In its 40-year history, the Robert Wood Johnson Foundation (RWJF) has invested in excess of $300 million in nursing programs and initiatives, and may have done more than any other foundation to support, empower and advance nurses. This is in considerable part due to the vision and drive of one man: Terrance Keenan.
A member of RWJF’s staff when the Foundation was established in 1972, Keenan is widely recognized as a key figure in shaping not only RWJF’s grantmaking, but health care grantmaking nationwide. His influence continues to be felt, even after his death in 2009.
Judith Stavisky, who was a senior program officer during Keenan’s tenure at RWJF, observed, “There is no more genteel but dogged champion of nursing.” From his early days at the Foundation until his retirement in 2003, Keenan encouraged initiatives to improve and expand nurses’ education, leadership, autonomy and influence.
Early in his career at RWJF, Keenan championed the new and then-controversial concept of nurse practitioners. “I think it would be safe to say the Foundation had a major role in the development and mainstreaming of nurse practitioners,” said Linda Aiken, PhD, FAAN, FRCN, RN, former RWJF program officer and currently the Claire M. Fagin Leadership Professor of Nursing and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. “In addition to giving money for programs, it gave legitimacy to the idea, which was very important.”
In 1973, when RWJF first began promoting the idea that the country needed more nurse practitioners—particularly to address the physician shortages in rural and low-income urban areas—there were only 4,000 nurse practitioners nationwide. Today, there are more than 100,000. But the growth did not come easily. Opposition came from many quarters. “Doctors were suspicious that we were giving nurses authority to do clinical interventions that were beyond their education,” Keenan said in a 2005 interview. “The nurse practitioner concept then was disliked by nursing deans, who thought we were taking their nurses and making doctors or doctor extenders out of them.”
Groundbreaking Programs to Build the Nursing Profession
RWJF funded early demonstration projects of community health service networks that relied on nurse practitioners in underserved urban and rural areas. These networks succeeded in increasing access to primary care, leading the Foundation to invest in nurse practitioner education through two initiatives: Primary Care Training for Emergency Nurses; and the Nurse Faculty Fellowship Program, which was designed to create a core of leaders in nurse practitioner education who would help establish master’s degree programs at schools of nursing. It ran from 1976 to 1982 and, in that time, trained 99 nurse fellows. Among them was Geraldine “Polly” Bednash, PhD, RN, FAAN, now the executive director of the American Association of Schools of Nursing.
“The impact those 99 people have had is significant,” said Bednash. “Nurse Faculty Fellowship Program was an important element in sending out people committed to the development of nurse practitioners. We now have this wonderful group of nursing leaders. They have assured that nurse practitioner education will remain as an important part of nursing education.”
In 1994, RWJF again made a significant investment in nurse practitioner education with Partnerships for Training. This 10-year program expanded primary health care to medically underserved urban and rural communities by providing distance learning nurse practitioner education through partnerships between 46 universities and community organizations and leaders. They identified potential students and often helped them financially and as mentors. Nearly 90 percent of the program’s 1,200 graduates remained in their communities working as nurse practitioners.
RWJF also helped tackle the problem that many nursing students lacked clinical experience when they graduated and began working in hospitals or at other health care sites. From 1982 to 1987, RWJF funded the Teaching Nursing Home Program and the Clinical Nurse Scholars program. The former provided nursing students with on-the-job training in nursing homes, similar to the training medical residents receive at teaching hospitals. The Clinical Nurse Scholar program prepared postdoctoral nurse educators to lead efforts to infuse an understanding of the realities of clinical practice into nursing education.
Many of the Clinical Nurse Scholars program’s 62 graduates went on to become nursing school deans, assistant deans and senior faculty, and to hold distinguished chairs at nursing schools. “All of us said Clinical Nurse Scholars launched our careers,” said Clinical Nurse Scholars program alumna Shannon Perry, PhD, RN, FAAN, professor emerita at San Francisco State University. “We have eminent scholars who are mentoring upcoming scholars; we have deans of schools of nursing with a vision because of some of the things they were exposed to in the Clinical Nurse Scholars program. We have colleagues around the nation we can call on.”
These programs improved the quality of nursing education and nurses’ skills and readiness, but did not address the nursing shortage that began in the 1980s. Recognizing the shortage as a problem that would require a significant investment in recruiting and preparing new nurses, RWJF funded the Ladders in Nursing Careers and Nursing Services Manpower Development Programs.
Ladders in Nursing Careers provided financial and other support to help health care workers attend nursing school. Through the program, they worked part-time and attended nursing school full-time while receiving full salary and benefits, with the requirement that they commit to working as nurses for their current employers for up to four years.
RWJF also created the Nursing Services Manpower Development program to increase the number of minority nurses. The program funded innovative models to recruit minorities and others underrepresented in nursing. The focus was on encouraging middle and high school students to consider nursing careers and supporting them as they applied to and attended nursing school.
While it was important to increase the supply of nurses, retention was critical to stemming the nursing shortage. In the late 1980s nurses were leaving the profession because they were frustrated with their work environments and burned out. The result was hospitals closing beds, canceling elective surgeries and diverting ambulances to other hospitals. To address this, in 1989 RWJF joined forces with the Pew Charitable Trusts to launch what was, at the time, the largest-ever philanthropic investment in a nursing initiative: Strengthening Hospital Nursing: A Program to Improve Patient Care.
The program provided planning grants to 80 hospitals and funded a demonstration program through which 20 hospitals designed changes in systems to improve patient care by removing impediments nurses faced to providing bedside care, including increasing their authority and reducing their workloads that were unrelated to direct patient care.
An outside evaluation of the program reported that the changes it generated ran “deep and wide.” According to the evaluation report, “core patient care practices were redesigned, affecting the practice patterns and the working relationships among the many different clinical care providers. In many cases, patient care practice was for the first time standardized.” Eight participating hospitals made “lasting improvement in patient care, and in most cases created new models of nursing practice and new relationships among nurses and other providers of care.”
Today, Terrance Keenan’s commitment to nursing lives on as RWJF continues to invest in initiatives and programs that champion and advance nursing and nurses, including the Future of Nursing: Campaign for Action.
These are just some of the early efforts that laid the foundation for even more innovative and ambitious RWJF programs that continue building nursing leadership, improving nurse education, strengthening the nursing workforce and, ultimately, improving health and health care for Americans today. Watch for more information on 40 years of RWJF’s work on nursing in Sharing Nursing’s Knowledge throughout the year as RWJF celebrates its 40th anniversary.