July 1999

Grant Results

National Program

Ladders in Nursing Careers Program


In 1993 and 1997, Texas Ladders in Nursing Careers (L.I.N.C.) worked to recruit students on a community-by-community basis, rather than an institution-by-institution basis.

The project was part of the Robert Wood Johnson Foundation (RWJF) Ladders in Nursing Careers Program national program.

Key Results

  • As of August 1997, Texas L.I.N.C. was operating within 12 communities; all 12 had institutionalized the L.I.N.C. model and planned to continue to use it for work force planning and career development within their health care organization.
  • Texas L.I.N.C. had enrolled 170 participants; 82 students had graduated as of August 1997 — 73 from nursing programs, and nine with degrees in allied health.
  • Working with the town of Eagle Pass and its small medical center, Texas L.I.N.C. helped develop the first fully accredited, hospital-based licensed practical nurse (LPN) program in the southwest part of the state.

RWJF supported this project through two grants totaling $542,798 to the Texas Hospital Education and Research Foundation, where the Texas L.I.N.C was housed.

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In the year preceding Project L.I.N.C., Texas hospitals reported a 9.5 percent vacancy rate for registered nurses. In rural areas, the RN vacancy rate ran as high as 13 percent. Nursing homes were in worse shape. About 25 percent of them lacked enough nursing staff on any given day to meet federal requirements.

In fact, Texas nursing homes ranked 49th among the states in the nurse-to-patient ratio. The state's ethnic populations also were underrepresented among the ranks of nursing, and Texas felt this would be a significant statewide problem as health care reform pushed health care delivery in the direction of culturally sensitive and patient-centered care.

In 1992, Texas had a large pool of more than 79,000 licensed vocational nurses (LVNs) (the equivalent of LPNs) that represented a population that could easily become registered nurses in a minimal amount of time.

Despite the obvious need for nurses in the state and a large population of LVNs ripe for advancement, there were barriers to overcome. A major one was the growing emphasis on fiscal constraint posed both by managed care and potential national health care reform. Another potential barrier was the vast size of Texas and significant cultural and other differences among health care institutions.

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Texas L.I.N.C.'s objectives were to:

  • Offer member hospitals, particularly rural hospitals, a means of providing educational opportunities for their existing work force while filling vacancies in nursing and allied health.
  • Promote cultural diversity in the health care work force by providing training opportunities to low-income, minority personnel — thereby enabling health care institutions to better serve their culturally diverse patient populations.

Texas initially tried to implement Project L.I.N.C. statewide and soon discovered that they had, in the project director's words, "bitten off more than they could chew." Given the vast distances in the state and the cultural differences among geographic regions, Texas L.I.N.C. decided to adopt a strategy of targeting communities that responded enthusiastically to the L.I.N.C. model.

Even so, bringing students and educational resources together was a challenge, particularly in rural parts of the state. Texas L.I.N.C. encouraged participating institutions to look within their communities for mentors and volunteers to work with students. Teachers have provided remedial education, pharmacists have taught medication courses, and social workers and chaplains have provided counseling and support.

Texas L.I.N.C. used a variety of means to link students with educational programs. In one community — the small, poor, mostly Hispanic town of Eagle Pass — Texas L.I.N.C. helped create a new LPN program. The 77-bed medical center that serves the town had always had difficulty recruiting and retaining nurses who understood the local culture, spoke Spanish, and wanted to remain in the economically depressed border town.

At one point, more than 90 percent of the nursing staff were Irish and Filipino nurses who cycled in and out of the medical center continuously. Project L.I.N.C. helped Eagle Pass overcome two significant barriers that had prevented community residents from obtaining a nursing education: finances and distance to existing nursing programs.

Working with the medical center's CEO, who was a registered nurse by training, L.I.N.C. helped develop an LPN school on-site that graduated its first class of all Hispanic nurses in 1997. The students remained in Eagle Pass, provided culturally appropriate nursing services to the medical center's patient population, increased their hourly wage by nearly 50 percent, and served as mentors and tutors for the subsequent LPN. class.

In San Antonio, Wilford Hall Medical Center, a United States Air Force facility, sponsored 36 students — the greatest number of L.I.N.C. students at a single site. The Air Force provided 75 percent of the cost of tuition for its L.I.N.C. students.

Texas L.I.N.C. provided counseling, workshops, and tutors. Because of Project L.I.N.C's success in moving students quickly through nursing and allied health programs — with top grades — the Air Force was considering the adoption of Project L.I.N.C. as a national model for work force development. Texas L.I.N.C. also was successful in facilitating the delivery of a nurse practitioner program from the University of Texas School of Nursing at Galveston into Wilford Hall Medical Center.

Distance also moved Texas L.I.N.C. to decentralize fundraising and services. Each site worked with its board and the local community to access funds. At Presbyterian Hospital in Dallas, the Board designated $200,000 for Project L.I.N.C. Wilford Hall Medical Center raised money through car washes and bowling tournaments. John Peter Smith Hospital in Dallas received a grant from Johnson & Johnson.

Because of the distances between the L.I.N.C. administrative offices and the participating hospitals, each institution had its own site coordinator and educational counselor. Using on-site coordinators benefited L.I.N.C. students because the coordinators knew the students intimately and were knowledgeable about the in-house support systems and resources available.

Texas L.I.N.C. faced a significant challenge during the first year of the grant when it lost its home within the Texas Hospital Association. According to the project director, their homelessness "had a tremendous impact on [their] ability to raise funds and start new sites." Texas L.I.N.C. eventually found a home in the Texas Hospital Education and Research Foundation.

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As of August 1997, Texas L.I.N.C. was operating within 12 communities. All 12 had institutionalized the L.I.N.C. model and planned to continue to use it for work force planning and career development within their health care organization.

Texas L.I.N.C. had enrolled 170 participants; 82 students had graduated as of August 1997 — 73 from nursing programs (7 of them from MSN programs), and 9 with degrees in allied health. Nearly 50 percent of Texas L.I.N.C. students were minority, which exceeds the 42 percent minority population for the state. Some 35 percent of students were male; 35 percent lived and worked in rural areas.


Articles about Project L.I.N.C. were featured in the Dallas Morning News and the Texas Hospital Association's monthly magazine, HealthTexas. Other articles have appeared in the Wilford Hall newsletter, Vital Signs, and in the Lackland Air Force Base newsletter, TaleSpiner. See the Bibliography for details.

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As of July 1997, Texas L.I.N.C. anticipated that the program would be permanently housed within the Texas Hospital Association's Institute for Health Policy Research, which the project director thought would facilitate fundraising and allow access to state funding. Individual project sites had committed to continuing Project L.I.N.C. Continuation of the program on a statewide basis depended on Texas L.I.N.C.'s ability to raise funds.

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Texas Project L.I.N.C.


Texas Hospital Education and Research Foundation (Austin,  TX)

  • Amount: $ 42,857
    Dates: February 1993 to December 1993
    ID#:  021764

  • Amount: $ 499,941
    Dates: January 1997 to June 1997
    ID#:  023384


Katie Matlack
(409) 772-8265

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Print Coverage

"Grant Makes Educational Goals, Dreams Attainable," Vital Signs, November 15, 1995.

"Grant Helps Nurses Pay for School" Dallas Morning News, November 21, 1995.

Tuma, Laura. "Helping Hospitals Polish their Diamonds in the Rough," HealthTexas. Austin, Texas: Texas Hospital Association, December 1995.

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Report prepared by: Karin Gillespie
Reviewed by: Patricia Patrizi
Reviewed by: Molly McKaughan
Original Program Officer: Polly M. Seitz
Current Program Officer: Rosemary Gibson

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