

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Eighty percent of the PIN survey respondents reported that they now have new connections with other nursing partners. Approximately one third of the survey respondents have been approached by other organizations about collaborating on efforts related to nursing workforce development. Such organizations include state government representatives; regional action coalitions; educators; community-based health providers in primary, acute and long-term care; state health workforce groups; local chambers of commerce; workforce development boards/alliances; health systems; and professional organizations. For many of the PIN partnership leaders from both funding and nursing, these represent new collaborators who they will bring into future partnership work based on their experiences in PIN. A unique result of the PIN partnerships identified across all five cohorts is the ability to frame nursing issues in a way that resonates with the interests of other groups and stakeholders. This ability expanded the types of potential partners by making nursing relevant to more groups. When working with multiple partners on one issue, partners found that it was important to recognize the differing needs of those partners to achieve success. Expanding the defined scope of the nursing issues, as well as determining the root causes and explanations and the ability to speak in the language of the potential partner, often created important opportunities. 5. Synergy Synergy is an important concept when evaluating the strength and impact of partnerships. As reported in the survey responses, partnerships identified new and creative problem-solving strategies, implemented locally relevant strategies, responded to needs and issues, obtained support, responded to relevant views and priorities, communicated to the broader community, and evaluated progress and impact. Developing goals that were widely supported among the partners was not viewed as being as effective from the respondents’ perspectives, but respondents may not have been well informed on the process of goal development. Many partnerships were able to develop new insights on how to utilize the PIN partnerships to develop initiatives that met the local needs of the health care community. For example some were able to develop a seamless process and unified curriculum for nursing education between community colleges and universities to facilitate educational pathways for all levels of nursing. The partnerships created synergy among community and partner agencies, which was demonstrated in actions such as creating educational programs relevant to specific contexts (such as long-term care and home health care), applying for other grants related to nursing workforce development, creating a regional simulation center, and developing statewide initiatives, such as core competencies for educational programs and a format for nurses to access continuing education programs. Survey respondents indicated that by working together, they were able to achieve the following (85% or more indicated “very well” or “extremely well” for each the statement):

develop goals that were widely supported by the partners; implement strategies that were likely to work locally; identify new and creative ways to solve problems; include the views and priorities of the people affected by our work; respond to the needs and issues of the target community(ies); and obtain support to help us move forward in our work together.

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When these responses were further analyzed by project focus area, there was some variation observed, with those working on faculty development emphasizing new and creative ways to solve problems more than others, while those working on geriatrics and long-term care responded more positively with respect to obtaining support to move forward in their work together. Over 90% of the survey respondents agreed or strongly agreed with each of the following statements:

Our work as a PIN partnership has enhanced our ability to address important issues. We have been able to sustain the partnerships that were developed during the PIN

project. Local partnerships will continue after the national PIN program support ends.

Partners working on geriatrics and long-term care agreed most strongly that they would be able to sustain the partnership. The partnerships working on faculty development, education infrastructure, and collaboration and leadership expressed the highest levels of agreement regarding working on important issues. Those working on diversity had slightly lower levels of agreement than others, but still reported strong levels of agreement with these three statements related to the importance of their work in PIN. An example of synergy was the Bingham Foundation’s (PIN 5) statewide initiative to develop common competencies, which was a catalyst for the formation of an organization called the “Maine Nursing Education Collaborative” which is composed of all nursing education programs (RN) in Maine. As a result, they were able to partner with AARP and local health systems and engage with the Maine Action Coalition. In New Hampshire, the Endowment for Health (PIN 5) assessed the nursing workforce needs in their state and identified a gap in available programs for “aspiring” nurses to be able to continue their education. They were able to engage their state Office of Minority Health to utilize the Office’s funding to help meet the training needs of this population. Both the Humboldt Area Foundation (PIN 5) and the Blue Foundation for a Healthy Florida (PIN 4) partnership reported that the creation of a simulation center, and the relationships established with other foundations, helped the foundation to be in a better position to more effectively engage in dialogue about health care reform. Many of the PIN partnerships created synergy among community and partner agencies, which was demonstrated in actions such as creating educational programs relevant to specific contexts (such as home health), applying for other grants related to nursing workforce development, creating regional simulation centers, and creating programs for nursing leadership development. One of the key ways that synergy was fostered was through the work of the foundation partner. Survey respondents who were not the lead foundation partner (N=129) were asked to comment on the effectiveness of the leadership of the lead foundation partner. As can be seen in Table 16 below, over 75% of respondents indicated “excellent” or “very good” for the effectiveness of the lead foundation partner on most of the elements of good practice of partnership leadership, such as fostering trust, creating a positive environment, maximizing the investment of resources, working together to develop a common language, taking responsibility for success, inspiring and motivating partners, communicating the vision, facilitating creativity, empowering the partners,

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and providing the vision – all necessary to build the various elements needed for a successful partnership. The lowest ranked attributes were for recruiting diverse people and organizations into the partnership, and resolving conflict, which some of the lead funders may not have viewed as core to their role. The rank order of the response categories was relatively consistent across all five PIN cohorts. Nonfunding partners found that working with a foundation partner with these attributes opened doors or identified opportunities for synergistic work that would otherwise not have been possible.

Table 16: Effectiveness of the Leadership of the Lead Foundation Partner

Effectiveness of Lead Foundation Partner

N % Excellent/ Very Good

Fostering trust, respect, inclusiveness and openness in the partnership. 105 81% Creating an environment where differences of opinion can be voiced. 103 80% Maximizing the investment of resources and skills of the partners. 103 80% Working together to develop a common language in the partnership. 102 79% Taking responsibility for our success. 102 79% Inspiring and/or motivating people involved in the partnership. 100 78% Facilitating the partners to be creative in our work together. 100 78% Empowering people involved in the partnership. 99 77% Providing vision to the partnership. 99 77% Communicating the vision of the partnership. 97 75% Recruiting diverse people and organizations into the partnership. 90 70% Resolving conflict among partners. 83 64%

Some funders identified the opportunity for collaboration as a valuable experience that could create synergy in their future work. Since they often encourage their own grantees to partner, the insights they gained through PIN helped them to see the work required to successfully manage a collaborative project, and to translate these insights into future funding strategies. One partnership lead commented: “The partnership drove home the understanding of power and potential of multi-sector partnerships -- without synergy and cohesiveness of all partners on all levels the grant would have been unsuccessful.” A number of examples of synergy have been identified through interviews, observations, and written reports. These illustrate how PIN prompted new collaborations and opportunities in local areas to engage additional stakeholders in nursing and other health workforce issues. Some examples of the new collaborations include:

Established a state academic resource center (Horizon Foundation for New Jersey, PIN 5);

Coordinated work across AHEC, the Colorado Center for Nursing Excellence, and other foundations on issues of home health care (Caring for Colorado Foundation, PIN 5);

Helped to create legislative earmarks to increase nursing education infrastructure (Ventura County Community Foundation, PIN 1, and Mississippi Hospital Association Health, Research & Education Foundation, PIN 1);

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Established a nurse-led foundation for continuation of the clinical placement system (Greater San Antonio Healthcare Foundation, PIN 3);

Established a regional or state nursing workforce center (Wyoming Community Foundation, PIN 3, and Health Care Foundation of Greater Kansas City, PIN 3);

Established a simulation alliance to coordinate simulation activities within the region or state (The Blue Foundation for a Healthy Florida, PIN 4, American State Bank, (PIN 3) and Humboldt Area Foundation, PIN 5);

Developed a multi-stakeholder regional collaborative to implement Nursing Core Competencies in all nursing programs in region (Tufts Health Plan Foundation, PIN 4); and

Established a relationship with a national organization to sponsor gerontology certification preparation education courses for nurses in long-term care (Vetter Foundation, PIN 4).

The work conducted through PIN initially created the infrastructure for the PIN partnerships to be positioned to apply for other funding opportunities. One of the PIN funders observed: “We’ve had other opportunities, for example we applied for a HRSA grant and a Department of Labor grant -- we didn’t get them but we were ready to go and didn’t have to spend time briefing people to write the letters of recommendation because we have those people, and they can write their own letters because they know what the projects are. We also have a PIN 6 collaboration building on the previous one -- all the same partners and more.” Few PIN 4 and 5 nurse leaders reported seeking funding from the Health Resources and Services Administration (HRSA), Division of Nursing, whereas several from PIN 1-3 indicated that they would be seeking funds from this source. The differences in the number of partnerships seeking funds from HRSA may reflect a change in funding priorities at the federal level to support nursing over the life of the PIN program. This may be indicative of a shift in funding attention from individual disciplines to inter-professional education and training. D. Create Sustainable Solutions for Local and Regional Nursing Workforce Development Almost all of the partnerships indicated that they are continuing to work on strategies to sustain the partnership work, but found it challenging. Strategies included continuing the specific work conducted during PIN, expanding activities into other nursing or health professions workforce areas, and/or transitioning the work begun under PIN to a new entity or different host organization. Survey respondents ranked the importance of factors that will keep them working together to create sustainable projects, as follows:

leadership (74%, N=134); continued funding (65%, N=120); relationships (64%, N=117); business plan (39%, N=72); trust (33%, N=60); more partners (29%, N=54); and a more formal organization structure (24%, N=44).

Only 5% (N=10) of survey respondents indicated that they are unlikely to continue working together.

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Eighty-six percent (N=159) of survey respondents indicated their future work together would address nursing workforce issues; 44% (N=81) indicated they would work on other health workforce issues. Twenty-eight percent (N=51) indicated their work would address population-specific issues, and 26% (N=48) indicated community development as a focus. Respondents could indicate multiple responses. The three areas ranked most highly, as indicated above, are described in greater detail below. 1. Leadership The PIN funding model required the “grantee” and project lead to be a funder. In most of the PIN partnerships, the funding partner served as convener of the project activities; this often included hiring a project director who managed operations and was accountable to the funder or a steering committee. A strong and effective dedicated project director has consistently been demonstrated as a key element of success in moving many of the partnerships forward in a timely manner, and helped those partnerships to accomplish their workplans effectively. These project directors worked with the funding leads to achieve shared leadership of the partnership, with investment in partnership operations across a range of constituencies, and reflected the collaboration that developed. Few of the partnerships across the five cohorts exhibited the traditional experiences of the nursing leaders where the foundation partners were “hands off” in terms of the project activities. Foundation leaders were actively engaged in most of the PIN partnerships. One nursing leader commented: “The funder really wanted it to be a partnership among our organization, our evaluator and the foundation, and she took the lead with the other foundations. Having her participate in our meetings on a quarterly basis raised the bar for our other partners since she was so actively engaged.” While the lead foundations were aware of their role as the “grantee” from the beginning, this was often reinforced after interactions with program staff or the evaluation site visit at the end of the first year of funding. A PIN funding lead stated: “It required a much deeper level having the foundation be the applicant. After the evaluation visit, we as the foundation stepped up our participation in the steering committee and some subcommittee work and I feel like that was because WE were the grantee and had a particular role we had committed to.” Another PIN funder observed: “It might have been challenging for us to be the lead for some of those around the table with whom we haven’t worked with as much. For the most part people think of our foundation as playing that role. We assist a number of community collaboratives and initiatives in applying for grant funding and we get a lot of requests to do that kind of work including workforce and economic development. We were continuing to secure the matching funds and were looking for other grant and funding opportunities to complete our match. One of the things that may have happened with a few of the partners is that they felt like it was the foundation’s responsibility to secure the additional funds since we were the grantee.” PIN partnership nursing and funding leaders expressed similar sentiments across all cohorts, speaking to the importance of key individuals in creating the partnership, managing it, and building the capacity for future work. Several interviews included a comment such as: “We

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would never have accomplished this much – or be able to continue our work – without the leadership of [xxx].” A clear example of leadership emerged from the Vetter Foundation (PIN 4) partnership, which developed a free-standing course in Gerontological Nursing that prepared nurses to take the national certification exam. This course was endorsed by the American Healthcare Association and is now being marketed nationally. It will help to enhance the ability of nurses in long-term care nationwide to improve the care of the elderly. The Caring for Colorado Foundation partnership (PIN 5) helped to raise the visibility of home care in multiple conversations across the state. Members of the partnership were on groups such as a governor’s task force and payment reform projects, and were able to ensure that home care was “at the table” in topical areas where it had rarely been represented before. This visibility may contribute to longer-term sustainability through some of the health care reform efforts, such as contributing to the development of accountable care organizations in Colorado. 2. Funding One of the factors discussed in depth was the importance of ongoing funding in maintaining partnerships. Many partners identified sources of funding beyond the PIN project, primarily from local/regional foundations and health-related organizations with some support from government in the context of workforce-related projects. This theme was consistent across all PIN cohorts. Funders have made comments such as:

“We should have probably started working on the sustainability aspect sooner.” “We waited until too late to start looking at sustainability. We’d talk about it and people

would act on it, and everyone just assumed we would be funded.” “We should have formalized our processes for thinking about ongoing support of the

project much earlier.” When asked what they would have done if the funding had been larger, most partnerships indicated they either would have done more of the same thing or would have expanded their scope, reaching more people and providing more service/programs. One PIN funder commented: “If it was bigger we probably would have done something more aggressive. More money would have meant greater capacity to make inroads with additional schools, and we could have offered our programs to a broader array of students.” Another PIN funder suggested: “We would have done something to hold more regional meetings across more of our state and get a higher proportion of people involved in the discussions.” A few PIN partnerships used fees to augment their resources, and create a base to continue beyond the PIN funding through implementing participation fees or requiring contributions from existing partners. Most of the partnerships were able to leverage additional support due to the work already in progress. Even the partnerships that had been able to institutionalize projects within existing organizations have faced challenges finding sustained support, so seeking an ongoing resource base continues to be a priority. The Maine partnership (PIN 5) received funding from the statewide Department of Labor for the computer-based clinical placement system. Both the Arkansas Community Foundation and West Central Initiative partnerships (both in PIN 4) were able to establish relationships with their state

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AHECs that opened up new channels for funding through the Department of Labor. The Community Foundation of the Great River Bend (PIN 4) was able to partner with the Riverboat Development Authority to secure additional funding for their “Clinical Nurse Faculty Preparation” program. Most of the PIN partnership leaders reported by the end of the funding period that they were in the process of seeking additional funding sources from any feasible source, such as state and regional agencies and federal grant sources. Many also indicated that they would be seeking additional funding to sustain the project activities from foundation sources. Each of the partnerships indicated that finding sustained funding has been difficult and is a work in progress. Survey respondents indicated that 37% (N=68) had identified continued funding from local or regional foundations, and 31% (N=57) reported funding from health-related organizations (these are not mutually exclusive responses). Only 11% (N=21) reported government funding from workforce-related sources. The PIN funders recognized the importance of addressing nursing workforce issues, but in some cases indicated they would not be able to continue support due to funding priorities and limited resources to address multiple important community issues. Several funders indicated that they did not see their role as being the sustaining funder of ongoing nursing workforce development, and hoped that other funding agencies would step forward to support nursing work. Nursing is a priority for some of the funders, but rarely appears as the top priority since funding attention is focused across the health professions and in particular on improving the health workforce as a whole in many cases. As a result, nursing may continue to be part of sustained local initiatives in communities but will not be the primary emphasis. One PIN lead funder commented: “We have definitely come a lot further in our support for nursing. Our foundation is still a little challenged by the need for additional, ongoing financial support for nursing in general. One thing that has been an outcome of participating in PIN is making more links between local nurse leaders and opportunities to get them involved in places outside of nursing and forms of leadership roles in the board of the foundation, or affiliate foundations. We have some grants and other forms of support that are available but nursing is not currently a strategic program focus for the foundation because of all the other health and community issues we need to address given our mission and mandate.” Another funder had a slightly different perspective: “When we started the match I was really excited because I saw working on the project as a way to get all these smaller private foundations that typically fund in small geographic areas together because this was a project that would impact them locally but it was a statewide initiative. I saw this as a way to build a local funding collaborative -- and when that did not happen, it was hugely disappointing. Coming up with the match was not difficult, but coming up with a sustained source of funding has proven difficult. As long as we had the carrot of a prominent national project the small private foundations loved coming in as a match, but using it to create a sustaining funders collaborative that didn’t have that carrot -- well, it didn’t happen.” Some of the PIN lead funders reported continued funding for aspects of the partnership activities, either through commitment of their own resources or by leveraging the partnership. Both the Richmond Memorial Health Foundation (PIN 2) and the Texoma Health Foundation (PIN 5)

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awarded continuing funding to the local PIN partnership. The Endowment for Health partnership (PIN 5) became linked to the local United Way for continued funding. Community Foundation of Great River Bend (PIN 4) obtained $20,000 from a local grant to create a model to expand community-based clinical placements. The Dakota Medical Foundation (PIN 2) was awarded $500,000 from the state legislature to support simulation. In Maine, the partnership (PIN 5) was able to secure state Department of Labor funds for ongoing support of the computerized clinical placement system. The Arkansas Community Foundation partnership (PIN 4) secured funding from the US Department of Agriculture to create a learning laboratory in six nursing homes to provide continuing education for the long-term care employees. The Horizon Foundation for New Jersey (PIN 5) provided some funding for the early operations of the New Jersey Action Coalition. In New Hampshire, the Endowment for Health (PIN 5) was part of the development of the local action coalition through its role in a PIN 5 partnership. The PIN proposal asked funders to place themselves on a continuum consisting of three categories. Prospective PIN partnerships indicated their place on the funding continuum in their application to PIN. The continuum is defined as:

A. Had not made any grants to enhance nursing programs or projects in the last five years.

B. Had made grants to address issues of the nursing shortage within the last five years but had not developed a specific funding strategy around nursing issues.

C. Had already developed focused strategies that affect the nursing profession, had made grants in the field, and were ready to expand in new nursing program areas.

Table 17 illustrates the shifts along the funding continuum for all of the 50 PIN partnerships. Nearly half (N=23) of the partnerships moved along the funding continuum, indicating an increased strategic investment in nursing. Another 22 maintained a constant place on the continuum (at the A, B or C level). Only one funder reported a decreased investment in nursing by the conclusion of their PIN partnership project.

Table 17: Shifts Along the Funding Continuum

Number of Partnerships Place on the Funding

Continuum PIN 1 PIN 2 PIN 3 PIN 4 PIN 5 PIN 1-5

A A 1 1 A B 3 3 1 1 2 10 A C 2 1 1 4 B B 1 2 3 6 2 14 B C 4 1 1 3 9 C C 3 3 1 7 C B 1 1

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3. Relationships A key factor in creating sustainable solutions for ongoing workforce development was building effective partnerships. In all cohorts, the PIN partners described being able to work together effectively, especially in terms of having access to the information and expertise needed, using resources appropriately, establishing rules and processes, and the ability to adapt and respond to suggestions and changes. Consistently, there was a strong sense that the issues they were addressing were relevant and important and that the appropriate stakeholders were involved to represent needed interests. Organizations believed that there was an individual benefit for them as well as an opportunity to contribute to community benefit, and that other partners were appropriately dedicated and invested in the projects. Additionally, many partners indicated (in survey responses and in interviews) a strong conviction that the work done within the PIN partnership would have been difficult for any of the partners to accomplish individually. These findings have been consistent across all of the PIN cohorts. One PIN lead funder commented: “The lesson learned is how to build an effective partnership. First and foremost, every partner has to believe in the cause. We have a good group in that respect and starting from that foundation we’ve been able to work together because it is not easy to have different groups of people in dispersed geographic areas and have them come together periodically to figure out how to move forward. I think we’re doing it well because people believe in the cause.” Another PIN lead funder observed the following as an outcome of the work of their PIN partnership: “We’ve become great resources to each other. I’ve had a couple inquiries about future projects and whether our foundation might be interested. These are folks that before I would not have as readily reached out to and have candid conversations and have them come to us. I have one funder on the Board who asked us to see their grantee and assess whether would we fund them. So its examples like further partnership, mutual support for good organizations, a being a candid, open valuable information resource.” In another partnership, the lead funder observed: “At the beginning our challenge was figuring out where we fit in the process. The foundation had a hard time figuring out our role and what we were to do. Everyone was kind of dancing around trying to figure out what they were going to do because they were so used to [the university] taking over. [The nursing leader] understood that and was willing to be compromise in the best sense of compromising and letting other people be involved in that process. That’s when our consultants encouraged us to take an active role, and be the neutral party that keeps everybody involved. It still took a year but after that we began to function better as a group.” Many partnership projects continued beyond the PIN funding, and several partners have expanded their role in the field of nursing workforce issues despite financial challenges. At the individual level, participants have become more involved in work groups, task forces, and other projects. There is also an increased knowledge of the key organizations and individuals that should be involved in future partnerships. In some cases, the success of the partnership enabled projects to push partners beyond their typical comfort zone, and the collaborative model was seen as one that could be applied to address community needs in other sectors in the future.

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In the PIN 1-4 cohorts, several of the initiatives were “institutionalized” within the partnership organizations. Some examples of institutionalization are the West Central Initiative (PIN 4), which is continuing through the work of the local AHEC, and the John T. Vucurevich Foundation (PIN 4) residency program that is being incorporated into the regional hospital nurse orientation program. In contrast, seven of the PIN 5 partnerships appear to be ending with the conclusion of the RWJF funding. The Texoma Health Foundation (PIN 5) and the Bingham Foundation (PIN 5) partnerships are exceptions, and the initiatives are being incorporated into other existing programs and/or state action coalitions. Several challenges to working together have been identified throughout the five PIN cohorts. Most of these were based in the process and nature of partnership, and were not specific to nursing. Many of the PIN partners reported similar difficulties balancing the PIN project with other activities, turnover of participants within the partnership, the ability of partners to fulfill necessary roles, and successfully communicating accomplishments to the community. Factors beyond the control or scope of the partnerships included a shortage of resources and funding, the challenges of the central issue of the nursing workforce, and the need for long-term planning to adequately address problems and make substantial, necessary changes. Convening in-person was a problem identified by many partners, especially those that span large geographic areas and when the partners are educational institutions represented by faculty who face multiple competing priorities for their time. For many of these faculty, the partnership work did not appear to directly benefit them and was seen as service to the community which, while important, did not lead to professional rewards or recognition, especially if it was not generously funded or perceived as scholarly. E. Value of Participating in PIN Program to Develop Nursing Workforce Solutions Survey respondents indicated a number of benefits of participating in a national initiative, at both national and local/regional levels, and offered other insights on program participation. Ninety percent (N=165) indicated development of valuable relationships as the most important benefit, followed by ability to have a greater impact as a partnership than would have been possible as individual organizations (73%, N=135), and enhanced ability to address an important issue (70%, N=129). Responses were consistent across the focus areas of the partnerships. The most common drawback identified related to diversion of time and resources away from other priorities or obligations (31%, N=57). This was expressed more often by those working on faculty development or education infrastructure projects, perhaps reflecting other issues in higher education settings. Frustration or aggravation with a lack of progress of the partnership was identified by 14% (N=26); again, those working on education-related topics noted this most often, as well as those working on diversity issues. Finally, 11% (N=20) reported conflict between personal responsibilities and the partnership’s expectations; those working on diversity, and on collaboration and leadership projects, identified this as a drawback more often than others. 1. Participating in a National Initiative PIN partnerships reported that there was exceptional merit in participating in a national initiative, which provided synergy to accomplish the partnership goals. Being selected as one project in a relatively small national cohort in a specific year, and as one of 50 partnerships overall, brought an enhanced amount of “prestige and recognition” to the funders and other partners involved, as

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well as the association with the Robert Wood Johnson Foundation. Ninety-two percent (N=169) of the PIN survey respondents indicated they benefited because they were part of a program funded by RWJF. This helped them to gain local attention to the workforce needs within their community that would not have occurred otherwise. Participation in the partnership allowed projects access to resources, people and organizations they would not have had, and they were able to achieve things they would not have achieved otherwise. The fact that PIN was a national initiative funded by RWJF gave credence to the project in the local area, helped to develop attention to workforce needs within the local community that would not have occurred otherwise, and stimulated additional collaborations. Eighty-eight percent (N=161) of the PIN survey respondents agreed or strongly agreed with the statement that being part of a national initiative accelerated the achievements of the local partnership. Funders commented on the impact of the role of RWJF as the national funder, and the leverage this offered to gain recognition and prestige locally and regionally. Seventy-eight percent (N=143) indicated that they benefited from working closely with the Northwest Health Foundation. Ninety-two percent (N=169) of survey respondents indicated that their participation in PIN gave them access to resources, people, and organizations that otherwise might not have been available to them. The nurse leaders frequently identified that they were able to garner more cooperation with groups such as health care agencies, workforce investment boards, AHECs and nursing education programs because of their participation in PIN. Several indicated that they were able to gain access to other local funders because of PIN. Lead funders from all of the cohorts have made observations such as:

“We are very grateful for the opportunity that we have had … to form the partnerships that we have formed within our local community, and also the partnerships with the Robert Wood Johnson and Northwest Health Foundations and everyone there.”

“When I get things in the mail about nursing, it’s far more interesting for me to read than it was prior.”

“The PIN network and national meetings have allowed us an opportunity to explore other success stories and learn about moving forward. The program gave us a chance to profile the success of our work in ways that could benefit other states.”

“[We] are so pleased with the outcome of everything that we had done. [Our board] realized that it was beneficial to be a part of PIN.”

A PIN lead funder stated: “We were able to support nurse leaders in coming together for a meeting on the IOM recommendations which was directly related to participating in PIN. Being able to get people interested, active, and engaged was something related to our work with PIN. I think it helped raise the status of our work to identify that we were a PIN partner. A number of our other partners were able to get additional grant dollars because of their involvement.” Another funder stated: “There are some nursing initiatives that we get invited to because of PIN. There was workforce legislation that went through our state legislature last year that involves the workforce authority and we were part of thinking about how that was going to look. Then we were invited to the IOM meeting, meaning all the people who were at that meeting from our state could talk about what made sense as far as implementing those recommendations. I don’t know that we would have taken the lead on doing that without being in PIN.”

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PIN nursing leaders observed: “Being part of the PIN community and getting the information on things happening in

nursing, are important parts. In talking to different partners, and now talking to users I have the broader national view of issues in nursing.”

“I am able to take the information from the PIN emails and use that as a resource to make an argument for a change or innovation.”

“It was great that we had partnership funders and other states, and could see what they’re doing and how they’re addressing it.”

2. Developing a Local Strategy Nearly two thirds (N=116) of PIN survey respondents agreed or strongly agreed that they would not have actively pursued a project on nursing workforce issues without participation in PIN. One quarter of the respondents (N=46) agreed or strongly agreed that some of the partnership goals could have been accomplished without participating in PIN, suggesting that the PIN initiative was an important catalyst to work together on nursing workforce issues. Eighty-nine percent (N=163) indicated that their partnership made an impact on local/regional nursing workforce issues because of their participation in PIN. Of the PIN subject areas, the three areas of greatest impact identified across survey respondents were collaboration and leadership, educational infrastructure, faculty development and retention. As one funder commented: “Without a doubt I now have a bigger sense of the world connected to nursing workforce issues and funding around that. I sit on the board for [another] Foundation and I think as a board member in a hospital having been involved in some of these other experiences makes me a better board member. This issue is huge and we have to get more nurses educated.” A PIN lead funder stated: “To be more locally relevant, I think I would have put out a call to nursing educators in our region early in our process asking them what information they had on measures of impact of these new educational strategies, and seeing if we could work together throughout the project to collect that information. If we had done that, by now we might have had some results flowing in and more evidence on which to base our next steps. We have figured out how to improve the process of education, now it’s the impact and outcome measures and results I want to pursue.” The nurse leaders interviewed said that the issues surrounding the nursing workforce were now better understood by all of the partners. Specific strategies were developed that had true impact such as educational partnerships to address the educational needs of nurses in the health workforce, leadership programs for nurses, and educational pipeline development to increase diversity in the nursing workforce. A clear benefit of the PIN program emerged locally when a funder invested in a second PIN partnership. For example, the Blue Cross Blue Shield of Michigan Foundation was the lead funder for a PIN 1 partnership, and participated again in PIN 5 as a supporting contributor to the partnership lead by the Community Foundation of Southeast Michigan. The Colorado Health Foundation, also a PIN 1 lead funder, supported the PIN 5 partnership lead by the Caring for Colorado Foundation. Similarly, the Mount Sinai Health Care Foundation, a PIN 2 lead funder, supported the PIN 5 partnership lead by the Cleveland Foundation.

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3. Creating New Relationships Both foundation and non-foundation respondents were overwhelmingly positive about the benefits of participating in the PIN partnership for the development of valuable relationships, the ability to have a greater impact collectively than could have been achieved individually, the enhanced potential to address an important issue, and the ability to make a contribution to the community. The benefits of working with NWHF also received specific recognition. One PIN partner stated that: “the benefit of participating in the national PIN network created new networks of nurses and experts.” The Humboldt Area Foundation (PIN 5) established a relationship with the Florida Simulation Alliance partnership (Blue Foundation for a Healthy Florida, PIN 4), and adapted lessons learned from this previous PIN partnership in its work in Northern California. The Dakota Medical Foundation (PIN 5) utilized the programs developed in the Vetter Foundation partnership (PIN 4) in educating nurses working in geriatrics. The Caring for Colorado Foundation partnership (PIN 5) linked with multiple PIN partnerships to identify credible subject-matter experts on topics related to the nursing workforce, the faculty shortage, and implementation of the IOM recommendations. The Dreyfus Health Foundation (PIN 1), although based in New York, was funded to create a partnership in Mississippi, and subsequently established a close connection with PIN Pacific (PIN 3). The Mount Sinai Health Care Foundation (PIN 2) became a supporting partner with the Cleveland Foundation (PIN 5). A PIN nursing lead observed the following about working with other PIN partnerships: “We have received advice and insight. We’ve used some of the work from other PIN partnerships in our own work, mostly for resources and information that we’ve been able to incorporate into our work.” Another nursing lead said: “I got a lot of encouragement by looking at another project that was similar to ours and learning from them the things they were experiencing; this made it easier to understand what we were experiencing.” Most partnerships connected in some way with at least one other partnership for consultative or collaborative work, often making initial connections at the annual meeting. Through these relationships, partners learned how other partnerships were approaching the same issues in different ways and recognized the many challenges they had in common. Relationships developed through these connections were especially important for sharing lessons on how to create an effective collaborative process. 4. Articulating New Insights PIN funders were consistent across the five cohorts in articulating new insights. Some funders had a long history of working with nursing, and for some this was their first experience with nursing. A PIN funder expressed this as follows: “Now I understand nursing a little bit better. I think they still have their own special language but the fact that we were working on something that would help affect the system -- that was helpful in my understanding. The need to place nurses for training, the practical hands-on experience, trying to figure out navigation through the education system, what Biology 101 means at this university versus another school, the whole scholarship piece for the faculty -- these were really tangible things for me to get my head around, and to try to understand the system as a whole, as well as the nursing community.”

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Funders reflected on the new insights they gained about the role of nursing in the community, and in the health workforce, and identified opportunities for continued work in the future related to nursing. Several PIN funders have made statements such as: “I now see the nursing profession as the backbone with the community health centers, and of the health care system overall.” In some cases, specific work with nursing will not continue due to funding priorities, but in many cases funders indicated they hope to build upon PIN either through work with nursing or with other health workforce groups. Many funders had not previously worked in multi-sector partnerships, and they identified new insights into the benefits of such partnerships and their new recognition of the potential to develop such partnerships for other future projects. Funders from various cohorts have articulated new insights about nursing as follows:

“I came into it with my only experience as a patient and feeling that the best care I had gotten was from a nurse. I started from a very positive point. There were times when I was disappointed but I think now that it was my own naivete.”

“My level of understanding about the nursing field has changed enormously, about the different kinds and levels of nursing education or training -- whether it is acute care or long-term care, how education is delivered, issues about the aging nursing leadership, lack of incentives for practicing nurses to move into teaching positions.”

“I had assumed the nursing profession and physicians were working more in collaboration with each other, and it was quite disappointing that wasn’t the case.”

“I feel a thousand times more educated than before but I still feel ignorant because there is still so much to understand.”

“The nurses were very patient with me. They are so accustomed to using acronyms and I had to keep asking time and again. They had to be careful about the language they used that wasn’t readily understandable to outsiders. [One thing] I brought to the table was my own ignorance.”

“Some of the nursing leaders really didn’t understand how foundations work. In some ways they think of us as an ATM and don’t recognize our own foundation funding priorities and strategies we’re trying to implement.”

“We know some things better about nursing. It was difficult going to the conferences and not even knowing their terminology, their way of speaking or how they referred to things. We were so out of that loop… we learned a lot, it was interesting but it was difficult to understand.”

Other funder comments were more broadly focused on health care in general, but related back to nursing. A PIN lead funder said: “The Affordable Care Act came on board during the PIN project. I learned a lot about how quickly some things can change -- how federal policy and economic decisions can ripple through, the need for support, how fragile the health care workforce is. I look at those issues differently now because I know how they play out in the workforce. There are factors that make retention and turnover real issues and there are things that can be put into place that can really help with that. I was totally unaware of those issues before PIN. Now with the IOM report as well we are understanding more about what needs to be supported to expand the nursing workforce.” The nurse leaders also expressed similar sentiments across the cohorts, indicating that they developed new insights into foundation operations and increasingly realized the importance of positioning their projects to be attractive for ongoing foundation funding. They recognized that

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they needed to seek out funding partners who would support the focus of their proposed project, rather than assuming that the funder would support them simply because they are from the local community. With many funders increasingly focusing on multiple health professions, some nursing leaders recognized the importance of engaging in local interprofessional initiatives, as these may be the focus of investment of future funding. Nurse leaders also commented on the benefits of collaborating with the new state action coalitions, and in some partnerships were able to link the PIN project directly to the work of the coalition for continued nursing workforce initiatives. 5. Operational Observations When asked what they would do differently, many PIN nurse leaders indicated that they would involve and engage all of the partners at the beginning of the project. Developing dedicated staff support for the work of the partnership was identified as needing to be addressed at the initiation of the project. Those partnerships that integrated staff support from the beginning of their work were able to move forward with their activities at a faster pace. A continued theme throughout recent PIN cohorts is the importance of starting to think about evaluation activities and reporting early; many partnership leaders (funders and nursing) indicated they have changed their evaluation strategies across multiple projects from evaluating activities to evaluating conceptually. Nursing leaders also spoke explicitly to thinking about the sustainability of the project from its beginning; one said: “From the beginning we probably should have worked on sustainability when all the buy-in is there; when you come back to talk about sustaining it the funding is a challenge.” Some nursing leaders indicated that they would begin with considering the business case for their proposed project, and potentially develop a business or action plan at the beginning. Foundation leaders expressed similar sentiments. Funders also appreciated the reporting and accountability requirements, as well as being part of PIN: “It was eye opening, it was uncomfortable right at the beginning… to become a grantee and then have to figure out the rules. We were very aware that if we did not do this according to our grant application and figure out what we want to do, that [we] would be held responsible for that money. It was a position that we took extremely seriously, maybe even to a fault, protecting the [foundation] and what we wanted to see happen. At the beginning it was uncomfortable but we got more and more comfortable through the three years about what was expected of us.” One funding partner observed: “One thing that became a point of irritation to me was that some members of our working group frequently did not come to the meetings. I found that so frustrating because I was taking time out of what was a very busy schedule for me and I began to question their commitment. I am not sure … if my expectations were unrealistic. We really thought about the meetings and whether we needed to be there in person, whether the meeting was needed, we developed a protocol for decision-making. We learned from it and developed a more flexible way of operating but at the time I was very frustrated that I was hauling myself across town to meetings to find out three key people weren’t there. I thought: I am not even in this field why am I at every meeting and these other people are not.” A nursing partner related a significant challenge: “We had six or seven partners all of whom were generous with time, money, interest, and information. As the economic challenges were hitting the community, and the organizations got stressed, all of a sudden the person from the collaborative who was connected to the organization lost their spot to have influence within the

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organization. How to institutionalize a collaborative project amongst all the collaborators in a way that is meaningful and sustainable is the challenge.” Some partnerships observed that personnel issues created challenges either initially or during the project. These were emphasized when there was a change in project director, or when there was a change in leadership of key partner organizations. A PIN nurse leader had a comparable observation about staff turnover: “Everyone was on board, but when we had turnover in the key leadership, then you’re trying to bring new people up to speed. There was a lot of transition that made it difficult.” The increased time commitment needed for the partnership was cited by several projects. One PIN funder described the following challenge: “There was sometimes conflict in terms of who is in charge, who makes some decisions -- trying to negotiate those kinds of things was sometimes challenging and the fact that we were not physically located near made it difficult.” In addition, budgetary issues created challenges, such as observed by this nurse leader: “We were affected by cutbacks, and they had to go back and put it in their budgets but then they couldn’t afford it. It wasn’t because they didn’t see value, they just didn’t have the control to fund it.” In the face of these challenges, however, there were many achievements attributable to participation in PIN. The involvement and coordination of efforts of unique partners and stakeholders was a success in and of itself for many partnerships. Through these efforts, partners increased their credibility in the nursing field and in philanthropy, and shared best practices. Partnerships implemented the programs outlined in their original proposal and many went beyond these goals during the funding period and even further after the funding formally ended. In many of the PIN 4 and 5 partnerships, there were clear accomplishments related to improving the delivery of health services at the local level, often as a result of new collaborations among multiple providers in the local health system. Approximately two thirds of survey respondents in each of the four focus areas of faculty development, collaboration and leadership, geriatrics and long-term care, and education infrastructure indicated new opportunities for collaboration; the responses were just over half for those working on diversity issues. Funding and nursing leaders, in the end-of-funding interviews, generally indicated that the amount of funding was sufficient, but that the two-year funding period was not, and appreciated the flexibility of a no-cost extension (44 of the 50 PIN partnerships extended their project work beyond the initial two-year timeframe). Similarly, only 41% (N=55) agreed that the two-year timeframe was sufficient to accomplish the partnerships’ project goals. General feedback about the program provided a few specific suggestions related to finding the matching funds, a longer period of time to use funds, and establishing relationships with NWHF and RWJF as resources for other projects. Other comments indicated that the PIN project was a worthwhile investment, and developing partnerships was an important endeavor to continue in some form; partnerships were key for establishing and cementing relationships among key partners at the regional and national level. One funder said: “The PIN programs have had a tremendous effect on nursing and its future and, thus, contribute to the society as a whole.” Several respondents explicitly said “thank you” for the opportunity to participate.

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F. Value of Support Provided by the National PIN Program Office The national PIN program office provided technical assistance as a specific strategy to support partners on key issues of communications support, network development, evaluation consultation, and strategic coaching and facilitation. 1. Utilization and Satisfaction Survey respondents were asked to comment on their utilization of, and satisfaction with, several elements of technical assistance provided by the national PIN program office. As shown in Table 18 below, over three quarters of survey respondents indicated that they took advantage of networking and/or collaboration with other PIN partners. Nearly two thirds participated in educational webinars or conference calls, and slightly over half had participated in evaluation consultations. Despite considerable effort from the PIN program staff on assisting partners with communications consultations, only 42% (N=77) survey respondents had been involved in these, and slightly fewer had used the PIN Wiki.

Table 18: Use of Technical Assistance Opportunities

Nursing Partners

Funding Partners

Other Partners All

Technical Assistance N % N % N % N % Networking 66 87% 47 85% 45 85% 158 86%Collaboration with other PIN partners 64 84% 35 64% 41 77% 140 76%Educational webinars/conference calls 52 68% 40 73% 27 51% 119 65%Evaluation consultations 41 54% 37 67% 25 47% 103 56%Communications consultations 35 46% 23 42% 19 36% 77 42%PIN Community Wiki 32 42% 26 47% 18 34% 76 41%

PIN participants’ level of satisfaction (very satisfied or satisfied) with these various technical assistance opportunities is presented in Table 19.

Table 19: Satisfaction with Technical Assistance Opportunities

Nursing Partners

Funding Partners

Other Partners

All

Satisfaction with Technical Assistance N % N % N % N % Networking 52 68% 37 67% 31 58% 120 65%Collaboration with other PIN partners 50 66% 36 65% 23 43% 109 59%Educational webinars/ conference calls 45 59% 29 53% 20 38% 94 51%Evaluation consultations 40 53% 31 56% 18 34% 89 48%Communication strategies consultations 32 42% 21 38% 14 26% 67 36%PIN Community Wiki 24 32% 17 31% 11 21% 52 28% These quantitative findings reflect a lower level of satisfaction than expressed in annual meeting evaluations and in the qualitative comments obtained both in interviews and from project reports.

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The results presented here may be somewhat skewed by the perceptions of the survey respondents as compared to the project leaders (who completed the reports and the interviews). 2. Creation and Support of the PIN Community A goal for the PIN program is to create a nationwide network of private philanthropy and others dedicated to supporting innovative and comprehensive activities that promote the nursing profession. Network development is a key strategy of the PIN program as it seeks to sustain interest and investment in the nursing workforce issue across the country. Three key strategies focus on the building of the peer network: web-based interactions, annual meeting, and educational webinars and conference calls. Survey respondents took advantage of networking opportunities, primarily through the annual meetings, as well as the educational webinars and conference calls. All respondents indicated a high level of satisfaction with the networking opportunities and the opportunities for collaboration with other PIN partners. The PIN program used its website, www.PartnersInNursing.org, as both an information and reporting source and a portal (Wiki) for communication among partners. The ability to communicate in this manner served to facilitate interaction among the partners, as well as with the PIN program office. The Wiki was used primarily as a site to promote accountability: partners were required to post periodic reports and other information there. In some cases PIN partnerships also used the site to create a locally-relevant space to coordinate their own partnership activities. The results from interviews, surveys and project reports across the five cohorts indicate that the Wiki was utilized by some partnerships, but many individuals were not familiar with the concept of a wiki, did not find it useful or easy to navigate, and as a result did not use it frequently. Satisfaction with the Wiki was rated at 28% (N=52) satisfied or very satisfied by PIN survey respondents. Despite efforts by program staff to redesign and enhance this resource, it appears that it was not as valuable for PIN partnerships as had been anticipated.

The annual meeting of the PIN partners was a significant part of network development. The meetings provided a venue for PIN partners to meet and learn about each other, develop peer mentoring relationships with other PIN partnerships, attend focused trainings and receive face-to-face technical assistance from PIN staff, consultants and presenters. Seventy-one percent (N=130) of survey respondents reported a high level of satisfaction with the annual meetings as a place for networking across the PIN community; anecdotal reports of annual meeting surveys conducted by the PIN program staff reported a similar level of satisfaction, if not higher. As a PIN funder observed: “Going to the PIN project conferences further allowed you to understand; you could see national models and talk to nurse leaders from throughout the country.” The first PIN partner meeting in 2006 focused on establishing the PIN community, and had a strong emphasis on creating the framework for evaluating the work of the PIN partnerships. The 2007 meeting offered PIN 1 partners a chance to present their work to date, and introduced specific strategies on collaboration with Arthur Himmelman, as well as sessions on strategic communications. At each subsequent meeting the partnerships had an opportunity to share their work, although the specific strategies varied by meeting. The 2008 meeting emphasized collaboration and partnerships, remembered by many participants for the Lego team activity. The 2009 meeting theme was “Increasing Resilience in a New Economy” and challenged participants to think about their roles in influencing policy, as well as providing partnerships with specific time to build relationships with other PIN partnerships.

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The 2010 meeting was linked to the launch of the IOM Future of Nursing report. In 2011, the meeting focused on the value of a diverse nursing workforce, and illustrated techniques for storytelling. The 2012 meeting addressed networking and peer learning, and introduced the sustainability pilot opportunity with Ned Schaub. The 2013 annual meeting addressed sustaining impact, and continued the partnerships’ work with Ned Schaub. Partnership leaders acknowledged the importance of addressing sustainability and building capacity to continue the work of their PIN partnership, but the specific responses to the 2013 annual meeting content were more mixed than in previous years in terms of added value and new ideas. Partnership leaders (both nursing and funding) saw the annual meeting as an opportunity to advance their learning and build new relationships, and appeared eager for topics and presenters that would challenge them and give them new information that they could not otherwise access. Clearly this is a challenge for the PIN program staff in planning the final “legacy” meeting that will take place in Fall 2014. The partnerships gained the most value from the annual meeting by being able to learn about work in other partnerships and having a chance to network with others. The value of networking among the partnerships was the technical assistance opportunity consistently ranked the highest by survey respondents in each cohort. Funders regularly commented on the value of meetings to build new networks across funders, which then transferred to other local, regional or national venues where funders might work together. Nursing leaders identified many linkages in their interviews, and the final project reports documented frequent contacts that helped to accelerate local work by learning from previous PIN partnerships. Various funding partners from the five cohorts have offered comments such as: “An important thing is the national relationships through the PIN meeting -- finding out what other projects are doing and linking up with other foundations, which leads to the national nurse funders group and things that we might not have known about had we not been part of PIN.” One partner who worked closely with business observed some resistance from academic partners at the annual meeting when they would raise the value of partnering with private interests such as business or private foundations. This partner commented: “It was like we were intellectual allies but it was a little frightening to see the insulation of the academic world. I thought those messages were clear and the benefits were clear and for whatever reasons there was a lack of interest or lack of understanding. We need to work on the lack of understanding of different kinds of foundations.” Some partnerships focused their efforts more on local development than on networking across the PIN community. At the conclusion of their funding period, one PIN lead funder commented: “I now feel really strongly that we could have benefited from getting more of our partnership directly involved in PIN. It would have been great to have a few more people come to the annual meeting, having that direct networking opportunity with people doing similar work across the country. I regret we didn’t have our project manager participate because she would have gained a lot and been more in touch with how much bigger the PIN partnership is than just being a grant. Some people in our partnership recognized it was so much larger but after every meeting or interaction with program officers or attending the meetings the direct experience for people would have meant so much more than me trying to relay this back as a funder.”

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Both nursing and funding leaders frequently indicated that networking with other partnerships occurred at the annual meeting, and through the wiki, conference calls, and in other professional nursing venues. The one-year site visit was cited as an effective mode of communicating learning from other partnerships to all members of the local group, who might not participate in other PIN-related networking activities. Each of these areas was important for the partnership to find new ideas and learn from others about collaboration, success factors and areas of difficulty. Most of the reports and interviews cited the webinars and quarterly conference calls as being very useful, offering opportunities for learning from other partnerships and providing a chance to have questions answered. The first-year site visits by a member of the evaluation team were noted in almost every report as being helpful not only to the project evaluator but also to the partnership members as a whole. Partners valued the opportunity to “check-in” with someone from the overall program, and the visits gave more local participants a chance to meet and speak with someone from the national program. Survey respondents indicated high levels of satisfaction with opportunities to connect with other PIN partners through networking (86%, N=158) and collaboration (76%, N=140), as well as for technical assistance provided through educational webinars and conference calls (65%, N=119). One funder commented: “[We valued] the ability to reach across the partnerships to help each other learn; there’s a real sense of community that RWJF and NWHF clearly fostered.” A PIN funding partner stated: “RWJF and NWHF are exceptional with technical assistance for the grantee; we want to support our grantees and to be there for them in the same way.” 3. Evaluation Consultation The PIN program had very specific expectations for evaluation reporting based upon a common format for all partnerships, with a considerable amount of flexibility built in to accommodate local partnership emphases and design of local evaluation activities. For some partnerships, this was an initial challenge, as many partners (both funders and nursing) had not engaged in this kind of evaluation accountability in previous projects. Several partners commented in their interviews that they had come to approach evaluation in a different way as a result of their PIN experience. This demonstrated that the commitment to evaluation modeled by NWHF had a ripple effect to foundations involved in PIN partnerships. This quote from a funder summarized the experiences of many of the funders with the PIN evaluation: “We now realize we need to set the tone for evaluation from the beginning, building those evaluations in right from the start. What do we really want to achieve and how are we going to measure it? I feel like that’s a struggle, an after thought. PIN has given me that additional lesson of the importance of bringing evaluation into the equation from the very beginning. We’ve looked at evaluation as an endpoint, but PIN has really forced me to look at it differently. So I give the credit to what the PIN program has brought to us.” Another funder commented on their site visit with the evaluator, saying: “I still remember the meeting [the evaluator] attended where they asked us a question that floored us and probably shouldn’t have. They asked us not just how we thought we should proceed, but whether we thought we should proceed. That’s a really good way to think about it -- does this need to continue, and if it does, this is what it should look like. Asking that question gave us permission to think about it differently and think about ok this was a good start but what next.”

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Both funding and nursing leaders gained new insights about the importance of evaluation planning and starting evaluation early in the partnership. They indicated that they learned a great deal about evaluation from the PIN participation, evaluation training, and reporting mechanisms. Many found that that they were able to use the PIN evaluation structure and approach in other projects – both as funders and as grantees/applicants. Funders also appreciated the reporting and accountability requirements: “I loved the fact that we were held accountable to report back. Sometimes it felt a little burdensome but I think it kept us focused on what we were supposed to accomplish. It wasn’t just “here’s the money and go do it and tell us how you do” but it was “here’s the money and keep us informed, we expect you to come to the annual meeting and report out and we expect to hear about these outcomes.” I thought that was good. In our own grantmaking process we are now using some of those best practices we learned.” Satisfaction with the evaluation consultants (Linda Norman and Sherril Gelmon) was high, in particular with respect to site-specific technical assistance (on-site during site visits, consultations during the annual meeting, or other contacts throughout the year). Many partners indicated a shift in their perspective on evaluation, recognizing the value and purpose of evaluation at the outset of projects, rather than as an afterthought; many partnerships indicated they would carry this perspective to future projects. 4. Strategic Coaching and Facilitation PIN program staff devoted considerable time to strategic coaching of PIN partnership leaders, and facilitation of various efforts to help the partnerships achieve their goals. The guidance provided (based on time of their employment with PIN) by Judith Woodruff, Jennifer Fuller and Renee Jensen Reinhardt, and their timely responsiveness, was mentioned in many reports. Specific observations included: “They were always available and upbeat and inspiring and easy to talk to.” “Staff were superb!” In both the final reports and the interviews, the PIN program staff was praised by the partnerships for their expertise, excellent communication and problem-solving skills, and flexibility. Despite changes in program leadership during 2013, comments about the staff continued to include descriptions such as professional, helpful, motivating, organized, talented, responsive, extraordinary, and committed. Communication beyond the scope of the funded partnerships was especially appreciated. Many partnership leaders also commented on the flexibility of the PIN program staff in assisting them in budget reallocation when specific partnerships activities changed. Most frequently, staff was cited for being knowledgeable about the projects and processes needed to enhance the work of the partnership. Almost every person volunteered that the staff were exceptionally helpful to meet their needs. “They also have been very quick in their responses and always made sure that we understood what was expected of the project.” When asked a specific set of statements about the PIN staff, respondents were very satisfied, with 80% or more of PIN survey respondents indicating satisfied or strongly satisfied on these statements:

The PIN staff were flexible and easy to work with.

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The PIN staff were responsive and provided useful direction when we experienced challenges.

The PIN staff supported achievement of our goals throughout the duration of the project. The PIN staff modeled collaboration and inspired us to work together. The PIN staff facilitated and supported networking among PIN partners.

Other comments offered about staff included:

“I always felt supported by them, I felt like I could reach them with any questions about our work, and I learned a lot from both of them!”

“The PIN staff supported us, cheered us, taught us and generally made this project a success.”

“I hope that I am as respectful as a program staff, in terms of the flexibility, willingness to think about how projects might evolve over time, to work with us.”

“I can't say enough about the high caliber of professionalism, service, and humanity embodied by the PIN staff. Amazing.”

5. Communications Support Technical assistance on communications and public relations was provided to the partners and to PIN from an external communications firm which provided coordinated messaging and media relations for RWJF’s Human Capital programs and projects. This consultant provided extensive one-on-one work with PIN partners, including video consultation and development; creation of logos and other marketing materials; assistance to PIN partners with opinion-editorials for local publications and other written media; and consultations regarding best practices and methods for communication among multiple partners, including electronic newsletters, Google or Yahoo Groups, Facebook, Twitter, and other media strategies. Several PIN partnerships spoke specifically to the benefit of working with PR Solutions throughout their funded project. Satisfaction with the communications strategies consultations, as reported in the survey, was highest for nursing (42%, N=32), than for funders (38%, N=21)) or other partners (26%, N=14). Across all respondents, satisfaction with the communications strategies consultations was reported at 36% (N=67). These numbers may reflect the pattern of respondents, some of whom may not have worked as closely with these consultants as project leaders. V. DISSEMINATION There are many opportunities for dissemination of program outcomes and lessons learned from the national evaluation. The co-evaluators have previously reported on presentations in the annual evaluation reports, and have now begun work on summative articles describing the evaluation of the PIN program in general as well as the developing insights about partnerships. To date, presentations have been made at meetings of the American Public Health Association, AcademyHealth, Community-Campus Partnerships for Health, the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Health Care, the International Association for Research on Service-learning and Community Engagement, International Institute on Partnerships, and the International Forum on Quality and Safety in Healthcare. Many partnerships have disseminated their work through poster and verbal presentations at regional/national meetings and through written publications, and are also using online

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technology for ongoing dissemination; a catalog of these efforts is beyond the scope of this report. Many have indicated they have plans for continued dissemination about their project outcomes and lessons learned beyond the end of the funding period. Ideally, there will be collaborative efforts among program staff, evaluators and partnerships to disseminate the insights from PIN. The PIN end-of-funding survey instrument was cited in a monograph entitled “Partnerships: A Workforce Development Practitioner’s Guide” which was published by the Commonwealth Corporation in June 2013. This guide referenced work of the “CAN-DO” partnership (Irene E. and George A. Davis Foundation), and its successor the Western Massachusetts Nursing Collaborative (Commonwealth Corporation was contracted as the evaluator for the CAN-DO PIN partnership), as well as the overall PIN program. The guide is available at http://commcorp.org/resources/detail.cfm?ID=999. The PIN 1-5 evaluation team will continue to seek opportunities to disseminate findings and insights, in collaboration with the PIN program staff as well as with PIN partnership leaders who have expressed an interest in dissemination. The findings will be used to help understand the impact of the PIN program in local communities as well as nationally. The literature on evaluation of partnerships and collaborations is not extensive, and this work hopefully will contribute to the philanthropy and nonprofit literature, as well as to the nursing knowledge base. Partners have specifically requested that the program “ensure participants are aware of the accomplishments and receive summaries of the evaluation findings.” To date, the evaluation annual reports and executive summaries have not been posted on the PIN website or provided on the Wiki, but we hope that these reports may be made available to PIN participants. VI. CONCLUSIONS Collectively, the PIN partnerships have made a significant impact on nursing workforce issues in their region. Since the partnerships were developed as strategies to address local issues related to the nursing workforce, each had a unique focus based on local needs. The complexity and involvement of the communities and number of partnerships increased with each PIN cohort. The conclusions below are framed by the six concepts that have framed the evaluation. Evaluation Concept 1: Expand Philanthropy’s Role in Nursing Workforce Development The goal of the PIN initiative was to expand philanthropy’s role in local and regional nursing workforce development. Each of the PIN projects was successful in achieving this goal, some to a greater extent than others. Participation in PIN changed how many foundations approached community engagement and partnerships. A consistent theme was that the role of the foundation was viewed as being a convener, facilitator, and champion for a specific issue, which created a “safe place” for organizations to come together to solve a community problem, even those that typically were competitors. Foundations were able to identify and engage partners from business and government, in addition to those engaged in health care issues, who were new players as compared to those the nursing partners typically approached for problem-solving. The nursing partners consistently indicated that the collaborations with multiple community agencies were a key factor in the success of the PIN project activities.

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The PIN initiative was able to enlighten foundations’ knowledge of the contribution that nursing workforce makes to health care delivery within the community, and established as a priority the importance to the economy of a well-prepared nursing workforce. Many lead funding partners indicated that their foundation expanded its activities to be more engaged in community issues as a result of participation in PIN. The foundations as “grantee” allowed them to become a catalyst for others to invest in the nursing workforce, leading to new collaborations within their regions and more engagement in other community issues. A funder quote that exemplifies the results of participation in PIN was: “Local philanthropy can be very powerful in bringing people together. A funder doesn't need to be directly connected to health care to understand the importance of the issues we face and to support them.” An overwhelming theme among the nursing partners was a greater understanding of foundations, how they operate, and the importance of linking with those who have a mission and priorities that are consistent with a specific initiative. The nursing partners, like the foundation partners, also learned about the importance of including multiple partners from outside of health care. Working with the foundations in the PIN initiative changed the way the nursing partners approached grant related activities. Both the nursing and foundation partners reported a heighted awareness of the importance of evaluation. Many foundations changed their evaluation processes to utilize a conceptual framework approach that was consistent with the evaluation methods of the PIN initiative. Each indicated that they had a new appreciation for reporting outcomes and impact in addition to the participation in the grant activities. The partner relationships in almost all of the projects matured during their participation in PIN. They were able to build new ways to work together and pursue new opportunities as a result of the PIN initiative. Evaluation Concept 2: Advance Local and Regional Nursing Workforce Solutions Each of the PIN partnerships was unique and a common quote was: “When you’ve seen one PIN partnership, you’ve seen one PIN partnership.” As the PIN projects were designed to meet the specific needs of the communities, the purpose and approaches were very individualized. The value of working as a local partnership allowed them to address issues that were of importance to the community instead of having to tailor their grant activities to a national priority, as with many other workforce related grant programs. For other communities and areas that have similar issues and problems, the PIN partnerships can serve as a model of how to approach nursing workforce issues that could be generalized to other health care workforce issues. While the major purpose of PIN was to advance nursing workforce solutions in local and regional communities, an important aspect that each of the 50 partnerships communicated was the importance of community involvement in the issues of nursing workforce and the need to spend part of their time educating others about the specific issues of their area. Just as nursing partners learned about the workings of the foundation community, the community partners developed a better understanding of the issues associated with the nursing shortage. Funders developed a greater appreciation for the complexities of nursing and the issues surrounding expanding and enhancing the workforce. They consistently emphasized that they

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learned new information about the critical role that nurses play in improving the health status of a community and its relationship to the economy of the community. As one funder stated: “We learned so much about the complexities of the issues surrounding nursing. To be involved in this partnership during the age of health reform was particularly interesting. Our nursing community is sophisticated, committed, and patient. It was inspiring to be part of a group that is truly focused on long term goals.” Evaluation Concept 3: Grow and Enhance Local and Regional Partnerships The PIN initiative was successful in developing a model of how local and regional partnerships can come together to address issues that no one else is working on and create a synergy across multiple sectors of a community to begin communication and problem-solving. An important outcome of most of the PIN partnerships was the development of new models and methods of partners working together to bridge their respective interests and priorities. Many indicated that engaging “less traditional partners” enhanced the effectiveness of the project and expanded the impact within the community or region. However, at the end of the project, several PIN partnerships indicated that there was a missed opportunity of developing a substantial relationship with the business community. Some important lessons learned addressed the need to carefully choose partners who were aligned with the goals of the project; more partners did not necessarily enhance the impact of the project. Almost all of the partnerships emphasized the need to pay attention to the organizational structure of the partnership, and allow sufficient time for the partners to get to know each other. Close relationships between the partners were an essential factor in the success of the PIN projects. Another key factor in growing and enhancing partnerships was the ability to establish mechanisms to address and overcome challenges and differences among the partners. Multiple commitments of the partners and changes in leadership created difficulties and delayed progress when they occurred. Partnerships need to establish methods to address these issues when they surface. The importance of engaging other agencies such as workforce boards created new networks for many of the PIN partnerships and helped not only to expand the influence of the PIN project but enhanced success in engaging other partners. At the end of the PIN project, most had expanded beyond the local level to a regional or statewide initiative. Evaluation Concept 4: Create Sustainable Solutions for Nursing Workforce Development The PIN partnerships were similar to other grant-related initiatives, in that some continued beyond the funding and some ended. One of the biggest issues to sustainability was finding ongoing funding to support the work. Most of the partnerships indicated that now they recognize the need to begin to plan for sustainability at the beginning of the project, rather than waiting until the project is well advanced in its work. Some of the most successful efforts in sustainability were those that were able to integrate the project activities into the work of a partner organization. Others were able to develop a fee structure to support their ongoing work or garner support from other external agencies. A key outcome of most of the PIN partnerships was the continuation of the relationships among the partners. Even for those where the work of the project ended with the conclusion of the PIN

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funding, the partners have often continued to work together on nursing workforce related issues or other health care workforce issues. Evaluation Concept 5: Demonstrate Value of Participation in a National Program Each of the PIN partnerships accentuated the importance that participating in a national program had on the success and recognition of the project. It enhanced their ability to attract and engage partners in their work. The association with a Robert Wood Johnson Foundation project raised the profile and importance of the project at the local level. The organization of PIN facilitated the partnerships to establish new networks of contacts and a process to share information with others who were working on like problems. Both nursing and foundation partners highlighted that they had developed new contacts that led to participation in other organizational activities. The national grantee meetings created an opportunity to learn from others while they were engaged in the partnership activities and to utilize new strategies in their projects. Many commented that the connections that they made through PIN would be continued as they work on other workforce initiatives in their communities and regions. Evaluation Concept 6: Clarify Value of Support Provided By the National Program Office The PIN national program office received praise from each of the 50 partnerships. The helpfulness of the staff and the quick response to questions and issues were the key elements cited. The ability to have questions answered and resources identified quickly enhanced the progress and success of the projects. The partnerships indicated that they benefited from the multiple resources provided by the program office and the PIN website, as well as the connections to others who were working on similar issues. All of the partnerships expressed the value of the PIN community that served as a resource during their project and extended after the projects were completed. Final Comments PIN was a catalyst to start many of the projects that became PIN partnerships, and the partnerships were a necessary step to begin addressing nursing workforce issues. Despite the successes of the PIN partnerships, many participants identified specific issues that continue to need attention beyond the PIN initiative. These include:

Creating leadership development initiatives within nursing practice and as part of the nursing curriculum.

Increasing diversity within the nursing workforce. Enhancing emphasis on nursing’s role in community-based and primary care delivery,

particularly as part of health systems reform. Recognizing the value of increasing the educational level of nurses and understanding

how career progression contributes to enhanced patient care outcomes and health care quality.

Continuing to prepare the nursing workforce to meet the needs of an aging population. This report has presented findings that summarize the experiences of the PIN 1-5 partnerships. Given that the PIN project’s success relied upon development of personal relationships and effective partnerships, it is appropriate to end the report with a synthesis of partners’ viewpoints on their experiences of the PIN project:

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1. The time was right to work on nursing workforce issues. 2. The level of commitment among the PIN partners was high, partners were dedicated

to this project, and organizations benefited from being part of this work. 3. Participants in the PIN partnership knew and understood the goals for the PIN project. 4. People involved in PIN partnerships trusted one another, communicated openly with

each other, and were willing to consider various approaches to their work and compromise when necessary.

5. The organizations involved in the PIN partnership were the “right” organizations to address local issues and represented a cross-section of those who have an interest in what they were trying to accomplish.

6. Partners were able to adapt to changing conditions that affected their collective work, and keep up with the work necessary to coordinate all the elements of their project.

7. Celebration of achievements was an important element in working together. 8. What individuals were trying to accomplish within PIN would have been difficult for

any single organization to do by itself. PIN was successful in meeting the goal of enhancing the nursing workforce through the use of partnerships among funders and nursing organizations. PIN can serve as a model for communities of how partners can join together to have an impact on a national issue and create solutions at the local level. The evaluation team would like to express our appreciation to RWJF and NWHF for giving us the privilege of evaluating the PIN initiative for the annual and comprehensive evaluation of the PIN 1-5 projects. It has been a joy to be engaged not only in the overall evaluation but also to work closely with the local partners in evaluating their work and assisting them to meet their project goals, Submitted: June 2014 Nashville, TN and Portland, OR

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Appendix 1: PIN Partners Previous Participation in RWJF Projects RWJF was interested to learn what synergies there were among PIN partnerships with other RWJF programs. Survey respondents were asked about their involvement as organizations or individuals in various RWJF funding, scholars and fellows programs. As shown in Table 1-1 below, across the PIN 1-5 cohorts, 38% of the funders responding had previously been involved in the RWJF Local Initiatives Funding Partnerships (LIFP) program, and half of the nursing partners had been involved in LIFP and/or the Center to Champion Nursing state teams. Previous participation of individuals in RWJF programs has been minimal. A PIN funder who had previously participated in LIFP commented: “I have always like the Robert Wood Johnson partnerships with local funders. We did a lot of local initiatives grants and they were neat. In these grants they back off of the prescriptiveness and let the light shine brightly in the local areas.” Across all partners responding to the survey, approximately one quarter (24%, N=4) had participated in the Center to Champion Nursing state teams. Nearly one quarter (22%, N=41) had participated in the Local Initiative Funding Partnerships (LIFP) program. Approximately ten percent had participated in Evaluating Innovations in Nursing Education (12%, N=22). A smaller number of respondents had participated in Transforming Care at the Bedside (8%, N=15).

Table 1-1: Involvement of PIN Partners in RWJF Projects (Organizations)

Nursing Partners

Funding Partners

Other Partners All

Organizational Participant in RWJF Programs N % N % N % N %

Center to Champion Nursing state teams 26 34% 11 20% 7 13% 44 24%

Local Initiative Funding Partnerships 12 16% 21 38% 8 15% 41 22%

Evaluating Innovations in Nursing Education 14 18% 4 7% 4 8% 22 12%

Transforming Care at the Bedside 5 7% 2 4% 8 15% 15 8% Interdisciplinary Nursing Quality Research Initiative 0% 1 0 0% 3 6% 4 2%

New Jersey Nursing Initiative 2% 1 1 2% 0 0% 2 1% Very few survey respondents had been involved individually in any other RWJF projects, as shown in Table 1-2 below. There may actually be greater synergy across RWJF projects than these results demonstrate, as individuals previously involved in other RWJF projects may not have responded to the end-of-funding survey.

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Table 1-2: Involvement of PIN 1-5 Partners in RWJF Projects (Individuals)

Nursing Partners (N=76)

Funding Partners (N=55)

Other Partners (N=53)

All (N=184)

Individual Participant in RWJF Programs N % N % N % N % Nurse Faculty Scholars 2 3% 0 0% 1 2% 3 2% Executive Nurse Fellows 3 4% 0 0% 0 0% 3 2% New Careers in Nursing Scholarship Program 1 1% 1 2% 0 0% 2 1% Clinical Scholars Program 0 0% 0 0% 0 0% 0 0% Health Policy Fellows 0 0% 1 2% 0 0% 1 1%

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Appendix 2: Bibliography for Partnership Survey Development

Asthana, S., Richardson, S., & Halliday, J. (2002). Partnership working in public policy provision: A framework for evaluation. Social Policy & Administration, 36(7), 780-795. Atkinson, A. (2005). The development of an evaluation framework for partnership working. The Electronic Journal of Business Research Methods, 3(1), 1-10. Austin, J.E. (2000). The Collaboration Challenge: How Non-profits and Businesses Success through Strategic Alliances. San Francisco: Jossey-Bass. Bergstrom, A., et al. (1996). Collaboration Framework: Addressing Community Capacity. Fargo, ND: The National Network for Collaboration. Brinkerhoff, J. (2002). Assessing and improving partnership relationships and outcomes: A proposed framework. Evaluation and Program Planning, 25, 215-231. Butterfoss, F.D. & Francisco, V.T. (2004). Evaluating community partnerships and coalitions with practitioners in mind. Health Promotion Practice, 5(2), 108-114. Center for the Advancement of Collaborative Strategies in Health. (n.d.). Partnership self-assessment tool – questionnaire. Accessed on 12 November 2009 from http://cacsh.org/pdf/psatquestionnaire.pdf Chrislip, D.D. & Larson, C.E. (1994). Collaborative Leadership: How Citizens and Civic Leaders Can Make a Difference. San Francisco: Jossey-Bass Inc., Publishers. Cravens, D.W., Shipp, S.H., & Cravens, K.S. (1993). Analysis of co-operative interorganizational relationships, strategic alliance formation, and strategic alliance effectiveness. Journal of Strategic Marketing, 1, 55-70. El Ansari, W. (1999). A study of the characteristics, participant perceptions and predictors of effectiveness in community partnerships in health personnel education: The case of South Africa. (Unpublished doctoral thesis). University of Wales College Newport, United Kingdom. Fawcett, S., Francisco, V., Schultz, J.A., Berkowitz, B., Wolff, T.J. & Nagy, G. (2000). The Community Tool Box: A Web-based Resource for Building Healthier Communities. Public Health Reports, 115(March/April & May/June), 274-278. Glasbergen, P., Biermann, F. & Mol, A.J.P., eds. (2007). Partnerships, Governance and Sustainable Development: Reflections on Theory and Practice. Cheltenham, UK: Edward Elgar Publishing Limited. Relevant chapters include:

- J.E. Austin. “Sustainability through partnering: Conceptualizing partnerships between business and NGOs.” p. 49-67.

- J.M. Brinkerhoff. “Partnership as a means to good governance: Towards an evaluation framework.” p. 68-89.

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- J. Meadowcroft. “Democracy and accountability: The challenge for cross-sectoral partnerships.” p. 194-213.

Glendinning, C., Powell, M. & Rummery, K., eds. (2002). Partnerships, New Labour and the Governance of Welfare. Bristol, UK: The Policy Press. Relevant chapters include:

- M. Powell & M. Exworthy. “Partnerships, quasi-networks and social policy.” P. 15-32. - B. Hudson & B. Hardy. “What is a “successful” partnership and how can it be

measured?” p. 51-65. - K. Rummery. “Towards a theory of welfare partnerships.” p. 229-245.

Granner, M.L. & Sharpe, P.A. (2004). Evaluating community coalition characteristics and functioning: A summary of measurement tools. Health Education Research, 19, 514-532. Gray, B. (1989). Collaborating: Finding Common Ground for Multiparty Problems. San Francisco: Jossey-Bass Inc., Publishers. Halliday, J., Asthana, S.N.M., & Richardson, S. (2004). Evaluating partnerships. Evaluation, 10(3), 285-303. Hardy, B., Hudson, B. & Waddington, E. (2003). Assessing Strategic Partnerships: The Partnership Assessment Tool. London: Office of the Deputy Prime Minister and The Nuffield Institute for Health. Jobin, D. (2008). A transaction cost-based approach to partnership performance evaluation. Evaluation, 14(4), 437-465. KPFE (Swiss Commission for Research Partnerships with Developing Countries). (1998). Guidelines for Research Partnerships with Developing Countries. Bern: KPFE. Lasker, R.D., Weiss, E.S., & Miller, R. (2001). Partnership synergy: A practical framework for studying and strengthening the collaborative advantage. The Milbank Quarterly, 79(2), 179-205. Levinger, B. & McLeod, J. (2001). Partnership Principles, Practices and Methodology: A Southern Perspective. Newton, MA: Education Development Center, Inc. Liebenthal, A., Feinstein, O.N. & Ingram, G.K. (2004). Evaluation & Development: The Partnership Dimension. New Brunswick, NJ: Transaction Publishers. Relevant chapters include:

- D.C. North. “Partnership as a Means to Improve Economic Performance.” p. 3-7. - R. Axelrod. “Theoretical Foundations of Partnership.” p. 9-20. - M. Catley-Carlson. “Foundations of Partnerships: A Practitioner’s Perspective.” p. 21-27. - E. Stern. “Evaluating Partnerships.” p. 29-41. - R. Klitgaard. “Evaluation of, for and through Partnerships.” p. 43-57. - R. Picciotto. “The Logic of Partnerships.” p. 59-67. - M. Barrados. “Challenges for Governance in Partnerships for Delivering Services.” p.

129-139.

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- D.L. Stone. “Research Partnerships and Their Evaluation.” p. 149-160 Markwell, S. (2003). Partnership Working: A Consumer Guide to Resources. Wetherby: Health Development Agency. Mattessich, P.W., Murray-Close, M. and Monsey, B.R. (2001). Collaboration: What Makes It Work. 2nd ed. Saint Paul, MN: Amherst H. Wilder Foundation. Neu, C.H. (1988). Strategic governance: A community integration process. National Civic Review 77(2), 133-142. Provan, K.G. & Milward, H.B. (2001). Do networks really work? A framework for evaluating public-sector organizational networks. Public Administration Review, 61(4), 414-423. Rendón, L.I., Gans, W.L., & Calleroz, M.D. (1998). No pain no gain: The learning curve in assessing collaboratives. New Directions for Community Colleges, 103, 71-83. Skelcher, C. & Sullivan, H. (2008). Theory driven approaches to analysing collaborative performance. Public Management Review, 10(6), 751-771. Smith, M. & Beazley, M. (2000). Progressive regimes, partnerships and the involvement of local communities: A framework for evaluation. Public Administration, 78(4), 855-878. Weiss, E.A., Anderson, R.M., & Lasker, R.D. (2002). Making the most of collaboration: Exploring the relationship between partnership synergy and partnership functioning. Health Education Behavior, 29, 683-698.

Documents

Partners Investing in Nursing’s Future · The complexity and involvement of the communities and number of partnerships increased with each PIN cohort. Evaluation Concept 1: Expand