Enrollments in bachelor's-degree nursing programs have declined consistently over the past five years nationwide, dropping 4.6 percent in 1999 alone, according to the latest annual survey by the American Association of Colleges of Nursing (AACN). And while enrollments in master's programs grew steadily through most of the 1990s -- thanks to increased interest in nurse practitioner and other advanced clinical nursing programs -- they too have experienced slight declines in the past two years.

In some cases, lower enrollments are the result of intentional cutbacks due to faculty shortages, state-mandated enrollment caps on baccalaureate programs, a limited supply of clinical training sites, or other resource constraints. But, in large part, the decline -- particularly in entry-level baccalaureate programs -- is an indication of lowered interest in nursing careers in recent years.

One reason is the proliferation of new career opportunities for women, who still make up more than 90 percent of the RN workforce. Another is lingering belief that nursing is not a secure job, a hangover from a few years ago when news media were awash with reports of hospital cost-cutting and RN layoffs under the pressures of managed care. But in many regions, today's workforce situation is the exact reverse, with escalating demand for baccalaureate- and graduate-prepared nurses being felt keenly throughout the health care industry. Already, increasing numbers of elderly, rapid expansion of front-line primary care, higher numbers of registered nurses (RNs) approaching retirement, and other pressures have led to mounting shortages of RNs in more markets across the nation. Indeed, the Bureau of Labor Statistics projects that employment for registered nurses will grow faster than the average for all U.S. occupations through 2008.

Some schools are seeing the change already. At the University of Texas at Tyler, Dean Linda Klotz says that while the College of Nursing is receiving fewer applications, "applicants are more qualified, so our enrollment has been consistently increasing slightly over the last six years." The news is the same for some private schools: Elaine Marshall, dean of nursing at Brigham Young University, notes, "We have a unique situation of high interest in nursing with more qualified applicants than our programs can accommodate." At Bethel College of Minnesota, "Our basic baccalaureate program has a longer waiting list than in previous years," reports nursing chair Sandra Peterson.

But for many nursing schools nationwide, it's been an ongoing challenge to keep application and enrollment numbers up. Instead of waiting for the tide of public perception to shift in favor of nursing careers, schools are battling slipping or stagnant enrollments on the home front with creative recruiting practices that range from movie theater advertising to innovative partnerships with hospitals in an effort to fill more student slots.

Proven Strategies

In a recent survey by AACN for this bulletin, deans were questioned about methods they've employed in recent years to boost enrollments, particularly in bachelor's-degree programs. Here are some of their proven approaches:

Recruiting from within. Encouraging associate-degree nursing graduates to continue their education is a simple, inexpensive way to boost enrollments in Bachelor's of Science in nursing (BSN) programs, deans are finding. "We go to job fairs put on by associate-degree programs, and we've been very successful in getting new students this way," says Connie Carpenter, director of nursing at Oklahoma Panhandle State University. "We are not talking about large numbers, because we are located in a very rural area, but I predict that our fall enrollment will be the largest we have had to date for our program that started in 1996." At Thomas Jefferson University in Philadelphia, Nursing Chair Pamela Watson goes to hospital-based diploma programs and associate-degree programs "to talk about the value of advancing one's career potential through advancing one's nursing education. Then I talk about what we are doing to promote career mobility."

Judith Karshmer, head of the Department of Nursing at New Mexico State University, has found success recruiting from bachelor's- to master's-degree programs. "We use a longitudinal approach. It starts when they are admitted to the bachelor's program -- I start to talk about grad school, planting the seeds," says Karshmer. "Each semester we have a group exit interview for the BSN students in which I give them a picture of their progress toward that master's degree. When they are close to graduating, I tell them I can guarantee a certain number of traineeships that pay tuition plus a $10,000 graduate assistantship, but they have to go straight into the program. Lots of them have never worked in nursing before, and they think it's pretty nifty to stay on for an advanced degree and be paid."

Advertising and promotion. In the same way corporate recruiters use advertising to attract fresh talent, nursing schools are utilizing media and promotional outlets to advance messages about their particular academic programs, and about the rewards of a nursing career. At Baker University School of Nursing in Kansas, 1999 enrollments for the entry-level baccalaureate program were up 21 percent over 1998, a situation Dean Kathleen Harr attributes to "greatly intensified recruitment efforts." These included a combination of radio and newspaper ads, and a year-long run of still slides shown at local movie theaters before the start of the films. The school also set up a prominent display at a large regional mall in Topeka.

"The movie ads are designed not necessarily as a call to action, but as a way to increase the visibility of our program to the local community," explains Harr. "We think it's been effective because many potential applicants have commented on them." The radio ads too, have prompted calls from potential students. "The strongest message we can radiate is the one students provide us -- the reasons they give us for wanting to come into nursing. We've found many are drawn to the field because they are caring people who want to help others. So we try to portray nursing in its humanistic light. We use images showing a student nurse holding a baby, for example."

She acknowledges that many nursing students enter their studies with the idea that they want to take care of infants or children, and then change their minds when they discover all the other opportunities available to them. "But this nurturing image is what draws them in initially, so that's what we focus on."

Priming the early pipeline. The message that nursing is a rewarding career choice is being directed at younger groups as a way for schools to stimulate interest that will pay off in years to come. Indiana University-South Bend's nursing school, for example, offers college-credit courses on their campus to high school students in such areas as medical terminology and introduction to health careers. Allentown College of St. Francis De Sales in Pennsylvania is piloting a nursing camp for interested high school students this summer, and Southern Connecticut State University has worked with a local magnet high school for the past few years "which has resulted in several students coming to our program," according to Nursing Chair Cesarina Thompson.

Janet Sipple, chair of nursing at Moravian College in Bethlehem, Penn., says her school concentrates on high school and even younger students. "We have declared war on the situation in our profession," she asserts. "We've turned to our senior clinicians for help, encouraging those who are happy and excited about nursing to conduct 'shadow days' for high schoolers interested in nursing."

Shadowing students spend the day at St Luke's Hospital alongside a practicing RN, getting a first-hand glimpse of the many facets of nursing. "Afterwards, we call them to let them talk about their experiences, and ask any questions." The program can be labor-intensive for the school, but the payoff is great in terms of exposing the profession. "It's been outrageously successful," notes Sipple. "Students come away so excited. In the two years we've been doing it, we've had at least 50 shadow graduates choose nursing careers. Not all have come to our school, but at least they are out there preparing."

Moravian College is also part of a small consortium of Lehigh Valley colleges that includes Cedar Crest College and Allentown College, working together to expose nursing to middle schoolers in grades 6 to 8. Through assemblies, coloring books and programs with scout troops, "We are helping younger girls -- and boys -- discover the varying roles they can take on as nurses," Sipple says.

Reaching even deeper into the pipeline is the University of Mary Hardin-Baylor in Belton, Tex., which has begun targeting students as young as elementary school. Dean Nancy Schoenrock explains that the School of Nursing has been conducting "career days" at local elementary schools, sending a student nurse and faculty member to introduce kids to the world of nursing. "We'll show up with an infant mannequin and a stethoscope, and have hands-on activities, give out stickers and prizes, and so forth. In many cases the only contact children have with nurses is when they are getting a shot. We want to expose them to more positive images of nursing at an early age." She points out that there is plenty of competition from other professions, and that some children make decisions very early about things they want to do in life. "What we do now may have an effect in 10 years."

Targeting underrepresented and nontraditional groups. Throughout 1999, AACN held regional conferences for the Division of Nursing of the U.S. Department of Health and Human Services to develop recommendations for expanding baccalaureate nursing enrollments. One key finding in the subsequent report was the need to recruit more minority students and faculty. "Diverse populations benefit from seeing someone who 'looks like them,' such as student and faculty role models," the report stated. Many schools have stepped up efforts to provide tutoring and remedial opportunities for English as a Second Language, set up mentoring programs targeting minority high schoolers, and link up with historically black colleges. For example, a partnership between the University of Florida (UF) College of Nursing and historically black Bethune-Cookman College in Daytona Beach aims to increase minority enrollment at UF's graduate nursing programs through a range of activities. Among them are the Gator-Cat mentoring program to assist students who want to pursue graduate study, joint faculty workshops and teaching exchanges, and the appointment of a full-time faculty member liaison.

Issues of diversity also extend to gender -- males being an underrepresented group in the profession. Although men make up just 6 percent of all RNs, that number is growing through better awareness. "We use men in our advertising and photography, and last year we had a male PhD nurse practitioner present our annual lecture to diploma students," reports Sipple. "Afterwards, the men came up to shake his hand and chat -- usually they just disappear." Interested male students at Moravian also receive a complimentary membership to the American Assembly for Men in Nursing, "so they get literature directly from other male nurses, and can better connect with clinical mentors."

Hiring dedicated recruiters. Taking a page from today's hard-pressed employers, many schools are hiring experienced in-house recruiters to help them find adequate numbers of qualified applicants to fill empty slots.

Barbara Witt became dean of nursing at Auburn University two years ago, and as part of her negotiations, arranged to hire a full-time recruiter for the Montgomery, Alabama campus' School of Nursing. "We now have a full-time salaried employee who is a nurse, and 100 percent of her attention is directed toward recruiting and advising students," explains Witt. "She goes to career nights, transfer days, and high schools; does direct mail recruiting; forms relationships with counselors at community colleges; and works with high school future nursing clubs, among other activities."

This option, though costly, enabled Auburn-Montgomery to dramatically increase its enrollment of diploma and associate-degree RNs into bachelor's degree programs from 11 to 50 in two years. "A dedicated recruiter is a front-end investment that takes some years to pay off, but it's worth it," says Witt. "From my point of view, it's the only way to go. Because the recruiter works for me directly, we can make mid-course corrections and be generally more nimble in our approaches." In addition, the recruiter -- a former faculty member -- also handles advising for the RN-to-Baccalaureate program, helping transfer students with their credits and preparing newcomers for academic life. "She understands the students' issues and problems; with that kind of focused attention, we are earning the reputation that this college really cares about its students."

Improving financial aid. Educators point out that many more students would consider nursing careers if their training expenses were defrayed. So despite tight budgets throughout nursing academia, schools are finding ways to build creative financial aid packages that pay off. Fairfield University in Connecticut offers "bonus" financial aid for nursing students, above and beyond what students in other majors receive. Other schools, like the University of Maryland, have boosted scholarship support. Elsewhere, some schools report they are expecting increased enrollments in RN-to-Baccalaureate programs because local institutions have reinstated tuition reimbursement in response to the nursing shortage and competition for new recruits.

Enhancing distance learning. Many deans surveyed by AACN described the positive effect distance learning programs have on enrollments. Norann Planchock, dean of nursing at Northwestern State University in Shreveport, La., reports, "We have finally put the last course in the RN-to-BSN program on the Internet, which we expect to boost enrollment in this area." Nancy Johnson, coordinator of student affairs at the University of Missouri-Columbia Sinclair School of Nursing, notes that several areas of study within the master's program are now available via the Internet, as well as all the core courses. "Our Master of Science Internet courses are being heavily marketed through Web advertising and mass mailings," she adds.

Polishing the image of nursing. Many still hold the view that nursing is a risky, low-status, under-rewarded profession, and some of those people are high school guidance counselors, nurse educators say. In its 1999 report to the federal Division of Nursing, AACN noted the feedback of nursing deans who say that high school counselors often steer brighter students into other majors, such as medicine, science and business, and also encourage many students interested in nursing, especially minority students, to go to community colleges offering associate-degree nursing programs, "consequently not seeming to value" higher educational preparation for nurses. A program to educate high school counselors about nursing roles and careers is "greatly needed," the report urged.

Many schools are making a concerted effort to reach out. For the past two years, members of the Pennsylvania Higher Education Nursing Schools Association have used its resources to be a presence at the annual convention of state high school guidance counselors. According to Villanova University dean of nursing Louise Fitzpatrick, immediate past president of the association, "We try to get all the baccalaureate and higher- degree schools to participate by sending materials and brochures, which we package into a bag for all counselors, along with some other giveaways. We also select certain deans and department heads to be present, and sponsor a breakfast that allows us sit down and talk with them about the state of nursing in our region."

Partnerships Prioritize Student Enrollments

At some schools, applications have increased without special recruiting efforts, but enrollment is still sliding or stable because of unyielding resource constraints. Kathleen Ann Long, dean of the College of Nursing at the University of Florida and AACN president-elect, reports, "We had more qualified BSN applicants than we could accept for fall 2000. A shortage of qualified faculty members was an important factor in our decision to limit the enrollment."

Some schools are forging unique partnerships with local institutions to expand the enrollment pool. The University of Texas at Arlington secured funding from the member hospitals of the Dallas/Ft. Worth Hospital Council to cover the additional cost of 80 more nursing students. As a result, 20 additional students will be enrolling each semester beginning fall 1999, increasing total enrollment in the school's entry-level BSN program from 320 to 400. Also working in partnership to increase enrollment -- and the nursing workforce as a whole -- is the Nursing Shortage Consortium of South Florida, with 35 members in Miami-Dade, Broward and Palm Beach counties, including hospitals, staffing agencies, and four nursing schools. In New York, a task force spearheaded by the Kaleida Health System under the direction of the State University of New York at Buffalo will mount strategies to deal with the current shortage of RNs, recruitment and marketing, and faculty aging. The group is comprised of representatives of major agencies, nursing education programs, legislators, and policymakers.