Dr. Linda Aiken Oral History 2008 A
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NINR History Project Telephone Interview with Dr. Linda Aiken
Conducted on June 10, 2008, by Philip Cantelon
PC: I’m speaking with Dr. Linda Aiken, A-I-K-E-N, on June 10th, 2008. I have your permission to record the call?
LA: Yes.
PC: Very good. Thank you. Back in the early years of discussions of an institute for nursing, in 1983 you served on the board of the Institute of Medicine’s review, and part of that section was a review of the nursing profession?
LA: Yes. It was a study on nursing.
PC: Can you tell me a bit about that?
LA: As I remember, it was yet another study on the shortage of nursing and how to solve it that had been generated by widespread reports of poor quality of care and nursing shortage, and we debated long and hard the sort of issues about how to solve the nursing shortage. But I think one of the most important, well, without a doubt the most important recommendation that came out of that report was the establishment of an independent agency for nursing research within the context of the NIH, which was adopted, led to the development of the National Center for Nursing Research, which then became the National Institute for Nursing Research.
PC: At that time you were with the Robert Wood Johnson Foundation?
LA: Yes.
PC: And what was your role there?
LA: I was vice president of the Robert Wood Johnson Foundation.
PC: Did they have a—in charge of a certain particular policy area?
LA: Not at the time they didn’t. It was a small organization at that time. But functionally speaking, I was in charge of research and evaluation for the foundation, which meant the outcomes evaluations of all of its programs in every field. Although this was not a formal designation, but something that I developed myself, I sort of became the developer of nursing programs—all of them.
PC: Tell me about your background a bit that would lead you in this direction.
LA: Of course I am a nurse, with a clinical nurse specialist in heart surgery, a lot of clinical experience. I decided that hospitals were not really optimally managed for good nursing care, and I decided in my twenties that I wanted to run a hospital and a nursing school in the same place to integrate practice and education together. I went to get my Ph.D. in order to kind of jump the age queue in order to take on a role like that at a young age, and in the process got very interested in research and went to the University of Texas, got my Ph.D. in sociology and demography. So I became interested in large-scale research and got a postdoctoral fellowship at the University of Wisconsin that happened to be funded by Robert Wood Johnson Foundation, and they invited me to become a program officer at the foundation. That was when the foundation had just started as a national philanthropy, and it turned out to be a good match between my clinical and research skills and the foundation, and my role just kind of grew very rapidly there.
PC: When did you get your own school of nursing?
LA: I never did. I decided that I would prefer to have an impact through research on hundreds of nursing schools, maybe thousands, and thousands of hospitals. So I went into large- scale domestic and international research.
PC: Doing this funded by . . . ?
LA: The NIH.
PC: Who at NIH?
LA: The NINR.
PC: Okay, in the group in the Institute of Medicine when they were doing this study, 1981- 83?
LA: I think so, yes.
PC: What was the group that made up the nursing section, I guess is the best way to call it.
LA: You mean the committee members?
PC: Yes.
LA: Oh, I can’t even remember back that far, and I don’t really have anything with me to look.
PC: Let me throw out some names. Roy Bulger?
LA: Roger Bulger?
PC: Roger Bulger. I’m sorry.
LA: Yes. He was the head of a very important organization, the Academic Health Centers organization. He was a physician, but he’s very interdisciplinary and very supportive of nursing.
PC: Was he an active member of this committee?
LA: Remind me who the chair was. I can’t remember.
PC: I’m not positive. Was it Barbara Hansen?
LA: No, she wasn’t the chair. She was nurse researcher.
PC: John Thompson?
LA: No, he wasn’t the chair. I didn’t even remember he was on it. Was Carolyn Davis on that list?
PC: Yes.
LA: She may have been the chair.
PC: Were those selected by the Institute of Medicine?
LA: Yes. The reason I can’t remember this is I think I’ve been on every commission and every IOM report on nursing in the last twenty-five years. So the only one about this that stands out in my mind is that recommendation to establish the NINR.
PC: How did that come about, because the profession itself as I understand it was not in any way united on this?
LA: As we looked at all of the information about the nurse shortage and what the causes and consequences were, it was clear that we didn’t know enough and there wasn’t enough good research. So then we investigated why that was, and in particular very little research by nurses. There had been historically some research by health services researchers but secondary to other questions. So it didn’t really yield advances in solving the nursing shortage. So we asked ourselves why was this important, questioned why didn’t it have more data to inform policy decisions. And we concluded that to the extent that there was any nursing research home in the federal government, it was in the Health Services Administration and HRSA, which was not and still is not a research institution, so it didn’t have a reverse peer review, and the monies were relatively small, and it was not in a context where there was enough visibility for the research or opportunity to actually conduct large-scale research and bring it to the attention of other scientists and to policymakers. So we concluded that there needed to be a nationally supported research organization and that it needed to be placed in a high-visibility, legitimate research agency and not a service agency. Of course at the time, the NIH was such an agency.
Now I don’t remember that the NINR, or its precursor, the center, was ever controversial among nurses. I don’t believe nurses had ever really seriously thought about it one way or another. I think it was more controversial in terms of NIH politics and policies than it was with regard to being controversial to nurses.
PC: As opposed—nurse educators?
LA: I don’t think so. I don’t remember that it was. I remember nursing, and especially educators and researchers being very supportive.
PC: Rhetaugh Dumas was always supportive?
LA: You know, it’s been a long time ago. I don’t remember that any major nurse figure was opposed to it, but I could be wrong about that. I just don’t remember it.
PC: Okay. The story was always that Jessie Scott would oppose it or would become unraveled if this happened.
LA: Jessie Scott was no longer at HRSA, I don’t believe.
PC: That’s correct. She was not.
LA: And once Jessie Scott left, HRSA never really had any influence or any power. I think it would have had to have been done whether Jessie Scott was there or not because it’s not a research institute. But really the Division of Nursing and HRSA never had any influence after Jessie Scott left.
PC: Okay. When we talk about the, and you did an interesting piece on the number of nurses, whether or not there was a surplus or a shortage in 1983 about the same time as this report came out, but in part of that, sort of the corollary, were there sufficient numbers of nurse scientists?
LA: No, there were definitely not.
PC: How did you think about this in terms of rectifying that through the center?
LA: There weren’t enough nurse scientists in any part of nursing, and nursing is a great big field. So there are many totally different kinds of problems that scientists work on in nursing, but in particular—so we concluded there was a shortage overall in their scientists, in part because there was no grant funding for nurse scientists to really build programs of research. There had been programs to educate nurse scientists, and I was such a nurse, I had a nurse scientist award to get my Ph.D. But in those days, there weren’t any research funds that were easily available and available at large enough quantities. So when we did the IOM study, it was particularly clear that there weren’t any nurses in policy research in what I would call nursing outcomes research or health services research. There were hardly any nurses in the country that had a capacity to use these very large datasets that had become available that other disciplines were using to help inform policy, and there were really no nurses in that field at all. This is a bit of a controversial thing because the NIH in general and the NINR specifically was really more targeted towards clinical research and not health policy research. But nevertheless, over time it has served as a very good vehicle to develop the field of nursing outcomes and policy research.
PC: Could you comment a bit on NIH’s reaction to the idea of a nursing research institute or center?
LA: As I remember, many in the larger scientific community that supported the NIH and specifically the administration of the NIH at the time were opposed to having more institutes. I think they thought that over time, that would fragment their money and make it difficult to advance science in some of the areas that they placed a high priority on. I think they didn’t understand what nursing research was, and nursing research certainly wasn’t very high on their priorities, but they also had an overall opposition to the establishment of institutes.
PC: How well had the nursing community explained what nursing research was?
LA: Not well. I would say it’s been difficult. I think it’s still difficult for the nursing community to explain what nursing research is, and I still think to this day, even though the NINR has now a very good track record in supporting research, that it’s not well understood among the general scientific community about what nursing research is.
PC: How would you sum it up to explain what it is to a layman like me?
LA: I’m not sure I can say this off the top of my head as concisely as I might be able to write it down if I thought about it for a while, but nursing research is the study of problems that nurses are responsible for in clinical care and in phenomenon in health care that affect the outcomes of nursing care. So nursing research could theoretically be on some of the same topics that you might see in another agency, but nurses generally take a different perspective on those questions and ask them from a different point of view, and often get a different answer that is more informative for sort of evidence of clinical care and also the evidence behind management and policy decision-making.
PC: In pushing this, how many nurses were in favor of more of this nursing research? Let me rephrase that. What was the impetus for the rising interest in nursing research in the late seventies, early eighties?
LA: I think it was a growth of university nursing programs, that more universities were opening nursing schools as a result of actually the money that Jessie Scott invested in nursing in the 1970s. That money expanded nursing programs in colleges and universities, and for those programs to be sustained, their faculty had to do research like all other faculty in academic institutions. I think that was the major factor.
PC: Was this a response to expanding the schools because of Medicare, Medicaid, and the like?
LA: Well, I think that was one of the policy rationales that was given for expanding nursing school enrollments and medical school enrollments, but there may be a difference in policy rationale for getting public funding and the ultimate—or there may be multiple reasons why these things are done. I think nursing as a profession was interested in moving nursing education into universities, and the opportunity that came along to expand nursing consistent with Medicare and Medicaid made that possible.
PC: And also medicine itself became more sophisticated, more complex, more scientific?
LA: Yes, that was all happening along at the same time, and nurses like physicians were becoming more interested in science-based practice and what really works and what really doesn’t. But I would say that was probably a secondary issue to nursing really wanting to mainstream nursing education in the best institutions of higher education in the country, and therefore the need for nurses to be active researchers.
PC: Tell me about Jessie Scott’s role here. You mentioned investing in nursing education.
LA: Of course I’m not a nurse historian and they could tell you more than I could. I only knew Jessie Scott very late in life because of the differences in our ages, but Jessie Scott basically had developed the political clout and the Division of Nursing to get nurses resources. She had a very big impact on particularly, I would say, baccalaureate nursing education, getting a foothold in major universities by her success in getting funding, and the funding was kind of a capitation nature funding that gave universities, and all nursing schools for that matter, a sort of per capita amount to increase their enrollments. Also there were monies to expand capital buildings, so she made it possible for nursing education to expand, and a lot of that expansion took place in higher education.
PC: And this was all through HRSA?
LA: Right.
PC: And the Division of Nursing.
LA: Right.
PC: So she had begun quite a significant program that I guess Jo Eleanor Elliott then took over.
LA: Yes.
PC: But Elliott did not have the same kind of clout?
LA: No, and not being really around in that particular era, not being a part of it, I couldn’t explain to you why Jessie Scott was so powerful. But she was able to garner resources from outside of nursing, and no one after her could ever do that.
PC: Did she do that the way the nurses lobbying group did, that is through Congress or did she have an angel in Congress?
LA: I don’t know the answer to that. She’s a very powerful personality, and I don’t know if she had—I’ve never heard that she had some special person in Congress that was the angel. She was definitely a formidable person that had a vision and could implement it,
going head to head with other people that are trying to garner resources in HRSA. There are some nurse historians I think like Joan Lynaugh that could really give you that story.
PC: Okay. The last name?
LA: Lynaugh, L-Y-N-A-U-G-H. She’s a professor emeritus University of Pennsylvania and a nurse historian.
PC: Okay, good. I’ll check that. Thank you. While the IOM was doing its report, it was also doing a study on restructuring the NIH similar with one about the same time except published maybe I think a year later. What impact did that have on your study?
LA: I think that may have been one reason why this idea came up to recommend the National Center for Nursing Research where there were some—all of these studies were in the same division in the IOM called something like the Division for Health Care Services or something like that. So the staff and the boards—the boards at the IOM that were comprised of Institute of Medicine members—they crossed over these various studies. I suspect that because this restructuring initiative was going on at the same time, that it was that kind of crossover between the discussion of these various areas that might have been one of the reasons why this idea came up in a context of a project that was supposed to be about the nursing shortage.
PC: As I recall from the study on restructuring the NIH, I think the person who chaired that was T. Franklin Williams?
LA: Yes, who is a physician who knew a lot about nursing and cared a lot about nursing. I can’t really remember the details of this—I’ve been on so many committees with him in the past—but it would have seemed to have been natural given his interests in long-term care and nursing that there was some kind of cross-fertilization of ideas going back and forth across these two committees.
PC: Plus you got instant support within an institute at NIH with him.
LA: Yes. But now, was he in place at the time?
PC: I thought he was with the Institute of Aging. Did he come to that later?
LA: You’d have to check out the dates because I’m not sure he was there that early, but I could be wrong.
PC: By 1984, Congressman Madigan had taken this under his wing. Did you have anything to do with that? Any discussions with him or his staff?
LA: No. I really wasn’t involved in the sort of trying to take this recommendation and push it on.
PC: What was your role following this while you were at the Johnson Foundation?
LA: All along this time, we’re developing these programs, and one of the big programs that I developed was kind of consistent with this idea, which was the Clinical Nurse Scholars Program. It was a program to train nurse scientists to take existing faculty members in teaching institutions and give them a two-year fellowship to basically prepare them to be NIH researchers. So I was kind of working on the production side of getting some people that could actually compete within the NIH.
PC: So that when the money started coming out, there would be people there ready to take advantage of it.
LA: Right.
PC: Did you ever work with Doris Merritt?
LA: I know Doris Merritt, but I can’t remember in what context. What was she doing? Maybe that will jog my memory.
PC: She was the acting director of the NCNR from 1986 to ’87 when Ada Sue came in.
LA: I wasn’t really involved that much in the early establishment of the NINR because I was really at that time at the foundation, and I didn’t myself need grant money. I was really more engaged in policy, and so my research at the time and the programs I was doing at the foundation—besides this Clinical Nurse Scholars Program, which may have been where we had that interaction with Doris Merritt and later Ada Sue Hinshaw—were really more with HCFA and over in the Medicare insurance side. I was doing a lot of demonstration programs with Medicare waivers and working with HCFA, so I was kind of in another part of the government at that time.
PC: When did you come to NCNR as a researcher, or NINR?
LA: Never until I got to the University of Pennsylvania where I had to then get grants. So then I changed sides from being a grantor to a grantee.
PC: And that was what year?
LA: In 1988.
PC: So again, early on just after Ada Sue got there.
LA: Right.
PC: How much preparation did they give you in grants? When I say preparation, how much direction and such do they have in terms of the programs they wanted to sponsor?
LA: They meaning . . . ?
PC: NINR. Or were they open to . . . ?
LA: I think they were open. I don’t remember any particular—obviously there were some sort of project announcements and so forth, but my first grant attempt was really not to the NINR, it was for the Center for AIDS Research. It’s one of these great big multimillion-dollar AIDS research centers where investigators could submit their own RO1s, basically their own studies under this large umbrella. I developed two studies under the Center for AIDS Research, and the center wasn’t funded, but then I took my two studies and combined them together and got that funded.
PC: Got it funded through . . . ?
LA: NINR.
PC: By that time the council was in place and all was well with the world.
LA: Yes.
PC: Was there much discussion about the appointment of the council within the nursing community or research nursing community?
LA: I don’t know that I was paying much attention at that point. I’m kind of a person with one foot in nursing research and one foot in policy, and I’m not sure I was really paying all that much attention to the NINR because I had other agencies that I could submit grants to.
PC: When you left the Johnson Foundation to come to Penn, did you still take an interest in forming policy?
LA: Yes.
PC: How did you do that on, I guess let’s talk about it as a national level within NINR?
LA: When I was at the Robert Wood Johnson Foundation, what I did was—I had venture capital there to invest, but with the venture capital at the Robert Wood Johnson Foundation, we would design big demonstrations and then I would evaluate them for the foundation. In other words, the design, multisite evaluations to determine if twenty of something to improve school health or whatever actually improved patient outcomes. So I wasn’t actually doing the research, but I was designing the research and then commissioning it. When I went to the University of Pennsylvania, everybody said to me—I kept doing the same thing except I raised the money for the whole thing myself.
Obviously it wasn’t possible to do these large-scale demonstrations, so I changed my strategy and looked for natural experiments that were going on that would allow me to study the impact, and that’s been my pattern with the NINR, but large-scale studies of hundreds of hospitals and tens of thousands of nurses and millions of patients. So I did research on a scale that no one else in nursing was doing at the time that the NINR started funding me.
PC: Would you say that’s your greatest contribution to nursing research?
LA: Yes. I would say scaling up nursing research to a magnitude that it’s visible to other people and can more easily have a policy impact. So I’m very much into scaling up research. And still, I would say most of the nurses that are funded by the NINR are doing relatively small studies of a hundred patients in a clinical trial.
PC: And yours encompasses thousands?
LA: Yes.
PC: Or tens of thousands.
LA: Well, I mean like right now we have four state studies, so we’re studying a thousand hospitals and 250,000 nurses, and multimillions of patients that get their care there.
PC: Was there in these policy considerations in the eighties with the Reagan administration an attempt to prove that nursing research could save the government considerable sums of money in patient care and time and the like?
LA: You’re asking me if there was?
PC: Yes.
LA: Well yes. I don’t remember it being that much of an interest of the Reagan administration per se, but this is one of the things I was doing at the Johnson Foundation. One of the things that made the Johnson Foundation unique at that time is that we partnered a great deal with the federal government. I would not say that there were many ideas that came out of the Reagan administration, but they could be interested in public- private partnerships. So we did a number of things on the nursing side that began to demonstrate the impacts of nursing. For example, I funded a project called a Teaching Nursing Home Program at the Robert Wood Johnson Foundation where the foundation put up $10 million or some such thing as that to establish ten teaching nursing homes that would be the analogue of a teaching hospital. Then we did a national evaluation of that that the foundation supported, and it was a national evaluation of that program, and a major component of it being the introduction of geriatric nurse practitioners into nursing homes that provided the evidence for the Congress to, for the first time ever, approve Part B Medicare reimbursement for nurse practitioners. So I was kind of working through the policy angle on nursing outcomes showing that in these different service settings that nurses did provide a cost-effective benefit for the Medicare program, which was of course our major vehicle for setting policy, and then to try to use that to get a policy change. So we did that, we got the hospice benefit through Medicare on nursing being very much of a part of hospice. So that was my sort of angle during that time. It tended to be more focused on nurse practitioners, and we supported a number of nurse practitioner programs.
PC: How would you evaluate your role on the IOM committee in terms of accomplishments? What do you think your personal accomplishment was on that committee?
LA: I was much more wanting to push the committee to make some specific recommendations on solving the nursing shortage that the committee was unwilling ultimately to do. So the only really salvation of that from my point of view was the recommendation of the establishment of the NINR. So I went into federal government to basically invest again in expanding nursing school enrollments to set some standards for nurse staffing in hospitals, some things like that to really try to substantially change the nursing shortage, and there was a lot of pushback on that committee for doing anything. So I think the recommendation to establish the NINR was kind of a fallback position, which turned out to be more, I think, to have probably the most significant impact on nursing of any single thing that I can remember that’s happened since I’ve been involved in professional nursing. I think that it really changed the whole context of nursing.
PC: Do you recall who in the committee pushed the hardest for that as a separate entity?
LA: No. I can’t remember.
PC: Okay. There are a number of names being batted about, and I was just sort of curious.
Could you help me with a couple of names perhaps please? Ellen Weicker?
LA: Not ringing a bell.
PC: Okay. Faye Abdella?
LA: Yes. Faye was a very famous nurse who was probably assistant surgeon general or some top nurse in the federal structure in the Public Health Service. As I remember, she was probably a contemporary of Jessie Scott or shortly thereafter, but she was more in the formal public health services compared to Jessie Scott who was managing her [inaudible]. But anyway, Faye Abdella had a major role in the development of academic nursing and in supporting nursing research. Was she on the committee? I can’t remember that.
PC: She was certainly involved in writing about it, that is writing about the shortage or the number of nurse scientists and wondered whether there would be enough of them.
LA: I’m sure she was an advocate for the development of more nursing research.
PC: She was. Yes. One of the things that was discussed was she hoped that the NINR or whatever it would become would not embarrass itself because there would be a shortage of nurse scientists, and she wanted to be sure that they had sufficient numbers. The National Commission on Nursing?
LA: Is this the American Hospital Association national commission?
PC: I don’t know. I came across it in a report, but I don’t know about it. Is that something that the . . . ?
LA: I think that was going on about the same time as the IOM report.
PC: Yes.
LA: I believe it was sponsored by the American Hospital Association.
PC: Aha. Okay. So that had a different goal, I guess.
LA: Well, it was more focused again on what are some of the solutions to the nursing shortage. I think it fell short of making any major recommendations. I haven’t read it for a long time, but I’m sure it said things like we need to improve the work environment of nurses, things like that. But it certainly didn’t come out with any major—I’m sure it didn’t say anything about research, and I doubt that it said anything about nursing education. It was probably focused on how can hospitals get more nurses.
PC: Okay. Is there anything that I may have missed as I have sorted through this in terms of your activities or role in NCNR or NINR?
LA: Well, I think I’ve probably been a more influential person later than in the beginning, because I was in very much of a different role and I wasn’t applying for grants and I really wasn’t available to be on the board or anything like that because of my foundation role. So there are many more nurses that I think were more important than I was in the early establishment of the NINR. I think in ’88 when I came to Penn that I developed a different style of grant submissions that were highly successful and got a huge amount of press and visibility for the NINR, so I think my influence has been more probably in the last fifteen years.
PC: Aha. Last fifteen.
LA: Well, from whenever it was—oh, maybe twenty. Time is rushing on.
PC: So it’s really the grants has impact on it now. So if I can make a pact with you to call back when I get to that part of the book and talk a little about that, would that be okay?
LA: Sure.
PC: Terrific.
LA: All right. Thank you so much.
PC: Well thank you. I’ve enjoyed it, and I will get this off. You’ll have it, as mail gets out of here, probably the end of the week or next Monday.
LA: Okay, great.
PC: All right. Thanks very much. Bye.
LA: Okay. Bye.
End of interview
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