PHOENIX -- Getting top grades, serving as president of her student nursing association and networking with professionals didn't get Chloe Burtcher the nursing job she knew was her calling when she received an associate degree from Yavapai College in 2012.
"We were told from the first day of nursing school that it was going to be hard to get a job, but I knew I could beat any odds," she said.
Burtcher said she didn't give up despite rejection after rejection. She enrolled in more nursing classes and volunteered for hospitals doing blood pressure and cholesterol checks at public-screening events. She started a Facebook page to connect other new registered nurses seeking jobs with volunteer opportunities.
After nearly a year, Burtcher found a hospital job that she said will give her the experience she needs to become a nurse practitioner, a nurse who can take care of patients without a physician's oversight.
"I knew I just needed to keep my heart in it and I'd finally get to where I wanted to be," Burtcher said.
Nursing has long been considered a career with boundless demand, in part because of Arizona's rapid growth, but recent years have seen a tightening job market. Experts, educators and leaders in the field of nursing point to the economic downturn, a state mandate that colleges and universities turn out more nurses and changes in the nature of health care as reasons.
Surveys by Arizona State Board of Nursing found that during the past three years almost 20 percent of the state's new registered nurses were unemployed after a year. For those who got jobs, nearly 40 percent had job searches lasting nine months or more, even after sending out more than 50 resumes for any available clinical job, any shift, almost anyplace in the state.
Robin Schaeffer, executive director of the Arizona Nurses Association, which represents 80,000 Arizona nurses, said she worries the current struggles faced by many nursing graduates will lead to a shortage of those wishing to become nurses when demand picks up again.
"If we don't work this out, we will be in trouble," she said.
The tight job market has come as a surprise for many new registered nurses.
Kristen Cleary, who graduated from Arizona State University in 2012, said she was lucky to get a hospital job in Tucson after a three-month search in which she sent dozens of resumes.
"When you start nursing school, you have the impression that school is the hard part," Cleary said. "But that's not the case; it's getting the job."
Demand for experience
A nursing career has traditionally started in a hospital, working alongside doctors and more experienced nurses. The next step often takes nurses into caring for patients in their homes.
However, both sectors are seeing a tight hiring market of late.
Examining the issue in a report titled "What Happened to the Shortage of Registered Nurses: The Arizona Experience 2008-2012," the Arizona Hospital and Healthcare Association noted that during the economic downturn many part-time nurses went full-time and non-practicing nurses returned to work. Meanwhile, nurses of retirement age stayed in their jobs.
More experienced nurses had an edge over new graduates for jobs, the report said.
Lee McPheters, a health economist at Arizona State University's W.P. Carey School of Business, said that health care jobs continued to increase through the economic downturn but have slowed of late for reasons that aren't completely clear.
"It might be that short term it's a cost-savings measure," he said. "But it may also indicate that with the current uncertainty in the health care environment hospitals are reluctant to take on more professionals."
Greg Vigdor, CEO of the Arizona Hospital and Health Care Association, said patient counts and health care spending have declined around the country. In Arizona, he said, that might stem from slower population growth and cuts to the Arizona Health Care Cost Containment System, the state's Medicaid program.
Elizabeth Maish, chief nursing officer at Tucson Medical Center, said that hospital nursing is becoming increasingly specialized as patients live longer with more complicated health problems. That requires skills that often are beyond a new nurse's expertise, she said.
"Hospitals will hire only a few new-grad nurses in order to match them them with a core team of nursing experts since it takes a year or more to create new experts," Maish said.
Marie Fredette, executive director of Arizona Association for Home Care, said home health care providers seldom hire new nurses because employers also require another layer of experience.
"In the home setting, a nurse has to function totally on their own without reliance on another nurse or a doctor down the hall to help sort out problems," she said. "That takes more experience than new registered nurses usually have."
Push for nurses
In 2002, health care organizations and experts pointed to a looming nursing shortage, fueled in part by low pay and a growing number of career options for women. The Joint Commission, an independent group that accredits U.S. health care organizations and programs, noted with alarm that fewer people were entering the profession.
Congress responded by passing the Nurse Reinvestment Act, which provided scholarships and loans along with grants for nursing education.
Pointing to Arizona's rapid growth, the Arizona Hospital and Healthcare Association successfully lobbied the Legislature to provide funding making it possible for colleges and universities to double the number of nursing graduates by 2007.
"Out of the hundreds and hundreds of bills I was involved with, I remember this bill specifically because the testimonies were so moving," said Susan Gerard, a former lawmaker who was chairwoman of the Senate Health Committee at the time.
Pam Randolph, the Arizona Board of Nursing's associate director of education, said that by 2009 nursing graduates totaled nearly 2,800, up from about 1,200 graduates in 2002.
"The mandate worked," she said.
The Arizona Hospital and Healthcare Association's report assessing what happened to the anticipated nursing shortage notes that as of 2010 the supply of nurses in Arizona had reached the level expected to be needed in 2017.
Regardless of whether an individual receives an associate, bachelor's or master's degree in nursing, all graduates take a standardized exam leading to a license that allows them to practice as registered nurses.
According to the Arizona State Board of Nursing, 68 percent of new registered nurses had an associate degree and 32 percent had bachelor's degrees in 2012.
While nursing jobs are more difficult to come by these days, health care industry leaders see renewed demand on the horizon. Among the reasons: More people are expected to gain access to health care under the Affordable Care Act and baby boomers are retiring in large numbers.
Meanwhile, 1 million nurses over age 50 -- almost a third of the current nursing workforce -- could retire in the next 10 to 15 years, according to a recent report by the U.S. Department of Health and Human Services.
Peter Buerhaus, a health care economist and national expert on nursing employment, said he empathizes with new nurses struggling to find jobs in Arizona but urges them to "hang in there because overnight there are going to be jobs -- a lot of jobs."
"With what's coming with nursing retirements and more people being insured, the bubble will burst and we will still have a nursing shortage," he said.
Robin Schaeffer, with the Arizona Nurses Association, notes that a third of nurses currently employed in Arizona are older than 55. While demand for new nurses has declined of late, she said, it is more of a momentary lull.
"It actually feels like we are in the eye of a really big storm, not just a bubble," Schaeffer said.
Sherry Stotler, Maricopa Integrated Health System's chief nursing officer, said she knows current new nursing grads struggle to find jobs -- hospital jobs and jobs that often require hospital experience -- but said she expects that to change soon. More nurses will retire as the economy improves and others working to keep health insurance for their families may leave the profession because they can get insurance under the Affordable Care Act.
"No one has a memory of a time when there were too many nurses; there is only a memory of a nursing shortage," Stotler said. "I think even in the next one to two years, we may be facing a shortage again."
Riding the wave can be unsettling for aspiring nurses such as Caroline Branch, a Grand Canyon University student, who is president of the Student Nurses Association of Arizona.
Branch said she and her classmates felt blindsided when a clinical nursing instructor approaching retirement age told them, "I still have your job."
"You go into this profession knowing there is always turnover, there are always nursing jobs, so when you hear that message for the first time, you say to yourself, ‘What am I even supposed to think much less do about that?'" she said.
Arizona's nursing educators say that while they are painfully aware of the challenges facing new graduates they must prepare enough nurses to meet anticipated demand.
Teri Pipe, dean of Arizona State University's College of Nursing and Health Innovation, said the situation needs to be considered in the context of the larger job market for new graduates.
"When the average employment rate is 24 or 25 percent, compared to other university students we still have a very fortunate situation in nursing," Pipe said.
"In the next three or four years we will see a mass exodus of older nurses who will retire," said Anne McNamara, dean of Grand Canyon University's College of Nursing and Health Care Professions.
Melissa Goldsmith, associate professor and faculty coordinator for the University of Arizona's nursing program, said nursing jobs are predicted to increase 26 percent between 2010 and 2020 due to more people needing health care.
"I don't have a crystal ball to predict when, but we are going to see a shortage again," she said.
Branch, the student, said that nursing school is too hard and too expensive not to try to find some way to work with future employers to bridge the gap. Hospital-sponsored residencies make the most sense, she said, but those are rare because of the expense.
"So, it looks like it's going to be up to us when we get done with nursing school to either help make the solutions, or ride the wave of overabundance until someone hires us or someone retires," she said.