By John Russell

For years, the demands of a nursing education also brought a reward. It was a recession-proof career, a lure for generations of students. “I knew going into school I was choosing a safe major, because all you heard is how badly hospitals needed nurses,” said Bush, a junior at Indiana University School of Nursing.

Just how many nurses hospitals still need is a big question. In recent months, major hospital chains in Indiana and around the country have reorganized and chopped tens of thousands of jobs, citing declining admissions and lower reimbursements from insurance companies and government programs.

As hospitals shed jobs, openings for nurses and other health professionals are popping up in other settings: outpatient clinics, rehabilitation centers, walk-in clinics and patients’ homes.

The jobs pay a little less than the annual median wages of $65,950 for registered nurses in the U.S., but that’s where the growth is, health-care experts say.

That leaves nurses and students who want to work in hospitals wondering about their future.

When Bush graduates next winter, she probably will have to scour lots of online job listings and prepare for competitive interviews. Bush says the news is unsettling and sometimes intimidating. Yet she tries to remain upbeat.

“Just like any job, you have to market yourself,” she said. “You need to be a good employee. You need to use your connections.”

What happened?

It wasn’t supposed to be this hard. Nursing long has been a steady, well-paying career, with plenty of openings. Nursing students often got multiple offers before graduating. Hospitals scrambled to fill nursing positions.

For generations, nursing helped families enter or remain in the middle class. The profession provided stimulation, useful skills and community respect. It gave peace of mind during economic downturns that crunched many other occupations.

Now it’s a different picture. Hospitals, facing empty beds and falling revenues, say they have no choice but to consolidate labs, close programs and slash jobs. They say the pace of change is greater than at any time in recent history.

So far this year, the health-care sector has announced 41,085 layoffs, the third most behind financial and industrial companies, according to outplacement firm Challenger Gray and Christmas.

IU Health, the state’s largest hospital system, cut 900 jobs this fall, or about 2 percent of its workforce. St. Vincent Health cut about 800 people, or about 5 percent. Franciscan Alliance cut 275 jobs, or about 1.4 percent.

Only a fraction of the hospital jobs affected, perhaps 25 percent, involve nurses, said Kim Harper, executive director of the Indiana Center for Nursing. But the contraction has made it tougher for nurses to find hospital jobs and for nursing students to get their first break.

Nursing jobs still abound, just in other settings. It’s part of the great migration of nursing jobs from full-service hospitals to outpatient clinics, patient homes, rehabilitation centers and walk-in clinics.

“Times are changing, and the venues are changing,” Harper said.

In the nursing world, the shift is called a move from “high-acuity care,” with specialized staffing and expensive equipment to treat seriously ill or injured patients, to “lower-acuity” or “chronic care,” often requiring less-urgent treatment.

The new jobs are popping up in unlikely places, said Blayne Miley, director of policy and advocacy at the Indiana State Nursing Association. He said he recently spoke with a new nursing company in New Albany that provides care coordination for patients being discharged from hospitals.

“The changing landscape is basically creating the opportunity for a business model that wasn’t really there before,” he said.

Still, hospitals have typically paid top wages for nurses. As more nurses move out of hospitals and into other settings, the average wage for nurses could drop a bit, Harper said.

About 60 percent of the nation’s 2.7 million registered nurses work in hospitals.

For nursing students such as Bush, the seismic changes come at a critical time, as they are trying to break into the job market.

Bush, 21, Irvine, Calif., seems to bring a lot to any job interview. She is president of her class at the nursing school, has high grades and works part time as a patient care intern at IU Health Methodist Hospital.

On the hospital’s fifth floor, she helps nurses care for patients who have been in accidents or suffered strokes.

“You are there for the patients and their families when they are scared and in pain,” she said. “We take care of them. It’s just another day in the life of a nurse, but for them, it’s a day they will always remember.”

Jennifer Burton was taking her nursing board exams the same day that IU Health announced layoffs in September and immediately wondered about her future. Like Bush, she had worked at Methodist as a patient care intern while finishing up her studies. She had hoped to get a full-time job at Methodist after graduating, but her supervisor advised her to start looking elsewhere.

Luckily, within two months, the hospital had openings for floor nurses. She got the job and started Nov. 3.

“It was a lot tougher than I expected,” said Burton, 30, Greenwood. “You go into nursing school and expect to have tons of options.”

At the IU School of Nursing, graduates look for an average of six months to find a job, compared with two or three years ago, when they often had multiple job offers before graduating, said Marion Broome, the school’s dean.

“We have been through this before in the nursing profession,” she said. “Every time there’s a change in the way health care is financed, there’s usually some repositioning of health systems, and a portion of that always affects nurses.”

A different reality

National experts say nurses can’t assume they will get multiple job offers anymore.

Still, nursing advocates say nursing students still have a better chance of landing a job soon after graduating than many other students.

Nursing students with a bachelor’s degree are much more likely to have job offers at the time of graduation (59 percent) than the national average across all professions (29 percent), according to a news release last week from the American Association of Colleges of Nursing.

Still, the long-term outlook is anything but clear. Roughly 40 percent of the nation’s nurses came into the profession in the 1970s and 1980s. Most of those nurses are now in their 50s, nearing retirement.

“We’re going to have a tsunami of retirements just over the horizon,” said McMenamin.

Demand for care will probably go up as Americans age and the Affordable Care Act brings millions more people into the health-care system, he said. So in coming years, he expects demand for hospital care and nursing services to rebound.

That could mean more jobs again for nurses — if they can hang in there.

“The future looks very bright,” McMenamin said, “but the present looks very uncertain.”