As a corollary to its work to expand the role of nurses as a way to improve access to care, RWJF also worked to reduce the chronic shortage of qualified nurses. As Rep. Lois Capps (D-CA) put it, "Enacting nursing staffing policy that guarantees appropriate and safe staffing levels is one way to improve quality of care in our health care facilities." (See Charting Nursing's Future, October 2007.)

Nurses are the largest group of health care professionals in the United States. Nurses have been in short supply fairly consistently since the 1980s. RWJF has funded efforts to address that shortage off-and-on since that time. For a brief period during the 1990s, it looked as if the shortage had leveled off. But it reappeared, as did RWJF's efforts to address it.

A 2001 report by Health Workforce Solutions concluded that the contemporary nursing shortage is driven by a broader set of factors than previous shortages. Current factors include:

• An aging population in need of more nurses
• The nursing profession's failure to attract minorities, men and young people
• Competition from other career opportunities for women
• A shortage of nursing school faculty (resulting in more applicants to nursing schools than faculty to train them)
• Nurses choosing fields other than hospital nursing
• Older nurses retiring (which adds to the shortage of nursing faculty)

RWJF initiatives since the 1980s to address nursing shortages have approached the problem with a variety of tactics:

• Some initiatives focused on recruitment: expanding the pool of those entering the profession and expanding the capacity of nursing schools to train them.
• Others focused on retention: improving the work environment, job satisfaction and career advancement to keep working nurses in the nursing workforce.
• Others took a more systemic approach, looking for policy levers and community-level approaches to reduce the nursing shortage.
• Some used a combination of these tactics.

Past and current initiatives funded by RWJF to stem the nursing shortage include:

• The Nursing Services Manpower Development Program funded innovative efforts at nursing schools to expand their student bodies, particularly efforts to recruit and retain minority students. The $3.2 million program ran from 1989 to 1998.

• Ladders in Nursing Careers helped improve the career advancement ladder for nurses. The $5.3 million program, which ran from 1988 to 1997, helped nurses aides advance into positions as licensed practical nurses (LPNs), helped LPNs become registered nurses (RNs), and helped RNs move into advanced practice positions. During the program, the marketplace for nurses changed from a shortage of nurses to an apparent (and short-lived) excess. As a result, some participating institutions started sponsoring employees to get trained for allied health careers instead of nursing. LINC enrolled 934 participants, of whom 365 (39 percent) graduated by the end of the program. (See Program Results on Ladders in Nursing Careers.)

• Colleagues in Caring supported 23 state and multi-county consortia that worked on a regional basis to:
  • Develop agreements among nursing schools to allow nurses to transfer credits from associate degree programs to baccalaureate nursing programs
  • Align the supply of nurses more closely with marketplace demand
  • Develop programs to recruit and retain nurses
  • Affect public policy on nursing education and workforce issues

Projects funded between 1994 and 2003 by the $6.9 million program developed new strategies for recruiting nurses, implemented new systems for collecting local data on nursing shortages, made it easier for nurses to develop their skills and built coalitions to advocate for nursing. (See Program Results on Colleagues in Caring.)

• Jobs to Careers seeks to advance and reward the skill and career development of low-wage workers who provide care and services on the front lines of the health care system. It supports partnerships of employers, educational institutions, and other organizations to expand and redesign systems to create lasting improvements in the way that institutions train and advance their frontline workers and test new models of education and training that incorporate work-based learning. RWJF has provided $14.5 million to Jobs to Careers since beginning the program in 2005.
  
• Partners Investing in Nursing's Future builds funding partnerships with local foundations to look for community-level solutions to local nursing workforce shortages. RWJF has committed $11.7 million in funding through 2013.
  
• Wisdom at Work supported research to identify effective interventions to retain older, experienced nurses in order to address the nursing shortage by reducing attrition. The $1.9 million program, which ran between 2006 and 2009, focused on innovative uses of technology, hospital design and human resources policies.
  
• Charting Nursing's Future is a series of policy briefs published by RWJF (with assistance from Sprain Communications) designed to educate and inform hospital executives, state and national lawmakers, nursing and nursing education leaders and other policy-makers about a wide range of issues relating to the nursing shortage, the role of nurses in quality initiatives and more. (See Program Results on ID# 049624.)
  
• The New Jersey Nursing Initiative addresses the nursing faculty shortage in RWJF's home state by developing, implementing and evaluating a statewide model for recruitment and retention of nurse faculty in New Jersey. The $22 million effort began in 2007 and will continue to 2012.
  
• The Robert Wood Johnson Foundation New Careers in Nursing Scholarship Program funds scholarships in accelerated bachelors' degree programs at nursing schools, with preference given to schools that increase the number of students in these programs or increase enrollment and retention of disadvantaged or minority students. The $19 million program runs from 2008 to 2011.
  
• The Robert Wood Johnson Foundation Initiative on the Future of Nursing convenes stakeholders from within and outside health care to make recommendations to address widespread national nurse, nurse faculty and other health care worker shortages and reinforce the central role of nurses in the quality of U.S. health and health care systems. RWJF has provided $6.2 million to the effort from 2008 to 2011.
  
• Evaluating Innovations in Nursing Education is identifying, evaluating and disseminating innovative strategies to increase the teaching capacity of nursing schools, as well as to promote the recruitment and retention of nurse faculty, with the long-term goal of educating more students. RWJF started the effort in 2008 and committed $9 million through 2012.

RWJF and its grantees have learned the following lessons from these efforts to stem the nursing shortage:

• Local solutions. According to the Partners Investing in Nursing's Future Web site, nursing shortages vary geographically, so the solutions must be localized.
• Offer technical assistance for financial aid applications. Nurses who want to advance in their careers need counseling and assistance to navigate the financial aid maze. (See Program Results on ID# 021760.)

Wisdom at Work identified 12 best practices for retaining experienced nurses:

• Establish the possibility of phased retirement.
• Pair knowledge transfer with phased retirement.
• Boost 401(k) participation.
• Offer services to help employees plan for retirement and other life phases.
• Establish training, lifelong learning, and professional development.
• Create mentoring programs.
• Provide flexible work options.
• Attain "magnet" hospital status.
• Manage talent.
• Cultivate corporate cultures that value the mature worker.
• Provide caregiving and grief resources.
• Redesign workplaces and implement ergonomic improvements.

(For more details on these best practices, see Charting Nursing's Future, April 2008.)

Charting Nursing's Future, April 2007 detailed these promising strategies for addressing the nursing faculty shortage:

• Fund education for those willing to teach and provide stipends that allow them to study on a full-time basis.
• Raise faculty salaries to encourage more nurses to choose academic careers.
• Engage health care providers in paying a greater share of the cost of workforce training.
• Develop new degree programs to better prepare nurse educators and speed their entry into the faculty role.
• Revise curriculum to promote more efficient use of faculty and enrich student learning.

An earlier issue of Charting Nursing's Future (January 2005) described how employers, educators and government officials must work together to address the nursing shortage.