At the Intersection of Health, Health Care and Policy Cite this article as: Paul S. Jellinek, Renee J. Reinhardt, Maryjoan D. Ladden and Marla E. Salmon Round Six Of Partners Investing In Nursing's Future: Implications For The Health Sector, Policy Makers, And Foundations Health Affairs, 34, no.7 (2015):1245-1249 doi: 10.1377/hlthaff.2015.0144
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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GrantWatch By Paul S. Jellinek, Renee J. Reinhardt, Maryjoan D. Ladden, and Marla E. Salmon
Round Six Of Partners Investing In Nursing’s Future: Implications For The Health Sector, Policy Makers, And Foundations In its 2011 report on the future of nursing, the Institute of Medicine issued recommendations to position nursing to meet the challenges of twenty-first-century health care. Following release of the report, the Robert Wood Johnson Foundation funded eleven local and regional partnerships of nurses, foundations, and other stakeholders to begin implementing some of the recommendations in their regions. A qualitative evaluation of these partnerships found that although not all goals were met, most of the partnerships achieved meaningful gains. Partnership participants emphasized the value of engaging foundations and other stakeholders from outside nursing in the implementation process, the necessity of funding for implementation, the need for policy makers to address constraints that local and regional partnerships by themselves cannot address, and the unique leadership and convening role that local and regional foundations can play to help their regions respond to complex challenges for the nursing profession. ABSTRACT
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or years, nursing leaders across the nation have lamented how difficult it has been to make headway on some long-standing challenges facing their profession—challenges such as increasing the proportion of nurses with baccalaureate and advanced degrees, finding ways for nurses
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to play a greater leadership role in health care, increasing the diversity of the nurse workforce, and increasing the number of nurses going into areas such as mental health and long-term care. As one nursing educator told us, “Here in our state, it’s STP—the Same Ten People, all nurses, talking at each other, year after year, and getting nowhere.”
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But when the baby-boom generation began to enter retirement, it appeared that these issues could no longer be put on hold: The demand for nursing care would begin to surge at the very time that record numbers of nurses would be retiring (although a recent study has found that many nurses have been delaying their retirement).1 To attract and retain the kind of nursing workforce that would be required to meet the needs of the twenty-first century, the issues facing nursing would finally have to be addressed. In 2006, in an effort to expand the circle beyond nursing and break through the gridlock, the Robert Wood Johnson Foundation (RWJF), together with the Portland, Oregon–based Northwest Health Foundation (NWHF), launched Partners Investing in Nursing’s Future (PIN), a nine-year national initiative designed to address nursing workforce issues through a series of collaborative partnerships involving local and regional funders, nurse leaders, and other key stakeholders. The program was funded by the RWJF and managed by the NWHF, a regional “conversion” foundation that had helped transform nursing education in Oregon.
PIN: A New Approach Between 2006 and 2011, sixty-one grants totaling approximately $12.5 million were awarded by the RWJF. There were six rounds of funding to fifty sites across thirty-seven states and the US Pacific Islands; eleven of the fifty sites received more than one grant. The grants were matched with approximately $17.5 million from some 290 local and regional funders, including foundations, government agencies, and health care and educational organizations. Each PIN grant was awarded to a local or regional foundation that agreed to play a leadership role in the partnership, with coleadership from the nursing profession. The hope was that these lead foundations would draw on their networks of relationships and their credibility as honest brokers (that is, having no financial or political stake in the out-
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GrantWatch come) to engage all of the key constituencies and organizations, including other funders—whose involvement in the partnership would be critical to its success. As Judith Woodruff, then director of workforce development at the NWHF and national program director for PIN, noted in 2011, “The model that we’ve encouraged is that philanthropy’s role is not just as a check writer, but as an outsider with influence and the ability to get not just nurses to the table, but others who need to be part of the solution—health care organizations, colleges and universities, government agencies, chambers of commerce, and business people.” During the first five years of the program, five rounds of two-year grants (PIN 1–5 grants) were awarded to fifty partnerships that focused on a wide range of nursing workforce issues, including leadership, recruitment and retention, faculty development, diversity, long-term care, and public health.2 Shortly after the fifth round of PIN grants had been announced, the Institute of Medicine (IOM, now known as the National Academy of Medicine) released a report called The Future of Nursing: Leading Change, Advancing Health,3 which was funded by the RWJF at the initiative of its board of trustees. The report included a series of recommendations intended to “(1) ensure that nurses can practice to the full extent of their education and training, (2) improve nursing education, (3) provide opportunities for nurses to assume leadership positions and to serve as full partners in health care redesign and improvement efforts, and (4) improve data collection for workforce planning and policy making.”3 The RWJF funded AARP’s Center to Champion Nursing in America to launch the Campaign for Action, a national initiative to guide and promote implementation of the recommendations. In addition, the RWJF and the NWHF decided that the sixth and final round of PIN grants (PIN 6) would focus on the implementation of the recommendations.4
Study Data And Methods This article presents findings from an independent qualitative evaluation of the PIN 6 grants. The evaluation includ1246
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ed site visits to all of the partnerships; a review of all of the grantees’ semiannual structured narrative reports, in which they reported their progress toward each of their goals on a ten-point scale; and two rounds of in-person and telephone interviews with the foundation and nursing coleaders and other key members of each of the partnerships, as well as with local evaluators working with each of the partnerships. The Grants The applicant pool for the PIN 6 grants was restricted to previous PIN grantees. This was done so that, as the RWJF’s senior adviser for nursing, Susan Hassmiller, put it, they could “hit the ground running” and not have to take the time required to develop new partnerships. Some changes in partnership members did occur, however, in accordance with the partnerships’ new focus on the IOM recommendations. Eleven PIN 6 grants were awarded, seven of which were three-year grants and four of which were eighteen-month grants. The RWJF’s $1,850,000 in PIN 6 grants was matched with $3,801,314 from seventy-three local and regional funding partners (for a list of the local and regional foundation funding partners, see the online Appendix).5 The Institute Of Medicine Report The IOM’s Future of Nursing contains four key messages and eight recommendations. Each of the PIN 6 partnerships selected at least one key message or recommendation that it would seek to implement. Most partnerships selected more than one, and six partnerships also addressed one of five related issues. ▸ KEY MESSAGES : The messages are related to the quote from the report above. The first message is that “nurses should practice to the full extent of their education and training.”3 The Daisy Marquis Jones Foundation, in Rochester, New York, selected this message. The second is that “nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”3 The Con Alma Health Foundation, in Albuquerque, New Mexico; the Daisy Marquis Jones Foundation; the Dreyfus Health Foundation, in New York City; and the Wyoming Community Foundation, in Laramie, selected this message. 34:7
The third is that “nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.”3 The Massachusetts Senior Care Foundation, in Waltham, Massachusetts, and the Wyoming Community Foundation selected this message. No partnership selected the fourth message, that “effective workforce planning and policy making require better data collection and an improved information infrastructure.”3 ▸ RECOMMENDATIONS : The eight recommendations and the partnerships that selected them were as follows. First, “remove scope-of-practice barriers”3 (Tufts Health Plan Foundation, Watertown, Massachusetts). Second, “expand opportunities for nurses to lead and diffuse collaborative improvement efforts”3 (Daisy Marquis Jones Foundation; Faye McBeath Foundation, Milwaukee, Wisconsin; Massachusetts Senior Care Foundation; and Tufts Health Plan Foundation). Third, “implement nurse residency programs”3 (no partnership selected this recommendation). Fourth, “increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020”3 (Arkansas Community Foundation, Little Rock; Community Foundation of the Land of Lincoln, Springfield, Illinois; Jonas Center for Nursing Excellence, New York City; Richmond Memorial Health Foundation, Richmond, Virginia; and Tufts Health Plan Foundation). Fifth, “double the number of nurses with a doctorate by 2020”3 (no partnership selected this recommendation). Sixth, “ensure that nurses engage in lifelong learning”3 (Faye McBeath, Massachusetts Senior Care, and Tufts Health Plan Foundations). Seventh, “prepare and enable nurses to lead change to advance health”3 (Community Foundation of the Land of Lincoln and Con Alma Health, Dreyfus Health, Faye McBeath, and Massachusetts Senior Care Foundations). And eighth, “build an infrastructure for the collection and analysis of interprofessional health care workforce data”3 (Con Alma Health and Faye McBeath Foundations). ▸ RELATED ISSUES : The five related issues and the partnerships that adopted
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them are as follows: diversity (Con Alma Health Foundation), interprofessional education (Tufts Health Plan Foundation), long-term care (Arksansas Community and Daisy Marquis Jones Foundations), mental health (Faye McBeath Foundation), and care transitions (Massachusetts Senior Care Foundation). ▸ THE PARTNERSHIPS ’ SELECTIONS : There was variation in the number of partnerships that selected each of the key messages, recommendations, and related issues. As shown above, some were not selected by any partnership. The fourth key message (“effective workforce planning and policy making require better data collection and an improved information infrastructure”) was not explicitly selected by any of the partnerships. However, it corresponds to the eighth recommendation (“build an infrastructure for the collection and analysis of interprofessional health care workforce data”), which was selected by two of the partnerships. Given the similarity between the second key message (“nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression”) and the fourth recommendation (“increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020”), it could be said that nine of the partnerships worked on some form of seamless progression. That made this the most widely shared priority among the PIN 6 partnerships. Also worth noting is that several of the partnerships with the largest number of stated IOM priorities—the Faye McBeath, Con Alma, Daisy Marquis Jones, Massachusetts Senior Care, and Tufts Health Plan Foundations—were in fact primarily focused on a related issue (such as mental health in Milwaukee or care transitions in western Massachusetts) instead of a key message or recommendation. In these partnerships the expectation was that they would address key messages or recommendations in the process of addressing their primary objective. For example, in the process of strengthening long-term care nursing, the Rochester partnership expected to “expand opportunities for nurses to lead and diffuse collaborative improvement efforts” (the second recommendation)
Each PIN grant was awarded to a local or regional foundation that agreed to play a leadership role in the partnership, with coleadership from the nursing profession. and expected that nurses “would practice to the full extent of their education and training” (the first key message).
Study Results Because of the diversity of local needs and circumstances and because the PIN 6 partnerships were free to choose the IOM recommendations or key messages that they wished to address, the specific goals and objectives set by the partnerships varied. Most reported making substantial progress toward achieving all or most of their goals and objectives. The eleven partnerships were asked in their final narrative reports to indicate on a ten-point scale how much progress they had made over the course of their PIN 6 grants toward achieving each of their goals and objectives, with a score of 1 meaning “no progress” and a score of 10 meaning “goal/objective completed.” The mean score for the partnerships was 8.4; scores ranged from 6.0 to 9.3. The mean score was consistent with the mean score of those partnership members who were interviewed at the end of their grants during the national evaluation.2 Examples of specific outcomes are described below. North Carolina North Carolina’s Regionally Increasing Baccalaureate Nursing (RIBN) project (which had been piloted in western North Carolina under a previous PIN grant) was expanded to eight additional regions by mid-2014, including sites at nine universities and thirty-one community and private colleges. RIBN creates educational partnerships between universities and community or private colleges that enable nursing students to enroll in two institutions to receive a seamless four-year nursing curriculum. The project is addressing the IOM’s fourth recommendation.
As of 2014 almost 200 students were enrolled in the RIBN track. Thus, RIBN is enabling a larger proportion of North Carolina’s nursing students to obtain a bachelor of science in nursing (BSN) degree, which should result in better outcomes for more patients. As the IOM report indicates, “Several studies support a significant association between the educational level of RNs [registered nurses] and outcomes for patients in the acute care setting, including mortality rates.”3 New York The Academy for Leadership in Long Term Care, in Rochester, New York, was established to offer a range of leadership and professional development programs to nursing staff in long-term care facilities in the region. As the IOM report points out, “Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care.”3 Under the PIN 6 grant, eightytwo registered nurses and licensed practical nurses received training in leadership, clinical updates, or professional development through the academy (addressing the second recommendation and the third related issue). Massachusetts The Care Transition Education Project was successfully developed and tested. Its purpose was to increase the competency of nurses in leading and improving patient care transitions among different clinical settings in western Massachusetts (addressing the second, sixth, and seventh recommendations and the fifth related issue). During the course of the PIN 6 grant, more than 400 nurses and nursing students participated in such training, and several of the participating hospitals reported reductions in preventable readmissions after their nurses had been trained. Successes And Setbacks Not all goals were met during the course of the PIN 6 grants. In some cases, midcourse adjustments were made to the objectives; in others, reaching goals took longer than anticipated. For example, one partnership put its nurse leadership training program on hold because participation was lower than anticipated. In another case, one of the states in a multistate partnership dropped out after the individual leading the project in that state changed jobs. In yet another case, a bureaucratic bottleneck at the state
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GrantWatch level delayed implementation of the partnership’s seamless academic progression model. In general, partnerships with a limited number of clearly defined goals that successfully engaged partners beyond nursing and were able to achieve some “early wins” that kept the partners engaged appeared to be the most successful in achieving their goals.
Not all of the partnerships successfully engaged organizations outside of nursing.
Implementing The IOM Recommendations The largely positive experience of the PIN 6 grantees demonstrates the feasibility of making significant progress in the implementation of those IOM key messages, recommendations, and related issues that they addressed in a variety of real-world settings. In fact, a number of the partnership participants interviewed for the PIN 6 national evaluation2 cited the value of the IOM report itself in both inspiring and validating their efforts. However, a few commented that the report did not provide them with sufficient empirical evidence to persuade policy makers and other stakeholders in their region of the merits of some of the recommendations. The progress made by the PIN 6 partnerships in addressing issues that have long seemed intractable suggests the value of reaching beyond nursing and engaging a broader spectrum of affected constituencies and organizations to help implement the IOM recommendations. Asked at the end of their PIN 6 grants to indicate on a ten-point scale how important collaboration with nonnurse partners had been in advancing their partnership’s goals, most of the nurses interviewed for the PIN 6 national evaluation rated this item 8.0 or higher (mean score: 8.6).2 A nursing dean in Wisconsin commented: “We couldn’t have done it on our own. In nursing, we often talk to ourselves, which doesn’t advance our goals as quickly or as effectively as when we talk with others.” For example, by engaging some of the major employers of mental health nurses in Milwaukee, the Wisconsin partnership gained useful insights into employer needs that have helped nurse educators redesign the way in which mental health nursing is taught in area nursing schools. And a nursing dean in Wyoming said 1248
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that the involvement of nonnurse partners—including foundations, hospitals, the state health and workforce services departments, the state business council, AARP, and the state medical society—had “opened doors, added new perspectives, and raised important questions we wouldn’t have thought of.” Among other things, the breadth of Wyoming’s partnership added weight and legitimacy to its efforts to create a common statewide academic pathway for nurses seeking the BSN degree. However, not all of the partnerships successfully engaged organizations outside of nursing. One nurse educator, who scored this item only a 4 on behalf of her partnership, remarked, “Other than [the lead foundation], there were no nonnurse partners.” While valuing the collaboration within their partnerships, many of the partners interviewed indicated that it took several years of working together (including the work done under their previous PIN grants) to reach a sufficient level of trust and understanding to achieve the breakthroughs necessary to accomplish their goals. They also underscored the critical role that the various foundations’ funding had played in the gains made to date. And they expressed concern that without continued funding, it might not be possible to sustain those gains or to make further progress. While many of the participants have contributed a great deal of unpaid time and effort to their partnerships, each partnership has relied heavily on paid staff to manage and execute its work. It is not yet clear whether all of the partnerships will be able to raise the additional support necessary to retain those staffers now that the PIN grants have ended.
Implications For Policy Makers Despite the gains achieved by many PIN 6 partnerships, a number of them encountered policy-related barriers that 34:7
they were not in a position to overcome. For example, the Arkansas partnership, which sought to improve the quality of long-term care by encouraging longterm care nurses to raise their level of education, was frustrated by state regulations that require the presence of one registered nurse per building but do not require that nurse to have a BSN degree. Along similar lines, several of the partnerships that were working on the IOM recommendation to increase the proportion of BSN degree nurses to 80 percent by 2020 expressed initial frustration that there was no pay differential in their state between nurses with an associate degree and those with a BSN degree. This fact made it more difficult to persuade nurses with an associate degree that it was worth the substantial financial investment (including the cost of the additional education and the opportunity cost of not working while being back in school) to acquire the BSN degree. However, according to several of the nursing leaders interviewed for the PIN 6 national evaluation,2 this problem has become somewhat less acute over the course of the PIN 6 grants, as major hospitals have increasingly begun to require their nurses to hold (or obtain) a BSN degree. In some cases, downward pressure on Medicaid long-term care reimbursement rates has reduced the willingness of employers such as nursing homes to help pay for additional training or education of their nurse employees. And looking ahead, changes in state policies may make it more difficult to sustain and build on the gains achieved by some of the PIN 6 partnerships. For example, recent cuts to North Carolina’s education budget have raised concerns about the capacity of the state’s universities to accommodate the increase in BSN students that is expected to result from the RIBN project. In sum, the PIN 6 experience suggests that partnerships that include nurses and key stakeholders from outside of nursing can make meaningful strides toward implementing the IOM recommendations. It also underscores the importance of funding for staffing and related costs—without which reports such as the IOM’s all too frequently would simply gather dust on a shelf. In addition, full implementation of
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the IOM recommendations is likely to require attention by policy makers to policy-related barriers that—as noted above—the partnerships by themselves were not in a position to overcome. For example, while a number of the PIN 6 partnerships successfully created simplified academic pathways to increase the supply of nurses with a baccalaureate degree, it may not be possible to reach the IOM’s goal of ensuring that 80 percent of nurses have such a degree by 2020 without corresponding policy changes to increase the demand for these nurses.
Implications For Philanthropy The experiences of the PIN 6 partnerships (as well as those of the earlier PIN partnerships) also have implications for philanthropy. For example, several local and regional foundation executives indicated that their involvement in PIN represented their foundation’s first foray into the health care field and that as a result of what they had learned and accomplished through PIN, they intended to fund more work in nursing or other areas of health care. But perhaps a more far-reaching implication for philanthropy has to do with changed perceptions about the role that foundations can play in their communities or regions beyond simply providing funding. Not all of the lead foundations in PIN 6 chose to play an activist role. However, the experiences of most of the PIN 6 partnerships illustrate the impor-
This model of collaboration between national foundations and local and regional foundations may well have application beyond nursing. tant role that these local and regional funders can play in engaging and mobilizing the wide range of organizations and constituencies whose involvement is required to address complex local and regional challenges of all kinds. Several of the foundation executives who were coleaders of their PIN 6 partnerships commented that their PIN experience had fundamentally changed the way their foundation views its role, and not just its nursing role. One foundation executive explained, “I now appreciate the importance of being not just a funder but being a catalyst and a facilitator.”
Conclusion The pivotal role that local and regional foundations played in PIN 6 also has implications for large national foundations. National foundations often seek to address complex problems at the local or regional level. However, they rarely have the kind of local or regional presence or networks of relationships re-
quired to convene and sustain broadbased partnerships at the ground level. In designing PIN 6, the RWJF and the NWHF recognized that implementation of the IOM recommendations would ultimately have to be carried out at the local and regional levels and that, consequently, it made sense to engage interested local and regional funders that could assemble and mobilize all of the nursing and other stakeholders necessary to break through the gridlock within nursing. This model of collaboration between national foundations and local and regional foundations may well have application beyond nursing. For example, it might be able to address other challenges that require the involvement of a wide range of local or regional players, such as fostering economic development, improving race relations, or promoting a culture of health. The model would be less suited to issues that are primarily addressed at the state or national level, such as changes in state scope-of-practice regulations or federal physician payment policies. ▪ Paul S. Jellinek ([email protected]) is founding partner and principal at Isaacs-Jellinek, a division of Health Policy Associates Inc., in San Francisco, California. Renee J. Reinhardt is a Partners Investing in Nursing’s Future program officer at the Northwest Health Foundation, in Portland, Oregon. Maryjoan D. Ladden is a senior program officer at the Robert Wood Johnson Foundation, in Princeton, New Jersey. Marla E. Salmon is a professor of nursing and global health in the Evans School of Public Policy, University of Washington, in Seattle.
The evaluation on which this report is based was funded by the Northwest Health Foundation through a grant from the Robert Wood Johnson Foundation.
NOTES 1 Auerbach DI, Buerhaus PI, Staiger DO. Registered nurses are delaying retirement, a shift that has contributed to recent growth in the nurse workforce. Health Aff (Millwood). 2014; 33(8):1474–80. 2 A separate evaluation of the PIN 1– 5 grants was conducted. See Norman L, Gelmon S, Ryan K. Partners Investing in Nursing’s Future: final evaluation report:
PIN 1–5 cohorts [Internet]. Portland (OR): PIN; 2014 Jun [cited 2015 May 27]. Available from: http://www.partnersinnursing .org/wp-content/uploads/2015/ 04/PIN1to5FinalReport Complete082014.pdf 3 Institute of Medicine. The future of nursing: leading change, advancing health [Internet]. Washington (DC): National Academies
Press; 2011 [cited 2015 May 27]. Available from: http://www.the futureofnursing.org/sites/ default/files/Future%20of%20 Nursing%20Report_0.pdf 4 Besides funding the Campaign for Action and the PIN 6 grants, as of November 2014 the RWJF had also provided two-year State Implementation Project grants to Action Coalitions in thirty states
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(including six of the states that had PIN 6 partnerships) to promote the implementation of the IOM’s recommendations. The extent of interaction and collaboration between the Action Coalitions and the PIN 6 partnerships varied across the PIN 6 sites. 5 To access the Appendix, click on the Appendix link in the box to the right of the article online.
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The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/34/7/1245.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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GrantWatch By Paul S. Jellinek, Renee J. Reinhardt, Maryjoan D. Ladden, and Marla E. Salmon
Round Six Of Partners Investing In Nursing’s Future: Implications For The Health Sector, Policy Makers, And Foundations In its 2011 report on the future of nursing, the Institute of Medicine issued recommendations to position nursing to meet the challenges of twenty-first-century health care. Following release of the report, the Robert Wood Johnson Foundation funded eleven local and regional partnerships of nurses, foundations, and other stakeholders to begin implementing some of the recommendations in their regions. A qualitative evaluation of these partnerships found that although not all goals were met, most of the partnerships achieved meaningful gains. Partnership participants emphasized the value of engaging foundations and other stakeholders from outside nursing in the implementation process, the necessity of funding for implementation, the need for policy makers to address constraints that local and regional partnerships by themselves cannot address, and the unique leadership and convening role that local and regional foundations can play to help their regions respond to complex challenges for the nursing profession. ABSTRACT
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or years, nursing leaders across the nation have lamented how difficult it has been to make headway on some long-standing challenges facing their profession—challenges such as increasing the proportion of nurses with baccalaureate and advanced degrees, finding ways for nurses
doi:
to play a greater leadership role in health care, increasing the diversity of the nurse workforce, and increasing the number of nurses going into areas such as mental health and long-term care. As one nursing educator told us, “Here in our state, it’s STP—the Same Ten People, all nurses, talking at each other, year after year, and getting nowhere.”
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But when the baby-boom generation began to enter retirement, it appeared that these issues could no longer be put on hold: The demand for nursing care would begin to surge at the very time that record numbers of nurses would be retiring (although a recent study has found that many nurses have been delaying their retirement).1 To attract and retain the kind of nursing workforce that would be required to meet the needs of the twenty-first century, the issues facing nursing would finally have to be addressed. In 2006, in an effort to expand the circle beyond nursing and break through the gridlock, the Robert Wood Johnson Foundation (RWJF), together with the Portland, Oregon–based Northwest Health Foundation (NWHF), launched Partners Investing in Nursing’s Future (PIN), a nine-year national initiative designed to address nursing workforce issues through a series of collaborative partnerships involving local and regional funders, nurse leaders, and other key stakeholders. The program was funded by the RWJF and managed by the NWHF, a regional “conversion” foundation that had helped transform nursing education in Oregon.
PIN: A New Approach Between 2006 and 2011, sixty-one grants totaling approximately $12.5 million were awarded by the RWJF. There were six rounds of funding to fifty sites across thirty-seven states and the US Pacific Islands; eleven of the fifty sites received more than one grant. The grants were matched with approximately $17.5 million from some 290 local and regional funders, including foundations, government agencies, and health care and educational organizations. Each PIN grant was awarded to a local or regional foundation that agreed to play a leadership role in the partnership, with coleadership from the nursing profession. The hope was that these lead foundations would draw on their networks of relationships and their credibility as honest brokers (that is, having no financial or political stake in the out-
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GrantWatch come) to engage all of the key constituencies and organizations, including other funders—whose involvement in the partnership would be critical to its success. As Judith Woodruff, then director of workforce development at the NWHF and national program director for PIN, noted in 2011, “The model that we’ve encouraged is that philanthropy’s role is not just as a check writer, but as an outsider with influence and the ability to get not just nurses to the table, but others who need to be part of the solution—health care organizations, colleges and universities, government agencies, chambers of commerce, and business people.” During the first five years of the program, five rounds of two-year grants (PIN 1–5 grants) were awarded to fifty partnerships that focused on a wide range of nursing workforce issues, including leadership, recruitment and retention, faculty development, diversity, long-term care, and public health.2 Shortly after the fifth round of PIN grants had been announced, the Institute of Medicine (IOM, now known as the National Academy of Medicine) released a report called The Future of Nursing: Leading Change, Advancing Health,3 which was funded by the RWJF at the initiative of its board of trustees. The report included a series of recommendations intended to “(1) ensure that nurses can practice to the full extent of their education and training, (2) improve nursing education, (3) provide opportunities for nurses to assume leadership positions and to serve as full partners in health care redesign and improvement efforts, and (4) improve data collection for workforce planning and policy making.”3 The RWJF funded AARP’s Center to Champion Nursing in America to launch the Campaign for Action, a national initiative to guide and promote implementation of the recommendations. In addition, the RWJF and the NWHF decided that the sixth and final round of PIN grants (PIN 6) would focus on the implementation of the recommendations.4
Study Data And Methods This article presents findings from an independent qualitative evaluation of the PIN 6 grants. The evaluation includ1246
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ed site visits to all of the partnerships; a review of all of the grantees’ semiannual structured narrative reports, in which they reported their progress toward each of their goals on a ten-point scale; and two rounds of in-person and telephone interviews with the foundation and nursing coleaders and other key members of each of the partnerships, as well as with local evaluators working with each of the partnerships. The Grants The applicant pool for the PIN 6 grants was restricted to previous PIN grantees. This was done so that, as the RWJF’s senior adviser for nursing, Susan Hassmiller, put it, they could “hit the ground running” and not have to take the time required to develop new partnerships. Some changes in partnership members did occur, however, in accordance with the partnerships’ new focus on the IOM recommendations. Eleven PIN 6 grants were awarded, seven of which were three-year grants and four of which were eighteen-month grants. The RWJF’s $1,850,000 in PIN 6 grants was matched with $3,801,314 from seventy-three local and regional funding partners (for a list of the local and regional foundation funding partners, see the online Appendix).5 The Institute Of Medicine Report The IOM’s Future of Nursing contains four key messages and eight recommendations. Each of the PIN 6 partnerships selected at least one key message or recommendation that it would seek to implement. Most partnerships selected more than one, and six partnerships also addressed one of five related issues. ▸ KEY MESSAGES : The messages are related to the quote from the report above. The first message is that “nurses should practice to the full extent of their education and training.”3 The Daisy Marquis Jones Foundation, in Rochester, New York, selected this message. The second is that “nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”3 The Con Alma Health Foundation, in Albuquerque, New Mexico; the Daisy Marquis Jones Foundation; the Dreyfus Health Foundation, in New York City; and the Wyoming Community Foundation, in Laramie, selected this message. 34:7
The third is that “nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.”3 The Massachusetts Senior Care Foundation, in Waltham, Massachusetts, and the Wyoming Community Foundation selected this message. No partnership selected the fourth message, that “effective workforce planning and policy making require better data collection and an improved information infrastructure.”3 ▸ RECOMMENDATIONS : The eight recommendations and the partnerships that selected them were as follows. First, “remove scope-of-practice barriers”3 (Tufts Health Plan Foundation, Watertown, Massachusetts). Second, “expand opportunities for nurses to lead and diffuse collaborative improvement efforts”3 (Daisy Marquis Jones Foundation; Faye McBeath Foundation, Milwaukee, Wisconsin; Massachusetts Senior Care Foundation; and Tufts Health Plan Foundation). Third, “implement nurse residency programs”3 (no partnership selected this recommendation). Fourth, “increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020”3 (Arkansas Community Foundation, Little Rock; Community Foundation of the Land of Lincoln, Springfield, Illinois; Jonas Center for Nursing Excellence, New York City; Richmond Memorial Health Foundation, Richmond, Virginia; and Tufts Health Plan Foundation). Fifth, “double the number of nurses with a doctorate by 2020”3 (no partnership selected this recommendation). Sixth, “ensure that nurses engage in lifelong learning”3 (Faye McBeath, Massachusetts Senior Care, and Tufts Health Plan Foundations). Seventh, “prepare and enable nurses to lead change to advance health”3 (Community Foundation of the Land of Lincoln and Con Alma Health, Dreyfus Health, Faye McBeath, and Massachusetts Senior Care Foundations). And eighth, “build an infrastructure for the collection and analysis of interprofessional health care workforce data”3 (Con Alma Health and Faye McBeath Foundations). ▸ RELATED ISSUES : The five related issues and the partnerships that adopted
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them are as follows: diversity (Con Alma Health Foundation), interprofessional education (Tufts Health Plan Foundation), long-term care (Arksansas Community and Daisy Marquis Jones Foundations), mental health (Faye McBeath Foundation), and care transitions (Massachusetts Senior Care Foundation). ▸ THE PARTNERSHIPS ’ SELECTIONS : There was variation in the number of partnerships that selected each of the key messages, recommendations, and related issues. As shown above, some were not selected by any partnership. The fourth key message (“effective workforce planning and policy making require better data collection and an improved information infrastructure”) was not explicitly selected by any of the partnerships. However, it corresponds to the eighth recommendation (“build an infrastructure for the collection and analysis of interprofessional health care workforce data”), which was selected by two of the partnerships. Given the similarity between the second key message (“nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression”) and the fourth recommendation (“increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020”), it could be said that nine of the partnerships worked on some form of seamless progression. That made this the most widely shared priority among the PIN 6 partnerships. Also worth noting is that several of the partnerships with the largest number of stated IOM priorities—the Faye McBeath, Con Alma, Daisy Marquis Jones, Massachusetts Senior Care, and Tufts Health Plan Foundations—were in fact primarily focused on a related issue (such as mental health in Milwaukee or care transitions in western Massachusetts) instead of a key message or recommendation. In these partnerships the expectation was that they would address key messages or recommendations in the process of addressing their primary objective. For example, in the process of strengthening long-term care nursing, the Rochester partnership expected to “expand opportunities for nurses to lead and diffuse collaborative improvement efforts” (the second recommendation)
Each PIN grant was awarded to a local or regional foundation that agreed to play a leadership role in the partnership, with coleadership from the nursing profession. and expected that nurses “would practice to the full extent of their education and training” (the first key message).
Study Results Because of the diversity of local needs and circumstances and because the PIN 6 partnerships were free to choose the IOM recommendations or key messages that they wished to address, the specific goals and objectives set by the partnerships varied. Most reported making substantial progress toward achieving all or most of their goals and objectives. The eleven partnerships were asked in their final narrative reports to indicate on a ten-point scale how much progress they had made over the course of their PIN 6 grants toward achieving each of their goals and objectives, with a score of 1 meaning “no progress” and a score of 10 meaning “goal/objective completed.” The mean score for the partnerships was 8.4; scores ranged from 6.0 to 9.3. The mean score was consistent with the mean score of those partnership members who were interviewed at the end of their grants during the national evaluation.2 Examples of specific outcomes are described below. North Carolina North Carolina’s Regionally Increasing Baccalaureate Nursing (RIBN) project (which had been piloted in western North Carolina under a previous PIN grant) was expanded to eight additional regions by mid-2014, including sites at nine universities and thirty-one community and private colleges. RIBN creates educational partnerships between universities and community or private colleges that enable nursing students to enroll in two institutions to receive a seamless four-year nursing curriculum. The project is addressing the IOM’s fourth recommendation.
As of 2014 almost 200 students were enrolled in the RIBN track. Thus, RIBN is enabling a larger proportion of North Carolina’s nursing students to obtain a bachelor of science in nursing (BSN) degree, which should result in better outcomes for more patients. As the IOM report indicates, “Several studies support a significant association between the educational level of RNs [registered nurses] and outcomes for patients in the acute care setting, including mortality rates.”3 New York The Academy for Leadership in Long Term Care, in Rochester, New York, was established to offer a range of leadership and professional development programs to nursing staff in long-term care facilities in the region. As the IOM report points out, “Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care.”3 Under the PIN 6 grant, eightytwo registered nurses and licensed practical nurses received training in leadership, clinical updates, or professional development through the academy (addressing the second recommendation and the third related issue). Massachusetts The Care Transition Education Project was successfully developed and tested. Its purpose was to increase the competency of nurses in leading and improving patient care transitions among different clinical settings in western Massachusetts (addressing the second, sixth, and seventh recommendations and the fifth related issue). During the course of the PIN 6 grant, more than 400 nurses and nursing students participated in such training, and several of the participating hospitals reported reductions in preventable readmissions after their nurses had been trained. Successes And Setbacks Not all goals were met during the course of the PIN 6 grants. In some cases, midcourse adjustments were made to the objectives; in others, reaching goals took longer than anticipated. For example, one partnership put its nurse leadership training program on hold because participation was lower than anticipated. In another case, one of the states in a multistate partnership dropped out after the individual leading the project in that state changed jobs. In yet another case, a bureaucratic bottleneck at the state
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GrantWatch level delayed implementation of the partnership’s seamless academic progression model. In general, partnerships with a limited number of clearly defined goals that successfully engaged partners beyond nursing and were able to achieve some “early wins” that kept the partners engaged appeared to be the most successful in achieving their goals.
Not all of the partnerships successfully engaged organizations outside of nursing.
Implementing The IOM Recommendations The largely positive experience of the PIN 6 grantees demonstrates the feasibility of making significant progress in the implementation of those IOM key messages, recommendations, and related issues that they addressed in a variety of real-world settings. In fact, a number of the partnership participants interviewed for the PIN 6 national evaluation2 cited the value of the IOM report itself in both inspiring and validating their efforts. However, a few commented that the report did not provide them with sufficient empirical evidence to persuade policy makers and other stakeholders in their region of the merits of some of the recommendations. The progress made by the PIN 6 partnerships in addressing issues that have long seemed intractable suggests the value of reaching beyond nursing and engaging a broader spectrum of affected constituencies and organizations to help implement the IOM recommendations. Asked at the end of their PIN 6 grants to indicate on a ten-point scale how important collaboration with nonnurse partners had been in advancing their partnership’s goals, most of the nurses interviewed for the PIN 6 national evaluation rated this item 8.0 or higher (mean score: 8.6).2 A nursing dean in Wisconsin commented: “We couldn’t have done it on our own. In nursing, we often talk to ourselves, which doesn’t advance our goals as quickly or as effectively as when we talk with others.” For example, by engaging some of the major employers of mental health nurses in Milwaukee, the Wisconsin partnership gained useful insights into employer needs that have helped nurse educators redesign the way in which mental health nursing is taught in area nursing schools. And a nursing dean in Wyoming said 1248
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that the involvement of nonnurse partners—including foundations, hospitals, the state health and workforce services departments, the state business council, AARP, and the state medical society—had “opened doors, added new perspectives, and raised important questions we wouldn’t have thought of.” Among other things, the breadth of Wyoming’s partnership added weight and legitimacy to its efforts to create a common statewide academic pathway for nurses seeking the BSN degree. However, not all of the partnerships successfully engaged organizations outside of nursing. One nurse educator, who scored this item only a 4 on behalf of her partnership, remarked, “Other than [the lead foundation], there were no nonnurse partners.” While valuing the collaboration within their partnerships, many of the partners interviewed indicated that it took several years of working together (including the work done under their previous PIN grants) to reach a sufficient level of trust and understanding to achieve the breakthroughs necessary to accomplish their goals. They also underscored the critical role that the various foundations’ funding had played in the gains made to date. And they expressed concern that without continued funding, it might not be possible to sustain those gains or to make further progress. While many of the participants have contributed a great deal of unpaid time and effort to their partnerships, each partnership has relied heavily on paid staff to manage and execute its work. It is not yet clear whether all of the partnerships will be able to raise the additional support necessary to retain those staffers now that the PIN grants have ended.
Implications For Policy Makers Despite the gains achieved by many PIN 6 partnerships, a number of them encountered policy-related barriers that 34:7
they were not in a position to overcome. For example, the Arkansas partnership, which sought to improve the quality of long-term care by encouraging longterm care nurses to raise their level of education, was frustrated by state regulations that require the presence of one registered nurse per building but do not require that nurse to have a BSN degree. Along similar lines, several of the partnerships that were working on the IOM recommendation to increase the proportion of BSN degree nurses to 80 percent by 2020 expressed initial frustration that there was no pay differential in their state between nurses with an associate degree and those with a BSN degree. This fact made it more difficult to persuade nurses with an associate degree that it was worth the substantial financial investment (including the cost of the additional education and the opportunity cost of not working while being back in school) to acquire the BSN degree. However, according to several of the nursing leaders interviewed for the PIN 6 national evaluation,2 this problem has become somewhat less acute over the course of the PIN 6 grants, as major hospitals have increasingly begun to require their nurses to hold (or obtain) a BSN degree. In some cases, downward pressure on Medicaid long-term care reimbursement rates has reduced the willingness of employers such as nursing homes to help pay for additional training or education of their nurse employees. And looking ahead, changes in state policies may make it more difficult to sustain and build on the gains achieved by some of the PIN 6 partnerships. For example, recent cuts to North Carolina’s education budget have raised concerns about the capacity of the state’s universities to accommodate the increase in BSN students that is expected to result from the RIBN project. In sum, the PIN 6 experience suggests that partnerships that include nurses and key stakeholders from outside of nursing can make meaningful strides toward implementing the IOM recommendations. It also underscores the importance of funding for staffing and related costs—without which reports such as the IOM’s all too frequently would simply gather dust on a shelf. In addition, full implementation of
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the IOM recommendations is likely to require attention by policy makers to policy-related barriers that—as noted above—the partnerships by themselves were not in a position to overcome. For example, while a number of the PIN 6 partnerships successfully created simplified academic pathways to increase the supply of nurses with a baccalaureate degree, it may not be possible to reach the IOM’s goal of ensuring that 80 percent of nurses have such a degree by 2020 without corresponding policy changes to increase the demand for these nurses.
Implications For Philanthropy The experiences of the PIN 6 partnerships (as well as those of the earlier PIN partnerships) also have implications for philanthropy. For example, several local and regional foundation executives indicated that their involvement in PIN represented their foundation’s first foray into the health care field and that as a result of what they had learned and accomplished through PIN, they intended to fund more work in nursing or other areas of health care. But perhaps a more far-reaching implication for philanthropy has to do with changed perceptions about the role that foundations can play in their communities or regions beyond simply providing funding. Not all of the lead foundations in PIN 6 chose to play an activist role. However, the experiences of most of the PIN 6 partnerships illustrate the impor-
This model of collaboration between national foundations and local and regional foundations may well have application beyond nursing. tant role that these local and regional funders can play in engaging and mobilizing the wide range of organizations and constituencies whose involvement is required to address complex local and regional challenges of all kinds. Several of the foundation executives who were coleaders of their PIN 6 partnerships commented that their PIN experience had fundamentally changed the way their foundation views its role, and not just its nursing role. One foundation executive explained, “I now appreciate the importance of being not just a funder but being a catalyst and a facilitator.”
Conclusion The pivotal role that local and regional foundations played in PIN 6 also has implications for large national foundations. National foundations often seek to address complex problems at the local or regional level. However, they rarely have the kind of local or regional presence or networks of relationships re-
quired to convene and sustain broadbased partnerships at the ground level. In designing PIN 6, the RWJF and the NWHF recognized that implementation of the IOM recommendations would ultimately have to be carried out at the local and regional levels and that, consequently, it made sense to engage interested local and regional funders that could assemble and mobilize all of the nursing and other stakeholders necessary to break through the gridlock within nursing. This model of collaboration between national foundations and local and regional foundations may well have application beyond nursing. For example, it might be able to address other challenges that require the involvement of a wide range of local or regional players, such as fostering economic development, improving race relations, or promoting a culture of health. The model would be less suited to issues that are primarily addressed at the state or national level, such as changes in state scope-of-practice regulations or federal physician payment policies. ▪ Paul S. Jellinek ([email protected]) is founding partner and principal at Isaacs-Jellinek, a division of Health Policy Associates Inc., in San Francisco, California. Renee J. Reinhardt is a Partners Investing in Nursing’s Future program officer at the Northwest Health Foundation, in Portland, Oregon. Maryjoan D. Ladden is a senior program officer at the Robert Wood Johnson Foundation, in Princeton, New Jersey. Marla E. Salmon is a professor of nursing and global health in the Evans School of Public Policy, University of Washington, in Seattle.
The evaluation on which this report is based was funded by the Northwest Health Foundation through a grant from the Robert Wood Johnson Foundation.
NOTES 1 Auerbach DI, Buerhaus PI, Staiger DO. Registered nurses are delaying retirement, a shift that has contributed to recent growth in the nurse workforce. Health Aff (Millwood). 2014; 33(8):1474–80. 2 A separate evaluation of the PIN 1– 5 grants was conducted. See Norman L, Gelmon S, Ryan K. Partners Investing in Nursing’s Future: final evaluation report:
PIN 1–5 cohorts [Internet]. Portland (OR): PIN; 2014 Jun [cited 2015 May 27]. Available from: http://www.partnersinnursing .org/wp-content/uploads/2015/ 04/PIN1to5FinalReport Complete082014.pdf 3 Institute of Medicine. The future of nursing: leading change, advancing health [Internet]. Washington (DC): National Academies
Press; 2011 [cited 2015 May 27]. Available from: http://www.the futureofnursing.org/sites/ default/files/Future%20of%20 Nursing%20Report_0.pdf 4 Besides funding the Campaign for Action and the PIN 6 grants, as of November 2014 the RWJF had also provided two-year State Implementation Project grants to Action Coalitions in thirty states
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(including six of the states that had PIN 6 partnerships) to promote the implementation of the IOM’s recommendations. The extent of interaction and collaboration between the Action Coalitions and the PIN 6 partnerships varied across the PIN 6 sites. 5 To access the Appendix, click on the Appendix link in the box to the right of the article online.
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