Nursing Students Assess Nursing Education

Nursing Students Assess Nursing Education

Nursing Students Assess Nursing Education LINDA NORMAN, DSN, RN,* PETER I. BUERHAUS, PHD, RN, FAAN,y KAREN DONELAN, SCD,z BARBARA MC CLOSKEY, DNSC, RN...

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Nursing Students Assess Nursing Education LINDA NORMAN, DSN, RN,* PETER I. BUERHAUS, PHD, RN, FAAN,y KAREN DONELAN, SCD,z BARBARA MC CLOSKEY, DNSC, RN,§ AND ROBERT DITTUS, MD, MPHO

This study assessed the characteristics of nursing students currently enrolled in nursing education programs, how students finance their nursing education, their plans for clinical practice and graduate education, and the rewards and difficulties of being a nursing student. Data are from a survey administered to a national sample of 496 nursing students. The students relied on financial aid and personal savings and earnings to finance their education. Parents, institutional scholarships, and government loans are also important sources, but less than 15% of the students took out bank loans. Nearly one quarter of the students, particularly younger and minority students, plan to enroll in graduate school immediately after graduation and most want to become advanced nursing practitioners. Most of the nursing students (88%) are satisfied with their nursing education and nearly all (95%) provided written answers to two open-ended questions. Comments collapsed into three major categories reflecting the rewards (helping others, status, and job security) and three categories reflecting the difficulties (problems with balancing demands, quality of nursing education, and the admissions process) of being a nursing student. Implications for public policymaking center on expanding the capacity of

*Senior Associate Dean for Academics, Vanderbilt University School of Nursing, Nashville, TN. yValere Potter Professor of Nursing, Senior Associate Dean for Research, Vanderbilt University School of Nursing, Nashville, TN. zSenior Scientist in Health Policy, Massachusetts General Hospital, Boston, MA. §Research Associate, Postdoctoral Fellow, Vanderbilt University School of Nursing, Nashville, TN. OJoe & Morris Werthan Professor of Investigative Medicine, Director of the Division of General Internal Medicine, Director of the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN. Address correspondence and reprint requests to Dr. Norman: Senior Associate Dean for Academics, Vanderbilt University School of Nursing, 101 Godchaux Hall, 21st Avenue South, Nashville, TN 37240. E-mail: [email protected] 8755-7223/$ - see front matter n 2005 Published by Elsevier Inc. doi:10.1016/j.profnurs.2005.04.003 150

nursing education programs, whereas schools themselves should focus on addressing the financial needs of students, helping them strike a balance among their school, work, and personal/family responsibilities and modifying certain aspects of the curriculum. (Index words: Nursing students; Nursing education; Satisfaction and rewards) J Prof Nurs 21: 150 –158, 2005. A 2005 Published by Elsevier Inc.

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VER THE PAST several years, state governments, hospitals, private organizations, professional associations, and nursing education programs have initiated actions to address the shortage of nurses and increase the number of people becoming nurses. These efforts seem to be having a positive effect as enrollments in nursing programs are increasing after steadily dropping each year between 1995 and 2000. Enrollments in baccalaureate programs increased by 8.8% in 2003 and doubled (16.6%) in the following year. In 2003, enrollment in associate degrees, diploma programs, and baccalaureate degree programs increased by 9.0%, 14.2%, and 16.6% respectively (American Association of Colleges of Nursing [AACN], 2003a; National League for Nursing, personal communication, 2004). These gains in enrollment could have been even greater, but capacity constraints involving faculty shortages, lack of classroom space, and inability to secure clinical placement sites prevented many education programs from admitting all qualified students seeking admission in recent years. For example, baccalaureate nursing education programs turned away more than 5,000 qualified applicants in 2002 and were unable to admit more than 15,000 qualified students in 2003 (AACN, 2003a). Despite this capacity problem, the upswing in enrollments could not have come at a more needed time. The current shortage of nurses has entered its seventh year, lasting three times longer than each of the six shortages that have occurred since the 1960s. Moreover, a shortage of between 400,000 and

Journal of Professional Nursing, Vol 21, No 3 (May – June), 2005: pp 150 –158

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800,000 registered nurses (RNs) is expected to develop during the next decade because most of the current RNs, who were born during the baby boom generation, begin retiring at the same time 80 million Americans start turning 65 years old and consuming more health care, hence driving up the demand for nurses (Buerhaus, Staiger, & Auerbach, 2000; U.S. Department of Health and Human Services, 2002). To address the current shortage and avert the development of a much larger one in the future, efforts to increase the number of people becoming nurses must be strengthened and continued for years to come. While these efforts are ongoing, it is also important to retain current nursing students and those entering nursing education programs. Because RNs will become an increasingly scarce resource, educators need to maximize graduation rates to positively affect the number of nurses entering the workforce and employers need to ensure that they are retaining graduates in the workforce. This article reports the results of a study designed to describe the characteristics of nursing students currently enrolled in nursing education programs, ascertain plans for clinical practice and graduate education, describe the ways students finance their nursing education, and identify the rewards and difficulties of nursing education. Data for the study come from a national survey of nursing students conducted as part of a larger project evaluating the effectiveness of the Johnson & Johnson Campaign for Nursing’s Future. A related study (Buerhaus, Donelan, Norman, & Dittus, 2005) based on these data examined nursing students’ perceptions about a career in nursing, awareness of the current shortage of nurses and its causes, how the shortage is expected to affect nurses in the future, and awareness and impact of the Johnson & Johnson campaign on the decision of newly enrolled students to select a career in nursing.

dents’ names were randomly drawn from the American Student Lists of College Nursing Students. The students received an initial mailing with a cover letter, survey instrument, us $2.00 cash incentive, and a postage-paid return envelope. Multiple additional contacts were made with nonresponders including follow-up reminder postcards, additional full mailings, and telephone interviews. The data were weighted using nursing students available from the American Association of College of Nursing to ensure balance by geography and program year. CONTENT ANALYSIS

Guided by the qualitative method of content analysis of Krippendorff (1980), 465 responses to the two open-ended questions about the rewards and difficulties of being a nursing student were broken down into phrases and coded into themes. Each response was reviewed line by line to ensure capture of all relevant data. Six themes reflecting the rewards and five themes reflecting the difficulties of nursing education emerged. Themes were collapsed into the three most rewarding and difficult categories. An intrarater reliability of .91 was established by one researcher recoding 10% of the responses 1 week after the initial coding. Another member of the research team then coded a different 10% sample, attaining an interrater reliability of .91. LIMITATIONS

The American Student Lists of College Nursing Students are compiled using data supplied by colleges, universities, and nursing schools across the country. The list may exclude students whose schools refused participating in assembling the lists. The list is the best one available to researchers but may have gaps in coverage of the nursing student population. Results

Methods DATA

The data are from a national survey of nursing students conducted by Harris Interactive from April 11 through June 23, 2003. The mailed self-administered survey was completed by 496 nursing students. The target population was American students who had either enrolled in a basic entry RN program or who declared nursing as their intended major. The stu-

Results are presented in two sections. The first section describes the characteristics of nursing students currently enrolled in nursing education programs, their plans for work and education after graduation, how they finance their nursing education, and who and what influenced their decision to pursue nursing education. The second section describes the results of the content analysis of the students’ written responses describing the rewards and difficulties associated with being a nursing student.

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CHARACTERISTICS, FINANCES, PLANS AFTER GRADUATION, AND SATISFACTION WITH NURSING EDUCATION

Sample Characteristics

Most of the nursing students responding to the survey are white, single, and women (Table 1). Their average age is 26 years, with most (76%) aged between 18 and 30 years. Less than one fifth (15%) of the students are older than 36 years. Students enrolled in associate degree programs are, on the average, 6 years older (30 years old) than those enrolled in baccalaureate degree programs (24 years old). Roughly one third have children younger than 18 years living in the household and one quarter (27%) are married or living with a partner. Most are

enrolled in a nursing education program and two thirds (64%) are taking clinical courses. Few are attending school but have not yet been accepted into a nursing education program. The sample contains a fairly balanced distribution of freshmen, sophomores, and juniors but includes few seniors. Although not shown in Table 1, few students aged 25 years and younger are married (12%) and only a small percentage have children (10%), where most of those older than 25 years are married (55%) and three fourths have children. A greater proportion of minority students (42%) versus nonminority students (32%) have children, are slightly older, and are enrolled in an associate degree program (31% vs. 25% for nonminority students). Financing Education

TABLE 1. Characteristics of Nursing Students (2003) Characteristics

Sex Female Male Age (years) 18–22 23–30 31–35 N36 Mean overall Mean associate degree Mean baccalaureate degree Race/Ethnicity White, non-Hispanic Black/African American Hispanic Asian or Pacific Islander Other Marital status Single Married/living with partner Widowed/Divorced/Separated/Other Children younger than 18 years living in household Yes No Student status Currently studying to become an RN Enrolled in a nursing program Attending school but not yet accepted into a nursing program Taking clinical courses Yes No Freshman or first year in program Sophomore or second year in program Junior or third year in program Senior or fourth year in program Newly enrolled in nursing education program after the campaign Already enrolled in nursing education program before the campaign

n (%)

459 (93) 36 (7) 219 156 47 73 26 30 24

(44) (32) (10) (15)

353 57 32 19 28

(73) (12) (8) (4) (6)

307 (62) 155 (32) 34 (7) 166 (34) 328 (66) 492 390 (79) 92 (19)

319 177 132 141 117 101 132

(64) (36) (27) (29) (24) (20) (27)

359 (73)

Students were asked to indicate the primary source of their nursing education’s funding (Figure 1). Financial aid was the major source of funding identified by the larger percentage of the total group (32%), followed by parental support (18%), personal savings (16%), and government loans (15%). Only a handful of the respondents (8%) reported that institutional scholarships and bank loans(5%) paid for most of their education. There were significant differences (P b .05) in the source of major funding for education between age and minority groups. Far more younger students than older ones reported that the source of funding for the biggest share of their educational costs came from their parents (27% vs. 3%). Also, more younger students received institutional scholarships as their major source of funding compared with older students (11% vs. 2%), but older students were more likely to use personal savings as the major source of educational funding compared with younger students (29% vs. 9%). In general, loans from the government and banks were used equally by younger and older students. More minority students (47%) used financial aid as the major source of funding than did nonminority students (27%) and used government loans (8%) less than did their nonminority counterparts (17%). Fewer minority students (7%) than nonminority ones (22%) reported that their parents paid for most of the costs of their education. Plans After Graduation

Most of the students (61%) plan to work in patient care in a hospital after graduation, and only 1 in every 10 (9%) is interested to work in non-hospital patient

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50 45

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40 35 30 25

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15 Minority

10 5

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Figure 1. Major sources of funding for nursing education (2003).

care settings. Slightly more of the younger students (62%) plan on working in patient care in a hospital compared with their older counterparts (58%), but more of the older students (16% vs. 5%) expect to work in non-hospital patient care settings. Overall, approximately one quarter of the students expect to enroll in graduate school immediately after graduation (Figure 2). Of these students, there was a significant difference (P b .05) between younger (29%) and older students (20%) and between minority (33%) and nonminority students (24%) concerning their plans for continuing their education. Of those who plan to pursue graduate school, half (52%)

are interested in becoming nurse practitioners and one quarter (23%) as nurse anesthetists. Few students indicated an interest in graduate preparation in research or administration and only 5% plan to pursue doctoral education. Satisfaction with Nursing Education

Most of the students (86%) were satisfied with their nursing education (38% were very satisfied and 48% were somewhat satisfied); only 14% were dissatisfied (11% were somewhat dissatisfied and 3% were very dissatisfied) with theirs. There were minimal differences in the level of satisfaction based on age, type of

70

% in age group

60 50 25 & under 40

> 25 Minority

30

Non-Minority 20 10 0

Patient Care: Hospital

Patient Care: Non- Graduate School: hospital Nursing

Figure 2. Nursing students’ plans after graduation from a basic nursing education program (2003).

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nursing education program, and minority status. More students who were enrolled in clinical courses (41%) reported being very satisfied with their nursing education compared with those who were not yet enrolled in clinical courses (34%). Fewer students enrolled in baccalaureate (38%) and associate degree (39%) programs; minority (33%) students were very satisfied with their nursing education compared with diploma (44%) and nonminority (40%) students. However, the total level of satisfaction was the same for each of these groups (86%). Older students (17%) were more dissatisfied with their nursing education than were younger students (12%). REWARDS AND DIFFICULTIES OF BEING A NURSING STUDENT

The questionnaire included two open-ended questions: (1) bWhat is the most rewarding part about being a nursing student?Q and (2) bWhat is the hardest part about being a nursing student?Q Nearly all the students (95%) provided written answers. Content analysis of their comments collapsed themes into three major categories reflecting the rewards (helping others, status, and job security) and three categories reflecting the difficulties (maintaining balance, program quality, and frustrations over admissions) of being a nursing student. REWARDS

Helping Others

Nearly half of those who provided written responses said that the most rewarding part of being a nursing student was being able to bhelp peopleQ and bmake a difference.Q They described the rewards of nursing as the ability to btouch lives,Q bimpact someone else’s life,Q and bchange lives for the better.Q Learning to bsave livesQ was the most frequently mentioned reward, and students anticipated being called on to provide life-saving measures regularly throughout their career.

entry into a nursing education program and succeeding in it elevated their status on campus. Students wrote about family, friends, and acquaintances commending them for taking on a bdifficult programQ and bentering a challenging occupation that many people cannot handle.Q Others commented on the bspecialQ nursing knowledge that allows them to blisten to symptoms and determine what is going on in a person’s bodyQ and btaking control of uncontrollable situations.Q Students expressed awe with how the application of nursing knowledge and skills directly impacts patients’ health and well-being and delight in seeing bchanges in people’s condition resulting from my interventionsQ and bpeople getting well and knowing I had a hand in it.Q Nearly one quarter of the students described their zest for learning and applying the bspecial knowledgeQ of nursing. The enthusiasm for learning expressed by the students related to an intense desire to master nursing roles and the accolades and expressions of respect from others that these accomplishments engendered. Job Security

Forty-five students wrote about the job security of a nursing career. Expressing their belief that the demand for nurses was strong, students believe that ba job is waiting,Q that they are bguaranteed a job,Q and that they will bfind work anywhere in the U.S. or anywhere in the world.Q Students rarely mentioned salaries or how much they expected to earn once they graduated and began working. Students who had worked in other fields looked forward to a nursing career and anticipated bcoming home after a day at work and feeling like I’ve accomplished somethingQ and bfeeling good after working all day.Q Some thought that nursing would provide ba nice livingQ and one student captured the views of others by noting that she did not anticipate bgetting richQ from nursing but looked forward to ba steady jobQ and bbeing able to provide for my family.Q

Status

DIFFICULTIES

Although few of the students expressed the pursuit of a nursing education and becoming a nurse as a blife-long dream,Q many wrote about their sense of pride as a nursing student and eventually becoming a practicing nurse. Students received newfound respect from family members, acquaintances, and peers after choosing nursing as a career. Many indicated that nursing is considered as one of the more challenging academic majors at their institution; thus, gaining

Students also experience difficulties in the course of their nursing education, and the three major categories that emerged in this study involved maintaining balance, program quality, and frustrations over the admissions process. Balance

Nearly two thirds of the students wrote about the difficulty of maintaining a bbalanceQ between a

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brigorousQ and bdemandingQ nursing program and other aspects of their lives. Many reported being overwhelmed from bjugglingQ school, work, and a home life that involved caring for children, a situation expressed by many older students who reported bexhaustionQ from trying to manage school, work, and family responsibilities. On the other hand, younger students described how the rigor of their nursing education did not allow them to participate in campus activities enjoyed by non-nursing students. Students not yet accepted into a nursing program described the pressure and amount of studying required to compete for the limited spaces available in a nursing program. Those accepted into a nursing program were far more likely to describe academic rigor as binformation overloadQ stemming from a bfastpacedQ program that bcovered too much information in a short period of time.Q These students commented that it was frequently impossible to cover adequately all the assigned reading and grasp the benormousQ amount of information presented in lectures. They wrote about frequent periods of sleep deprivation caused by many late nights of studying followed by early morning classes and clinicals along with inflexible classroom and clinical schedules that conflicted with work, family, and personal responsibilities. Quality of Nursing Education

Approximately one fifth of the students were concerned about the quality of their nursing education. They particularly questioned the content of their program and the dedication of professors. They also expressed concern that information overload overwhelmed their ability to sift through materials and identify key concepts. Students also questioned the amount and depth of clinical practice time that they obtained and perceived a disconnection between the nursing role that they are taught and the role that they observe in clinical sites. Some felt that their program contained too much bbusy workQ and others felt that they were functioning in clinicals as bnursing assistants rather than nurses,Q which led to the conclusion that they were not developing breal nursing experience.Q Some students described nursing professors as bunconcerned about students’ progressQ and binsensitive to their needs.Q Others felt that instructor oversight in clinical settings was inadequate and that, consequently, they were bon their ownQ during clinical time. Several students questioned whether their professors had recent clinical experience and were concerned that some professors were bout of

date with current hospital realities.Q More than a few students commented that job-related rewards and bonuses for nursing professors appeared to be tied to research activities rather than teaching responsibilities, leading to the belief that students and teaching were secondary. Admissions Process

Thirty-five students commented on the difficulty in gaining admission into a nursing school. Students wrote about qualified students being turned away or discouraged from applying because of bsteep competitionQ for a limited number of spaces. Faculty shortage was the most frequently cited reason for limitations in admissions. One pre-nursing student commented on her frustration with an admissions process that accepts a limited number of students only to have a large number of these students drop out soon afterward, leaving unfilled spaces in the program. Discussion

This study sought to describe the characteristics of nursing students currently enrolled in nursing education programs, ascertain plans for clinical practice and graduate education, describe the ways students finance their nursing education, and identify the rewards and difficulties of nursing education. Findings suggest that, in many ways, nursing students today are not unlike those who have been entering nursing over the past several decades. Most are women and white, and although the average age of students has increased over time, the profession continues to attract both younger and older people. Most younger students were enrolled in 4-year baccalaureate nursing education programs, which suggests that they may see nursing more as a professional career with improved opportunities for continuing their education and obtaining employment in positions that require a minimum of a baccalaureate degree. In contrast, most older students, particularly those older than 30 years, were enrolled in 2-year associate degree programs, and a much higher proportion of older nursing students were married and had children living at home compared with younger students. This finding more than likely reflects the attractiveness of nursing as a second or even a new career for women in their 30s. We found that students of all ages are juggling responsibilities involving their personal and family lives, work, and meeting the academic and clinical

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demands of their education program. Older students particularly had trouble balancing school, work, and family obligations, whereas younger ones experienced similar struggles in addition to frequently forfeiting the social life of a college student. These findings suggest that all nursing students could benefit from initiatives geared specifically toward helping them with time management strategies, prioritize various demands on their time, deal with distractions effectively, and set realistic expectations of themselves and others. Most nursing education programs have an office of student services or at least one is available on campus. Specific strategies need to be developed to help nursing students achieve and maintain an effective balance. The needs of nursing students may be similar to those of other college-level students; however, the clinical and curriculum demands of the former are more intense and need to be addressed by an office of student services. Being a nursing student is complicated and challenging, and not providing students with assistance in finding a reasonable balance in their lives can only increase dissatisfaction and resentment, worsen academic performance, and result in a decision to withdraw from a nursing program altogether. Given the current and projected shortage of nurses in the United States and throughout the world, decreasing attrition in nursing majors, those who are in pre-nursing courses, and those in the clinical portion must be a priority for nursing programs. On the average, tuition and fees total us $3,000 for an associate degree (if completed in four semesters) and us $14,000 for a baccalaureate degree education in a public institution (us $65,000 in a private institution) (U.S. Department of Education, 2002). This study shows that nursing students are struggling to meet these financial requirements. More than half of the students reported that financial aid and personal earnings and savings (particularly for older students) were the primary sources of funding, and many had to work while going to school to pay their education costs. Only 15% used loans to finance their education, which suggests that students may not know or understand the benefits of federal loan programs that have recently become available. Most federal loans for nursing education forgive a certain portion of the loan balance each year in exchange for work in underserved areas after the completion of a student’s basic education program. Universities often centralize financial aid counseling for students, regardless of academic major, and these offices typically emphasize financial aid from universities to finance the education of nursing students. Thus,

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educating financial aid officers to understand the array of nursing education funding options may help students become more aware of federal loan programs and make more informed choices in funding their nursing education. Beyond helping students finance their nursing education in the most economical manner, schools (or the parent institution) could offer programs or provide individual counseling for students on managing personal finances and family budgets. Such services could help students better balance the demands of school and their personal life. The financial struggles articulated by nursing students also provide an opportunity for policymakers to consider making more funds available for nursing scholarships. The recovering national economy means that many state budgets are improving and that legislatures are in a better position to consider addressing the financial needs of nursing students. Similarly, many corporations and private civic organizations have provided scholarships and grants to individuals. For example, the Johnson & Johnson Campaign for Nursing’s Future organized regional celebrations and has raised several millions of dollars for student scholarships, faculty fellowships, and grants to nursing schools to expand their capacity. Programs such as these need to be replicated by other corporations and civic groups throughout the country. Beyond financing matters, students are concerned about information overload, too much busy work, and a disconnection between course work and the real world of clinical practice, findings in agreement with those of a study done by Yoder and Salyor (2002). A large amount of assigned reading interferes with learning, and students are frustrated with a curriculum and evaluation methodology that placed a heavier emphasis on didactic content than on learning through time in clinicals. Although calls for adoption of new teaching approaches in nursing education are not new (Wadle & Munns, 1983; Mohr & Naylor, 1999), most basic nursing programs are organized as lecture and reading courses where faculty assign background reading and give lectures on key concepts. Synthesizing, applying, and translating information into useful clinical knowledge typically occur during the time students spend in clinical assignments. Moreover, Adams, Murdock, Valiga, McGinnis, and Wolfertz (2004) found that nursing programs continually add content and nursing experiences (e.g., informatics, health-care cost/finance, evidenced-based practice) and rarely delete content from the curriculum, resulting in congested programs that overwhelm

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students. These findings are consistent with the views of many nursing students in our study and suggest that nursing education programs should evaluate their course offerings with an eye toward eliminating or reducing parts of the curriculum. Minimal attention has been paid to strategies that help new nursing students learn how to study nursing content and how to synthesize information from readings and lectures into useful clinical knowledge. Policymakers could help greatly by funding conferences aimed at redesigning nursing curricula, disseminating conference results and best practices, and helping faculty learn about new teaching methods and strategies including greater use of the internet and decision support technology to provide nursing education. Despite the difficulties of being a nursing student, most of the students were satisfied with their nursing education. Students derived a certain status associated with being a nursing student from non-nursing students who view nursing as intellectually challenging and from friends and parents who indicated a newfound respect for them. They also valued nursing knowledge that would enable them to help patients, save lives, and bring about positives changes in patients. Students also believe that nursing offers great job security. That students are satisfied with their education and at the same time experience many difficulties is not unlike what most practicing nurses report that they are satisfied with being a nurse but find many characteristics of their workplace climate (particularly in hospitals) dissatisfying (Aiken, Clarke, & Sloane, 2000; Aiken, Sochalski, & Anderson, 1996; Buerhaus, Donelan, DesRoches, Lampkin, & Mallory, 2001; NurseWeek, 2002; Norrish & Rundall, 2001). Just as hospitals are being urged to become magnet hospitals and improve their workplace environment (American Hospital Association, 2002; Buerhaus, Needleman, Mattke, & Stewart, 2002; Havens & Aiken, 1999; Institute of Medicine, 2004), nursing education programs need to improve the learning environment of the students they teach. With regard to the nurse labor market, there is good news for hospitals as findings indicate that immediately after graduation, most students (61%) anticipate working as staff nurses in in-patient settings. Older students are, however, more likely than younger students to desire non-hospital staff positions. Thus, hospitals, the sector of the nurse labor market experiencing shortages of nurses most acutely, should consider ways to attract older nursing graduates, perhaps by offering preferences of shifts, reducing

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the number of hours per shift, and making ergonomic improvements designed to prevent these older nurses from experiencing musculoskeletal injuries. Because older RNs are less likely to accept unreasonable restrictions on their autonomy or control over nursing practice or to tolerate a workplace in which they experience lack of respect from physicians, administrators, and others (including other nurses), hospitals also should examine their organizational culture and take steps to minimize such practices and behaviors. Although the number of students entering nursing education programs is increasing, it is important to consider that only 70% are interested in direct patient care and must be factored into the spaces available in nursing programs. Findings also suggest a positive impact for nursing education programs that face current and future faculty shortages. Nearly 30% of students and proportionately more minority than nonminority students plan to enter graduate school immediately after graduation (most intend to become advanced nursing practitioners). In the past, new graduates of basic nursing education programs were expected to work for a few years before pursuing graduate education. However, the relatively large proportion of students planning to pursue graduate education right away may expand the pool of nurses with graduate education and be persuaded to become nursing educators. Graduate nursing education programs would be wise to require courses on teaching and learning to emphasize the teaching role and responsibilities of all advanced nursing practitioners and to develop strategies to help convince these future graduate students to become instructors. Finally, the recent increased interest in nursing as a career is occurring at a time when many nursing schools are turning away qualified applicants because of shortages of faculty, classroom space, and clinical placement sites. These capacity constraints will limit the ability of the nursing education system to supply employers with all the nurses they need and thereby contribute to increased immigration of nurses educated in foreign countries (AACN, 2003b; Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Brush, Sochalski, & Berger, 2004; Buerhaus, Staiger, & Auerbach, 2003). These constraints also will make it very difficult for nursing schools to make needed changes in their curricula, provide services needed by students, and proactively respond to changing student and faculty needs. However, eliminating capacity constraints impacting nursing education

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programs across the country is unlikely to be achieved by support provided by the states and the private sector or by nursing faculty. Rather, the Congress will need to provide substantial funding to assist schools in developing and implementing creative strategies to increase their enrollments and to provide sufficient funding for students while they are pursuing nursing education, which, heretofore, it has been unwilling to do. Unless and until the

Congress decides to act, the current underproduction of new graduates is likely to continue. Acknowledgments We thank Mamie Williams and Brenda Cornett for their help in preparing this manuscript. The study was funded by a grant from Johnson & Johnson (New Brunswick, NJ) and is part of a project designed to evaluate the effectiveness of the Johnson & Johnson Campaign for Nursing’s Future.

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