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Beyond mission alignment, the relationships we build with donors may be the single biggest contributor to our success as fundraisers. But not all relationships are created equal; building the wrong relationship may bring you closer to the donor but further from the gift.
Understanding the Limits of Professional Friendships
When I entered the field of nonprofit fundraising, I recognized the significance of relationships to the work but didn’t fully understand or appreciate the type of relationship for which I was aiming or how to build them. Not yet a buzzy topic, relationship boundaries were essentially my ap -
proach, avoiding sharing too much of myself or topics that might be problematic.
I was asking lots of questions and gathering information, but not necessarily the information I needed to craft and deliver a successful solicitation. In essence, I was aiming for professional friendships. Unfortunately, while the relationships I built were positive and strong, they weren’t leading to the gifts I intended. Healthy boundaries are, of course, a necessary first
step but not enough.
Asking for money—the express purpose of our roles— is uncomfortable for many
About the Author
Faith McGown is co-author of the newly released book Are We Friends or Coworkers? Exploring Relationships at Work . Guided by the desire to align her work with her values, Faith found her way to fundraising after careers in journalism and sales. For nearly two decades she has supported the missions of regional, national, and international nonprofits dedicated to improving health and increasing equity. Currently based in Dallas, TX, she takes immense satisfaction in facilitating investment into work that improves lives.
people, including those who do the work. Unfortunately, to avoid discomfort we often fail to be direct in the hope that our vagueness will avoid rejection. In doing so, we unwittingly introduce doubt and uncertainty into the relationship. Ambiguous relationships are rarely productive and often lend themselves to misunderstandings. Indeed, it took me several years of not getting it quite right to understand how to do it better.
From Rapport to Results
In my early years as a major gift officer, I built friendships even though I knew friendship wasn’t my aim. Transactional also wasn’t my aim. Less personal than my established friendships, these new relationships were still focused and built on likeability, rapport, and commonalities—sometimes ones that had nothing to do with the work at hand. Why? Like most of us, I learned how to make friends as a child and never really learned how to build other kinds of platonic relationships. As a result, I unconsciously and incor -
rectly used friendship as my gauge for measuring donor interest and readiness. While my too-friendly, unfocused donor relationships didn’t cause problems, they also didn’t support success. I was an average fundraiser, performing well enough to satisfy supervisors but not achieving the success I hoped for or feeling satisfied that I was facilitating the most meaningful giving experience I could for donors. That is until, several years into my fundraising career, I went to work for someone who at first blush I (mistakenly) perceived as not valuing donor relationships of any kind. She had little patience for the time my colleagues and I spent building them. Focused on closing gifts quickly, she directed me to solicit in the initial meeting, a pace that felt incongruent to the principles of major gift fundraising: land the meeting, show up, ask for money, repeat. My fellow gift officers and I balked at this brash and transactional approach and covertly resisted it, preparing proposals for initial meetings but rarely presenting them.
The Power of Purposeful Relationships
Despite my resistance to the directive, the pressure to move quickly was an unexpected gift that transformed my approach to this work. It revealed an alternative to pursuing friendships and forced me to focus the relationships I was building in a way I hadn’t before. With less time for pleasantries and little to no time for details that didn’t directly support goals, I was able to facilitate better and more focused conversations without the distraction of unnecessary details.
Up to that point, I centered my goals (without revealing them), the prospect centered theirs, and our conversations weren’t necessarily aimed in the same direction. With less time, focusing conversations became more important, and the need to clearly identify our shared purpose became clear. Building purposeful relationships not only led to greater success for me and the missions I supported, but it also improved the quality of my relationships and better supported the
goals of donors. Identifying and centering purpose eliminates confusion and doubt, fosters trust, and improves outcomes.
In more recent years, as a manager to other gift officers, I’ve observed similar confusion around relationships and have seen vast improvements—in performance, comfort with asking for financial support, and stronger connections—using purposeful relationships. It seems many of us strive to introduce purpose only after establishing friendship, somehow expecting friendship to make it all easier. Minus identification and confirmation of shared purpose, however, conversations, meetings, phone calls, and emails have no clear destination and can extend seemingly forever without ever achieving anyone’s goals. Further, lack of clarity in the relationship leads to uncertainty, confusion, and, in some cases, even distrust.
Here’s what has helped my teams and me build better relationships with donors and prospects.
Identifying and centering purpose eliminates confusion and doubt in donor relationships
Identify shared purpose.
Purpose is inherent in all work relationships, including those with donors. In most cases we wouldn’t be in the relationship were it not for the work, and all parties have their own unique purpose and goals. Identifying the specific shared purpose of our relationships is an important and crucial step. Why are we coming together? What might be the other party’s purpose? Where is the mutuality within that? As a major gift officer, the purpose of the relationships we build with donors and prospects is to secure financial support for our employer’s mission. But that’s
not a shared purpose. Our professional responsibilities are not what brought the prospect to the relationship. Despite goals unique to each of us, our shared purpose is supporting a mission important to each of us.
Confirm shared
purpose.
Once identified, shared purpose must be confirmed by all parties, including your donor. Doing so sets the course and tone for the relationship, minimizing uncertainty and doubt—for both of you. Initially this feels scary: will assigning purpose reduce the quality or warmth of the relationship? Will the donor be comfortable directly ad -
dressing purpose within the relationship? Will I lose this prospect? These and other fears are not invalid. Indeed, there have been times for me when this conversation revealed no shared purpose at all. And, yes, in those cases, I’ve lost that prospect. The relationship didn’t progress, but like the push to move quickly, recognizing a dead end is also a gift.
After all, prospects don’t support our missions—donors do. Our role is not to collect prospects, but to secure philanthropic support. So, while this direct approach has cost me prospects (or more aptly, has disqualified prospects), it has saved me significant time with the wrong prospects. Additionally, although initially uncomfortable for its novelty, addressing the relationship directly has always been well received and even appreciated, eventually leading to less anxiety and doubt for everyone. Determining quickly that there’s no shared purpose, and thus no reason to continue building the relationship—at least for now—focuses efforts on the right people at the right time.
Center (and recenter) shared purpose.
Once shared purpose has been confirmed, every conversation and interaction can be structured around it to work toward clear and agreed-upon goals. The purposeful relationship framework improved my results dramatically. Within six months of using this approach I secured a $1,000,000 donation, the largest gift I had secured on my own at that time, and one of the largest from an individual in the nonprofit’s history. It wasn’t a fluke. The same has been true for the teams with whom I have shared this approach. By reducing uncertainty in favor of clarity, everyone benefits. Most importantly, the quality of my relationships improved, and some have become true friends.
Benefits Beyond Donor Relationships
The purposeful relationship approach has also worked remarkably well for relation -
ships with colleagues. When a recent email exchange turned away from the work at hand and into tit-for-tat territory, I was able to shift the direction by acknowledging my colleague was upset and re-centering our shared purpose: “I understand your frustration and hope we can agree we need to [fill in shared purpose].”
The simple but clear statement disarmed my frustrated colleague, refocused our communications, and moved the conversation toward resolution.
The approach has also served as a valuable tool for managing my own reactions and responses. When I felt betrayed by a colleague who changed course from the plan we had agreed upon and informed me only after informing senior leaders, I found myself frustrated and avoiding her. Re-centering our shared purpose beyond this specific part of this particular project helped me continue to show up positively despite disappointment and hurt.
Successful relationships in the workplace, whether with
donors or colleagues, must be centered on shared goals and mutual objectives. Too often we focus on strengthening relationships without ensuring they’re the right kind of relationship. Friendly relationships are, of course, always the goal, and friendships with donors are not in and of themselves a problem. The problem comes when friendship becomes the focus at the expense of purpose.
Meanwhile, transparently centering purpose in the relationship lends itself to true friendship. Efforts centered on the work itself, the shared values that brought us together, and our mutual vision for the future, tend to deliver stronger results.
Published by
Association for Healthcare Philanthropy 2550 S Clark Street, Suite 810
The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the Association for Healthcare Philanthropy.
Philanthropy Strategies for Complex Healthcare Systems Calibrating for Success
By Mark J. Marshall
The joke in our industry is if you have seen one healthcare system, you have seen—well, one healthcare system.
Like all jokes, there is some truth to it: healthcare systems have become increasingly complex. There used to be a real divide between different types of healthcare organizations—medical schools and academic medical centers, community hospitals, children’s hospitals, etc. The world of today has many of
these in one extremely complex system. The services provided at each of them vary wildly and so should our philanthropy strategy.
The Ecosystem
Healthcare has been in an era of transition and consolidation for more than 30 years. The likelihood of this intensifying is very real and coming to a health system near you soon. Mergers and acquisitions were the highest in 2024 since 2019, with an anticipated rise in activity for 2025. Particularly
concerning, Kaufman Hall, a healthcare consulting firm, reported that nearly one third of mergers or acquisitions involved a hospital in financial distress.
Mergers and acquisitions are being driven by not just finances but organizational needs, the expansion of new medical schools (particularly those looking at primary care, including rural communities), mental health facilities, and other specialty services. Gaining economies of scale has been essential, but philanthropy has not
always gained those economies in the same way that the healthcare delivery system has—but it can.
If healthcare experts are right, mergers and acquisitions will continue to accelerate, creating larger and larger systems that are increasingly complex. The philanthropy program must mirror that to be successful.
The Challenge
While all hospitals provide valuable services to their patients and patients’ families, how they do that and the profile of those services and patients varies wildly.
There are really three types of patient groupings :
Transactional : Some levels of care are a bit transactional and treated by everyone involved as a consumer activity (e.g. influenza, broken toe) and many of the donor behaviors associated with that type of care are community based.
Transformational: These are often the high-profile stories that we think of first. Those areas of care may be high energy and dramatic (e.g. trauma, cardiac, cancer) and the donor behaviors there are very emotional and high energy—heavily tied to
gratitude for the outcome, albeit fleeting.
Chronic: Many patients have a long-term relationship with their care facility, afflicted with illness or conditions that require monthly, lifelong care (e.g. diabetes, cystic fibrosis). Donor behavior is often tied very specifically to supporting efforts to cure or treat the very focused issue related to their care.
Add in the complexities of the level of care provided at different sites across a complex system and it’s easy to see the challenges for philanthropic priorities. What the system or a particular site or program “needs” is not always going to align with donor interests and capacity. This is particularly true when academic medical centers interface with community hospitals.
Medical research historically attracts the largest gifts, and if you are a chief development officer with a large goal or a system executive with fundraising as a metric, there is an odd incentive to focus on total top-line dollars. Big ideas attract big dollars. We know that. The idea of cur -
ing cancer is “worth more” than refurbishing the waiting room at a community hospital. The reality is if you want to raise the most money, you could focus on a few key areas (the same would be true of higher education), but there is a need to support the broader organization.
The Opportunity
Every challenge comes with an opportunity; these complex systems come with many challenges and therefore many opportunities. Too often we jump right into the fray of raising dollars rather than building a strategy that will pay the biggest long term, comprehensive dividends. We will focus on four key elements for success :
A Seat at the Table
To often I hear, “we weren’t included anywhere in the merger and acquisition talks.” While that may be a reality we have to accept, it doesn’t mean we can’t play a role. Ideally, you are doing your due diligence on the merger and acquisition of the philanthropy program in order to encourage the right
structure. Part of those important questions include:
• How is philanthropy funded at the other organization? Whether it is self-funded or from the system makes a big difference when you might inherit a significant staff and/or goal.
• What is the structure of the development office? Is it a foundation or foundations? Whether the foundation is a free-standing foundation, and whether it is a supporting organization or a public good organization, can make a tremendous difference.
Several mergers have been shocked to find that there were “deals” made in past mergers where the foundation was promised seats on the board or that they would never be merged.
• Who controls patient and prospect records, past and present? More than one organization has been surprised to find out that their joint venture doesn’t give them access or control over patient information (yes, all HIPPA compliant).
Getting that seat at the table is essential to ensuring you
have the strongest foundation for program success.
Leadership Support
Does all the leadership believe in philanthropy as a priority and have clarity around its role in the institution? One of the hallmarks of successful programs is that their leaders understand philanthropy and have clear expectations of outcomes. The most effective leaders see the strategic value of philanthropy and its incredible return on investment, provided philanthropy revenue supports strategic priorities. We always need
to create transparency on philanthropy and educate on its impact. Prioritizing that process matters.
Finally, does leadership have a commitment to properly funding philanthropy? In combined organizations you will have an increased investment of both dollars and, very likely, leadership time. Creating a unified vision of the role of philanthropy for the organization AND the role of leadership in philanthropy will pay dividends.
Clear Priorities
Perhaps the hardest thing that we ask any complex
organization to do out of everything a complex system does, is to identify philanthropic priorities. While the process is less important for this discussion, the concept is very important.
As there are more and more hospitals in the system, look for opportunities for each location to see itself in the priorities. While priorities do not need to be evenly distributed, they should be representative. Larger systems, particularly those with an academic research element, will have a matrixed approach that includes systemwide priorities (e.g. cancer
care, neuroscience, women’s health) and location-driven priorities (e.g. a new emergency room, surgical waiting room, patient assistance fund).
Appropriate Metrics
As we have entered the era of data-driven philanthropy, there has been an appropriate focus on key performance indicators (KPIs). We need to build KPIs that are appropriate for our dissimilar entities that all exist within a common system.
Expecting community hospital development officers and those supporting a cancer center (especially an NCI) to have the same level of productivity and even the same type of activity is unrealistic. Building multiple metric sets based on roles at the organization allows for effective staff and program management.
Because of the geographic distribution of health systems, you will want to account for the socioeconomic setting of each hospital and the variables impacting fundraising production to set realistic goals and staff KPIs.
Calibrate for Success
The role of philanthropy continues to grow at many institutions, while it struggles to be impactful at others. As more and more institutions merge, we have an opportunity to do it right. It is hard to prove a negative, but it is clear that those organizations who are not proactive about the role of philanthropy do not see the benefits of the combined organization.
The strategy is also clear: 1) Fight to get a seat at the table, or at the very least ensure that philanthropy’s voice is present. 2) Take the time to build partnership with the system and hospital leaders, never taking it for granted. 3) Create priorities that serve the broader system. And, 4) Create KPIs and goals that ensure success is measured and achievable.
About the Author
Mark J. Marshall has 30+ years in nonprofit and philanthropic leadership, where he has worked with many of the great organizations in higher education, healthcare, and human services. Currently, he is chief strategy officer and co-owner at BWF, where he focuses on comprehensive/capital campaigns, strategic planning, leadership and team coaching, and institutional/ organizational growth through philanthropy.
The Reciprocity Disconnect
Why Grateful Patient Programs May Be Missing the Mark
By Gail Rudolph , CMCT, CFRE
Gratitude is a powerful force. It’s why hospital foundations across the country have invested heavily in grateful patient programs: the belief that patients, once healed, will feel compelled to give back.
Yet many foundations are quietly wrestling with the same problem: the giving isn’t following the gratitude.
Even with strong donor communications, well-crafted appeals, and high-quality care experiences, some programs struggle to convert former patients into active donors. The impulse to give back seems to fade once patients return to their daily lives.
This isn’t a failure of mission, intention, or even execution—it’s often a failure of understanding the subtle science of ethical influence.
Revisiting the Principle of Reciprocity
Dr. Robert Cialdini, widely considered the “Godfather of Influence,” outlines seven universal principles of influence in his groundbreaking research. One of the most powerful—and most misunderstood—is reciprocity: the idea that people feel naturally obligated to return a favor or kindness when they have received something meaningful first.
As one of just thirteen individuals globally who have
been personally trained and endorsed by Dr. Cialdini to teach these principles, I’ve come to appreciate how easily they can be misapplied when their nuances aren’t fully understood. In fact, without careful implementation, these principles can backfire—leading to disengagement instead of connection.
At first glance, grateful patient programs seem to align perfectly with this principle. A patient receives exceptional care. They feel thankful. They give back.
But in practice, it’s not that simple.
The Reciprocity Misconception
One of the most common missteps hospital foundations make is equating care received with a gift given. But from the perspective of the patient, that care—no matter how excellent— was paid for, either directly or through insurance. This distinction is crucial. In the psychology of reciprocity, there is no moral obligation to repay something trans -
actional. The patient likely views their care as a service, not a favor.
And so, the principle of reciprocity remains inactive.
This helps explain why programs built solely around gratitude for treatment often underperform. Without triggering the reciprocity instinct, patients may appreciate the care without feeling compelled to support the institution philanthropically.
Limits of Branded Generosity
Another frequent mistake in attempting to leverage reciprocity is the use of branded merchandise—mugs, tote bags, golf towels, or T-shirts—as donor gifts.
These items are perceived as promotional, and they can actually undermine the reciprocity effect. Why?
Because the moment a gift is branded, it ceases to be about the recipient and instead becomes about the organization. Instead of “you thought of me,” it feels like “you want me to advertise for you.”
Gifts only activate reciprocity when they are perceived as personal, unexpected, and meaningful.
About the Author
Gail Rudolph CMCT, CFRE, is a best-selling author and one of the world’s leading experts in ethical influence and fundraising strategy. With decades of experience leading high-impact campaigns—including multi-million-dollar capital efforts—she helps organizations unlock donor potential and accelerate results.
As the founder of the Gail Rudolph Collaborative, Gail blends neuroscience, ethical influence, and values-based leadership to move missions forward.
This isn’t just theory. Scientific research confirms that gifts only activate reciprocity when they are perceived as personal, unexpected, and meaningful. A branded mug may be useful, but it rarely meets any of those criteria.
Creating Authentic Reciprocity in the Hospital Setting
If reciprocity is not about branded trinkets or billed services, what does activate it in the context of a hospital?
The answer lies in the human moments that go beyond the expected.
Consider:
• A physician who calls a patient at home to check in post-discharge.
• A nurse who sat with a family member late into the night, offering comfort.
• A foundation staff member who held someone’s hand during a difficult procedure.
These are the moments that patients recall when asked what stood out during their hospital experience. They are unscripted, personal, and emotionally resonant. Most importantly, they are perceived as voluntary and generous, and thus, they have the power to unlock the reciprocity instinct.
Asking the Right Questions
Too many grateful patient strategies are built on assumptions about what patients value.
The more effective approach is simple: ask.
Incorporate a post-care survey designed not only to gauge satisfaction but to uncover the meaningful moments. Instead of asking,
• “Were you pleased with your care?”
Consider these alternatives:
• “Was there a specific person who made your experience easier or more comfortable?”
• “Did anything surprise you in a good way during
your stay?”
• “Was there a moment that felt especially meaningful to you or your family?”
The goal is to surface the elements of care that patients feel were above and beyond. These are the entry points for reciprocity, because they represent moments when patients felt truly seen, supported, and cared for outside of what they expected.
Crafting Appeals That Reflect the Real Gift
Once you understand what made a difference to your patients, you can translate those insights into appeals that resonate.
Instead of generic messages such as:
“You received outstanding care. Please consider giving back so others can too.”
Try appeals that reflect the personal, emotional nature of the patient’s experience:
“You told us that what meant the most was how Nurse Ellen sat with your husband each evening and explained
everything with patience and clarity. That level of care is what your gift helps make possible.”
Or:
“Patients like you often tell us that their most powerful memories weren’t clinical— they were human. With your support, we can ensure others receive not just medical treatment, but meaningful connection.”
These messages honor the real reason someone might feel moved to give. They align your appeal with a moment that mattered. And that’s where reciprocity lives.
Reciprocity Is a Relationship, Not a Request
Activating reciprocity doesn’t end with the first gift; it’s the beginning of a relationship.
Key Recommendations for Hospital Foundations
Reframe the Value Proposition
Understand that patients don’t perceive medical care as a gift—they see it as a service. Instead, focus on the moments of care that exceeded expectations.
Avoid Promotional Gifting
Instead of branded merchandise, offer personal or meaningful acknowledgments that convey appreciation, not advertising.
Survey for Emotional Insight
Go beyond satisfaction surveys. Ask about the personal and emotional experiences that made a difference.
Tell Their Story Back to Them
Use patients’ language to reflect their experiences in donor appeals. Personalized storytelling beats institutional messaging every time.
Continue the Reciprocity Loop
Thank donors meaningfully and consistently. Show impact. Reinforce connection. Keep giving in ways that matter to them.
Continue the cycle of generosity by showing donors the impact of their support:
• Share updates on patients helped or programs launched.
• Highlight stories of lives changed because of their gift.
• Send handwritten notes that recognize milestones, not just contributions.
These ongoing touches reinforce the sense that the foundation continues to give to the donor, which sustains the reciprocal loop.
When gratitude is acknowledged and nurtured authentically, donors feel like true partners in healing, not just sources of funding.
Authentic Impact
The ethical use of influence isn’t about persuasion—it’s about precision. It’s understanding what motivates people to give, and why.
When hospital foundations align their messaging with genuine human experiences and apply the principle of reciprocity with care and
nuance, they create the kind of connection that lasts. Not just a one-time donation, but an ongoing relationship rooted in shared values, mutual respect, and, yes, gratitude.
Grateful patients don’t give because they feel obligated. They give because they remember how they felt in their most vulnerable moment. When a hospital transforms from a place of treatment into a place of care, that is the moment that compels giving.
As you refine your grateful patient strategy, remember: ethical influence doesn’t push people to give. It pulls them toward a cause they already care about.And that, ultimately, is what makes philanthropy meaningful.
SPONSORED CONTENT
Enduring Fundraising Principles for Healthcare Philanthropy Leaders
By Laura McGarry, Managing Principal, Graham-Pelton
Nonprofit leaders find themselves navigating the multi-pronged challenges of market volatility, administrative policy changes, federal funding freezes, and shifts in support for medical research and public health initiatives. While this moment poses unique complexities, several enduring fundraising principles offer both reassurance and practical direction.
History Has Lessons to Offer
During the 2008-09 recession, while the S&P 500 dropped by 38%, total giving only decreased by 7%. More recently, during Covid-19, many healthcare and human services organizations experienced an outpouring of support, with total giving growing by 5.1% in 2020. These examples remind us that when missions are threatened, communities often respond with increased generosity.
Continued
Your Mission Remains Essential
The critical needs your organization addresses don’t disappear. Patient care, medical research, and community health services remain vital regardless of political shifts.
Healthcare organizations that maintain consistent donor engagement typically navigate turbulence more successfully than those that retreat. Your mission doesn’t pause, and neither should your fundraising efforts.
Philanthropy Has Motivators
Beyond Economic Drivers
Most donors give because they believe in your mission. Recent studies confirm that personal values remain among the primary drivers of philanthropy, far above economic factors. As such, major gifts secured through one-on-one conversations allow you to understand each donor’s specific motivations and tailor approaches accordingly.
Strategic Adaptation
While fundraising should continue, consider the following strategic adaptations to meet the moment:
• Communicating transparently about challenges while articulating your path forward
• Centering messaging on impact and the constituents you serve
• Identifying creative funding approaches like donor-advised funds, crypto-philanthropy, or accelerated pledge payments
• Developing plans to diversify revenue streams
Confidence comes from focusing on what’s within your control: engaging your community authentically, articulating a compelling vision, and staying focused on mission. And trusting in philanthropy’s resiliency and ability to drive meaningful change.
