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Very soon, thousands of newly-minted nursing and medical students will matriculate at professional schools across the country. Most of them will be [horizontal ellipsis] excited? Anxious? Overwhelmed? Eager to learn? A little bit of each of these? When asked why they have chosen a professional career in healthcare, the answers vary widely. "To serve others, to make a difference, to help the less fortunate, to provide lifelong intellectual challenges, to follow a family tradition," and some "to make money." Few, if any, discuss the enormous financial burden this education often brings with it.

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Doctors now graduate from medical school owing an average of more than $155,000 and ~85% have at least "some" debt. Nurses graduate with debts of $10,000-$50,000, with those new graduates who have chosen nursing as a second career often owing even more. Loan repayment begins shortly after graduation, while doctors work as residents and nurses look for work in a job market that seeks "experience." Physicians opt to practice in highly paid specialties rather than primary care; nurses, who are typically paid a base salary that is not specialty specific, often choose tertiary, urban, and suburban medical centers rather than smaller, and perhaps more rural, work settings since these may pay less. The results of these choices are an estimated shortfall of primary care doctors, in both urban and nonurban settings, and a shortage of nurses willing to work in primary care clinics, subacute and long-term care settings, home care, and public health.


Although the significant costs of all health professional education are not new, the costs of nursing education have been identified as a continuing concern voiced in the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, with a call to transform education. Costs vary by pathway and level of education chosen, but the majority of individuals seeking nursing education self-finance most of their education even though limited grants and scholarships exist. Costs vary as well when comparing public, private, and proprietary options. Measuring costs can be accomplished in at least four ways: "production costs" of delivering education to students, the "sticker price" students are asked to pay, the total cost to students to attend college (room, board, tuition, fees, books, transportation), and the "net price" actually paid after awards and grants are considered (Manno, 1998). Coupled with the IOM's push for an all-BSN entry-level workforce and ever-increasing numbers of advanced-practice nurses, educational costs will remain a barrier for many potential practitioners.


What options exist to resolve these cost issues? The simplest approach is to throw up our hands, wail, and gnash our teeth about the high costs of all education. That, unfortunately, won't help create long-term plans that assure enough nurses who possess the leadership, healthcare financing and policy, quality improvement, evidence-based practice, and research skills to care for increasingly aging, medically complex patient populations. We also must develop plans that address current and future shortages of nurses who serve as primary care providers, nurse researchers, and nurse faculty.


One unique suggestion to address educational costs, originally put forth as a means to manage the shortage of primary care physicians, is to charge individuals to specialize. Bach and Kocher (2011) suggest that we make, in this case, medical school free to reduce students' debt burden and shift the workforce toward primary care. Their plan would waive tuition to medical school for all students, but only those who then choose to continue graduate education (residency) in primary care would receive salary stipends; no stipends would be provided for physicians choosing specialty practice areas. Could this work for nursing? Could nursing school become tuition free for those nurses who commit to work in primary care settings, clinics, schools, public health departments, critical access hospitals, or long-term care facilities? Could we shift the nursing workforce away from acute, tertiary care settings and away from the high-tech environment toward research and education?


How would the educational costs be paid? And by whom? Some options already exist. The National Health Service helps healthcare professionals repay loans in return for a commitment to work in underserved areas. The National Institutes of Health offer a similar program to promote work in public health and research. Some states support postbaccalaureate nursing education with outright grants or with tuition forgiveness based on work with vulnerable populations. The healthcare reform law includes incentive programs for primary care physicians who treat Medicare patients-nurses will need to lobby for similar consideration. The Oregon Consortium for Nursing Education (OCNE) uses a model that pools faculty, classroom, and clinical training site resources to allow working nurses to move more easily from an associate's degree to a baccalaureate degree. In addition to being a cost-effective path to a higher level of education, the OCNE model uses a single curriculum across 13 campuses that focuses on health promotion and wellness, clinical decision making, and leadership, the very skills outlined in the IOM initiative.


Would free nursing education actually help us achieve the educational goals we envision as necessary? Perhaps. To quote Bach and Kocher (2011), however, "Taking the counterintuitive step of making [horizontal ellipsis] education free," while charging those individuals who seek specialty placement or additional education, may be an initiative whose time has come.




Bach, P. G., & Kocher, R. (2011). Why medical school should be free. The New York Times. Retrieved from[Context Link]


Manno, B. V. (1998). Vocabulary lesson: Cost, price, and subsidy in American higher education. Business Officer, 31(10), 22-25. [Context Link]