CONTACT: Dan Mezibov
dmezibov@aacn.nche.edu
(202) 463-6930, x231

MEDIA BACKGROUNDER
(March 1999)

• Declining undergraduate enrollments don't necessarily mean declining interest in nursing careers. Although several nursing schools report a fall off in undergraduate applications, other schools have intentionally cut baccalaureate admissions because of faculty shortages or other resource constraints. Still other nursing schools report many vacant seats going unfilled.
  
  
• Despite a slight drop in total master's-degree nursing enrollments in fall 1998, the number of master's nursing students has climbed steadily over the last decade. The ranks of master's students have grown in response to rising demand for nurse practitioners, clinical specialists, and other RNs with advanced practice skills.
  
  
• Unlike the major nursing shortage of the mid-1980s, today not just any nurse will do. Meeting today's rising need for RNs requires not simply more RNs, but more RNs of the right types and educational mix.
  
  
• To meet workforce needs, employers are seeking nurses who are baccalaureate- and graduate-prepared as well as those to fill key specialties. Demand is particularly acute for experienced RNs.

1) Declining enrollments don't necessarily mean declining interest in nursing careers.

As health care facilities in many markets strive to meet an accelerating demand for registered nurses, enrollment of entry-level bachelor's-degree students at U.S. nursing schools fell by 5.5 percent in fall 1998, the fourth consecutive decline in as many years.(1)

While application levels remain strong at many schools, nurse educators continue to be concerned over headlines as recently as two years ago of hospital downsizings and of RN layoffs in markets affected by managed-care cost pressures. Those news accounts ran before the recent upturn in RN hiring. However, such media play apparently contributed to lasting, but now outdated, perceptions among many potential students who may have based their decisions not to apply on information that didn't reflect today's expanding nursing job market.

Moreover, several schools have intentionally cut baccalaureate admissions in recent years to cope with faculty shortages, budget constraints, limited classroom space, or other resource shortfalls. In some cases, schools redirected their limited resources to concentrate on meeting market demand for nurse practitioners, clinical nurse specialists, or other advanced practice nurses prepared in master's-degree programs.

Many schools also report having to reduce enrollments because of a tightening supply of clinical training sites. The availability of such sites has been dampened in recent years, as hospitals with fewer inpatients find they can accommodate fewer students, and as community-based facilities such as HMOs and primary care clinics -- used in nursing education traditionally -- also are being approached by medical schools and physician assistant programs seeking sites for primary care training.

To alleviate such pressures, AACN and other nursing and health care groups have urged lawmakers to redirect Medicare monies -- now used to fund hospital diploma nursing education programs -- into graduate-level nurse training programs that would also prepare future faculty. Such a move would also provide funding to reimburse clinical facilities as an incentive for accepting more students on-site. The Institute of Medicine, an arm of the National Academy of Sciences, supported the redirection in a 1997 report to Congress.(2)

2) Graduate enrollments continue to rise to meet demand for advanced nurse clinicians.

Total master's-degree enrollments in nursing fell by 2.1 percent in fall 1998.(3) Still, the modest decline was only the third time in the past 12 years for such a decrease at nursing schools, where master's enrollments have risen steadily in response to growing demand for nurse practitioners, clinical nurse specialists, and other RNs with advanced clinical skills.

Despite such growth, more than two-thirds of master's-degree nursing students are concentrated in part-time study, greatly delaying their entry into the RN workforce.

3) What's occurring does not appear to be a repeat of the pervasive nursing shortage of the mid-1980s to early 1990s, when employers hired qualified entry-level RNs virtually regardless of their nursing degree preparation. With today's more complex patient care, and with associate degree- and hospital diploma-prepared nurses already in oversupply, ensuring a sufficient RN workforce isn't merely a matter of how many nurses are needed, but what types, and providing them in the right educational mix.

Today's demand is different because:

• Today's demand is for nurses prepared at the bachelor's and graduate-degree levels who can deliver the higher complexity of care required across a variety of acute-care, primary-care, and community health settings, and to provide other needed services such as case management, health promotion, and disease prevention.
  
  
• Today's demand also is for nurses in key specialties, such as critical care; neonatal nursing; emergency, operating room, and labor and delivery units; and for advanced practice RNs such as nurse practitioners and clinical specialists.
  
  
• Though hiring of RNs is accelerating in more cities, today's demand varies region by region, market by market, contrary to the wide-reaching nationwide shortfall of RNs nearly a decade ago.

4) A host of factors are driving demand for more highly skilled RNs.

Despite a wave of managed care changes such as mergers, consolidations, and briefer lengths of stay that saw hospitals trim their ranks of inpatient RNs by 6 percent between 1992-1996, the number of employed RNs nationwide grew by its highest annual rate ever -- an average of more than 3 percent a year, to 2.1 million -- in the same period, according to the latest figures from the Division of Nursing of the U.S. Department of Health and Human Services. 4

Indeed, even as many hospitals cut their inpatient RN staffs, nursing employment boomed in other hospital areas between 1992 and 1996 -- up 25 percent in outpatient and labor and delivery units, up more than 15 percent in emergency rooms, and rising nearly 10 percent in surgical facilities, federal figures show.(5) In the same period, the number of RNs in community health centers rose 42 percent -- nearly triple the growth in the previous four years -- and climbed by 32 percent in long-term care facilities.(6)

Today's intensified hiring of RNs is also being spurred by:

• the mounting health care needs of increasing numbers of elderly;
• a growing population of hospitalized patients who are older, more acutely ill, and in need of more skilled RNs per patient;
• the rapid expansion of front-line primary care to many sites throughout the community;
• technological advances requiring more highly skilled nursing care; and
• an aging RN workforce. The average age of RNs in 1996 was 44, up from 40 in 1980. Moreover, only 9 percent of RNs were under age 30 in 1996, with high levels of retirements projected in the next 10 to 15 years.(7)

Federal figures project that if current trends continue, rising demand will outstrip the supply of RNs beginning approximately 2010. By 2015, says the federal Division of Nursing, 114,000 jobs for full-time equivalent RNs are expected to go unfilled nationwide.(8) But already, in an expanding number of markets, hospitals and other employers are struggling to meet a rising need for RN care and have stepped up recruitment.

5) At the entry-level, the BSN nurse is preferred.

The disproportionate supply of nurses with associate degrees and hospital diplomas has led many policymakers to call for the closure of significant numbers of these programs in favor of accelerated production of baccalaureate- and graduate-prepared nurses.

The National Advisory Council on Nurse Education and Practice, an advisory panel to the federal Division of Nursing, has recommended as a policy target that at least two-thirds of the basic nurse workforce hold baccalaureate or higher degrees in nursing by 2010.(9) Although 31 percent of RNs in the U.S. in 1996 held bachelor's degrees as their highest educational credential, 32 percent had two-year associate degrees, 27 percent held hospital diplomas, 9 percent had master's-degrees, and fewer than 1 percent had obtained the doctoral degree.(10)

A 1995 report by the Pew Health Professions Commission urged the closing of up to 20 percent of associate-degree and hospital diploma programs and more concentrated production of nurses from bachelor's- and graduate-degree programs.(11)

Policy leaders explain that the health system's complexity requires nurses who are capable of more independent clinical decisionmaking in less-structured environments, are prepared broadly in basic as well as behavioral and social sciences and management, can communicate effectively, and are oriented more towards health promotion, maintenance, and cost-effective coordinated care. The Bachelor of Science in nursing (BSN) curriculum provides such preparation, including training in community-based primary care not typically a part of associate-degree or diploma programs, and gives nurses a foundation to enter graduate training for advanced practice and management roles.

At increasing numbers of hospitals nationwide, baccalaureate-prepared nurses are practicing in ways that recognize their different educational preparation and competencies from other entry-level RNs. In these "differentiated practice" models, BSN nurses not only provide more complex types of patient care, but also design and coordinate a comprehensive plan of nursing care for the entire length of a patient's stay -- from pre-admission to post-discharge, supervise nurses aides and other unlicensed assistive personnel, design teaching plans for patients, and collaborate with physicians, family members, and other hospital departments and resource staff. Associate-degree nurses function primarily at the bedside in less complex situations, and provide additional care such as teaching patients how to maintain their care after discharge.(12)