Stepping up to the plate. It’s a baseball reference, to be sure, but these days it’s batted around wherever there is a challenge, let alone the crisis-within-a-crisis that nursing faces today.

No one, except for RNs themselves, can hit a home run in solving Crisis One: the well-publicized shortage of nurses, or Crisis Two: the shortage of nurses with advanced training. Nonetheless, hospitals, educators and politicians are stepping up to the plate to take a swing at the twin problems.

Closest to the action in Congress is Rep. Lois Capps, D-Calif., herself a nurse for 41 years. Capps, MS, RN, sponsors the Nurse Reinvestment Act, which among other things proposes a National Nurse Service Corps that would place nurses in needy communities in exchange for scholarships. In the six weeks after it was introduced April 4, the bill collected 102 House co-sponsors.

Sen. Tim Hutchinson, R-Ark., and Sen. John Kerrey, D-Mass., and Sen. James Jeffords, a former Republican and now an Independent from Vermont, are sponsors of similar bills, S.721 and S.706, respectively.

"Technology is making the world of health care so different that unless nurses are getting degrees or being certified, they get out-of-date really quickly," said Fay Bower, DNSc, MSN, RN, chair of the department of nursing at Holy Names College in Oakland, Calif.

The small Catholic college offers an RN-to-BSN curriculum and a master’s degree-level family nurse practitioner program.

Higher education is a nursing expectation and hope, but it can’t be forced, Bower pointed out.

It can be—and is being—encouraged, however. Consider the initiatives of hospitals, which employ 59 percent of all RNs, to grow the nursing workforce both in quantity and quality.

Five facilities since 1999 have partnered with Fresno (Calif.) City College in what is called the Paradigm Program, an intensive 18-month course leading to an associate degree, said Carolyn Drake, Ed.D., MSN, RN, the college’s dean of nursing.

The hospitals pay for theory classes and use their own employees and facilities for clinical instruction, all the while massaging work schedules to accommodate employee-students and maintaining their fringe benefits.

The partnership, drawing on respiratory therapists, laboratory technicians and others who may have never dreamed of becoming RNs, has produced about 70 nurses besides those enrolled in the college’s regular nursing classes, Drake said. Some have continued on to earn BSN degrees at California State University, Fresno.

The program has been a great marketing tool for hospitals, Drake said, and is evidence of what Bower sees as a new attitude among employers: "Look, I’ll help you with your career. I’ll help you with your education."

That attitude also extends to RN certifications issued by professional organizations. "A certification in a specialty really does say, ‘I have the knowledge and experience,’ " said Wanda Johanson, MN, RN, chief executive officer of the American Association of Critical-Care Nurses. "It’s another way to reassure patients."

The association represents 65,000 intensive care unit and emergency room nurses. Beyond certifications through rigorous testing, it contributes about $150,000 a year for scholarships leading to BSN and MSN degrees, Johanson said.

Christine Kovner, Ph.D., MSN, director of nursing at New York University, said she considers a baccalaureate degree, with its sociology and psychology courses in addition to the physical sciences, essential in today’s environment of older and higher-acuity patients.

In keeping with that belief, the New York City university has an arrangement with certain associate degree programs, which guarantees that RNs who meet a minimum grade point average can transfer into the BSN program at NYU, Kovner said.

About 1.1 million nurses, or 40 percent of all RNs, entered nursing through an associate degree program, according to the National Sample Survey of Registered Nurses, March 2000. That compares with 308,000, or 19 percent of RNs, in 1980.

About 792,000 RNs, or 29.3 percent, reported entering with a baccalaureate degree, up from 288,000, or 17.3 percent, in 1980, according to the survey compiled every four years by the Health Resources and Services Administration, a division of the U.S. Department of Health and Human Services.

The trend toward academic degrees has come at the expense of diploma programs, however. The survey counted about 800,000 diploma nurses, or 29.6 percent of RNs. By comparison, the 1980 survey showed about 1 million diploma nurses, or 63 percent of all licensed RNs.

About 15.5 percent of nurses had completed academic training beyond basic RN education, the survey also reported. "In most instances, the highest level achieved was a baccalaureate degree," the survey said.

So, nursing schools have gone elsewhere for graduate students. Namely, they have made it possible for early- and mid-career professionals from other disciplines to step into advanced nursing. NYU reports that 38 percent of its nursing students already have a college degree.

The University of California, San Francisco, has had a program for non-nursing degree students since 1991 and recently expanded it to 60 students per class, said Janet Coffman, associate director of workforce policy at the university’s Center for the Health Professions.

"The first year is a compressed basic nursing curriculum to get the student ready to take the nursing licensure exam," Coffman said. "The [next] two years are then master’s level education and advanced practice specialties, such as nurse practitioner and nurse-midwife, and some clinical specialties such as geriatrics."

Vanderbilt University in Nashville, Tenn., also is highly regarded for assimilating those from other disciplines into nursing graduate programs, Coffman said.

A master’s degree in administration prepares nurses for managing large and small operations, from hospital units to home health and ambulatory care settings, Bower said. Overall, though, at the master’s level, "the biggest and hottest specialty is nurse practitioner," she said. "They’re blossoming all over the United States," with specialties in family, obstetrics, pediatrics, geriatrics and adult care.

The bottom line, of course, is economics.

"In this managed care environment, if physicians can’t see lots of patients in a short period of time, they can’t make the living they used to make," Bower said. "So they use nurse practitioners to take care of primary care. A nurse practitioner and a physician working together can double the workload."

Statistically, the registered nurse survey found 88,186 nurse practitioners, an increase of more than 27 percent from 1996. The number of nurse practitioners who also are clinical nurse specialists increased to 14,643, or nearly 88 percent more than in 1996.

Still, the demand for nurses, particularly advanced practice nurses, is such that Allied Consulting Inc., the nation’s leading recruiter of hospital personnel other than physicians, is out of the RN business except in special cases, said Curtis Pryor, vice president of the Irving, Texas-based firm.

"It’s a no-win situation. There are just not enough of them out there," he said.

The American Association of Colleges of Nursing in Washington found that enrollment at its 556 institutions in the fall was down 2.1 percent from the previous year, the sixth consecutive year of decline. "There is a lot of opportunity … out there," said Robert Rosseter, the association’s director of public affairs. "A lot of people have the image that all nurses do is the horrible jobs in the hospital."

The government survey listed the United States with 2,696,540 licensed RNs. Even though that is an increase of 5.4 percent from 1996, it’s the lowest rate of increase ever, the survey said. In the previous four-year period, from 1992 to 1996, the number of RNs increased 14.2 percent to 2,558,874.

From his vantage point as a recruiter, Pryor said that three factors would relieve the shortage:

On the legislative front, Capps’ Nurse Reinvestment Act, as well as the Senate bills, cover two of Pryor’s three points: financial aid and boosting the image of nursing.

When RN education shifted from the three-year diploma program hospitals used to run to the two-year community colleges, "the associate degree was supposed to be followed by a year of very closely supervised work, almost like an internship," Capps said.

Because hospitals can’t afford that, they’ve asked the best nurses to voluntarily take on oversight of new RNs and clinical training and "they just burn out," she said. Capps also would like to focus on developing the diversity of the nursing profession.

"We don’t have enough young men entering nursing and we clearly don’t have enough minorities to be reflecting the communities that we serve," Capps said.

The public relations blitz also is a nod to her Santa Barbara district, which will launch a high school/ community college health academy in the fall. "They’re going to start recruiting 10th-graders," Capps said. "This will reach out to previously untapped populations—starting with the youngsters, 15- and 16-year-olds—and very basic health professions courses.

"By the time they graduate from high school, they can get their certified nursing assistant license. But they also can go on. They’ll be fast-tracked a little bit to get into the RN program."

If the Nurse Reinvestment Act is successful, Capps may be named nursing coach of the year for the 107th Congress. She and her colleagues will be known for managing nursing’s crisis-within-a-crisis by allowing the next generation to step up to the plate.