That, and the NCLEX: A Response to Steven Mintz

My Inside Higher Ed blogging colleague Steven Mintz asked a great question this week: Why is it so hard to get into nursing programs?

I would have answered it differently than he did.

He focused entirely on B.S.N. programs -- bachelor’s degrees in nursing -- and proposed, as an alternative, a hybrid liberal arts model requiring a master’s degree.

From his piece, you wouldn’t know that the largest local providers of nurses in most of the country are community colleges. But they are. Depending on the state, some have L.P.N. programs and some don’t, but A.D.N. programs are ubiquitous. (The C.N.A.-to-L.P.N.-to-R.N.-to-B.S.N. ladder is one of the most common, and successful, stackable credentials around.) At all three community colleges at which I’ve worked, and at every other one I know about, there’s far more student demand for spots in nursing programs than there are spots. The demand makes sense; nursing is an honorable, well-known and relatively well-paid line of work in which you help others. I get the appeal.

Why the limited capacity?

Some of that is entirely out of the control of colleges themselves. Although simulation helps somewhat, we’re still largely at the mercy of local hospitals for clinical placements. We get only so many spots; when they’re full, they’re full. (At this point, the programmatic accreditor for rad tech remains extremely strict about “real” clinical experience. With hospitals restricting student access due to the pandemic, we may have to skip a class. During a pandemic. When they’re most needed.) Even if we let every student into the program who wanted in, there would be a devastating bottleneck when it came time for clinicals.

More clinical placement opportunities would help, but that’s only part of it. The very salaries that attract students make it harder to attract faculty; the salaries we pay are generally far short of what they could make in the field. When we post for a full-time professor in a liberal arts field, we’ll typically get from 50 to 200 applications. When we post for a full-time professor in nursing, we’re lucky to get more than one qualified applicant per spot. Even when they arrive, they don’t always stay; sometimes the siren song of salary lures them away. In a collective bargaining college, where salaries have to be consistent across fields by rank, it’s markedly difficult to keep up with salaries in sectors outside of education. (That’s the same reason that it’s difficult to scale up quickly in fields like cybersecurity. We can’t even begin to compete with the salaries they can earn outside.) It would be a mistake to assume that teaching positions in nursing are in the same demand as teaching positions in, say, English. They just aren’t.

Rarely acknowledged corollary: if you want community colleges to beef up their offerings in high-demand, high-pay fields, you need to give those colleges a lot more money.

And then there’s the NCLEX. That’s the national exam A.D.N. students have to pass to get their R.N. licenses. I’ve never taken it myself, but I’m told it’s a beast. Nursing programs are judged, in part, by their pass rates on the NCLEX exam.

Think about that for a minute. You have limited clinical placements, you can barely hire enough faculty for the size of the program you have now and you’re judged largely based on student pass rates on the NCLEX. Which of those factors argues for throwing open the doors?

I’ve seen different approaches to selecting students. When I was at Holyoke, students took a Foundations of Health curriculum before entering nursing. That curriculum exposed them to other related health careers -- nutrition, epidemiology, community health worker, medical billing -- in hopes that some would peel off. It also put them through prerequisite courses with a heavy focus on biology. At a certain point, students would apply to the nursing program. The nursing faculty developed a scoring rubric by which to judge applicants against each other. (One of my contributions was to get them to include fluency in Spanish as a tiebreaker. Bilingual nurses were, and are, always in high demand by employers.) Admission was competitive. That helped to ensure a consistently strong NCLEX pass rate; if you choose mostly from students who are good at school, you’ll get cohorts that are mostly good at school.

Rarely acknowledged corollary: when students have to do a year or two of prerequisites before starting a two-year program, your three-year graduation rate will look artificially low. That’s because judging community colleges by the IPEDS headline rate is statistical malpractice.

Brookdale takes a more egalitarian approach, putting students on a wait list on a first-come, first-served basis. That gets around the difficult discussions of relative merit that are mostly foreign to the community college world, but it also makes maintaining a high NCLEX pass rate a special challenge. With that approach, manageable cohort sizes are effectively mandatory. I admire the department tremendously for the work it does, but we shouldn’t have any illusions that it could just double in size without a nearly unimaginable and sustained influx of resources, both financial and human. This model, too, wreaks havoc on the three-year graduation rate; time on the wait list counts against those normative three years.

If the country decides that it would be a good idea to increase the supply of nurses -- a decision I would wholeheartedly and enthusiastically support -- it would need to spend a ton of money to do it. It would need to provide much more support to hospitals and medical centers for the work of taking on clinical students. It would need to give far more money to community colleges and other providers of nursing education, both to bolster salaries and to bring in more people with those salaries. It would need to stop judging programs based on NCLEX pass rates. And it would need to find some reasonably tolerable solution to the issue of salaries across fields.

So sure, go ahead and work on B.S.N./M.A. programs if you want, but that’s a boutique solution. If you want to solve the problem at scale, you have to include community colleges in the discussion.