“We can’t address the variety of nursing workforce issues with a one-size-fits-all national program,” says RWJF Senior Adviser for Nursing Susan Hassmiller, Ph.D., R.N., F.A.A.N. “We need to approach this at all levels—national, regional, state and local—and engage a broad range of institutions.” Hassmiller’s sentiment is the driving force behind a unique partnership between the Robert Wood Johnson Foundation (RWJF) and the Northwest Health Foundation (NWHF).
The Partners Investing in Nursing’s Future program (PIN) funds local and regional charitable foundations and other funders as they invest in tailored solutions to nursing workforce problems in their communities and states. The grants are intended as seed money, explains NWHF’s Judith Woodruff, J.D., program director for PIN. “Of course, we hope for good outcomes in terms of the nursing workforce, but we know it’s hard to make a lot of progress in two years,” she explains. “But what we expect to come out of the funding period are stronger partnerships at the local and state levels, so that the organizations can move forward beyond the life of the grant. We went into the project with an eye toward building capacity, to build something that would be stable, enduring and productive into the future.”
Funds, Partners, Technical Assistance and Collaboration
PIN partners—the local foundations—receive two-year grants of as much as $250,000. They contribute matching funds, and then partner with local, state and regional organizations working to develop and implement solutions that make sense in the context of their communities.
The first of six waves of PIN grants went out in September 2006, supporting 10 foundations in nine states. An additional 21 grants followed in two successive waves, bringing PIN partnerships to a total of 25 states and the Western Pacific territories. Three more rounds of grants are on the way, with 10 new grants expected this year, increasing the geographic spread by another six states.
In turn, the local foundations work with a range of grantee-partners, including state workforce investment boards, economic development agencies, local businesses, hospitals, public health agencies, and educational institutions ranging from K-12 public schools to nursing doctoral programs. Their projects address nursing workforce development prioritized to their communities, including recruiting and retaining nursing faculty, developing new roles for nurses in the care setting, fostering ethnic and racial diversity and empowering nurses to assume leadership roles.
The PIN partnership also fosters improved capacity through technical assistance by the national program office, including specialized support for developing evaluation skills, assistance with communications challenges, and partnership maintenance. In addition to their annual meeting, the partners participate in an online Wiki to share their materials, and are encouraged to work with PIN projects in other states. For example, Mississippi’s two PIN projects worked together to develop the “next steps” in their work on diversity issues, and have been awarded joint funding by another national foundation to move ahead.
Making the Business Case
In western Massachusetts, the Irene E. and George A. Davis Foundation and the Regional Employment Board of Hampden County, as PIN partners, brought together a coalition of 17 nursing schools and health care institutions. Initially, the coalition, called the Collaborating for the Advancement of Nursing: Developing Opportunities (CAN DO) Partnership, focused on changes to nursing education in the region to increase both the supply and diversity of nurses. “But to implement systemic change required investment, and those investment decisions were at the highest level of these organizations,” says Kelly Aiken, program director at the Employment Board. “We realized that we really didn’t have good data on supply of and demand for nurses, nor did we have a good handle on what it would take to close that gap. So the driving factor for us was the need to be able to make the argument about the costs and benefits of nursing education. We knew that the language we needed to speak was that of the senior leaders of those institutions.”
So the coalition went about constructing a flexible and robust business case for increasing the supply of nurses. “We brought in an economist recently retired from University of Massachusetts Amherst’s Isenberg School of Management,” Aiken explains, “who understands the industry, as well as regional economics. The core of it is an interactive supply and demand model that takes data from our six participating nursing schools, our state agencies, the federal Health Resources and Services Administration and others, and then models the regional impact.”
The model allows for examination of a variety of “what if?” scenarios, and takes into consideration the potential impact from Massachusetts’ adoption of universal care for its citizens. Aiken says the model can be used for “very specific scenario planning. If one school decides to grow by 35 students per year, it can project the impact on the region.” Such projections, she says, are critical and persuasive tools for organizational leaders. She reports, too, that the state’s department of higher education has provided a grant to build from the region’s work and create a model to allow for statewide projections.
The Alaska PIN Partner, the Rasmuson Foundation, has supported two separate projects, one focused on workforce diversity, and the other on a preceptorship program for new nurses in rural areas of the state. Rasmuson partnered with the Alaska State Hospital and Nursing Home Association (ASHNHA) to create and implement a model for acclimating nurses to the practice of rural health care. The preceptorship approach needed first to be adapted to the practice of general medicine in rural settings, explains Program Officer Joel Neimeyer of the Rasmuson Foundation, since it is frequently used for more specialized types of nursing care—critical care in a hospital setting, for example. “In rural Alaska, the nurses are called upon to be skilled in many disciplines—one day obstetrics, the next the emergency room, then chronic care. Our rural areas don’t have a large number of providers, and the hospitals are small—with 15 to 18 beds. The nurses see all sorts of things. So what was needed was a preceptorship model for generalists.”
Along the way, the partners concluded that the training materials many of the facilities used for acclimating new nurses needed to be updated. “Over time, the orientation manuals had just gotten bigger and bigger, as new materials and checklists got added,” explains the Alaska Native Tribal Health Consortium’s Cynthia Roleff, M.S., B.S.N., R.N.-B.C., who facilitates this project which came out of a partnership among the nearly two dozen participating member organizations of the Alaska State Hospital and Nursing Home Association. “You end up with a beast of an orientation program. My manual was three inches thick! It becomes overwhelming, too big to be effective.”
“So we overhauled it,” Roleff continued, “asking the question, what do we need to see new nurses do to know that they can safely practice without direct supervision? We focused on core competencies, using the model developed by Carrie Lenburg, Ed.D., R.N., F.A.A.N., and created forms and an improved process which reflect her model.” Roleff says that the feedback so far is that the result is user-friendly tools that effectively measure the multifaceted skill set rural nurses need in their practice.
New nurses in Alaska’s rural areas face unique challenges, Roleff explains. “Transporting patients is one very big issue,” she says. “If you’re in a tiny community and have a burn patient, you may first have to get them from the village to a hub community, such as Nome, for example, and then from there to Anchorage, and sometimes from there to Washington state depending on the severity of the problem. There can be a significant period of time that rural health care workers, including nurses, need to get and keep the patient stabilized.”
The next step for the program, Neimeyer says, is that the Rasmuson Foundation is engaging a consultant from an academic institution to examine the project to see if it holds lessons that would merit a paper for a peer-reviewed journal, thus sharing the results of the effort to the “Lower 48” and beyond.
Fostering ongoing work on nursing workforce development beyond the life of the PIN grants is a key objective for RWJF and NWHF. “Our goal was to encourage local foundations to act as catalysts in their communities,” Hassmiller says. “So we’re thrilled by the broad range of work that our foundation partners are taking on, and at the creativity and energy they and their partners are showing. Better still, their ongoing commitment to the issue is one of the keys to solving the problem.”
NWHF’s Woodruff agrees. “We have some funding partners in the PIN program that haven’t been involved in nursing before, or even in health care, but that are making commitments to the future,” she says. “To attract and engage foundations that have interests in alleviating poverty, or improving higher education, or developing better community solutions, is fundamental to the long-term sustainability and success of this kind of program. The diversity of funders is one of the outcomes we had hoped for, and we are happy to see this realized.”