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Fact
Sheet CONTACT:
Robert Rosseter March
1999
WHILE DEMAND FOR RNs CLIMBS, UNDERGRADUATE NURSING ENROLLMENTS DECLINE
Continued declines in bachelor's-degree
enrollments at the nation's nursing schools have heightened
concern over the health system's ability to meet rising demand
for registered nurses across a variety of settings.
The following backgrounder explains what the latest enrollment numbers mean, how today's developments differ markedly from the nursing shortage of a decade ago, and provides other timely background on the changing nursing workforce.
MAJOR POINTS:
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 However, such media play apparently contributed to lasting, but now outdated, perceptions among many potential students who may have based their decisions not to apply on information that didn't reflect today's expanding nursing job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:
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:
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) # # # The American Association of Colleges of Nursing is the national voice for university and four-year-college education programs in nursing -- the nation's largest health care profession. Representing more than 500 member schools of nursing at public and private institutions nationwide, AACN's educational, research, governmental advocacy, data collection, publications, and other programs work to establish quality standards for bachelor's- and graduate-degree nursing education, assist deans and directors to implement those standards, influence the nursing profession to improve health care, and promote public support of baccalaureate and graduate nursing education, research, and practice. REFERENCES
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