When Marcy Hohorst, RN, realized she wasnt likely to get a med-surg nursing job as a new graduate from an associate degree program, she felt relieved. That would be my worst nightmare, said Hohorst, who started nursing school at age 50, after years of working as a personal trainer. Although she greatly respects med-surg nurses, she feared a job on a busy hospital floor would exhaust her, and she wouldnt have enough time to spend with patients. And I thought I was too old for it.
Instead, she volunteered on international surgical missions, and with that experience landed a per diem job at a stand-alone ambulatory surgical center in Manhattan. While there, she took an orientation course through the Association of periOperative Registered Nurses, earned a certificate and eventually was hired as a perioperative nurse by a hospital close to her Long Island home.
Hohorsts journey is an example of how as nursing roles change, so are the paths to a nursing career. Though many nurses still start out in a hospital med-surg job, it is no longer seen as the only way into the field, said Hohorsts sister, Janet Mackin, EdD, RN, dean at Phillips Beth Israel School of Nursing at Mount Sinai Beth Israel in New York.
Though hands-on bedside care will always be an important part of the profession, nursing roles are evolving in every setting, Mackin said. Home health agencies, ambulatory care centers, long-term care facilities and even some medical offices are offering orientation, mentorships and residencies to new graduates as well as to experienced nurses interested in a career change.
Higher education in hospital settings
Starting a nursing career in a hospital is no longer as easy as it was 10-to-15 years ago, when a nursing shortage gave new graduates their pick of jobs. Hospital hiring, flat since 2009, is not expected to increase soon, nurse recruiters and administrators said, although some mentioned states Texas and Florida that still are reporting shortages. Nurses are not retiring as quickly as predicted, resulting in a larger nursing workforce than originally forecast, workforce researcher Peter I. Buerhaus, PhD, RN, FAAN, wrote in a report published in the August issue of Health Affairs.
New graduates continue to report difficulty finding hospital jobs, particularly in urban areas with lots of nursing schools, said Theresa Mazzaro, RN, CHCR, nursing workforce planning consultant for PeaceHealth Center of Expertise in Vancouver, WA, and communications director for NAHCR. The older nurses arent leaving yet, which makes it difficult to hire new ones, she said.
When hospitals do hire nurses, they are looking for higher levels of skill and education, nursing workforce researcher Joanne Spetz, PhD, FAAN, wrote in a February 2014 report in Nursing Economics about the effects of healthcare reform on RN jobs. Quality-improvement initiatives under the Affordable Care Act provide incentives to increase staffing levels and offer more support to nursing staffs. But if they work as intended, the reforms also will mean shorter hospitals stays and fewer patients returning, which could mean fewer bedside nursing jobs, she concluded. The biggest change in [nurse hiring] in the last 10 years is the requirement of the nursing baccalaureate degree as minimum for most hospital jobs, Mackin said.
Some hospitals are hiring though not requiring more masters-prepared nurses who are looking for their first clinical experience, and these nurses often go into specialties and leadership roles, said Terry K. Bennett, MS, RN, CHCR, director of nurse recruitment at Johns Hopkins Bayview Medical Center in Maryland, and immediate past president of the National Association for Health Care Recruitment.
Venturing into the community
Hospitals still hire new graduates into specialty and internship programs, Mazzaro said, but these have become harder to get into, even with a four-year degree. Hohorsts daughter, who received her RN at the same time her mother did, opted to continue for her BSN, but still could not find a job in the New York area. She ended up getting hired into an ICU-internship program in upstate New York and finishing her BSN online, Hohorst said.
Because they required so much autonomy, community settings were once seen as the sole province of experienced nurses. New graduates, the view held, would not have the confidence to take care of patients in their homes or supervise others in a long-term care setting. In long-term care, we used to tell [new graduates], Go to the hospital and work a year and then you can come back, Lori Gutierrez, BS, RN-C, DON-CLTC, CBN, a clinical development specialist with Chamberlain College of Nursing in Arizona and clinical educator with the American Association for Long Term Care Nursing, said. Now, she said, some hospitals are suggesting new grads get nursing experience somewhere else first. Its funny how the tables have turned.
Healthcare reforms designed to keep patients out of the hospital are expected to create more growth in community healthcare settings. Home health is predicted to be the fastest growing segment of nurse employment, according to the Bureau of Labor Statistics, increasing 55% between 2010 and 2020, Spetz reported.
In the past 10 years, some home health agencies have added orientation and mentoring programs for new graduates, Elaine D. Stephens, RN, MPH, FHHC, executive vice president of the National Association for Home Care and Hospice, said. The Visiting Nurse Service of New York, which started its new grad program in 2000, offers a year-long paid internship that includes field-visits, shadowing and classroom work.Visiting Nurse Association of Boston began a residency program two years ago in partnership with a local nursing school. As jobs shift to the community, more home health agencies will be considering similar programs, Stephens said. We need nurses from all areas, she said.
Many ambulatory surgery centers have training programs for new graduates and nurses from other specialties, such as med-surg, said Jan Davidson, MSN, RN, CNOR, CASC, director of AORNs ambulatory surgery division. Other new grads take AORNs perioperative course on their own, as Hohorst did. Skilled nursing facilities also have started programs for new graduates, who often use their long-term care experience to get a job in a hospital, Gutierrez said. A new graduate is going to get a potpourri of lots of stuff, she said, including wound care, chronic illness care, dementia and behavioral health.
There are some opportunities for new graduates in general medical offices, said Kimberly Taaca, MBA, RN, executive director for primary care at DuPage Medical Group, a large, independent, multispecialty physician group in Melrose Park, Ill., though specialty offices and intensive outpatient clinics usually require nurses with some hospital experience. Her organization is starting to create partnerships with area nursing schools to offer clinical rotations in its clinics, she said, and she does not rule out hiring new graduates with sharp critical thinking skills, a background in customer service, and a good attitude. We can teach them a lot of what to do.
Just as it no longer necessarily begins in a hospital, a nursing career may be less likely than in the past to end there. The growing number of jobs in nonhospital settings may prove attractive for older nurses who decide to put off retirement, Buerhaus and his colleagues wrote in their report. Though Hohorst loves perioperative nursing, and will continue doing her per diem job for as long as her employer wants her, shes also planning for the future. Before I end my nursing career, Id like to have some time in hospice, she said. I think thats going to be the next natural progression.