Nursing on the critical list. (Cover Story).

CLEVELAND --When Sandy Sifford signed up to study nursing at Cuyahoga Community College, she was full of idealism and eager to help heal the world, one patient at a time. But just weeks before she was to graduate, Sifford dropped out of the program -- dispirited by the horror stories of career nurses and dismayed at how bleak her future as a registered nurse seemed.

Unfortunately for anyone who will need medical care, experiences like Sifford's are in line with a disturbing trend: Just as the aging demographic colossus known as the Baby Boom begins to need more and more medical care, fewer and fewer people are choosing nursing as a career. Just as devastating for community colleges, whose nursing programs have traditionally filled the majority of nursing positions, many associate's degree programs in nursing are seeing a downturn in the rate of enrollment.

Still, higher education officials Say community colleges may rep resent the last, best hope to head off the national health-care crisis that could result from the projected nursing deficit.

Coming Up Short

Dr. Denise Geolot, director of nursing at the Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services, said the current rate of growth for the nursing profession is the slowest on record since nursing data were first collected in the late 1970s.

As of March 2000, there were 2.7 million registered nurses in the United States, according to HRSA. That number reflects an increase of just 5.4 percent since 1996 -- down more than half from the 14.2 percent increase between 1992-1996.

A number of causes have contributed to this slowed growth, including an aging population of nurses and declining enrollments in nursing education programs.

The average age of a registered nurse is 45.2 years, up from 44.5 years in 1996, according to HRSA,. and 51 percent of nurses are older than 45. According to Nursing Economics, a health care journal, the number of registered nurses under the age of 30 fell 41 percent between 1983 and 1998, compared with a 1 percent decrease in that age category among the rest of the workforce.

At the same time these nurses are beginning to reach retirement age, there have also been declining enrollments in nursing education programs, creating a serious labor gap.

A 1999 report by the Nursing Executive Center found that, between 1993 and 1996, the rate of enrollment increase declined by 11 percent at two-year nursing degree programs, 42 percent in three-year nursing diploma programs, and 19 percent in four-year nursing bachelor's degree programs. If these enrollment trends continue, the total number of registered nurses is projected to be 20 percent below the number required by 2020, according to the Journal of the American Medical Association.

Why the Shortage?

But a pervasive perception among current and potential nurses that the profession isn't worth the headaches may be a more pernicious factor. Of all nursing staff working in hospitals, 32 percent were not satisfied with their jobs, according to HRSA. The nurses surveyed cited a variety of reasons for their dissatisfaction, including bad pay, inadequate staffing, heavy workloads and an increased use of overtime.

Sifford, the student who dropped out of Cuyahoga Community College, said the factor that most dissuaded her from a career in nursing was the steady stream of warnings she got from registered nurses during her clinical training at several Cleveland-area hospitals.

"The RNs were overworked," she said. "They went to work sick. There weren't enough nurses, so they couldn't take time off ... pulling all these shifts and giving patients with weak immune systems more illnesses," Sifford said. "I have met nobody who said they would do it [select nursing as a profession] again."

James McKenney, director of economic development for the American Association of Community Colleges, said job dissatisfaction among nurses is feeding a larger fire.

"[There is a] snowball effect. I have friends who are nurses who go to work sick and sometimes they can't go home because there is no one to back them up," McKenney said. "The word about these working conditions spirals out to the public -- horror stories -- and they don't go into nursing."

HRSA's Geolot said the horror stories aren't the only stories, though.

"Nursing is a very rewarding career, and unfortunately we only hear from those who are not satisfied," she said.

But Myrna Eshelman, director of nursing at Mesa Community College in Mesa, Ariz., agreed with McKenney, saying that dissatisfied nurses often contribute to the shortage when they leave the field due to burnout.

A survey conducted by the American Nurses Association found that 55 percent of registered nurses and licensed practical nurses would not recommend the nursing profession as a career for their children or friends, and 23 percent would actively discourage someone close to them from becoming a nurse.

At the same time job satisfaction among nurses is faltering, alternative career options have expanded in recent years for women who account for a majority of all nurses. The result is an increased likelihood that they will choose different professions.

Women graduating from high school in the 1990s were 35 percent less likely to become registered nurses than women graduating high school in the 1970s, according to a report in the journal Nursing Economics.

McKenney said nursing has had a difficult time competing with fields that offer better salaries with less stress and fewer demands. Even other fields within the medical profession are drawing women away from nursing, he said.

"Many more women are now going to medical school," McKenney said. "No one would dare say we would want to turn the clock back on that opportunity, but what it does mean is that some of the areas that [previously] got the best and brightest women ... suffer."

Community Colleges to the Rescue

As the nursing shortage persists, higher education officials agree that one of the first steps to address the problem would be the education of a new workforce of nurses. Although the shortage is national, repercussions vary for individual communities in the United States, McKenney said. That local variability suggests that community' colleges, which have a long track record of adaptation and flexibility, could play a vital role in addressing their respective regional shortages.

According to HRSA, 40 percent of all registered nurses receive their degrees at community colleges, while 30 percent receive three-year diplomas and 30 percent earn bachelor's degrees.

Dr. Frances Aronovitz, director of the school of nursing at Miami-Dade Community College in Miami, Fla., said community colleges must offer flexible programs receptive to student needs, especially because community college students tend to have a variety of other demands, including jobs and families.

To appeal to as many students as possible, Aronovitz said Miami-Dade, which graduates about 350 nursing students each year, offers a variety of ways to obtain degrees. One program allows students with bachelor's degrees in other fields to spend one year in an accelerated program, after which they may take the nurse-licensing exam.

Another program is geared toward individuals with other medical degrees and training, such as paramedics or licensed practical nurses. Their previous credits and training are counted toward a two-year degree in registered nursing, saving time and money.

Aronovitz said joint programs between community colleges and health care organizations are also useful in addressing the shortage. Such programs can provide funds for expensive nursing equipment and laboratories and demonstrate the benefits and real-world applicability of a nursing career, she said.

Baptist Health Systems recently launched a scholarship program, giving $150,000 to Miami-Dade to cover tuition, fees and books for 60 nursing students each year. The program also provides classroom space and hands-on training at Baptist hospitals. Upon graduating from the program, students are required to commit to one year of full-time wok at a hospital within the Baptist Health Systems.

Susan Sanders, director of nursing at Motlow State Community College in Tullahoma, Tenn., said two local health care providers have initiated several programs at Motlow similar to the Baptist project at Miami-Dade. Motlow is also looking to start a registered-nurse program aimed at licensed practical nurses, awarding them prior credit and shortening the time required to obtain an RN degree.

Despite such initiatives, Sanders said that during the last several years she has seen an enrollment decrease of 25 percent. Sanders said recruiting qualified nursing faculty, who must have a master's degree, has also proven difficult. That's a problem, given that all of Motlow's nursing faculty will retire within the next 10 to 15 years.

In addition to gaining the support of health-care organizations, Eshelman said community colleges must gain the interest of potential nursing students -- and that often means starting with high school students.

Mesa has begun a program with nearby Tempe High School, allowing students to take dual-enrollment courses in health and science. The credits are applied to both a high school diploma and a certificate in certified nursing. Eshelman said the program seeks to help young students make informed decisions about the nursing profession, hopefully providing a positive perspective.

Mesa is also working with Banner Health Care to offer a certificate in licensed practical nursing for students at a technical high school.

Eshelman said colleges must also work to recruit men.

"Unfortunately, nursing is still viewed as a female profession, and we have many more women than men," she said.

This fall, Santa Barbara City College in Santa Barbara, Calif., teamed up with Cottage Hospital to introduce a three-year health careers academy at nearby San Marcos High School.

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Students in the academy begin with introductory courses during their sophomore year of high school, taking more specific classes during their junior and senior years. At the end of the program they take a state board exam and, if they pass the exam, they receive certificates qualifying them as certified nursing assistants. Cottage Hospital will hire any graduate of the academy, and Santa Barbara encourages the students to pursue higher degrees in nursing education.

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Kay Bruce, a spokeswoman for Santa Barbara City College, said the goal of the academy is to reveal the benefits of a career in nursing and the abundance of jobs in light of the shortage.

So far the academy has 85 students enrolled, and SBCC expects enrollment to increase next year. Bruce said the program has so far proven popular, with a number of health professionals in the community -- including registered nurses -- volunteering as guest speakers.

A Group Effort

While community college officials agree that two-year schools are critical to filling the nursing gap, they also point to health care organizations and lawmakers as part of the solution.

Aronovitz said reforms must be made to the way health care organizations operate.

"Some of the changes have to take places within hospitals ... and the way nurses are allowed to practice. They must be given recognition for their education and knowledge," she said. "It means nurses need to be recognized as decision makers. In more successful hospitals, nurses ... have a say in regard to what happens with policies and procedures."

Aronovitz also said health care organizations must improve working conditions and salaries for nurses.

In May 2001, several members of Congress introduced legislation that would provide federal funding to help eliminate the nursing shortage.

Known as the Nurse Reinvestment Act, the legislation is being sponsored by Sens. Tom Daschle, D-S.D., and John Kerry, D-Mass., and Reps. Lois Capps, D-Calif., and Sue Kelly, R-N.Y. The bill would establish a National Nurse Service Corps to provide scholarships to nurses who commit to working in a health-care facility with a shortage of nurses. It would also offer grant money to individuals pursuing any form of nursing education, from certified nursing assistants to those studying at the doctoral level.

One of the provisions in the legislation introduced by Capps, who was a registered nurse for 30 years before running for office, establishes more health career academies similar to the one at Santa Barbara City College.

A spokeswoman for Capps said the Sept. 11 terrorist attacks have heightened Congress' awareness of the need to address the nursing shortage, and that Capps hopes that Congress will vote on the bill before adjourning in December.