Strategies to Advance Geriatric Nursing: The John A. Hartford Foundation Initiatives
Address correspondence to Claire Fagin, PhD, RN, 200 Central Park South Apt. 12E, New York, NY 10019. E-mail: firstname.lastname@example.org
This article chronicles the efforts of the John A. Hartford Foundation to improve the health care of older adults by strategically investing $34 million in geriatric nursing programs nationally. It includes a brief background of the Foundation followed by a description of the Foundation's geriatric nursing programs and the lessons learned that could be relevant to a variety of audiences.
The nursing shortage and its adverse effect on patient care in the United States has been well-documented and has received prominent attention in scholarly,1–3 policy,4 and public forums, including front-page coverage in major newspapers and on national television,5–7 but the overall nursing shortage obscures an even greater problem—the dearth of nurses trained in geriatrics and prepared to care for the needs of the United States' rapidly growing aging population. Nurses play a central role in the care of older adults in hospitals, rehabilitation centers, community settings, nursing homes, and homes. As more care is provided outside institutions, it is often the nurse who manages the transitions between the different settings of care. It is also the nurse who is most likely to help teach families and older adults the skills necessary to manage their ongoing health-related caregiving and self-care activities. Yet of the 2.5 million registered nurses (RNs) in the country, fewer than 1% are certified in geriatrics.8
This article addresses the efforts of the John A. Hartford Foundation (JAHF) to improve the health care of older adults by strategically investing $34 million in geriatric nursing programs nationally. A brief background of the Foundation will be followed by a description of the Foundation's geriatric nursing programs.9 The article will conclude with observations compiled thus far, which will be of relevance to nursing professionals, as well as private and public funding agencies, policy makers, and advocates.
Background: The John A. Hartford Foundation
Over the years, the Foundation's grant making has been guided by the principle “to carve from the whole vast spectrum of human needs one small band that the heart and mind together tell you is the area in which you can make your best contribution.”10 For more than 20 years, the programs of the JAHF have focused on the health of older Americans. About 10 years ago, aging and health became the exclusive concern of the Foundation's grant-making activities, with concentrations in two key areas: academic geriatrics and training (AGT) and integrating and improving services. Historically, a large proportion of Hartford's AGT commitments had been for projects involving geriatric medicine. In 1996, a companion focus on nursing began, followed in 1998 by efforts in social work. Since 1985, the Foundation has committed more than $246 million to AGT in all three health disciplines and in interdisciplinary team training. More than 50% of this funding has been for faculty development and investments in future health professionals.
Geriatric Nursing Initiative: Development Process
The Foundation's first venture into gerontological nursing was in 1996, when a $5 million grant was made to New York University to create the John A. Hartford Institute for Geriatric Nursing. At the time, little attention and funding was being directed nationally to gerontological nursing. Additionally, although there were nurses engaged in gerontological research and practice, there were few forums for the exchange of information and ideas and little recognition for the work being conducted. In the words of Mathy Mezey, EdD, RN, director of the Institute, “it was an uphill battle to convince educators and practice leadership that geriatrics is the core business of health care and that nurses need specific competence in geriatrics to assume their central role in providing high-quality care to older adults” (interview, Spring 2002). The original purpose of the Institute was to create a national repository of information about gerontological nursing care, relevant to both policy and practice. Additionally, its mission was to advance geriatric nursing practice and humanize care of the older adult. Work of the Institute included development of best-practice and curriculum standards and materials to enable all nurses working with adults to gain basic knowledge of geriatric nursing; the creation of awards to showcase outstanding examples of research, education, and practice; and the development of a summer research institute to expand faculty capacity.
The Institute was successful in meeting its goals, establishing a national geriatric nursing forum, and increasing the profession's recognition of its vital role. At the same time, its work revealed the serious academic and training gaps in the geriatric nursing profession and needs of newly recruited and practicing nurses. A career focus on research and care of older patients was not seen as attractive to a sufficient proportion of the dwindling number of entrants into the nursing profession. In part, this was due to the lack of a critical mass of exciting role models on which to base their careers, as well as the lack of incentives to pursue a career in geriatric nursing. A Foundation-supported survey confirmed these impressions, and a series of white papers regarding potential strategies that could begin to address these problems was commissioned late in 1999.11 A meeting was then held at the Foundation in January 2000. The expert group that was convened focused on strategies to prepare the next wave of leadership in gerontological nursing. Specific interest emerged in building a critical mass of academic teachers and investigators who would influence the academic agenda and bring nursing to bear more forcefully on the health care of older adults. After this meeting, Foundation staff developed recommendations to significantly expand the Foundation's work in nursing, which the Board of Trustees endorsed in March 2000. Expected outcomes included development and dissemination of models of excellence in education, training, and practice; expansion of evidence-based nursing research; stronger collaborations between academic and practice settings; enhanced gerontological nursing role models; and perhaps most importantly, creation of a new generation of nurse scholars and practitioners to lead care improvement for the growing older adult population in the coming decades.
Implementation of New Nursing Initiatives
By December 2000, a series of new grants totaling $14.7 million had been developed and funded. The new “Building Academic Geriatric Nursing Capacity (BAGNC) Initiative” had four main components. (Claire Fagin, PhD, RN, who also acted as a key senior consultant to the Foundation in the development of the program, leads this initiative.) For the first component, funding was designated to create five centers of geriatric nursing excellence at university schools of nursing that had exhibited a long-term commitment to gerontological nursing scholarship. The purpose of this funding was to begin to create, over a period of 5 years, a critical mass of gerontological excellence led by the field's most experienced and committed leaders. The second component of the initiative provided resources for up to 30 predoctoral and 30 postdoctoral scholars (10 of each per year for 3 years), to establish their careers in gerontological nursing research. In addition, funding for up to five nurses wishing to pursue careers in the management aspects of the geriatric enterprise was provided. The aim of this scholarship component was to increase recruitment and enable more-rapid completion of academic training, recognizing that the average graduation age of nurses receiving doctorates is 45. The third component of the initiative was support for leadership development for all scholar recipients through an annual meeting held in conjunction with the Gerontological Society of America annual meeting. The fourth and final component of the program was coordination of the overall initiative through an award to the American Academy of Nursing (AAN). The responsibilities of the Coordinating Center include the selection of Hartford scholars; creation and management of the leadership program; the fostering of collaboration, communication, and joint problem-solving across the five Centers of Geriatric Nursing Excellence; and the exploration of ways to maximize the effect of the BAGNC initiative and those of the Nursing Institute.
In early 2001, a fifth component was added to the initiative in the form of unding to seven additional schools of nursing. This new program was entitled the “Nursing School Geriatric Investment Program” and provided the schools with a total of $2.2 million for 3 years. This investment was given to enable each school to build its geriatric nursing and research infrastructure more quickly so as to reach its next level of excellence more rapidly. This program also further enriched the options for building academic capacity and added geographic and programmatic diversity.
Recognizing that gaps in undergraduate and graduate nursing education also needed to be targeted, the Foundation committed $3.99 million to the American Association of Colleges of Nursing (AACN) over a 4-year period. These funds were to support awards to 20 baccalaureate and 10 advanced practice nursing programs to stimulate curricular and clinical innovation in geriatric nursing education and training. Another award was subsequently made to the AACN for $2.23 million for 4 years, to provide scholarships and career development support for students who desired to enroll in advanced practice nursing programs in geriatrics. The AACN, as the national voice for baccalaureate and graduate education, was chosen as the organization to oversee these projects.
Finally, to document and formally evaluate the Foundation's work in geriatric nursing, a $900,000 grant for 3 years was given to The Measurement Group, an evaluation firm located in Culver City, California. The purpose of the cross-cutting evaluation was to capture the effective strategies used by each funded project to enhance geriatric nursing faculties and their capacities for research, develop best practice clinical and education models, and recruit and train students. In other words, to document the planned outcomes as well as those that were “serendipitous and magical” that result from the Foundation's $34 million investment in the field. A strategic decision was made to integrate this formal external evaluation with the new projects from their inception so that the approaches being used by each were being captured in “real time” rather than after the fact. The evaluation, although independent, was seen as an important component of the continuous improvement of the entire nursing initiative. A summary of all the programs in Hartford's nursing initiative are listed in Table 1.
Table 1. The John A. Hartford Foundation (JAHF) of New York Advancing Geriatric Nursing Program Summary
|The JAHF Institute for Geriatric Nursing||Promoting the highest level of competency in the practicing nurse||A national resource for training materials and best practices for nursing students, faculty, and practicing nurses||The New York University Division of Nursing |
Dr. Mathy Mezey, Director
Elaine Gould, Contact
|The JAHF Program: Building Academic Geriatric Nursing Capacity||Developing academic leaders, scholarship, and best practices in geriatric nursing||5 Academic Centers of Excellence;* pre- and postdoctoral and masters of business administration scholarships; leadership development and overall coordination||The American Academy of Nursing |
Dr. Claire Fagin, Director
Patty Franklin, Contact
|The JAHF Nursing School Geriatric Investment Program||Expand the capacity for leadership in the field of geriatric nursing in several major schools of nursing||A national 3-year program that awards funds to seven schools of nursing to support strategies to advance the quality of health care to older adults||The American Academy of Nursing |
Dr. Claire Fagin, Director Patty Franklin, Contact
|The JAHF Geriatric Nursing Education Project||Increasing gerontological nursing content in baccalaureate and advanced practice nursing programs||Awards to 20 baccalaureate and 10 advanced practice nursing programs for curriculum and clinical innovation in geriatric nursing||The American Association of Colleges of Nursing |
Dr. Polly Bednash, Executive Director
Diedre Thornlow, MN, RN, Contact
|The JAHF Creating Careers in Geriatric Advanced Practice Nursing||To provide scholarship monies to schools of nursing to expand opportunities for nursing students to choose a career in gerontological advance practice nursing||This 3-year program provides scholarship monies to selected schools of nursing to cover tuition and fees for one to 10 students each year||The American Association of Colleges of Nursing |
Dr. Polly Bednash, Executive Director
Diedre Thornlow, MN, RN, Contact
|External Evaluation of the Gerontological Nursing Initiative||To independently and objectively determine the effectiveness of the initiative in improving gerontological nursing care||Cross-site external evaluation that will strengthen project outcomes, document accomplishments, and identify lessons learned||The Measurement Group LLC, Dr. George Huba, President and Founding Partner Ghuba@TheMeasurementGroup.com|
Expert Panel on Graduate Geriatric Nursing Education and Practice
At the time the BAGNC initiative was conceptualized, although a serious problem was recognized in the lack of gerontological content in advanced practice nursing education, there was little agreement on potential solutions to this problem. (The Hartford Nursing Institute had already begun to address the matter of baccalaureate education competencies and curriculum.) The award to the AAN thus included modest funds to enable a consensus conference on this subject, to be convened in collaboration with the Division of Nursing of the Federal Health Resources and Services Administration. The conference, attended by policy makers, nursing faculty, and practicing nurses, provided a forum for their expert opinions on the specific needs of gerontological nursing graduate education and the barriers to progress. This meeting led to a report entitled “Caring for Older Americans: Recommendations for Building a National Program for Graduate Nursing Education in Gerontology,” which included policy recommendations for action.12 The conference stimulated an additional report, “Initiatives to Promote the Nursing Workforce in Geriatrics.”13 The recommendations from the consensus conference directly influenced the Foundation's decision to develop and fund the AACN projects targeted to advanced practice nursing education that were described above and has also stimulated new support for faculty development through the Division of Nursing.
Observations Thus Far
The Foundation's commitment to gerontological nursing has been rapid and intense. Given the national attention to the crisis in nursing supply, the nursing initiatives may be viewed as a timely, positive, proactive response to the momentum of broader trends in health care, particularly the nursing shortage and its effect on patient care. Some principles follow, which underpin the Foundation's strategic plan for geriatric nursing.
Focus on Excellence
At a time when much is written about the problems of health care, the Foundation has focused its efforts on defining and recognizing excellence. Selecting the top centers of geriatric nursing in the country and labeling them “Centers of Geriatric Nursing Excellence” has drawn attention to these programs in their own institutions and nationally and created a positive association between geriatric nursing and superior performance. Although not all the Hartford doctoral and postdoctoral scholars are required to study in these Centers, their existence draws applicants to the Scholars program, and their ongoing research, education, and practice programs stimulate scholars in their own institutions and beyond. Many of the Centers' faculty members participate in the programs of the JAHF Nursing Institute, and efforts to create synergy across all funded projects are already bringing results. In the process, the focus on excellence has helped to generate and restore enthusiasm for a beleaguered field.
Importance of Networking
Because of the small size of the field, many gerontological nursing professionals had been acquainted with one another, but opportunities to meet and work with and learn from each other were limited. In pursuing strategies to accomplish the goal of strengthening the field of geriatric nursing, several activities have emerged. These include designing a variety of forums to bring like-minded professionals together to focus on joint learning and problem-solving activities. These forums include national meetings focused on communication strategies; conferences among the various groups that involve presentations and sharing of experiences and insights; leadership meetings for scholars, mentors, project staff directors, and others; and expert panel meetings. Additionally, professional organizations such as the AAN and AACN have been chosen to play multiple roles in coordination and communications. The result is that no single program operates alone in its own “silo.” In the process of building networks, the Foundation has helped to create a national peer group of professionals. Examples of mutual learning are myriad and include the creation and sharing of curricular products, approaches to faculty development, Website structure and content development, best practices, and approaches to in-service training and distance learning.
Gerontologizing Professional Organizations
Linkages have been sought with professional nursing organizations, such as the AAN and AACN. In giving these organizations leadership and financial oversight roles, gerontology has become embedded in their national agendas. This in turn has helped to focus attention on and legitimize gerontological nursing within their national constituencies.
When a long-term grant is made to an organization, the Foundation recognizes the need for flexibility in program planning and budgeting. Foundation staff see themselves as grantees' partners and realize the likely need for changes in project plans during the course of the grant. Foundation staff work with grantees to smooth requests for changes that enhance achievement of the original mission in response to unforeseen opportunities and barriers. Flexibility also allows the grantees to stay energized in their work and stimulates creative thinking, because there are always possibilities to enhance and improve the work being done in an environment in which change is not viewed as failure.
External and Internal Evaluation Strengthens Projects
In addition to the formal crosscutting external evaluation being conducted by The Measurement Group and individual projects' assessment of their own progress, each year the Foundation conducts its own evaluation of each grant. This includes a site visit to each of its grantees that is the basis for a formal progress report to the Foundation's trustees. These site visits focus on the individual project's activities and obstacles encountered during the course of the previous year. They are also seen as an opportunity to plan ahead and often include external consultants whose expertise is intended to strengthen and support the project's long-term success. The internal and external evaluation processes are seen as strengthening the grantees' progress by asking them to engage in an annual “look-back” that allows for mid-course corrections and a continuous redefining of their own strategic plans. Although the Foundation and grantee internal evaluations capture the progress being made within individual grants, the crosscutting external evaluation provides indispensable qualitative and quantitative information on the results of the overall nursing initiative and the process whereby these results were achieved.
Recognition of Talent
The goal of the nursing initiative is to recognize and highlight talent. Thus many of the projects feature the development of best practices, curriculum models, and the fostering of a new generation of gerontological nursing leaders. Again, the guiding philosophy is the nurturing of, and focus on, excellence.
Scholarship Awards are Important
Despite what surveys had told us about low interest in gerontological nursing, the scholar awards have demonstrated the utility of money and publicity in attracting leading students at all levels, including postdoctoral. The bottom line is that scholarship money to pursue geriatric nursing attracts students to the field and empowers programs that can offer scholarship funding by making them more competitive in terms of attracting students.
Leveraging Dollars Provides Long-Term Program Sustenance
Leveraging dollars is an essential component of the Foundation's expectations regarding longer-term survival and sustenance of the models that it helps to initiate. Leveraging opportunities are sought at all levels of government: within the philanthropic community, at the academic institutional level (extending beyond the confines of the nursing enterprise), and among relevant clinical service and aging organizations at the local, regional, and state levels. The partnerships thereby created bring new advocates for gerontological nursing on board and help to create a solid financial infrastructure, which is critical for long-term sustainability after the period of Foundation support.
There is clear evidence that thoughtful deployment of well-trained nurses can improve older adults' care.14,15 Increasing in numbers each day, older adults constitute the segment of the population that enjoys the greatest benefit from care and system improvements and is most vulnerable to medical mistakes.
The initiatives and strategy described above are a first step being taken by the Foundation to increase the availability of well-trained nurses, who are key agents in the provision of health care and its coordination on behalf of older adults. It is the Foundation's hope that the increased numbers of gerontologically prepared nurses and academic faculty will directly enhance the well-being of their patients today and stimulate further advances in the knowledge base that underpins their practice.