Investing in Nurses and Nursing

Decades ago, the leaders of the Robert Wood Johnson Foundation (RWJF) recognized the vital role nurses needed to play as the nation’s health care system evolved to expand access to care, improve quality, and reduce costs. Through innovative grantmaking, RWJF has helped shape the ongoing transformation of the profession, while positioning nurses to assume an expanded role in the health care system of the 21st century. The latest issue of Charting Nursing’s Future (CNF) takes a look back at RWJF’s nursing-related programs, tracing their impact on nurses' ability to improve care and to strengthen the nursing profession.

"Building a skilled and diverse health care workforce is a key strategy to achieving RWJF’s mission of improving the health and health care of all Americans. Through sustained investments in nursing education, leadership, and research, the Foundation will continue its longstanding efforts to strengthen the nursing profession while expanding access to care, improving quality, and reducing costs."

—Risa Lavizzo-Mourey, MD, MBA, President and CEO, Robert Wood Johnson Foundation

As the issue brief makes clear, since RWJF’s inception in 1972, its nursing-related grantmaking has focused on five areas:

• Expanding roles for nurses;
• Building educational capacity;
• Demonstrating nurses' contributions to quality and safety;
• Creating leaders for the 21st century; and
• Bridging gaps in research and data.

To date, RWJF has invested more than $538 million in nursing programs, including $91 million in the last two years alone, an indication of the growing importance of nursing in the Foundation’s vision of the future of health care. The various programs have contributed significantly to improving primary and inpatient care, thus improving Americans’ health, and they have reshaped organizational decision-making and influenced policy at the institutional, state, and federal levels.

One recent initiative that has had a particularly bold policy impact is RWJF’s work with the Institute of Medicine (IOM), resulting in the landmark 2010 report, The Future of Nursing: Leading Change, Advancing Health. Together with the RWJF-backed follow-up Future of Nursing: Campaign for Action, which supports state coalitions implementing the Future of Nursing recommendations, the report’s impact is sure to be far-reaching and lasting.

Expanding Nurses’ Roles

In the mid-1970s, RWJF played a key role in the rise of the nurse practitioner (NP). Beginning with regional demonstration projects, early efforts focused on educating nurses to become family NPs and nurse midwives. The NPs were deployed in remote areas of California, Alabama, Tennessee and rural New England. RWJF followed up with a program to equip emergency nurses to handle increased primary care responsibilities.

As RWJF's focus evolved, the Foundation worked to build an intellectual home for primary care nursing through the Nurse Faculty Fellowship Program, which prepared an elite corps of nurse leaders to establish master's degree NP programs within schools of nursing. The program's 99 fellows proceeded to do exactly that, and the program's legacy is the increase in the number of NP programs across the nation. Today, nearly 160,000 nurses have been educated as NPs, in part due to RWJF's efforts.

Building Educational Capacity

In 1988, RWJF launched what would grow into the Ladders in Nursing Careers program, a project to help low-income and minority, hospital and nursing home employees in New York City advance into licensed practical nurse (LPN) and RN positions by attending nursing school. At the program’s close a decade later, more than 500 future LPNs and RNs were poised to graduate or had entered the workforce, and the project had increased minority recruitment in geographic areas that had failed to bring people of color into the profession. Over the years, nearly 40 percent of program participants were minorities.

Beginning in 1994, RWJF's Partnerships for Training program supported eight regional partnerships around the nation that brought together academic institutions, hospital and community providers, government agencies, and others to develop distance education programs to prepare nurse practitioner, certified nurse-midwife, and physician assistant students. Such distance learning programs were rare at the time, in the early days of the Internet, but the partnerships succeeded. Over the course of ten years of RWJF support, they produced more than 1,100 primary care providers for underserved areas. Seven of the eight regional partnerships continued after RWJF support stopped.

RWJF's New Careers in Nursing program continues the Foundation's focus on expanding the nursing workforce and increasing its diversity, efforts that are particularly relevant in light of a looming nursing shortage. Through grants to schools of nursing, the program provides scholarships of $10,000 to college graduates pursuing nursing degrees through accelerated baccalaureate and master’s degree nursing programs. More than 2,700 students have received scholarships under the program, at 119 schools of nursing.

With an eye toward helping nursing schools increase their capacity to educate students, RWJF's Evaluating Innovations in Nursing Education program funds scholarly evaluations of 12 educational interventions that address the nurse faculty shortage by enhancing the satisfaction of faculty, improving faculty recruitment and retention, and making educational programs in nursing more productive. Ultimately, the program seeks, through its research projects, to enhance teaching productivity and advance faculty preparation—critical steps in achieving the Future of Nursing recommendation that at least 80 percent of nurses have a baccalaureate or higher degree by 2020.

RWJF's newest effort in this area is its Academic Progression in Nursing program, which funds nine state Action Coalitions implementing varying approaches to academic progression for nurses, including online and accelerated degree programs, community college baccalaureate programs, shared competency or outcomes-based curricula, the use of simulation education, and statewide or regional curricula. Partnerships among community colleges, universities, and employers are at the core of the program.

Advancing Quality and Safety

Quality and safety in health care are continuing areas of focus for RWJF. As the largest group of health care providers, nurses have a unique role to play when it comes to health and safety. But the CNF brief points out that as late as the start of the 2000s, many health systems lacked measures to quantify nurses’ contribution to patient care. RWJF recognized the importance of developing and applying standardized measures — both for quality-improvement and public-reporting purposes, and began in 2001 to fund eight research projects in the area. Grants to the National Quality Forum and the Joint Commission resulted in the embrace and implementation of 15 national voluntary consensus standards for measuring the quality of nursing care, including how often hospitalized patients sustain injuries when falling, develop pressure ulcers or infections from urinary catheters, and more.

To develop the research base that linked these measures of nursing’s contribution to the actual quality of care, RWJF launched the Interdisciplinary Nursing Quality Research Initiative (INQRI) in 2005. The program has supported more than three dozen interdisciplinary teams to conduct research in the area and to share their findings with the field.

The RWJF-funded Transforming Care at the Bedside project took another approach: testing the proposition that nurses and other front-line caregivers could identify lapses in quality and safety and test novel solutions in real time. The project, a partnership between RWJF and the Institute for Healthcare Improvement, produced striking results. A pilot program at three hospitals resulted in reductions in harmful falls and readmissions, and participants reported improved teamwork, staff engagement and capacity to make changes as a result of the program. The early success prompted RWJF to expand its grantmaking in the program significantly.

The Quality and Safety Education for Nurses (QSEN) project, launched in 2005, reflected the Foundation’s desire to enhance quality and safety education in nursing school, at both the undergraduate and graduate levels. The multi-year project developed a nursing school curriculum on quality and safety and initiated efforts to teach nursing faculty to include the material in their instruction. Now in its fourth and final phase, QSEN continues to promote innovation in quality and safety education, develop graduate faculty expertise in these areas, and generate tools—such as textbooks, accreditation and certification standards, licensure exams, and continued competence requirements—that will magnify nursing’s role in health care transformation.

Creating Nursing Leaders

Another important area of grantmaking for RWJF has been the development of nurse leaders, women and men whose front-line experience and advanced education prepare them to address a host of pressing health care problems. The effort is consistent with the Future of Nursing recommendation to prepare and enable nurses to lead “transformational change.”

The Foundation launched its first initiative in the area, the Clinical Nurse Scholars program, in 1982. The program sought to develop a cadre of superior nurse researchers—postdoctoral nurse educators focused on the care of hospital patients with serious illnesses or injuries. Many of the program’s 62 alumni have gone on to serve as nursing school deans, or in other leadership capacities.

The RWJF Executive Nurse Fellows program, created in 1997 and still going strong, provides world-class leadership development to a carefully selected group of senior nurse executives. Each year, 20 three-year fellowships are awarded to rising nurse leaders who learn from an advanced leadership development curriculum, intensive and ongoing coaching and mentoring, team-based learning and self-directed individual leadership projects. The influence of the program’s 200 fellows and alumni can be felt in the upper echelons of health care delivery, academia, public health, and state and federal government.

With an eye toward the nation’s nurse faculty shortage, in 2007, the Foundation created the RWJF Nurse Faculty Scholars program. The initiative gives a boost to nursing faculty members in the early stages of their careers, seeking to draw and retain nurses to academic positions, thus expanding the capacity of nursing schools.

More recently, RWJF partnered with AARP and the AARP Foundation to create the Center to Champion Nursing in America (CCNA), an effort to “build and sustain a 21st century nursing workforce with the skills and knowledge Americans need.” Among the CCNA’s projects are the Future of Nursing: Campaign for Action, following up on the IOM’s landmark report, and Nurse Leaders in the Boardroom, which seeks to increase nurses’ influence over the decision-making of health care organizations.

Bridging the Research Gaps

As the Future of Nursing report observes, “Effective workforce planning and policymaking require better data collection and an improved information infrastructure.” The need for reliable information is no secret to RWJF, which more than two decades ago began supporting efforts to expand research on nursing workforce issues. In 1990, RWJF grants to the National Council of State Boards of Nursing tested the feasibility of a national database of nurse licensure information, eventually leading to the creation of such a database, NURSYS. Now self-sustaining, the database serves individuals, employers, and the public at large, enabling verification of nurse licensure, and providing planners and policy-makers with more accurate counts of nurses across the nation.

In the mid-1990s, RWJF’s Colleagues in Caring: Regional Collaboratives for Nursing Work Force Development supported 23 statewide and multi-county collaboratives in their work to streamline nursing education and increase the capacity and attractiveness of the nursing profession. The collaboratives created systems to collect and analyze data on regional nursing shortages and to assist the profession and policy-makers in preparing for future workforce needs. Many of the funded collaboratives found ways to continue their work after their RWJF grants expired in 2003, and since then, 40 states have created what are now referred to as state nursing workforce centers.

Lessons Learned

As the CNF brief makes clear, RWJF’s contributions to the profession of nursing have had a profound effect on the nation’s health care system, who can access it, and how well they are cared for. At the same time, the grantmaking has drawn a new generation of nurses into the profession and helped expand their roles in the evolving health care system. Key to the success of RWJF’s work in the area has been its willingness to take risks, as it did in supporting the NP movement; its determination to keep peoples’ needs at the center of its investments; its desire to listen for solutions from nurses and others on the “front lines” of health care; its ability to recognize the vital contribution that nurses have to make as institutional leaders; and its recognition of the need to base workforce decision-making on accurate data and insightful analysis.