AACN Issue Bulletin
March 1997

In 1995, amid the consensus that nursing schools should expand their output of advanced practice RNs, a federal study probed the question, "Can they?" Through phone interviews and site visits, a Fairfax, Virginia-based consulting firm, Lewin-VHI, Inc., surveyed 20 graduate nursing programs nationwide to determine their ability to produce higher numbers of advanced practice nurses in the four APN specialty areas. Those specialties include nurse practitioners (NPs), who provide front-line basic health services and preventive care in primary- and acute-care centers; certified nurse-midwives, who provide prenatal and gynecological care to normal healthy women, deliver babies, and follow-up with post-partum care; clinical nurse specialists, who deliver hospital care in a range of specialty areas such as cardiac, oncology, neonatal, gerontological, and obstetric/gynecological nursing; and nurse anesthetists, who administer more than 65 percent of all anesthetics given to patients each year and are the sole anesthesia providers in approximately a third of U.S. hospitals. The study was commissioned by the U.S. Public Health Service.

Lewin-VHI found that most APN education programs already are at capacity in some aspects. But while some nursing schools needed additional faculty or bigger facilities to accommodate more students, the "single most significant factor" affecting a program's ability to expand is the availability of hospitals, HMOs, primary care clinics, and other facilities as sites for clinical instruction, the report noted.

In fact, the supply of training sites can dictate not only whether educational programs expand, but also if they must cut back. Although deans report that applications remain strong overall, some say they have deliberately cut admissions to nurse practitioner programs because of a tightening pool of training locations. In fall 1996, such measures helped master's-degree nursing enrollments drop by 3.4 percent below the year before, the first decline in six years, according to the latest survey by the American Association of Colleges of Nursing (AACN). Moreover, while 27 percent of nursing schools responding to an AACN survey in 1995 cited too few faculty as the chief reason for not accepting all qualified applicants to master's-degree programs, 23 percent blamed insufficient clinical or classroom space.

For many deans, Lewin-VHI's findings and its recommendations for expanding capacity could not have come too soon. While some nursing schools are producing the limit of graduates their communities can absorb, at least for the present, constraints in other markets find programs there struggling to meet current and projected demand for their own and other regions. The push to produce higher numbers of primary care providers in nursing, medicine, and other fields is coming on top of an adverse environment for clinical training already created by a spreading managed care system, deans say. As a result, the ability of many nursing schools to secure enough clinical training slots for students at both the bachelor's- and graduate-degree levels has been markedly dampened.

At some institutions, such as San Diego State University and the University of Alabama at Birmingham, recent declines in undergraduate nursing enrollments stem from budget cuts by the universities. Still, "I believe if the budget cuts had not affected schools, there would have been a problem with clinical sites," says Rachel Booth, dean of UAB's School of Nursing, who notes that the area's dwindling inpatient population does not provide enough clinical experiences for the all of the school's bachelor's-degree and graduate tracks. Meanwhile, in Oregon, undergraduate enrollments have been capped at the University of Portland School of Nursing for the last four years to match the limited supply of training slots, particularly in pediatrics, at area hospitals.

Although some schools are boosting graduate enrollments in high-demand specialties, others have been forced to scale back. "We are cutting back on our admissions of family nurse practitioner and pediatric nurse practitioner master's students -- from 20 to 15 per year for FNPs and from 15 to 10 per year for PNPs -- because of difficulty in finding and keeping clinical placements," says Barbara Durand, dean of the College of Nursing at Arizona State University.

As it attempts to place students for experiences in primary care centers in the New York City area, Pace University's Lienhard School of Nursing also must vie with other local schools that have opened their own NP programs and with medical students who must complete primary care rotations. "Suddenly there is such interest in sites that no medical school would touch in the past -- homeless shelters, community health centers, inner-city clinics -- sites where nurses and nurse practitioners have committed themselves for decades," says Karen Anderson Keith, chair of the school's family nurse practitioner program. "As soon as a medical school calls for a slot, kaboom, there goes a former NP student slot." In addition, many HMOs used for clinical training no longer take nurse practitioner students, citing productivity concerns, says Anderson Keith. "Many clinicians have been told they could lose their jobs if they did not see more patients and to refuse students for that reason alone. The bottom line, we've cut back planned enrollments by about 40 percent in our FNP program."

For several schools, such as Pace and the University of California at San Francisco (UCSF), the higher case loads and drive for higher productivity at managed care facilities have meant the loss even of clinicians who have long participated as on-site "preceptors" for NP students, but have been told to no longer take them. UCSF, already contending with more difficulty finding clinical placements for nurse practitioner and nurse-midwife students, has discontinued a nurse anesthetist program needed in Fresno, an area surrounded by a medically-underserved population, because of a merger-driven lack of firm commitments for student placements there, "despite just having had a training grant funded," says dean Jane Norbeck of the School of Nursing.

Such obstacles have made the task of finding willing preceptors considerably longer for many schools. What used to involve calling up to two preceptors two years ago now often takes calls to three or four. In addition, placement coordinators at the University of San Diego have run up against a "catch 22" encountered by other schools -- preceptors who do not accept students, even those with clinical experience, unless they are experienced in the specialty area requested. "It is now extremely difficult to place a family nurse practitioner student in a pediatric rotation without some previous pediatric experience," says K. Sue Hoyt, clinical placement coordinator for USD's nurse practitioner program.

With physician assistant programs growing and medical schools moving more instruction to primary care, community sites that nursing schools have used for years are being approached by other disciplines. "These pressures have necessitated my securing 160 new sites for our graduate nursing students in less than two years. I, too, worry that the well may run dry," says Sheila Northern, coordinator of graduate student placement at the University of North Carolina School of Nursing at Chapel Hill. Indeed, in some cases, competition is coming within a school's own institution. "The greatest difficulty is the nurse-midwifery program, where competition is directly with the medical school for clinical placements and faculty practice," notes Sue Hegyvary, dean of the School of Nursing at the University of Washington in Seattle.

As hospitals treat fewer inpatients and discharge them earlier, the number of students that hospitals can accept also has fallen. "It used to be we could have a 1-to-10 faculty/student ratio as a maximum in the hospital. We used a 1-to-8. We are now told that we can only have a 1-to-6 in most places or 1-to-4 in others due to decreased numbers of patients on units. This is not cost-effective or feasible," notes Patty Hawken, dean of the School of Nursing at University of Texas Health Science Center at San Antonio. Further, as more hospitals consolidate or merge, such specialty units as pediatrics, psychiatry, and obstetrics/gynecology are closed or concentrated at one facility only, thus diminishing an already limited supply of training sites. "Clearly, in pediatrics, we've had to move half of the experiences to community settings or outpatient clinics because of the downsizing units," says associate professor Joanna Kaakinen of the University of Portland in Oregon. In addition, she explains, the move by area hospitals to employ unlicensed aides has meant fewer registered nurses per floor, and therefore, fewer students permitted per shift.

The search for alternate training sites has forced some schools to contract with community-based facilities in adjacent states. Such is the case at the University of New Hampshire, while for West Virginia's Marshall University, competition from medical schools and physician assistant programs is causing some nurse practitioner students to travel to training locations up to two-and-a-half hours from their homes.

Indeed, the move into the community poses new concerns as students require supervision and many facilities accept students only in small numbers. Some clinical sites, even when they take students, also require a faculty member to be on-site. "There are still more student placements in the community than we have students to fill. Part of the problem is that they are scattered one student here, another student there, and that puts a strain on our faculty to do adequate instruction and supervision," notes associate professor Ardys Dunn of the University of Portland's School of Nursing. In some instances, deans fear that students assigned to preceptors for community or home experiences won't have the advantage of well-prepared clinical teachers. "Although we actively seek nurses with a [Bachelor's of Science degree in nursing], BSN students are often supervised by nurses without a BSN education," says Mary Jo Regan-Kubinski, chair of the Department of Nursing at Saint Mary's College in Notre Dame, Indiana. Elsewhere, home care agencies that employ small staffs of RNs often can accept only 1 to 2 students at a time, or hinder training with "unrealistic" restrictions, "like observation only," says dean Vickie Lambert of the School of Nursing at the Medical College of Georgia.

The managed care environment also adds its own constraints. "Just this week, two RN students [pursuing] their student experience were barred from a hospital that is the competitor to the hospital in which they are currently employed, because, as the barring hospital explained, of the 'competitive nature between the two institutions,'" reports Franklin University's Louise Gallaway, chair of the Columbus, Ohio, school's BSN completion program for registered nurses who have associate degrees or hospital diplomas. Moreover, mergers and sales of hospitals and other facilities into new corporate entities have slowed clinical placements of students through administrative delays. "We have numerous experiences of being in the process of negotiating contracts with agencies only to see [those agencies] sold before the contract is complete," says dean Lenora McClean of the School of Nursing at the State University of New York at Stony Brook. In addition, as new health care agencies spring up, they need time to write policies to manage students and staff. What's more, small agencies often are unsure of their roles with students, explains Carol Sharkey, associate professor at Regis University Department of Nursing in Denver. "Agency-to-agency contract negotiations can take months, particularly when the parent company is in another state," she says.

Still, for many schools, the steepest competition for clinical placements is not from outside, but from inside nursing itself. An acknowledged oversupply of associate-degree nursing programs at community colleges not only is seeking traditional training sites at hospitals, but increasingly is moving students into community and public health agencies, settings that typically have not been used by the two-year programs that have focused predominantly on preparing graduates for hospital practice. With many community colleges county-based, local health departments feel the need to support them, say deans of university and four-year programs. "Even if [associate-degree] students are limited to observation, they knock out learning opportunities for the baccalaureate student," explains nursing program director Janice Unruh Davidson of Bethel College of Kansas. Says one dean of a baccalaureate program, "It seems incredulous in a time of limited clinical opportunities to have these slots go to students who have not had the theoretical basis upon which to apply community health concepts," especially when community health is a hallmark of baccalaureate nursing instruction, she adds. While educators are quick to note the needed roles of associate-degree nurses (ADNs) in a health system that must use RNs based on their differing education and skills, they point, as well, to federal data showing the already overabundant supply of ADNs and projected shortages of registered nurses who are prepared at the bachelor's- and graduate-degree levels.

To cope at least in the short-term, some nursing schools, such as at the University of Arkansas for Medical Sciences, have moved students to 12-hour clinical shifts in programs such as obstetric/gynecological nursing to meet the limitations set by clinical sites. Elsewhere, "[agencies] have told us to plan for evening experiences as much as possible, because the day time is becoming too hectic to accommodate students," explains Joan Jenks, academic programs coordinator at the Department of Nursing at Thomas Jefferson University in Philadelphia. At the University of South Carolina, the College of Nursing recently opened a college-owned-and-operated women's health care center to accommodate the educational needs of nurse practitioner students. Meanwhile, in Wisconsin, Marquette University's College of Nursing is using faculty practice contracts to help agencies establish new primary care sites with opportunities for student training built in.

In several cases, clinical placements are regulated through voluntary collaboration among competing schools. In Bloomington, Illinois, bachelor's-degree nursing programs at Illinois Wesleyan University and Mennonite College of Nursing have "historically cooperated so that clinical education transpired in the two local hospitals on different days of the week," says Jerry Durham, dean of academic affairs at Mennonite. Other area-wide committees or consortia are coordinating placements for baccalaureate and associate-degree students for several local markets in Arkansas, Utah, and Texas by identifying available agencies and arranging their use by nursing students based on day and time.

However, of all the roadblocks cited by deans, one of the largest remains financial. "In some situations, the practitioners have refused to take students, even after many years of being preceptors because of reimbursement issues. This is particularly true in social work and in nursing where care provided by unlicensed students cannot be reimbursed," explains Mecca Cranley, dean of the School of Nursing at the State University of New York at Buffalo. Other deans, too, note the difficulty negotiating with preceptors based on extra work that is not compensated. "We cannot pay so we do not compare favorably with schools that pay or provide tuition vouchers," says Patricia Geary, dean of the School of Nursing at the University of Southern Maine.

Indeed, as competition mounts from schools or other professions who pay preceptors, and as managed care companies push for higher productivity, "cash consideration may be the only way to retain some preceptors. Some preceptors have heard of others being compensated and now expect to receive a payment for their services," the Lewin-VHI study notes. Just as training sites must become more available, it is also the case, nursing programs say, that "no expansion opportunity could be considered unless the continuing availability of preceptors [is] assured," the study points out.

To give preceptors and clinical facilities incentives to take on additional students, AACN and other nursing and health care groups are urging Congress to direct that Medicare funds that now support the handful of remaining entry-level diploma nursing schools at hospitals be channeled instead to training for nurse practitioners and other advanced practice nurses. In addition, AACN has urged that Medicare dollars for nursing education -- some $244 million in FY96 but restricted to hospitals and other inpatient facilities -- also be used for clinical training of APNs at primary care centers, HMOs, nursing-school-operated nursing centers, and other settings that deliver outpatient care to Medicare patients. The redirection would require no new money, be phased in over three years, and, say AACN and other backers, result in faster production of advanced RNs for an increasingly outpatient health system where more needs of Medicare patients will lie. The move not only would help reimburse preceptors and practice sites for student training, but also allow for hiring of additional faculty, thus helping to boost the number of APNs produced and ease the growing waiting lists at graduate nursing programs.

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