FOR YEARS, NURSING HAS BEEN

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1 Allison J. Terry Marilyn V. Whitman Impact of the Economic Downturn On Nursing Schools EXECUTIVE SUMMARY The challenges posed by the economic downturn on baccalaureate nursing schools in the southeast as it relates to their perceptions of changes in the number of applicants, acceptance rates, employer recruitment efforts, and student clinical and job placement were explored. Responses from deans and program directors indicated nursing schools are experiencing negative effects of the economic downturn in the form of graduates having difficulty finding employment, decreased recruitment efforts from prospective employers, difficulty locating clinical placements for students, and no change in faculty applicants despite an increase in undergraduate student applicants as well as graduate student applicants. These multiple factors combined could signal the death knell for programs that are illprepared to deal with such a crisis. Programs need to be aggressive in their efforts to draw health care recruiters as well as qualified faculty applicants to their campuses. Nursing schools must be able to clearly show why their graduates are superior to other programs graduates when competing for both highly qualified faculty applicants and prospective student employers. FOR YEARS, NURSING HAS BEEN touted as a sure-fire major for college students hoping to land a job after graduation. Prior to the economic downturn in 2008, the American Hospital Association (2007) re - ported a nurse vacancy rate of 8.1%, or approximately 116,000 unfilled nursing positions nationwide. In addition, long-term projections have consistently shown a growing need for more nurses with recent estimates suggesting the shortage will reach 260,000 by 2025 (Buerhaus, Auerbach, & Staiger, 2009). The Bureau of Labor Statistics (2009) most recent occupational outlook predicts a 22% growth from 2008 to 2018 in the nursing occupation and forecasts future job opportunities for RNs as excellent. The increasing demand fueled by the aging baby boomers coupled with the low expected growth in the number of qualified nurses has resulted in a superior job outlook for nursing school graduates. Findings from the American Association of Colleges of Nurs - ing s (AACN, 2009a & b) most recent survey of nursing school enrollments and graduations re - veals an increase in total enrollment in baccalaureate nursing ALLISON J. TERRY, PhD, MSN, RN, is Assistant Professor, School of Nursing, Auburn University Montgomery, Montgomery, AL. programs from 201,407 in 2008 to 214,533 in Increases in enrollment were also witnessed in RN-to-BSN programs (12.8%) and 12 new accelerated baccalaureate programs were launched in Not surprisingly, interest in baccalaureate and graduate nursing programs continues to grow as evidenced by the record high number of applicants (208,784 in 2009). Yet, despite the recent increases in nursing school enrollments, researchers warn that a significant shortage is still eminent (Buerhaus et al., 2009). One of the most pressing challenges lies in the impending demographic changes. The elderly population, individuals age 65 and older, is expected to grow 54% by 2020 (Keenan, 2003). The most recent national health statistics report compiled by the Centers for Disease Control and Prevention (CDC, 2006) shows individuals age 65 and older compose 38% of all hospital inpatients. The report also states that despite the increased efforts to shift services from inpatient to outpatient settings, hospital care has continued to increase among the elderly. Moreover, individuals are living longer, but with a higher rate of morbidity, requiring not MARILYN V. WHITMAN, PhD, is Assistant Professor, Department of Management and Marketing, University of Alabama, Tuscaloosa, AL. 252

2 only a greater number of nurses to provide the necessary care, but a higher level of acuity (Adams, 2009; CDC, 2006). The economic crisis, however, appears to have temporarily alleviated the nursing shortage; providing employers who were struggling to fill vacant nursing positions with a temporary respite. Over the past year, media reports have shined a spotlight on the lessen - ing nursing demand (Dougherty, 2008; Halsey, 2009; Hamilton, 2009). This scarcity in nursing jobs resulted in part from a 2-year period spanning 2007 and 2008 that witnessed an unprecedented increase in hospital RN employment (Buerhaus, 2009). As the economy took a turn for the worse, many nurses who had either left the profession altogether or left the hospital setting, returned to take advantage of the higher wages and lucrative benefits hospitals offer (Buerhaus, 2009). Addition - ally, nurses already working in hospitals increased their hours. The increase of nurses has indeed alleviated the hospital shortage. Yet, given that over half of the nurses that account for the increase are over the age of 50, the respite may very well be shortlived as these nurses will exit the workforce in a few years. Although the recession has alleviated one problem, it may have created another. Over the last decade, college nursing students have been showered with plentiful job opportunities upon graduating. As a result, the guarantee of a job has enticed many college students to choose nursing as their major (reflected in the AACN 2009 survey results reporting record number of applicants and enrollment numbers). The economic recession, however, may have reduced job opportunities for new graduates given the surge of nurses returning to the hospital setting or increasing their work hours. Moreover, recent reports in the popular literature have noted the difficulty some nurses are encountering in finding employment (Dougherty, 2008; Halsey, 2009; Hamilton, 2009). If more nurses are either increasing their work hours or returning to the workforce altogether, are nursing schools witnessing a decrease in the number of placement opportunities available to their new graduates? A study of the economic recession s impact on new graduate job recruitment and placement is missing from the academic literature. This study, therefore, seeks to fill this gap by exploring the challenges posed by the economic downturn on baccalaureate nursing schools in the southeast as it relates to their perceptions of changes in the number of applicants, acceptance rates, employer recruitment efforts, and student clinical and job placement. Methods This study s unit of analysis consisted of a convenience sample of baccalaureate nursing schools and/or programs located in the south - east region of the country, speci fically Florida, Georgia, Alabama, Mississippi, and Tennessee. The use of a sample of convenience localized in one region of the United States created a limitation for the project by decreasing the amount of generalization available for other states. The southeast region has witnessed significant population growth over the past decade with certain metro areas in Georgia and Florida experiencing the highest numerical growth (U.S. Census Bureau, 2007). Additionally, al - though the economic recession has indeed impacted all areas of the country, the southeast region has witnessed high unemployment, foreclosure, and bankruptcy rates compared to other regions (Associated Press, 2009). A total of 62 nursing schools and/or programs were identified. The targeted respondents were nursing school deans or program directors. A list of addresses was compiled by searching each nursing school or program s web site. The respondents were then sent an explaining the aim of the study and provided a link to the online survey. The survey consisted of 15 questions (including three demographic questions) and was comprised of both closed and open-format questions that inquired about recruitment, enrollment, and job placement trends since the economic downturn. The format of the questions and structure of the survey provided a framework for the instrument. The content of the questions as well as their format was validated through consultation with subject matter experts who were doctorally prepared university professors with a nursing research background. A pilot study was not conducted in this case due to the time constraints placed on deans and program directors in the various institutions surveyed. Such time constraints caused some deans and program directors to show reluctance in completing the primary survey, thus it is unlikely they would have been amenable to completing a pilot study prior to the primary survey. No identifiable information was collected in order to ensure respondents anonymity. Responses were asse - ssed using both nominal and ordinal-level variables. The percentages for each variable were examined, with findings reported based on responses per item since all respondents may not have opted to answer each question. Results Statistical analysis occurred using the Statistical Package for the Social Sciences (SPSS) version 16. Table 1 illustrates the characteristics of the sample. Deans or program directors from 24 out of the 62 baccalaureate nursing programs responded to the survey, representing 38.7% of the total population. The sample consisted mostly of programs within public institutions (65.2%), compared to those in private (17.4%) and reli- 253

3 Institution Type Table 1. Sample Characteristics (N=24) Characteristic % Public 65.2 Private, independent 17.4 Religiously affiliated 17.4 Average current enrollment Mean = 382 giously affiliated (17.4%) institutions with an average enrollment of 382 undergraduate students. Deans and program directors were asked to respond to a series of questions pertaining to recruitment and placement challenges since the economic downturn (see Table 2). Respondents were asked whether their respective programs had experienced positive, negative, or no effects due to the economic downturn. Over 58% indicated they had experienced negative effects, 8.3% noted positive effects, and 33.3% cited no change. Respondents were asked to indicate whether their respective program had witnessed an increase, decrease, or no change to a series of questions. Over 54% of respondents indicated they had witnessed a decrease in the recruitment efforts from employers since the economic downturn, compared to 4.2% who indicated witnessing an increase and 41.7% who indicated no change. Nearly 61% of respondents noted an increase in the number of undergraduate student applicants since the economic downturn and 56.5% witnessed an increase in graduate student applicants. Fur - thermore, half of the respondents (50%) noted no change in the number of faculty applicants since the economic downturn, compared to 20.8% who witnessed an increase and 29.2% who witnessed a decrease. Respondents were then asked if the current state of the economy had affected the number of students accepted for the academic year. Three quarters of respondents stated the current state of the economy had not affected the number of students accepted for the academic year while 25% stated it had. Of those who indicated the economy had affected the number of students accepted, 62.5% noted they would be accepting a greater number of students. When asked if the current state of the economy Table 2. Responses to Impact of Economic Downturn on Nursing Programs Survey Question Positive Negative No Change Our program has experienced effects do to the economic downturn. (n=24) Our program has witnessed a(n) in the recruitment efforts from employees since the economic downturn. (n=24) Our program has witnessed a(n) in the number of undergraduate student applicants since the economic downturn. (n=23) Our program has witnesses a(n) in the number of graduate student applicants since the economic downturn. (n=23) Has your program witnessed a(n) in the number of faculty applicants since the economic downturn? (n=24) Has the current state of the economy affected the number of students accepted for the academic year? (n=24) If Yes, will you be accepting a greater or lesser number of students? Greater 62.5 Lesser 37.5 Increase Decrease No Change Yes No Has the current state of the economy affected faculty recruitment efforts? (n=24)

4 Table 3. Responses to Impact of Economic Downturn on Clinical and Job Placement Survey Question Is this nursing program having difficulty finding an adequate number of clinical placements for students? (n=22) If Yes, which areas are specifically being affected? (n=15) Medical-Surgical (25%) Pediatrics (54.2%) Labor and Delivery (37.5%) Critical care (20.8%) Mental health (50%) Other (16.7%) What has been the primary barrier preventing students from being placed in clinical practice settings? (n=20) A lack of nursing clinical instructors (25%) Geographic location (5%) A lack of funding (5%) Inadequate facilities (brick-and-mortar) (25%) Other (40%) Graduates from our program have encountered difficulty finding employ ment since the economic downturn. Agree (includes Strongly Agree and Agree) Yes No Neither Agree or Disagree Disagree (includes Strongly Disagree and Disagree) had affected faculty recruitment efforts, 54.2% responded yes while 45.8% responded no. Table 3 shows the responses to the impact the economic downturn has had on student clinical and job placement. Respondents were asked to indicate whether their respective program was having difficulty finding an adequate number of clinical placements for students. Over 68% stated they were having difficulty compared to nearly 32% who were not. Respondents who indicated they were experiencing difficulty finding clinical placements were asked to select from a list of various clinical areas where they were experiencing difficulty (respondents were asked to select all that applied). Twenty-five percent in - dicated medical-surgical, over 54% indicated pediatrics, 37.5% indicated labor and delivery, nearly 21% indicated critical care, 50% indicated mental health, and 16.7% indicated other. Respond - ents who indicated other were asked to specify what areas they were experiencing difficulty. Res - pondents noted community health and primary care. When asked to indicate the primary barrier preventing students from being placed in clinical practice settings, a lack of clinical instructors, inadequate facilities, and competition from other nursing programs each represented 26.3% of responses. Other barriers cited included geographic location (5.3%), a lack of funding (5.3%), regulatory mandates (5.3%), and lack of preceptors (5.3%). Additionally, when asked if graduates from their respective programs had encountered difficulty finding employment since the economic downturn, 58.4% either agreed or strongly agreed, 4.2% neither agreed or disagreed, and 37.5% disagreed with the statement. Discussion Responses from deans and program directors indicated nursing schools are experiencing negative effects of the economic downturn in the form of graduates having difficulty finding employment, decreased recruitment efforts from prospective employers, difficulty locating clinical placements for students, and no change in faculty 255

5 applicants despite an increase in undergraduate student applicants as well as graduate student applicants. These multiple factors combined could signal the death knell for programs that are ill-prepared to deal with such a crisis. The findings indicate the need for programs to be aggressive in their efforts to draw health care recruiters as well as qualified faculty applicants to their campuses. Programs must be creative in locating clinical placements; student preceptorships can be implemented using multiple clinical sites in virtually every state if well coordinated. Nursing schools must be able to clearly show why their graduates are superior to other programs graduates when competing for both highly qualified faculty applicants and prospective student employers. The findings have great implications for universities public relations departments. Tradi tion - ally, nursing has had difficulty in acknowledging the need for marketing the skills of its practitioners at all levels. Nursing programs must have eye-catching brochures and easily navigated web sites that cater to the technology-savvy young adult. The programs must show they are changing as health care changes. In light of the economic downturn, programs must become more competitive than ever and market themselves to prospective employers as being capable of producing exceptionally qualified graduates and ultimately licensed nurses. As an additional implication, the demand elasticity for nursing services is projected to change in conjunction with a change in the demand for health care services. However, demand elasticity for health care overall is likely to change as health care reform is implemented and subsequently revised by a Republican Congress. If demand for health care services and nursing care becomes more inelastic, it will be less dependent on changes in pricing and nurses would feasibly have the opportunity to increase the price of their services. Yet, when such an economic environment becomes a reality in the health care market, health care facilities typically circumvent nurses opportunity to increase the price for their services by hiring lower-priced licensed practical nurses in place of registered nurses. Recommendations for further research were generated from this project. Additional research could determine what interventions programs have implemented to deal with the economic crisis and what the outcomes of such interventions have been. Additional research is also needed to involve additional states beyond the southeast region in the project so that it can be determined where it is most difficult to draw health care recruiters and prospective employers and where the nursing faculty shortage is being felt most acutely. In addition, in light of the propensity of associate degree programs in the southeast, particularly in Alabama (approximately 60%), the project could be expanded to include associate degree nursing programs. Although this exploratory study provides an overview of the challenges faced by nursing schools/ programs in the southeast and fills a gap in the literature, it does have limitations. The population of baccalaureate nursing schools/programs was limited to those located in Florida, Georgia, Alabama, Mississippi, and Tennessee. Our results, therefore, may not be generalizable to states in other regions of the country. Additionally, al - though the re searchers directed their correspondence to nursing school deans or program directors, it is unknown to the researchers who completed the survey. Lastly, the sample size is small, consisting only of 38.7% of the total population of baccalaureate nursing schools/ programs identified in the selected southeast states. However, given that the study was intended as a preliminary exploration of the recession s impact on recruitment and placement efforts, the re - searchers believe the data collected from the sample is relevant and helpful in exploring the challenges faced by nursing programs during tough economic times. Conclusion The findings of this research project were an exploration of the challenges baccalaureate nursing programs localized to the southeastern United States are experiencing as a result of the current economic downturn. A majority of the programs sampled have experienced a negative effect from the economic changes. Although the findings are not surprising, the widespread negative results are disturbing in light of the recent proposed changes in health care and health insurance. The findings are a clear indicator of the need for urgency in uniting quality, clinical competence, and creativity in 21st century nursing programs. $ REFERENCES Adams, L.T. (2009). Nursing shortage solutions and America s economic recovery. Nursing Education Perspectives, 30(6), 349. American Association of Colleges of Nursing (AACN). (2009a) Enrollment and Graduations in baccalaureate and graduate programs in nursing. Retrieved from aacn.nche.edu/media/newsreleases/ 2010/enrollchanges.html American Association of Colleges of Nursing (AACN). (2009b). Student enrollment expands at U.S. Nursing colleges and universities for the 9th year despite financial challenges and capacity restraints. Retrieved March 9, 2010, from nche.edu/media/newsreleases/2009/ StudentEnrollment.html American Hospital Association. (2007). The 2007 state of America s hospitals Taking the pulse. Retrieved from /pdf/TakingthePulse.pdf Associated Press. (2009). AP economic stress index: Measuring financial strain across the U.S. Retrieved from tives/_national/stress_index/index.html continued on page

6 Economic Downturn continued from page 256 Browning, E.K., & Zupan, M.A. (2002). Microeconomics: Theory and applications (9th ed.). Danvers, MA: John Wiley & Sons, Inc. Buerhaus, P.I. (2009). The shape of the recovery: Economic implications for the nursing Workforce. Nursing Economic$, 27(5), Buerhaus, P.I., Auerbach, D.I., & Staiger, D.O. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 28(4), w657- w668. Centers for Disease Control and Prevention (CDC). (2006). National health statistics reports: 2006 national hospital discharge survey. Retriev ed from nhsr/nhsr005.pdf Dougherty, C. (2008, May 7). Slowdown s side effect: More nurses. The Wall Street Journal, pp. D1. Halsey, A. (2009, April 5). Jobs scarce, even for nurses. The Washington Post, C01. Hamilton, W. (2009, May 18). Nursing demand slowing. Providence Business News, 24(6), 1. Keenan, P. (2003). The nursing workforce shortage: Causes, consequences, proposed solutions. Retrieved from usr_doc/keenan_nursing.pdf U.S. Bureau of Labor Statistics Office of Occupational Statistics and Employ - ment Projections. (2009). Occupa - tional outlook handbook ( ed.). Retrieved from gov/oco/ ocos083.htm#outlook U.S. Census Bureau. (2007). 50 fastestgrowing metro areas concentrated in west and south. Retrieved from census.gov/pressrelease/ www/releases/archives/population/ html ADDITIONAL READING Unruh, L.Y., & Fottler, M.D. (2005). Projec - tions and trends in RN supply: What do they tell us about the nursing shortage? Policy, Politics, and Nursing Practice, 6(3),

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