Efforts to increase the number of nurses in the United States are starting to win significant philanthropic support. The new interest, coming after years of inattention from grant makers, has been sparked by a serious shortage of nurses in many parts of the country. The problem is expected to become even more pressing as older Americans become an increasingly large share of the population.
Some of the biggest commitments so far:
But while interest is growing, the number of foundations that make grants for nursing remains small. Some grant makers that are focused on the topic are trying to recruit others by making the argument that it is not just health that is at stake, but economic development. They note that a strong nursing work force helps fuel a local economy, while other grant makers remind fellow foundations that the bedrock of a robust health-care system is its people.
"To be interested in improving the health-care system and to be interested in improving community health without being interested in nursing is a near impossibility," says Barbara J. Sabol, a program director at the W.K. Kellogg Foundation, in Battle Creek, Mich., which has made grants to support nursing since its founding in 1930.
Numbers Vary
The full extent of the nursing shortage is a matter of some debate.
In 2004 the U.S. Department of Health and Human Services estimated that given the current number of nurses entering the job market, by 2020 the nation will face a shortage of at least one million registered nurses. Other studies have forecast shortfalls in the hundreds of thousands.
Whatever the exact number, nursing experts agree that too few new nurses are entering the ranks to keep up, and the coming shortages will be difficult to head off without immediate, comprehensive action.
Experts say that periodic shortages are not uncommon in nursing, but the complex and interrelated trends driving the current shortage make it unlike any the profession has seen before.
The age of the country's nurses has risen sharply. The average age of a registered nurse in 2004 was nearly 47, and more than 40 percent of registered nurses were 50 or older, up from 33 percent in 2000 and 25 percent in 1980. The physical demands of nursing, like long shifts and lifting and moving patients, mean that many nurses in their 40s and 50s are already thinking about retirement.
At the same time, as the share of Americans over age 65 is increasing fast and complex new medical technologies are invented, hospitals need more nurses, not fewer. New opportunities for nurses are also available at pharmaceutical and insurance companies, putting further strain on the number who are available for patient care.
The obvious answer is that more people need to enter the profession, but nursing schools are facing a critical shortage of faculty members, who are retiring at an even faster rate than nurses as a whole, which severely curtails the number of students who can be admitted.
The public perception is that if there is a nursing shortage, it must mean that there aren't enough people who want to become nurses, and that's just not true, says Jeanette Lancaster, president of the American Association of Colleges of Nursing, in Washington. She says that efforts to raise the profile of nursing as a profession, especially Johnson & Johnson's advertising campaign, have led to significant increases in the number of people who want to become nurses.
"Most schools are turning away huge numbers of qualified applicants, because we just can't take more students," she says. A survey of nursing schools, conducted by the association, found that more than 42,000 qualified students nationwide were turned away in 2006 because there weren't enough spots for them.
Student Stipends
To help alleviate the faculty shortage in the San Francisco Bay Area, the Gordon and Betty Moore Foundation awarded more than $9.8-million over 10 years to the University of California at San Francisco to create an accelerated doctoral program in nursing in 2004.
Students receive stipends of $60,000 a year for three years to cover tuition and living expenses, provided that they agree to pursue their studies full time and teach at a Bay Area nursing school for at least three years after finishing their doctorate.
Aara Amidi-Nouri, who was among the first group of fellows, started teaching at San Francisco State University during the fall semester. Like many nurses, she got her master's degree while working full time. She had thought about continuing her education so she could go into teaching, but before the fellowship was announced, she says, it just didn't seem possible.
"I thought there's no way I could work and have a baby and get my Ph.D.," says Ms. Amidi-Nouri.
Other plans to increase the number of spots available in nursing schools are also winning foundation support.
The Oregon Consortium for Nursing Education has set an ambitious goal of doubling the number of nurses graduating in the state by 2010. The consortium has received foundation grants totaling $2.7-million to aid in that effort.
The nursing schools that make up the consortium — Oregon Health & Science University, in Portland, four of its branch campuses that have nursing programs, and eight community colleges across the state — have come together to create a curriculum that allows the institutions to share faculty members and other resources. In addition, students at the community colleges can complete their final year of a baccalaureate degree online, which means they don't have to relocate to get a four-year degree.
'Diverse' Nurses
With nursing schools and health-care systems thinking about how they are going to replace retiring nurses, it is an ideal time to take a closer look at exactly who is going to fill those positions, says Ignatius Bau, a program director at the California Endowment, in Los Angeles. The endowment has made grants to encourage greater ethnic and racial diversity in the health-care professions, including nursing.
"It's a two-for-one strategy," he says. "Let's get more nurses, but let's get more diverse nurses at the same time."
One of the fund's first forays into nursing was a three-year, $10-million effort to increase the number of students from underrepresented groups, especially Latinos and males, in nursing programs at six colleges and universities in the state's Central Valley. Mr. Bau describes the results of the program as mixed, but says it offered important lessons for future grant making.
At the outset of the program, in 2002, the emphasis was on recruiting more diverse students. But midway through the grants, says Mr. Bau, the schools realized that as their overall student populations became more diverse, so too were the applicants to the nursing programs. The real problem, school officials said, was retaining minority students, who were more likely than white students to have attended failing high schools.
So the endowment gave the schools permission to shift money that had been allocated for recruitment activities to tutoring and mentor programs and other academic assistance.
Tough Transition
Once nurses have entered the profession, keeping them there continues to be a challenge.
The fast-paced, often chaotic environment at hospitals can take its toll on nurses, as can the life-and-death decisions they must sometimes make. For nurses who have just graduated from school, it can be a difficult transition. Nationwide, more than 30 percent of new nurses leave their jobs in the first year.
"In nursing school, it's fantastic that we do get to do some very good rotations, but when you are in school, you are peripheral," says Jane W. Thornquist, a clinical nurse at NewYork-Presbyterian Hospital. Once you become a full-fledged nurse, she says, "the responsibilities are tremendous."
Ms. Thornquist was part of a nurse residency program the hospital started in 2006 to help new graduates cope. Professors from Pace University's nursing school run weekly sessions on topics like time management and conflict resolution. Participants are matched with experienced nurses who act as mentors, offering advice and helping them work through problems, and they also meet regularly to talk with one another about the challenges they face.
NewYork-Presbyterian started the program with a three-year, $300,000 grant from the Jonas Center for Nursing Excellence, also in New York. So far, 25 nurses have been through the first two rounds of the six-month program, and all remain employed at the hospital.
Mission Hospitals, Western Carolina University, and the Asheville-Buncombe Technical Community College — all in the Asheville, N.C., area — came together to create a simulation laboratory to help prepare nursing students for what they will encounter in hospitals.
The lab, which is also used by other nursing schools and hospitals in western North Carolina, was paid for, in part, with a $395,000 grant from the Duke Endowment, in Charlotte.
Included in the laboratory are nine computerized mannequins that have heart rates and blood pressure that rise and fall, airways that enable realistic breathing, arms that allow for IV insertion, and other lifelike features. The mannequins were a significant investment — each costs between $35,000 and $60,000 — but instructors say they are worth the money because they allow realistic simulations, such as a patient going into cardiac arrest.
The first time that the students face a real medical crisis with a patient will still be harrowing, says Alesia Carpenter, the lab's coordinator. But, she says, the hope is that their preparation with the mannequins "gives them more knowledge, more confidence, something else to build on."
Retaining Experience
The Robert Wood Johnson Foundation is taking a look at the other end of the career spectrum. Last January, the foundation awarded grants of about $75,000 each to 13 hospitals to study the results of efforts to keep experienced nurses on the job.
Five years ago, Tampa General Hospital, in Florida, one of the grant recipients, started a "lift team" — a group of specially trained employees whose job is to lift and move patients — in response to a growing number of on-the-job injuries.
"Nurses are getting older," says Mary Kutash, who heads nursing research at the hospital. "Patients are getting larger, and it's hard to move them." The lift team, along with the purchase of new lifting equipment and the addition of an injury-prevention coordinator, has led to a significant drop in injuries — 65 percent — and an even more startling cost savings.
Before the program started, the hospital spent more than $500,000 a year on lifting-related injuries. In 2006 the total was less than $5,000, even though the number of employees at the hospital had increased by 44 percent.
With the grant, the hospital is using surveys and focus groups to study whether the lift team has been as successful as a tool for retaining nurses.
Given the size of the problem and the myriad factors driving the nursing shortage, the Robert Wood Johnson Foundation and the Northwest Health Foundation, in Portland, Ore., are also trying to enlist other grant makers in the cause.
The foundations started Partners Investing in Nursing's Future, a five-year, $10-million program that awards two-year grants of up to $250,000 to partnerships of health-care systems, nursing schools, and local grant makers. The grants require local sources to raise $125,000.
The 21 partnerships that have received grants so far approach the nursing shortage in a variety of ways.
A project in Michigan seeks to keep experienced nurses working longer by helping them move from high-stress positions in hospitals to slower-paced settings, like outpatient care, home care, or hospices.
Three foundations in Wisconsin are collaborating on a project to increase the number of community and public-health nurses by creating paid fellowships at local clinics for fourth-year nursing students, who then agree to stay on as employees for at least one year.
An effort in Oklahoma plans to help nurses advance in their careers by offering online leadership training to nurses in rural parts of the state.
Economic Incentives
For some grant makers, concern about the nursing shortage can be as much about building a strong economy as it is about health, says Spicer Bell, president of the Community Foundation of the Eastern Shore, in Salisbury, Md.
The foundation is working with three hospitals to create a mentoring program to help retain new nurses.
Mr. Bell says a lot of the housing that has been built on Maryland's Eastern Shore in the past few years has been designed with older adults in mind, and people won't retire to an area unless it has good health care.
Plus, he says, nursing offers well-paying, professional jobs that people can train for at a local community college or a state university.
"They never have to leave home," says Mr. Bell. "It's homegrown economic development."
Attracting foundations that aren't necessarily interested in health care and getting them to think about the nursing shortage is one of the goals of Partners Investing in Nursing's Future, says Judith L. Woodruff, the program's director.
"One of the objectives is to reach out to foundations that are not the typical suspects," says Ms. Woodruff. "Because the problem is so big and has so many layers, relying only on funders that have a health-care focus is not going to be enough."