PART III. Case studies of entrepreneurial educators in schools and universities

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CHAPTER 6.

Patricia Chiverton’s case: Transforming a professional school at the brink of closure

Raffaella Borasi

(with contributions from Michelle Ames and Frank Beltram)

6.1 Pat’s story

  6.1.1. Introduction to Pat’s case

This chapter reports on the case-study of Patricia Chiverton, the dean of the School of Nursing at the University of Rochester from 1999 to 2008.  Pat’s effectiveness as an academic leader is unquestionable, as she moved her school from the brink of closure to being recognized as one of the most successful and innovative nursing schools in the country (as documented in Figure 6.1).  Her story also makes clear that this success was the result of a remarkable number of radical innovations that she promoted during her 9-year tenure as dean.

A psychiatric nurse by training and the holder of a Doctor of Education degree, throughout her career Pat demonstrated a relentless commitment to improving health and health care.  Pat advocated for and concretely worked towards developing new models of health care focusing on health promotion rather than disease management.  She also recognized the significance of the many changes that have taken place in the health fields in the past few decades—most notably technological developments that have opened up unprecedented possibilities for delivering health care— along with the current nursing shortage. Furthermore, she believed that nurses should take a proactive role in the development of these new models of health care, as they have the knowledge, attitude and talent to do so.  The following quote well articulates and substantiates this position:

“I really believe with the shortage of nurses we can’t provide care in the future the way we’re doing it today. So we need to engage with the public, teach them how to become better advocates for themselves, and that’s health promotion and wellness, that’s what nurses have always done.” (Pat)

Pat also believed that schools of nursing have a critical role to play in the future of health care in two major ways.  These include first of all contributing to the developments of new models of health care through their research and innovative practice, combined with developing and offering training programs to prepare future nurses for the new roles thus created for them.

“We want to be on the cutting edge end and we want to pilot the future of nursing – see what works, see what doesn’t work, take risks.” (Pat)

Being the Dean of a School of Nursing in a private research university with a large Medical Center provided Pat with unique opportunities to put her vision into action. The highly decentralized structure of the University of Rochester – where each academic unit is fully responsible for all its revenues and expenses, and the Dean acts effectively as the CEO of that unit (while also reporting to the Provost/Medical Center CEO) – also provided Pat with considerable leeway to act entrepreneurially. Yet she experienced many of the same challenges and tensions shared by most academic leaders in higher education institutions—as she struggled to achieve the difficult balance between academic mission (in terms of research, teaching, and clinical enterprise) and fiscal responsibilities, dealt with a tradition of individual faculty autonomy and the constraints imposed by faculty jurisdiction over curricular decisions, and had to operate within an academic culture not used to change and quick decision-making.

In Figure 6.1 we reported selected information about the UR’s School of Nursing (abbreviated as SON hereafter) at the time of Pat’s deanship.  We hope this information will help readers better understand this context, and also better appreciate the significance of Pat’s activities and achievements during her 9-year tenure as dean.  It is also important to note SON’s history of being a pioneer in their field, as its founding dean, Loretta Ford, developed the first “integrated model” of nursing that bridges across education, research and practice in the 1970’s, as well as the new role of nurse practitioner in the 1980’s.

Unlike most of the other entrepreneurial educators featured in this book, Pat explicitly thought of her activity in terms of entrepreneurship – at least at the time of our study.  Being familiar with the concepts and literature on business entrepreneurship, she could draw explicit connections to both in our interviews – as illustrated in several of the quotes reported in this chapter, and the following one in particular:

“I always believed that you can do anything you want to do, and you know, whether you have the resources or not, if you create it, it’s going to happen and that’s always been the case.” (Pat)

Figure 6.1. UR School of Nursing Profile (as of 2008)

  6.1.2. Highlights of Pat’s professional journey

Pat liked to describe her successful, and somewhat unusual, career as “being at the right place at the right time.”  While it is true that she had the good fortune of being presented with some unique opportunities throughout her career, her story shows that she was not only ready to recognize and seize the opportunities presented to her, but she also pro-actively created some of them herself.

It started with receiving her nursing degree at the Bachelor level at a time when most nurses were educated in 2-year Associate degrees programs, because her high school guidance counselor encouraged her to pursue a 4-year degree. This gave her a jump-start in her nursing career, and also opened up the possibility to pursue advanced degrees later in her career, when she was offered scholarships to do first a Master’s degree in Psychiatric Mental Health Nursing, and then an Ed.D. in Education.

As her husband was in the military, after graduation she traveled a lot and had some unusual job opportunities and responsibilities for a novice nurse—such as being in charge for a whole medical floor. When her husband was posted to Vietnam, she came back to Rochester and got a job in the Psychiatric Emergency Department. How this job developed is an interesting example of Pat always being on the look-out for opportunities to be involved in leadership and innovation.

“I came back to Rochester and started working on an inpatient unit. … I was used to being in a leadership role and I found it more difficult to just be a staff nurse. …I had worked there a couple of months and they asked me if I’d be interested in going into the Psychiatric Emergency Department. That was … very exciting … at that time you were the only nurse … so you were really in charge of what was going on, I wasn’t reporting to anyone else and I was working strictly with one of the doctors there in the ED. … I was there for almost 10 years and became the nurse manager. I had the opportunity to participate in research initiatives, to really practice and change the health care system.” (Pat)

Another example of how Pat managed to “create” new positions for herself came soon after finishing her doctoral degree. As there was a clinical chief position open, she took the initiative to talk with the person in charge about the nature of the position and succeeded in redefining that position before accepting it.

“The clinical chief position in Psychiatric Mental Health was open. I thought about it for a while and said I really like administration, I love creating new programs and putting things together. Now I went to see the Director of Nursing at the time and we talked about it and we talked about creating kind of a different type of Clinical Chief position.  So I became the Clinical Chief for Psychiatric Mental Health Nursing. I was responsible for all of the in-patient units, ambulatory care, community projects and everything related to psychiatric nursing. And again, I had the flexibility and the freedom to create new things, to manage budgets, to be in control of what was going on.” (Pat)

In 1995, she was offered the opportunity to join the faculty of the School of Nursing at the University of Rochester as Acting Associate Dean of Practice, overseeing all the clinical faculty as well as the Community Nursing Center.  The following year, she was appointed Associate Dean of Practice. In this role, she managed to turn around the financial situation of the Community Nursing Center, which at the time was experiencing serious financial difficulties, by taking a “business approach” to its running.

“The Community Nursing Center … at the time … had contracts with rural communities, so they would contract for faculty to go to rural communities to practice. Now they were losing huge amounts of money because our faculty salaries were higher than they were paid in the rural communities.  … So we came over and said ‘we’ve got to clean this up, we’re not doing anything that loses money.’ … So we cleaned up those contracts and started new initiatives.” (Pat)

Because of her success in this role, a few years later Pat was asked to take on the role of Interim Dean for a year, while they searched for a new dean.  While she did not see being a dean as her career goal, she agreed to do so for a short period of time to help her school at a difficult point in its history.  To her surprise, though, she was quite successful in this leadership role and she enjoyed it!  When a national search was held, the search committee concluded she was better than any of the candidates who had formally applied, so she was offered the position.

It is also worth noting that Pat remarked at several points in her story of how helpful her training and experiences as a psychiatric nursing were.  She felt she many of the skills that made her successful as a psychiatric nurse were also very beneficial to her throughout her career.  She also felt that her experiences as a practicing nurse helped her gain perspectives and attitudes that were alien to the academic world, yet helped her lead some radical innovations:

“I think one of the things I brought to the School of Nursing is a different way of thinking. … It was bringing the practice perspective, the different speed, the different way of thinking about things.” (Pat)

By the time Pat joined SON in the mid 1990’s, the school was experiencing some very difficult times. They were running serious deficits in several programs, there was not much innovation going on, and faculty productivity and morale was quite low.  Pat was able to turn this situation around through a combination of many initiatives involving both the creation of new programs and the development of new “business lines” within her School of Nursing, which together increased the school’s revenues – thus resolving their financial crisis – while at the same time moving forward their mission.

  6.1.3. Pat’s innovation #1: Closing the traditional undergraduate nursing program

How the idea came about and was evaluated/refined

One of Pat’s major responsibilities as interim dean, and then dean, was leading a strategic planning process for SON, where they examined what they could do best and where they should put their limited resources and efforts so as resolve their financial difficulties and become leaders in the field.  The stakes were very high, as the financial situation was so serious that the school was risking closure.

SON’s strategic planning process involved, among other things, a critical review of their instructional programs – to decide which ones to keep, which ones to phase out, and which new ones may be needed.  Figuring out their competitive advantages was an important part of this process:

“[We] said: ‘What do we do that is different?’ And we said, well, we do research and we do a higher level of education, we do advanced practice nursing.  … We can’t be everything to everyone. … We did a lot of benchmarking and we looked at creating an accelerated program for non-nurses.” (Pat)

While a new accelerated program for non-nurses might capitalize on the strengths of the faculty in her school and be more competitive, their current undergraduate nursing program was identified as a problem.  They did some benchmarking, and by doing so they realized that there were many other schools in the region that were offering a traditional undergraduate nursing program like theirs, but at a much lower cost because they did not have research faculty nor research project that took resources away from teaching.

“[In] our traditional undergraduate program… we were losing money, and our costs were triple everyone else’s costs … so it really did not make sense for us to run a program that anyone else could run.” (Pat)

As a result of this analysis, Pat considered closing the traditional undergraduate nursing program, and substituting it with a new one-year accelerated program for graduates in other fields who wanted to change career and become nurses.

Pat and her colleagues carefully examined the pros and cons of terminating the traditional undergraduate nursing program, as they realized that closing the program would likely trigger negative reactions from many of their alumni – and alumni were important constituencies for them, especially as they were trying to embark in a major capital campaign.  They did more benchmarking, as well as more precise forecasts of revenues and expenses, to learn more about the available alternatives and further evaluate the costs and benefits of both the program they were planning to close and the new one they wanted to propose in its place.

As the result of these analyses, they concluded that closing the traditional undergraduate program and starting a new accelerated one would be critical to the survival of the school, given their financial crisis as well as their vision for the school moving forward.

Planning and gathering the needed resources

Once the decision of closing the traditional undergraduate nursing program was made, a lot of decisions still had to be made.  This required first of all figuring out how to phase out the program, to ensure that all current students could complete their program.  It also involved thinking about how to communicate this development to various stakeholders.  Although they never made a written plan, a lot of planning took place to ensure a smooth transition.

Pat knew that she would need first to gain the support of the faculty – something she knew would not be easy given the novelty of the accelerated program proposed as an alternative, and people’s natural reluctance to stop anything they have been doing for a long time.  Getting the faculty buy-in involved honest discussions about the financial situation of the school in general and the undergraduate nursing program in particular, as well as the potential benefits of starting a new accelerated program in its place.  In the end, Pat was able to gain the faculty support.

Pat also carefully planned how she would announce the decision of terminating the undergraduate nursing program to current students and alumni.  She was committed to devote time and effort to make sure such a communication would be as good as possible.

Implementing and monitoring the initiative

While closing the undergraduate program was the logical decision, SON alumni’s reactions were even more negative than what Pat had expected:

“You know, it made many people very disheartened with us, our alumni were furious…” (Pat)

Her training as a psychiatric nurse really helped her deal effectively with this difficult and emotionally charged situation.

“It was funny, I had this group screaming at me and all we were trying to do was fix things, you know, and they saw us as the problem and we weren’t. … I understood that, so I wasn’t really affected. …I think being a psychiatric nurse in that instance made a huge difference, because for me it was a process, and I understood the process, I understand group behavior – so I do not take it personally. I look at it more from the perspective of what they had to do to get through it.” (Pat)

Despite this initial resistance, the decision to substitute the traditional undergraduate nursing program with an accelerated program for non-nurses turned out to be the right one, and greatly impacted the school’s enrollment and financial revenues for many years:

“That was one of the initiatives I think that has really made a difference.” (Pat)

  6.1.4. Pat’s innovation #2: Creating a new Master in Nursing Leadership

How the idea came about and was evaluated/refined

The idea for a new master’s program in Nursing Leadership came from realizing that there was going to be a need in the field – in the future, rather than immediately – for nurses that would have certain leadership skills, rather than just specialized medical skills expected for nurse practitioners.

This realization came, at least in part, from Pat and her colleagues’ own practice in creating new business lines.

“[The MS in Nursing Leadership] was created because we knew doing entrepreneurship that leadership was extremely important and we knew that nurses needed to think differently. …we were creating nursing programs in the nursing entrepreneurship center that needed the skills of those nurses and nurses weren’t educated that way, so we knew there was going to be a business need for them.” (Pat)

To identify what the needed skills would be, Pat and her colleagues tried to project what kind of nurses and skills would be needed.

“We looked at the future … what’s going to be the new nursing role. We looked at health promotion and how important that’s going to be. At the time, 9/11 had occurred and one of our faculty wrote a book about disaster management. So we knew that those two focuses were going to be very important … that was the direction that was going to be very important for the future.” (Pat)

 So they decided to develop a new Master’s program in nursing which did not lead to certification as a nurse practitioner, but rather provided advanced nursing education for nurses interested in taking on leadership roles within the areas of (a) health promotion and (b) disaster management.

The new program was very much in line with Pat’s overall vision of having nurses create and promote new models of health care – as this was exactly what this program was going to prepare current nurses for.  As such, Pat believed the new program would be an important addition to the School of Nursing’s program offerings, as its novelty would increase the school’s national visibility. The new roles for nurses the program created would also benefit the field of nursing more generally.

While a business plan per-se was never prepared, at this stage they did do some preliminary forecasting about number of students and expected revenues, as well as faculty needs and other costs to run the program, to test the feasibility of the proposed program.

“We did a semi-business plan … included the number of students that we thought would be coming in and the revenue, and the faculty costs, and so we did look at all of that [to decide whether to move forward].” (Pat)

At the same time, what made the program most appealing to Pat also represented a risk. Since they were trying to meet a future need that did not yet exist, preparing graduates for jobs that were not yet there, there was no certainty that they would attract students and those students would find the right kinds of jobs.

“It was probably one of our riskiest initiatives … because it was just our gut sense that this was going to succeed, and we did not have real support from anyone. Like, practice wasn’t out there saying we are sending you students. … Some of the criticisms about the program [were]: what are these nurses going to do? You’re educating someone to do roles that are not in practice today, because we were really thinking this is what’s going to be needed in the future.” (Pat)

Yet Pat and her colleagues reasoned that this risk was unavoidable when one “invented” new roles that did not yet exist, and they felt confident that they could overcome this risk based on the success experienced in the recent past when their School of Nursing created the new role of nurse practitioner.

“If we look back when we created the nurse practitioner program there were no positions out there then. I remember when I graduated I had to create a position for myself and so that’s kind of what we’re doing today.” (Pat)

 So they trusted their “gut instincts” and decided to go ahead with the initiative.

Planning and gathering the needed resources

Since a new Master program required state approval, a formal proposal for the new Master in Nursing Leadership was prepared and submitted to the state.  This included a description of key courses and their sequence.  One faculty member with expertise in one of the two focus areas was assigned to write this program proposal.

The start-up costs for this new program were essentially covered with internal operating funds – as it is usually the case in all academic institution when new instructional programs are started.  At the same time, they expected that the revenues generated by the program over time would eventually make the program not only self-sufficient, but also generate margins that could support the school more generally.

To ensure that this would happen, they identified some specific targets and metrics that they committed to monitor once the program was launched.

Efforts were made to minimize start-up costs as well as reduce long-term financial commitments for the institution. For example, they planned for courses to be initially taught by some of the current faculty (including the Dean herself) and other adjunct instructors on contracts, until they felt that the success of the program warranted hiring new personnel on a more long-term basis.

Appropriate compensation was established for both adjuncts and faculty teaching extra courses, so as to make those tasks sufficiently attractive, while keeping the costs down.

Implementing and monitoring the initiative

While the program was launched as planned, a few obstacles were encountered along the way that required some adjustments.

First of all, the greatest challenge came from having embarked in this initiative without the right “project leader” to carry out the implementation of the initiative (what Pat referred to as the “champion,” although this terms is used somewhat differently in the literature and in the rest of this e-book).  The faculty member who wrote the initial proposal to the state was too busy with other projects to give her full attention to this new program – and Pat knew that upfront, but at the time thought the first priority was to move fast and get the program approved by the state. However, not having the right project leader in place turned out to be a problem, which caused them to “backtrack” and slow down growing the program until such a person could be identified and secured. To take on this role, they ended up hiring a new person, who had the necessary expertise and personality to carry out the next phase of the program development.  She came up with a solid theoretical framework for the program, worked with the faculty to refine and strengthen the curriculum, and did marketing to attract students not only from nursing but other related areas as well.  Eventually, she was instrumental to the program’s success.

“The new program director is an academic leader who was able to galvanize the leadership faculty. She knew how to mobilize systems.” (Pat)

As the new program was launched, they were not sure how many students they would be able to attract, so they were thrilled when they filled their first class with 24 students. However, the following year enrollment dropped to 19 students, so they became concerned about the feasibility of the program over time. While they were ready to discontinue the program if it did not attract a sufficient number of students, Pat decided to give it a try for a couple more years, realizing that it would take a while before such a new program could take hold. She realized that they were taking a risk by doing so, but she believed enough in her vision to take that risk – and later she was proved right, as the program built to a steady enrollment of students and attracted very high-quality candidates.

“We knew we were taking a risk doing it. … So I think it had to do [with the fact] that we knew the future direction … we were willing to take a risk we wouldn’t have [taken] with other programs.” (Pat)

As one of the major concerns about this program was whether their graduates would find appropriate jobs, they also monitored what their graduated ended up doing.  At the time of our study, all of the graduates had been successfully employed, even if in some cases they had to “invent” new jobs for themselves.

Ensuring long-term sustainability and/or bigger impact

Despite these initial uncertainties and challenges, the Master in Nursing Leadership proved a success and became a permanent feature in the School of Nursing’s offerings.  The tuition revenues it generated were more than sufficient to ensure the fiscal feasibility of offering this program.

When the coordinator that was instrumental to the initial success of the program left, Pat took great care in ensuring that they hired a good successor who would continue to lead this initiative.

While they initially thought about the possibility of extending this program into other tracks besides the originally two (i.e., health promotion and disaster management), this did not happen.  Although at some point they seriously considered adding a track in forensic nursing, they decided that there was not sufficient interest/market to warrant such as extension and ended up pursuing a different path.  Having the Master in Nursing Leadership was very instrumental, though, in their effort to develop a new Doctor of Nursing Practice program that was launched a few years later, as it provided some common courses as well as alumni that could be interested in the new doctoral program.

  6.1.5. Pat’s innovation #3: Creating a new Center for Nursing Entrepreneurship

How the idea came about and was evaluated/refined

As the dean of a school of nursing in a research university, Pat did not downplay the importance of research – which she still saw as the core of the mission of an academic research institution; however, very realistically she recognized that research is expensive and one needs first to secure the resources to make it possible.  Pat’s “out-of-the-box” solution for funding more research was to generate new revenue streams by starting and running some successful “business lines” within the practice arm of the School of Nursing – what originally was the Community Nursing Center.

“I believe that you need additional revenue streams. Tuition isn’t going to do it – it can go up and down, and you can start new programs that do not work. And research isn’t going to do it, although is your golden rod.” (Pat)

The Community Nursing Center had started in 1989 with a grant which enabled a faculty member to work with a local organization to open a senior center downtown for two years – but when the grant run out, they had to close the center because it was not financially sustainable without external funding.  In its next phase, the Community Nursing Center provided nursing services to disadvantaged communities below cost – thus providing a valuable community outreach, but one that also led eventually to the serious financial difficulties Pat was asked to resolve when she first joined the School of Nursing as the Associate Dean of Practice.  Later, in her role as dean and in collaboration with the new Director of the Community Nursing Center (a long-term collaborator who had come with Pat when she joined the School of Nursing), Pat continued to expand the Community Nursing Center by starting a number of new “business lines” within it.

An interesting example of “business line” was Health Checkpoint – an initiative that well illustrates Chiverton’s interest in promoting new models of health care by capitalizing with new technological innovations.  This project was officially described as follows, and was quite revolutionary in the early 2000’s, when it was first launched:

“Health Checkpoint is an innovative method that integrates health promotion advice from nurses with telehealth technology, providing easy access for consumers to health promotion intervention. The following is a case example of this revolutionary technology that brings partnership between health care consumers and nurses to a new height.

The nurse meets with an individual at their work, school or community center. Together they identify a health promotion goal. The nurse then provides the individual with access to a wireless remote monitoring of human vital signs – everything from basic temperature, pulse, respiration and blood pressure t blood tests and lung function. This telehealth technology, HomeMedTM, asks the consumer questions about their health status and symptomatology and can do so in up to seven different languages. All of this information is transmitted wirelessly to the central monitoring station for review and trending by a nurse. Health Checkpoint TM is available twenty-four hours a day and does not require the presence of a nurse, after the initial care planning session, for the individual to use the technology.  Health Checkpoint TM provides immediate feedback to the consumer to let them know if their vital sign readings are within the parameters that have been established to measure their success in reaching their health promotion goals. The consumer maintains on-going communication with the nurse and together they focus on achieving the consumer’s individualized health promotion goal. Trended information can be electronically provided to other health care providers.”  (Health Checkpoint Project Description)

A very different example of “business line” was the creation of a Center for Lifelong Learning (CLL).  This Center was conceived initially as a way to reconnect with alumni by serving their needs for continuing education. However, the Center for Lifelong Learning not only succeeded in this initial goal, but also turned out to serve a number of other important functions – such as providing a “testing ground” for potential new programs, attracting new students to their degree programs, and providing additional revenues that can support the school’s research and educational mission.

The success of the first business lines within the Community Nursing Center motivated a re-conceptualization that eventually led to the creation of a Center for Nursing Entrepreneurship – the first one in the country.  As Pat started to read and learn about the field of entrepreneurship, she realized that “entrepreneurship” truly captured what they had been doing in recent years in the Community Nursing Center. She also began to see a close connection between empowering nurses to be more entrepreneurial, on one hand, and her overall vision for the School of Nursing in promoting new models of health care, on the other hand.

“So then we looked at what we were doing, and I was thinking about how to write about this … We started with faculty practice … but then we kind of transitioned out of the traditional faculty practice model into these businesses, and I was really struggling with how to conceptualize this … and that’s when we decided that what we were doing was entrepreneurship.” (Pat)

Pat began to conceive of a Center for Nursing Entrepreneurship that would not only provide an umbrella for the various business lines they had created and might continue to create in the future, but also would respond to the unmet need of helping other nurses learn about entrepreneurship and supporting them to start up successful businesses.

“I would hear that nurses have these wonderful ideas that they were giving away to their physician colleagues, or they were going to tech transfer and tech transfer said ‘I’m not interested’ because it was a service model and they didn’t understand service models. So we said … we’re going to create a center where any nurse can come with any idea and we’ll help move them through the process.” (Pat)

“Starting and running [businesses], that’s one of the hardest things … to be able to get an idea, generate it, get the champion, provide the business structure and the planning, incubate it for a short period of time and launch it.” (Pat’s collaborator)

As she did some benchmarking, she realized that no other nursing school around the country had such a Center.  Establishing the first Center for Nursing Entrepreneurship in the country had therefore the potential to give great national visibility to her School of Nursing – another reason in favor of pursuing the initiative. She thought that her School of Nursing was uniquely positioned to start such a Center, because of their experience starting new business lines within the school – something few other schools around the country had even thought of engaging in!

“We looked nationally, and nobody was doing it … Deans across the country were struggling because they did not have these additional revenue streams, so I was being asked to consult all over the country.” (Pat)

She also knew she already had the right person to direct such a Center on her staff – the current director of the Community Nursing Center, who had also up to that point led several of the business lines they had created.  She not only had a long history of collaboration with Pat, but also shared the same entrepreneurial attitudes and beliefs.

Pat felt this was the right time to move ahead with this initiative – given the momentum created by their successful business lines, the faculty’s positive feelings about those businesses as they could begin to see how they contributed financially to the institution, the alumni’s interest and willingness to invest in it, the fact that she had the right project leader in place, and the value that would come from being the first Center of this kind in the nation.

It is worth noting that a few people were very instrumental in helping Pat conceptualize what she had been doing as “entrepreneurship” and moving it to the next step of creating a “Center” to support nursing entrepreneurship.  They included a few entrepreneurs who were alumni and/or friends of the School of Nursing, the director of development in the Medical Center, her colleagues running the various business lines, and most importantly her long-term collaborator and at the time director of the Community Nursing Center.

Planning and gathering the needed resources

As she had already identified the current director of the Community Nursing Center as the right project leader, Pat immediately appointed her as the new Center’s founding director and involved her in the planning process.

The new Center for Nursing Entrepreneurship was conceived to subsume the Community Nursing Center with its existing business lines, while also adding the new function of supporting nurses with business ideas through the various stages of the process of starting up a new business in the health care field. Because the Center for Nursing Entrepreneurship essentially “morphed” out of an existing structure (the Community Nursing Center), this is a case when they did not need to, and thus did not engage in, any kind of formal business plan. They did, however, engage in a lot of detailed planning regarding the structure and functions of the new Center, its governance structure, and how they could ensure fiscal feasibility in the long-term.

For the same reason, “launching” the new Center also did not immediately require substantial investments in infrastructure – and, thus, financial resources – as key people and facilities were essentially already in place.  The revenues generated by the existing business lines provided much of the needed start-up money. Being the Dean, Pat also had sufficient control on the School’s resources that she could choose to invest some internal funds in the new initiative:

“I think it would have been very difficult if I wasn’t dean. I don’t know that we could have been as successful, because I was okay with letting things be kind of loose, where I wouldn’t have been if I wasn’t involved, if I didn’t have that belief in it…The businesses were absolutely key, because it gave us the money we needed.” (Pat)

The buy-in of the faculty was not a given, since a Center focused on supporting the creation of new businesses may seem quite far from the core missions of research and education of a school of nursing. However, by then the faculty had realized the key role that the Nursing Community Center and its various business lines had played in securing the financial viability and survival of their school, so they were more willing to support the initiative as part of the School’s strategic plan.

“Getting faculty buy-in was interesting, because faculty think our mission is to educate students and ask why are we out there dabbling with entrepreneurship. … they knew we were in desperate straights … they knew that those dollars helped save the School of Nursing. So it paved the way. … I don’t think it would have happened as quickly without the original crisis.” (Pat)

In contrast, the idea of a new Center for Nursing Entrepreneurship generated a lot of enthusiasm and support among alumni and supporters of the school. Pat soon identified a few donors who were excited about the idea and were willing to “invest” in it by providing the funds needed to establish a seed fund to support new projects and to support specific aspects of the new enterprise.

“I had a lot of alumns who were very interested, who were willing to invest dollars into it, which was another reason that we moved in that direction.” (Pat)

Another important step was establishing an Advisory Board for the Center.  The Board consisted of a combination of powerful alumni, as well as entrepreneurs and venture capitalists with an interested in nursing.  It played an important role for the Center by providing additional expertise, visibility, and also financial support in the form of major gifts to support seed funds and other aspects.

“I have a national board of entrepreneurs and venture capitalists, nurses or friends of people in nursing. … Members of the board are also interested in venture philanthropy.” (Pat)

While a lot of important decisions were made at this stage, some important planning continued to occur after the Center was officially launched.

Implementing and monitoring the initiative

The actual implementation of the new Center for Nursing Entrepreneurship was especially critical in defining its nature and operations.  For example, it was at this stage that they really figured out how the “Think Tank” and “Incubation” components of the new Center would work, so as to support other nurses interested in starting their own health care ventures.

Both Pat, the Center director and the directors of the various business lines had an important role in this implementation – with Pat taking more the “big picture” role of providing the framework and the external support, the director working on the day-to-day operations and generating and evaluating ideas for new business lines, and the business line directors running their respective business in an entrepreneurial way.

“I’m not the one running the Center for Entrepreneurship. … I bring the conceptual framework piece to the Center and then we hire people who can actually operationalize it at the Director level.” (Pat)

Pat identified the fact that the Center was run very efficiently, with minimum overhead and a very lean and capable staff, as a key reason for its success:

“We have a very lean staff; one of our successes is the ability of multi-tasking – so we do 40,000 flu shots a year, so our nurses may be out doing flu shots, they might be going to corporations and they might be managing psychiatric patients.” (Pat)

Each business line was also systematically monitored, using metrics that appropriate for the specific nature of the business. Business line directors were very aware that if their business did not make money (or at least break even) after a few years, it was likely to be closed – and this generates significant accountability!

“If they [business lines] did not bring in dollars, then we closed the business line. … that hasn’t happened a lot, but it has happened.” (Pat)

The Advisory Board also continued to play a very important role. In addition to overseeing the Center as done by boards of non-profit organizations, some board members also provided expert advice and reviewed specific proposals for new businesses, while others helped them make valuable connections with potential donors and investors.

As the Center continued to develop, Pat also made conscious and systematic efforts to keep all key constituencies informed of the progress and achievements made.

Securing long-term sustainability and/or bigger impact

As planned, revenues generated by the business lines run within the Center and gifts from alumni and other donors have continued to secure the financial feasibility of the Center.

From the beginning, Pat also planned for some of these revenues to be transferred to the School of Nursing, as a way not only to contribute to common infrastructure costs, but also to make explicit the fiscal advantages of maintaining the Center operative for the School.  This was indeed a very important move to secure the continuity of the Center, even when a later dean did not share the same vision.

  6.1.6. Pat’s innovation #4: Developing the National Forensic Nursing Institute

The National Forensic Nursing Institute (NFNI), which later became an independent for-profit company offering a variety of services to support professionals involved in forensic nursing, was one of several new “business lines” that Pat and her team initiated at her School of Nursing.  We have chosen to examine its development in more depth, as a way to provide valuable insights on the creativity and risk-taking that characterized the creation of most of the business lines created in this academic unit – although this was one of the few that ended up being “spinned off” into an independent company.

How the idea came about and was evaluated/refined

The initial idea for the NFNI came about as Pat and her colleagues realized that there was an increased interest in forensic nursing – as the result of increase in violence – along with an unmet need to prepare nurses in this area.

As they did some preliminary benchmarking, they also realized that there were only two other schools in the country offering programs in forensic nursing. Even if they recognized that this could be only a “temporary” need and opportunity, they thought it would be worth capitalizing on it.  At this initial stage, they were thinking just in terms of offering continuing education courses and maybe a new track in forensic nursing within their Master in Nursing Leadership program.

While at the time there was nobody on the faculty with expertise in forensic nursing, they did not let that fact deter them, as they thought that if the program was worthwhile they could always hire experts to develop and run it.  At the same time, because of previous experiences they were well aware of the importance of having the right project leader in place before launching an initiative, so they were committed to wait to launch this initiative until such an individual could be secured.

To further explore their initial “hunch” about the growing interest and need for training in forensic nursing, the director of the Center for Nursing Entrepreneurship went to a conference organized by the professional organization for forensic nursing to learn more about that area. It was at that conference that she found the right person to champion the new initiative.  Unfortunately, he was not willing to move! The creative solution to this problem was to create and offer him a position as a “virtual” or “distance” faculty member.

“He’s what we call a ‘virtual faculty member’. He comes here and teaches in our program; he does online advising; he participates in committee meetings through video conferencing. And it worked out extremely well.” (Pat)

With the right champion now secured, it seemed the right time to begin to pursue their idea, especially since a popular TV show, “Bones,” had just raised considerable interest in forensic issues.

“Timing is everything, too.” (Pat)

To get a better sense of the market, they first started to “field test” the demand for education in forensic nursing by offering a few courses through their Center for Lifelong Learning. These courses attracted a lot of students.

“We offered several course in forensic nursing [within the Center for Lifelong Learning]. Offered one, had over 60 students enrolled, had to turn people away. [So we] said, well, there might be some interest in this.” (Pat)

The success of these first continuing education courses in forensic nursing led to the decision of offering some of those same courses for credits as electives for their existing nursing programs. They also realized, however, that there were other on-going needs for training and support in the area of forensic nursing that could not be fully addressed just through offering a degree program or continuing education courses.  For example, the director secured consulting contracts with various places around the country.

So, they finally settled on the idea of establishing a “National Forensic Nursing Institute” as a for-profit business line that would provide a variety of consulting services within the area of forensic nursing.

Even if they realized that this could be only a “temporary” need and opportunity, they thought it would be worth capitalizing on it. Their main reasons were that they felt that this initiative would help them move forward their mission of having their School of Nursing involved in the development and dissemination of new models of health care, and also likely generate revenues that could help sustain other initiatives within the school.
Planning and securing the needed resources

Before going further with a business plan and decisions about whether to launch NFNI as an independent for-profit company or keep it as part of the business lines run within the School of Nursing, they decided to “incubate” this business for a few years within the Center for Nursing Entrepreneurship – so part of the planning was de-facto integrated with the implementation of the initiative.

Funds to invest in the hiring of the project leader first, and then incubating the business, came from “seed funds” in the Center for Nursing Entrepreneurship that Pat has previously gathered from donors through intensive fund-raising.

No other staff besides the project leader was hired at this point, with the expectation that all other personnel would be hired as free-lancers through contracts, as a way to maintain flexibility and minimize financial risk for the new company, at least at the beginning.

Implementing and monitoring the initiative

NFNI was launched first as one of the business lines run as part of the Center, using internal funds, to test out its viability and providing it a solid foundation.

“[In year 1] we hired [the director] … we paid his salary, we gave him time to get the business off the ground, we gave him marketing support, we gave him travel dollars to go out and be visible on one side. On the other side, we expected him to come up with a business plan and an implementation plan for how this was going to work. … Year 2 we had everything together and he was off building the business – so we invested during that year.” (Pat)

Part of the “incubation period” also included setting some specific targets and metrics to monitor the new business and decide whether it should be continued, and if so, whether it should become an independent company.

There was the expectation that it would take some time before the business could make any profits, and indeed it took over three years to reach that point:

“We felt that financially the first year he did not make any money, the second year he might have lost some, year 3 he was beginning to show a profit and then year 4 he did and it continued to grow. So once it was on the upward swing and the majority of start-up costs were paid for, we felt that he would do fine in a stand-alone business.” (Pat)

Ensuring long-term sustainability and/or bigger impact

Based on the positive results achieved during the incubation period, the decision was made to spin off NFNI as an independent start-up company, rather than continuing to run it as a business line within the School of Nursing. This decision was motivated by two major considerations. First, they realized that the School of Nursing did not have the internal capacity to run more business lines at the time. Second, they also felt they needed the flexibility of a stand-alone company so that it could “move faster” in order to respond to new market needs. Thus, we would argue that spinning off an independent company contributed to ensuring long-term sustainability to the business that had been successfully incubated.

The project leader created a formal business plan to launch an independent for-profit company, of which he would be the main owner, but with the School of Nursing maintaining part of the equity and thus benefiting financially. He then presented his business plan to the Center for Nursing Entrepreneurship Advisory Board for feedback and support. The Board was very enthusiastic about the project and recommended that they moved on with spinning off NFNI as a start-up for-profit company in which the School of Nursing would maintain some interest and equity:

“Our board … gave thumbs up, thought it was very viable, thought that it was a god business strategy, thought we had the right person, thought we had the right business elements, and from there we moved out” (Pat’s collaborator)

As this was the very first spin-off for a start-up company achieved in the Center for Nursing Entrepreneurship, they had to learn about how to value a company and how to determine the percentage of preferred stock that would be owned by the School of Nursing – so that they could get a return on their initial investment in the development of NFNI by continuing to share in the future profits of the company.

NFNI is now a successful independent company that provides several valuable services, as illustrated by this excerpt from their 2006 brochure:

• NFNI forensic nurse educators and consultants come on-site to provide education and training covering a forensic nursing practice topic …
• NFNI continuing education packages are designed to meet individual program needs [on a variety of specific topics within forensic nursing] …
• NFNI forensic nurse consultants serve as outside mediator and resource for communities as they develop a means to address issues of violence …
• NFNI forensic nurse consultants provide tangible assistance to medical facilities in all aspects of forensic nursing programs development from initial assessment and design to final implementation … (NFNI brochure, 2006).

NFNI has not only contributed financially to the School of Nursing, but also led to greater national visibility and contributed to address a social problem.

  6.1.7. Pat’s innovation #5: Securing new facilities for the School of Nursing

How the idea came about and was evaluated/refined

The many innovations instituted by Pat in her first years as dean of the School of Nursing brought it to a very different financial position, increased the national visibility and reputation of the school, and also resulted in considerable growth in number of faculty and students. With this growth and success, however, a new set of problems also came along, as they were running out of space!

To respond to the increased need for facilities, Pat thought about expanding the current building by creating a new wing with state-of-the art teaching facilities.

“We were out of space. We had the increase in enrollment, we also increased our research faculty. … there were pillars in our classrooms, the acoustics were terrible; it was just a dismal place. … I really believe the environment is so important, especially for nurses because they have to feel valued. … So I said, we need new space. We looked at what to do: do we build a new building? Do we renovate space that we have? … We decided not to build a new building because there is so much history attached to [our current building]. … So we decided to renovate and build an addition that would represent the future.” (Pat)

Planning and gathering the needed resources

Building the new instructional wing was no easy feat, as the project presented many challenges and required considerable fund-raising.  Plans had to be developed with architects before they could even know how much the project would cost.

Given many other competing building projects within the university’s Medical Center at the time, Pat was also told that she could not take on any debt for this facility project.

“Believe me, I had to fight for this … in the Medical Center there is a million and one building initiatives and why should you do one and not the other.” (Pat)

This meant that to move forth with her plan she had to raise all the funds needed for the building by securing gifts. She was successful in her fund-raising, and thus her building construction could begin.

Implementing and monitoring the initiative

Once she secured the permissions and funding, Pat essentially left the responsibility of overseeing the construction of the new instructional wing to other colleagues, who had showed both interest and experience in facilities projects.

The building was completed successful, and it turned out to be instrumental for enabling the School of Nursing to continue to expand their course offerings over time.  It also remains as a visible legacy of Pat’s leadership and impact on her organization.

  6.1.8. Updates to Pat’s story

Pat chose to retire shortly after our study was completed, after an 8-year tenure as dean.  Her original plans were to come back after a sabbatical year and take over the leadership of the Center for Nursing Entrepreneurship she had helped develop.  However, she was not able to implement that plan.

As the person who succeeded her as dean had a very different vision for the school, for a time it was not clear which of Pat’s innovation would stay – except for the new instructional wing, of course!  However, eventually the Center for Nursing Entrepreneurship as well as most of its business lines she had launched not only survived but continued to thrive, as well as many of the new programs she had put in place.

6.2. Analysis of Pat’s entrepreneurial activity

  6.2.1. Pat’s practices about vision

Pat’s story reveals the influence of her vision for the field of nursing, and the UR School of Nursing in particular, of becoming a leader in the development of new models of health care focusing on health promotion.  It is clear that Pat believed strongly in her vision and that vision informed both big decisions (e.g., the strategic plans she prepared for the School of Nursing, as well as major initiatives) and day-to-day decisions (e.g., when and where to stop a project, who should be hired, etc.).  The following examples make explicit how her vision was central to all her major initiatives:

• Health Checkpoint: The new monitors made it possible to conceive of a new model of health care which is more “remote” and controlled by patients; Health Checkpoint was created to further develop and disseminate this new model.
• Center for Nursing Entrepreneurship: The mission of this new center was specifically to promote new models of health care; the center was created to develop these new models, test them out and if successful launch them as business lines (whose revenues could contribute to support the other more traditional missions of the School of Nursing – research and education).

Pat’s vision also was the determining factor in making decisions about whether to continue to pursue an initiative or not when results were not turning out as expected, although she sometimes described this as using her “instincts” or “guts”. The story of the Master in Nursing Leadership is a great example, as Pat decided to keep this program alive even if it did not meet their established enrolment threshold at the beginning, because she saw its potential for the future of health care.

As important as her vision itself was Pat’s ability to have people “buy into” this vision and “making it their own.” Both she and her collaborators recognized this as one of her greatest strengths:

“I’m that quiet, behind the scene – but I can make things happen, you know, and I can get people to buy in and help build it.” (Pat)

“She does it so well that people buy in almost automatically. … She can convince people of almost anything.” (Pat’s collaborator)

How did Pat get other people to “buy-in” her vision? Characteristics such as being perceived as non-threatening and approachable, and being a very good listener, served her well here.  Her strength was not so much in her power of persuasion, but rather in being able to help other people see how “her mission is their mission” – as suggested by one of her collaborators.

In addition, Pat was willing to spend considerable effort, time and resources to produce good materials about the school that articulate her vision, and also to personally talk and present to various constituencies, especially alumni.

  6.2.2. Pat’s practices about opportunities

Pat and her team were very aware of the importance of recognizing and capitalizing on opportunities in their work and recognized this as a key element of their success.

First of all, Pat and her collaborators had an extraordinary awareness of their market – that is, the health care field – and that awareness was often the source of new ideas (as it was the case for Health Checkpoint and the National Nursing Forensic Institute, for example).  Such an awareness, in turn, came from purposefully engaging in a few practices such as going to conferences (in nursing as well as related fields), reading the literature, and continually doing benchmarking.  At the same time, they engaged in these activities in a particular way, as they were always proactively seeking opportunities by keeping their eyes and ears open to identify new needs and possible solutions.  They were also looking at other fields (technology in particular), searching for ideas and solutions that were new to nursing but could be applied to it.  Finally, they were oriented towards the future – that is, they did not just pay attention to current trends and needs, but more importantly they looked at where the health field was going, so that they could recognize in advance what may be needed and work towards that.

Pat also demonstrated the ability to recognize and capitalize upon new opportunities that may be revealed when solving a problem. This happened whenever she realized that the solution they found for a given problem might also provide the opportunity to address other needs.  A great example of this can be seen in the development of the Center for Lifelong Learning. When they first conceived of this initiative, it was in the attempt to solve the problem of reconnecting alumni, whom they thought could be attracted back to the school by offering professional development opportunities they would find useful. However, Pat was able to recognize early on that such a Center could also provide a perfect context for pilot testing new programs, as well as become a feeder for degree programs (as people who took short courses might got interested in pursuing a new advanced program).  These two functions for the Center of Lifelong Learning indeed proved to be the most valuable aspect of the initiative.

Pat and her colleagues were also aware of the importance of “seizing” opportunities when they present themselves – even if they may not have all the needed resources at hand.  At the same time, they were also careful about evaluating whether the opportunities they recognize as possible are really worth pursuing – as resources always presented a limition.  She and her team used specific strategies to do this analysis, including:

• Benchmarking (to see what competitors were doing and decide whether SON had a competitive advantage in pursuing that opportunity).
• Market research (to better evaluate the extent of the unmet need they had recognized as well as people’s willingness to consider the proposed solution).
• Undertaking pilots to test out new possibilities.
• Doing a financial feasibility analysis.
• Making sure they have the right champion/project leader to lead the initiative.

We can notice striking parallels between the practices identified above and those employed by business entrepreneurs like Donna and not-for-profit intrapreneurs like Gidget.

  6.2.3. Pat’s practices about risk

Undoubtedly, there was a lot of risk involved in many of the initiatives Pat undertook as dean and she could not have handled these situations without a high tolerance for risk – a trait she thought is very critical for successful entrepreneurs.

“It’s important to know that we did not know that these [initiatives] were going to work. I mean, we were taking a risk starting, especially the [Nursing] Leadership program. This was something we believed in but didn’t know that it was going to work – and still don’t know for sure.” (Pat)

“I will probably take more risk than a lot of people would take, especially in education.” (Pat)

While high risk tolerance may be one of her personality traits, a more interesting question for us to pursue is: How was she able to deal with high risk and, more specifically, what strategies and practices did she use to minimize and manage that risk?

First of all, Pat was clear that her willingness to take a risk, and her evaluation of the risk itself, were in great part a function of how strongly she felt that the initiative in question was “the right thing” to do, and how knowledgeable she felt about the field:

“If I believe that this is the direction that nursing is going and that we need to be on the cutting edge, I’ll make that decision knowing that our budget is kind of a fine line.” (Pat)

Therefore, one could say that her propensity to take a specific risk was greater the more she felt that doing so was in line with her vision and her understanding of where her field was going.  This can also be connected with her relative evaluation of “missing the boat” versus “sinking the boat” kind of risks (Brown & Cornwall, 2000). Because of her overall goal of maintaining her School of Nursing at the cutting edge of the field, she perceived “missing the boat” risks as very real and potentially costly.  In contrast, she feared less “sinking the boat” kind of risks, which she felt may be easier to control and handle.

This attitude may have come in part because of her overall attitude towards mistakes as “learning experiences” – so she was not too afraid of failing:

“One thing that we truly believe is that it’s okay to fail. So, if you try something, it doesn’t work, it’s just knowing how to cut your losses.” (Pat)

As suggested by this quote, though, this positive attitude towards mistakes and failure was closely connected with her confidence in the possibility of putting systems in place that could minimize the risk, at least to some extent. Indeed, Pat clearly identified and regularly used a few strategies to reduce and manage risk when embarking in new initiatives, such as:

• Doing some preliminary pilot testing before even deciding to embark in an initiative (as in the instance of the Forensic Nursing initiative).
• Controlling potential losses by having systems in place to monitor the initiative and decide whether to continue it before the losses could become significant.
• Especially when launching a new initiative, securing personnel through short-term contracts to make an exit strategy more possible (as done at the beginning of the MS in Nursing Leadership).
• Reducing up-front costs and, thus, financial risks.

It is interesting to note that, according to her collaborators, Pat’s strength was not in the technical evaluation of the risk of a given initiative – a task that she often left to some of her collaborators or hired experts for.  However, she clearly had a strong sense of the importance of minimizing and evaluating risk when it came to deciding whether or not to launch or discontinue an initiative.

  6.2.4. Pat’s practices about resources

Pat’s activities undoubtedly fits Stevenson & Jarillo’s (1990) definition of entrepreneurship as “pursuing opportunities without regard for the resources currently controlled”, as suggested by the following statement:

“There’s a group [of faculty] that says well, you know, we are spread too thin, we don’t have enough resources to do this. And I don’t look at it that way, I look at we’ll get the resources that we need to make it successful.” (Pat)

And this statement was substantiated by her actions throughout her career.  Some notable examples reported in her story were her willingness to explore the possibility of pursuing a new venture in forensic nursing even if at the time they did not have faculty in-house with expertise in this area, and planning for an expansion of the School of Nursing building which required considerable fund-raising before it could become a reality.

At the same time, it is important not to confuse Pat’s confidence in being able to gather the needed resources for a worthwhile initiative with being fiscally irresponsible. On the contrary, Pat demonstrated a remarkable understanding for the economic drivers for her institution and her success depended in great part from having been able to use this understanding – as well as some creativity – to actually gather the resources needed to implement her innovations.

Indeed, her analysis of what needed to be done to solve the School of Nursing’s financial crisis at the time of the first strategic plan reflected her deep understanding of the role played by net tuition, research grants, gifts and revenues from practice as the economic drivers of her institution. At the same time, her success also depended on taking on a non-traditional approach about the respective role and relative importance of those revenue sources for a nursing school in a research university.

More specifically, it is interesting to examine how she tried to maximize each of these different revenue sources for the School of Nursing.  First of all, she made very strategic decisions about which instructional programs should be closed or started, to ensure that they would attract sufficient numbers of students – and, thus, make rather than lose money for the institution.  Because research is the ultimate measure of success within a research university environment, Pat invested in hiring quality research faculty who could eventually be competitive for large federal grants – even if she realized that research will always cost more money than it will make.  She created business lines that could develop and disseminate new models of health care not only as a way of fulfilling the School of Nursing’s mission, but also because she recognized the potential of these business lines – if successful – to generate critical revenues that can be used to enhance the instructional and research missions of the school.

The additional revenues generated by these business lines also contributed overall to put the school in much better financial position.

“I really believe the only thing that saved the School of Nursing was the revenue that was generated through the Community Nursing Center, because those were dollars we could use to hire faculty, to invest in new programs, and that helped turn the school around.” (Pat)

Pat also moved one step further in this direction by conceiving of a new long-term revenue stream for the School of Nursing coming from having preferred shares in companies that have been “incubated” in the Center for Nursing Entrepreneurship and later “spun-off” as independent start-up companies – as done for the National Forensic Nursing Institute. As one of her collaborators explained:

“Pat and I are creating a legacy for the [School] … the School will get a part yearly of a revenue stream, so there are dollars attached to come to the school without fund-raising, without development, without tuition, without research – and that’s really very good for our school!” (Pat’s collaborator)

Finally, Pat recognized the importance of fund-raising and spent considerable efforts in this direction – with great results that are surprising given the limited resources of the donor pool typical of a nursing school.

“[Fund-raising] is a huge part of my role. I would say from a school perspective it’s about 60% of what I do.” (Pat)

Pat was aware that an understanding of the financial drivers is quite unusual in the nursing field, yet she thought it was very important for all nurses who wanted to be leaders and “agents of change” in today’s health care system.

“You need information, you need to know what your finances are, you need to know how much money is coming in, you need to see those accrual sheets and know when your bills are not being paid … so you need the information to manage.” (Pat)

“One thing that has always been missing in nursing is really that financial piece. Nurses never understood reimbursement, they never understood budget if they aren’t nurse managers, but they need to today. They need to understand where the money is coming from, how they can improve quality of care within a budget.” (Pat)

Pat pointed out that this kind of financial understanding is particularly critical for the leaders of any innovation or venture (what she called the “champions”), as they need to have a very good sense of the current financial situation and to act on this information.  This awareness, in turn, motivated Pat’s interest in developing new programs (such as the Nursing Leadership program) and infrastructures (such as the “Think Tank” within the Center for Nursing Entrepreneurship) that would support nurses in developing these important skills.

It is especially interesting to look at how Pat balanced the need to be fiscally responsible with the drive to pursue her mission. It is clear that Pat was very conscious of the need for each new enterprise to “make money”, or at the very least “not to lose money.” At the same time, it is also clear that her decision-making was mostly governed by her vision of how to move the School of Nursing to be the leader in the field in developing, testing and promoting new models of care, rather than financial considerations alone.

“I will never go into anything if it looks like we are going to lose money – but as long as we’re generating a little bit of revenue and I believe that that’s the right direction, then we’ll take the risk.” (Pat)

Another important element of Pat’s overall approach to resources was the recognition of the value of bootstrapping – that is, doing the most with the limited resources available.  Pat recognized the importance of bootstrapping in the success of most of her initiatives, and she also saw bootstrapping as something that characterizes entrepreneurial activity and contributes to its success. Among the specific bootstrapping strategies she and her team used, she explicitly highlighted the following:

• Having a “lean” but very capable staff – Since most of the costs of her initiatives were personnel, being able to have a “lean” staff could result in a very significant cost-saving. At the same time, they realized that to be able to function with a small staff, that staff needed to be very capable, flexible and willing to do what it would take to get the job done. Staff also needed to be able to “multi-task” – that is, be able to work on a number of different business lines or projects at the same time, making the best use of their time by dividing it among these different projects.
• Having most personnel paid through contracts – as this could save considerably in overheads and also give the institution more flexibility (and less risk) when starting a new venture.
• Carefully watching expenses — always looking for the cheapest way to do things and for cost-savings.

Pat pointed to the Center for Nursing Entrepreneurship as a living model of bootstrapping, especially when it came to having a cost-saving attitude. She attributed this to a combination of having a different appreciation of the value for money because of being involved in business (and thus being responsible for generating the funds one would be using), and having been used to make the most of scarce resources as practice nurses.

There were also occasions when specific partnerships were formed, as needed to carry out a specific initiative – for example, Health Checkpoint required a formal partnership (sanctioned with a legal contract) with the company who produced the monitors.

It is interesting to note that Pat’s deep understanding of economic drivers and appreciation of financial considerations did not come hand-in-hand with a facility with the more technical aspects of running a business – such as creating financial analyses and detailed business plans.  Indeed, both of her close collaborators we interviewed pointed out that her strength and interest was more in the “big picture” than in the actual evaluation of the financial feasibility of specific projects.  However, since Pat was aware of this limitation, she always made sure that she had collaborators that were good managers and financial analysts.

Pat recognized dealing with human resources as one of the most critical components of her activity and stated her belief that the secret to the success of any initiative or organization is in the quality of the people involved. More specifically, she greatly valued creativity, innovation and openness to change in the people she selected to work for her organization or for specific initiatives. She also mentioned the importance of identifying people who had a similar vision and attitude towards innovation, as well as passion and commitment:

“Another really important factor is … getting people who kind of have my same vision and feel like you can get anything accomplished and that makes a big difference…  that have a passion that they want this to succeed.” (Pat)

Furthermore, Pat emphasized the importance of identifying the right people for the right position, while also recognizing that “different people are necessary at different stages in your growth,” or even just for specific initiatives.  For example, in the case of the Nursing Leadership program, she soon realized that the first champion she had appointed at the beginning to move the project forward and get the program approved by the state was not the right person to continue to lead the project to the next stage; so she had to find a different person to take the lead from that point on.

Starting new ventures and initiatives, and recognizing that such ventures can grow and change significantly overtime, all call for a high degree of flexibility in personnel.  As mentioned earlier in this section, Pat preferred to hire most of the personnel needed for new programs and business lines on contracts – as it both provided for greater flexibility and helped minimizing risk. At the same time, she discovered over time that in order to secure the services of the best people, she would need to offer them more long-term contracts once they have “proven themselves.”

One of Pat’s strengths, according to both herself and her close collaborators, was being able to delegate and not micro-manage.

“I believe that anyone can be entrepreneurial, that they just need the support and encouragement, and I believe – one thing that I think has really helped me – is that I do not micro-manage people. I really look at the strengths in people, and give them control over what they do, and then just say go develop something – and I think they are twice as likely to be successful. They kind of go and get excited, and they own it, and they have their own ideas, and they move forward – so I think that makes a difference too, not trying to tell people what to do but give them the freedom to do something.” (Pat)

Delegating and not micro-managing, though, went hand in hand with careful selection of and a high level of accountability for the people she worked with. She thought that in order to develop the trust that is needed in order not to micromanage, the key is putting the right people in the right position, giving them the resources to perform their job, monitoring their results using appropriate metrics, and not being afraid to move people out of a position if it does not work.

“I’ll give the resources they need and the support – I’m always very supportive but I’m not going to do the work for them – and if they don’t pull it off, then they’re not going to stay. And I think you have to set that expectation, or else people will just hang around and not do a whole lot.” (Pat)

Pat identified securing a “champion” (what other subjects have referred to as “project leader”) for each new initiative as one of the most critical steps to ensure the success of that initiative. We have seen that finding the right “champion” sometimes may require looking far and outside the box – as it was the case with the Forensic Nursing initiative. It may also take more than one try – as illustrated, for example, in the case of the Nursing Leadership program.

What did Pat look for when searching for a champion? Most of all, she looked for passion, dedication, motivation, initiative – some of the very same characteristics identified in the literature as typical of entrepreneurs – and she tried to make a judgment about these qualities based on the person’s past record and performance at the interview:

“We look for someone who is very passionate about things, who wants to have high standards and high ideals, who is a real ‘go getter’. … You know that from past experience, we look at what they have developed over time and do they have the initiative to kind of just go and do it.”  (Pat)

Once a champion was identified, the next step was putting together a team that could work well with that champion – and if needed complement the skill set of the champion. Pat recognized that there is no “set formula” to go about creating such a team, as it depends on the personality of the champion as well as the nature of the enterprise.

It is worth noting that, because of her position as dean, Pat was able to exercise great control on the hiring and retention of personnel in her organization – something that is not true for most educators.  At the same time, several of the team-building practices she used may be relevant for anyone who is in the position of choosing collaborators to work on a specific initiative.

  6.2.5. Pat’s practices about growth

The School of Nursing experienced tremendous growth under Pat’s leadership.  Over her 8-year tenure as dean, the number of programs and business lines grew considerably, the number of students and faculty increased by over 30%, and the budget almost doubled. When asked to comment on this growth, Pat first of all recognized it as the inevitable consequence of her mission to promote new models of health care and the desire to influence as many people as possible in the field of nursing and health care more generally.

Looking at the implications of this growth for her and her team, Pat pointed out that her role did not change so much overtime, although the role of the people in her leadership team did:

“I think the people, the team that you need, changes over time as a result of the growth. … You need a different type of leader when you need people to be more empowered and less micro-managed … and that in some ways changed my role because I do not need to be as involved.” (Pat)

She also recognized that, as an organization grows and succeeds, one also tends to have different problems to deal with. In her case, this meant that overtime she experienced less dissatisfaction and day-to-day problems, and more problems generated by having hired high-power people with difficult personalities.  Another typical problem created by growth is running out of space.  As the School of Nursing experienced this problem, they took on the challenge of raising the necessary funds to build a new wing, thus establishing a visible testimony to their success.

  6.2.6. Other interesting elements about Pat’s case

The role of creating new organizations within the institution

The creation of the Center for Nursing Entrepreneurship represents a special kind of innovation, one that has some interesting similarities with the starting of a new business or not-for-profit organization discussed in previous chapters – yet some differences as well.  While the new “organization within the organization” still benefits of the security and financial background that can be provided by the larger organization (especially at the beginning), as a new branch it also opens up the opportunity to create new structures and expectations without having to “fight” current norms and expectations, thus allowing for a “parallel” system to be established and explored with minimum disruption and resistance from the rest of the parent organization.

This may be very valuable, especially when trying to deal with very radical and potentially “disruptive” innovations.  For example, Christensen and Raynor (1997) points out that among the very few companies that have succeeded in absorbing (rather than being left behind by) a disruptive technology, most created independent organizations to explore and begin to capitalize on the new technology – whether these organizations operated as a rather independent unit within the organization, or were “spinned off” as independent companies in which the parent company still maintain the majority of the stocks.

The value of creating “niche programs”

Pat also promoted the creation of programs in areas where there may be an intense but only temporary need – what she called “niche markets.”  She accepted the reality that some programs may only have a short life, yet be valuable for the institution and the students it serves during that period of time.  However, this short life span has important implications in terms of personnel.  A good example of this was the need for programs and services in forensic nursing, which led to a series of initiatives culminating in the creation of the National Forensic Nursing Institute.  These new “niche programs” created the need for hiring more faculty on contracts or in clinical positions, for whom only short-term commitments could be made, and with the expectation that the continuation of one’s position was dependent on the success of a program.

Developing an identity as an “entrepreneur”

It was really only as she conceptualized the Center for Nursing Entrepreneurship and began to read and write about entrepreneurship, that Pat started to think of herself as an “entrepreneur.”  A few colleagues and friends of the school played an important role at this stage, as they introduced her to the field of entrepreneurship and mentored her in this new area and/or provided an important sounding board for new ideas. It is worth noting that, despite her involvement with starting new businesses, Pat’s view of entrepreneurship was much broader, as revealed by the following quote:

“In the 80’s, it was talked about in terms of nursing going into private practice, there was a big wave back in the 80’s and they talked about entrepreneurship as private practice. But today the way we are describing it is somewhat different. It’s really about innovation, how do you do things differently, how can we address the nursing shortage by creating new models of care.” (Pat)

The importance and challenge of making quick decisions

While all our subjects were prompt in making and executing decisions – one of the traits identified by Bygrave (2004) as characteristic of entrepreneurs – Pat was probably the most articulate in discussing the need for this practice and the challenge it presented in a traditional academic institution.

First of all, being an innovator often put her in the position of deciding whether or not to engage in specific new ventures or initiatives (following a process very similar to the one articulated when discussing how she evaluates an opportunity), or whether or not to continue with an initiative. Such decisions often needed to be made timely, in order to take advantage of a specific window of opportunity, or to minimize financial losses. Indeed, Pat believed that making quick decisions was the only way to take advantage of opportunities that might need to be acted upon immediately, as more often than not “timing is everything” for the success of a new venture.  Similarly, she found it important to make timely decisions about whether to continue with a specific initiative that was not progressing as expected – as it was the case, for example, with the Master in Nursing Entrepreneurship.

Therefore, Pat put great emphasis on the importance of being able to make “quick decisions” in her position – even when this meant that she could not collect and consider all the information that could be useful to make the best possible decision:

“I don’t look at a lot of data. I mean, I’ll get the basics, but I think I make decisions quickly. … I kind of go to people who will give me input and take what I hear from them and then make a decision fairly quickly. … If it’s the wrong decision, then we go back and revisit it, and that happens sometimes – but again I look at it as a learning experience. If I made the wrong decision, then how do we fix it.” (Pat)

She was well aware that this was not the way decisions are usually made in an academic environment. Therefore, she was prepared for some resistance and misunderstanding on the part of some of her faculty.

“I think the faculty – not everyone, [but] there’s a couple of tenured faculty who don’t like the idea that I push initiatives. I mean, they see that the faculty should be making these decisions, even though it takes them a year to make a decision. They don’t like it that I come up with ideas and kind of push them forward.” (Pat)

She also attributed her willingness to make quick decisions – as well as a similar willingness shown by her colleagues in the Center for Nursing Entrepreneurship – to their common background as practice nurses.  Nurses in the field are always called to make quick decisions with only partial data available, so they learn to do that and then develop different expectations and habit with respect to decision-making.

Capitalizing on “crisis” to legitimate change

While not the only person who operated in a crisis and used the situation to support some radical innovations, Pat explicitly commented on this factor and as a result provided some valuable insights on this point.

Pat believed that the fact that her school was in a very difficult financial situation made a big difference in terms of accepting some of the radical changes in culture and processes that she instituted in SON – such as starting to operate for-profit business lines within the school, establishing processes to make and implement curricular decisions quicker, and having more short-term contract employees. The immediacy of the risk of closure moved faculty to consider and accept alternatives that might have been more difficult to accept otherwise.

“When we went through the strategic plan – well, I am a very open administrator, and tell them what our budgets are like and let them know what the situation is, because I have to help solve it. So they knew that we were in desperate straights and that the … Medical Center would have closed the School of Nursing if it hadn’t been for the Community Nursing Center. So they knew that those dollars helped save the School of Nursing. … I don’t think it would have happened without that.” (Pat)

The importance of operating in a decentralized university

Pat also mentioned the decentralized structure of her university as most critical to her success as a transformational leader, as it gave her the needed control on resources that allowed her to invest where she perceived there was the greatest likelihood to generate more revenues – in her case, the business lines run through the Community Nursing Center.

“[The fact that it was a decentralized school] was so important, absolutely important … it gave me the freedom and the flexibility to do whatever I wanted, I was responsible. All [my supervisor] cared about was my draw [on endowment] was 5.5% and I was making money, and that was it. So as long as I did those two things, I could do whatever I wanted.” (Pat)

Some unique challenges presented by an academic environment

Pat pointed to the following “impeding organizational factors” that are specific to working in an academic unit within a university, where there are strongly held beliefs and practices about faculty responsibilities and their role in governance:

• Internal tension between research and practice faculty: There is a historical tension and misunderstanding in research universities between faculty whose main responsibility is to produce research (what is the “golden rod” of success at a research university) and faculty who have different responsibilities (i.e., instruction and/or practice). Pat found this tension in her school and identified it as a negative force.
• Self-centeredness of tenured faculty: Pat noted that tenure-track faculty are not used to take revenues into considerations, nor worry about what would pay for their research as well as all the other aspects of the organization. Rather, most tenure track faculty tend to focus on their research and expect that others will take care of the rest.  Given faculty’s governance over curriculum, though, sometimes this attitude may impede making the right decisions in terms of instructional programs for the institution.
• Tenure system does not allow for sufficient flexibility: As tenured faculty are guaranteed employment (barring a major financial crisis or misdemeanor on their part) regardless of their productivity or willingness to adapt to the needs of the institution, it is inevitable that some people in that position will have little incentives to be productive – and may even become a financial burden on the institution.

  6.2.7. Concluding thoughts about Pat’s case

There is no question that Pat’s leadership not only added considerable value to the University of Rochester’s School of Nursing, but also transformed this organization in some significant ways.  We can point to a few tangible measures of success – such as improving the school’s national ranking, increasing the number of research faculty and external funding for research, increasing the number of students and graduates, and having significantly more resources to pursue the instructional and research mission of the school (as documented in Figure 6.1 at the beginning of this chapter).  Equally, if not even more valuable, however, was the progress made in terms of culture and climate during Pat’s deanship.

While we could point to some specific initiatives as especially significant during Pat’s tenure (such as the initial strategic plan and the creation of the Center for Nursing Entrepreneurship), the transformation she led cannot be associated with just one or even a few isolated initiatives.  Rather, it is the cumulative result of many innovations, both large and small, that she continually – and successfully – initiated in various areas and along different dimensions (including instructional programs, for-profit business lines, structures, ways of operating, facilities, just to mention a few).  Perhaps even more importantly, the end-result was also more than the sum of the value added by all those innovations, as it involved a change in mindset and expectations about what it means to be a successful School of Nursing and a member of such an organization.

It is also worth noting that both the number and the pace of the innovations Pat initiated are quite atypical of an academic environment where decisions often take a long time and change tends to happen very slowly (as observed by other authors who have studied academic entrepreneurship – e.g., Mars & Rios-Aguilar, 2010).  Therefore, her achievements are even more remarkable.

To conclude, we would like to articulate some additional insights, besides those reported in our analysis, that we gained by looking in depth at Pat’s activity and thinking:

• Long-term sustainability of a program is NOT always a desirable goal: The financial success of an organization may be enhanced by the ability of taking timely advantage of “niche markets” or opportunities that may have a short life yet be profitable – for example, responding to the need for training in a new technology or to help people in a period of transition. Doing this successfully, however, requires the ability to move very quickly, as well as to be prepared to “exit” timely – which in turn calls for certain structures (for example, “contract” staff that could be easily dismissed or moved to different projects).
• Sometimes the ultimate goal and measure of success for an initiative is not to sustain it directly, but rather to “spin it off.”  An organization has always limited capacity – no matter how large.  In order to achieve one’s social mission, oftentimes the best outcome is to create a new organization that can then continue to pursue the initiative without requiring additional assistance from the “mother” organization, or pass the project on to others to continue – even if this means losing control and ownership of that initiative.
• Many large enterprises are not conceived and created from “nothing”, but rather grow out of other smaller enterprises. It is reasonable that in most circumstances one would want to start up smaller and grow; when that happens, the final venture may be quite different from the original one in both size, scope and nature – yet because the venture gradually transformed, there may not be the same kind of business plan and “launch” that is usually described as an integral part of the process of starting a new company.
• Most entrepreneurial educators are not able to implement all of their initiatives: As the leader of an educational organization, Pat did not have the time to lead the implementation of all the many initiatives she wants to initiate, so she was obliged to rely on other people (what she referred to as “champions”) for this critical task.  This seems a price one has to pay for success and growth!

6.3. Commentaries on Pat’s case

We are collecting readers’ insights and lessons learned from reading Pat’s case on the companion website, and we invite you to add yours by following the specific guidelines provided in the “Guidelines for Contributions” document.

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