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The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where 番茄社区app reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

This week we're doing things a little differently and diving deep on one topic. For the past several months, 番茄社区app's Washington Correspondent Shannon Firth has been reporting on for-profit nursing programs. She's interviewed current and former students, regulators, lawyers, nurse leaders, and even former faculty. She's dug through emails, filed FOIAs [Freedom of Information Act requests], and listened to recordings of nursing board disciplinary hearings. What Shannon has been trying to understand is what's happening behind the scenes of these nursing programs. Today, she'll share with us what she uncovered. Join me in welcoming Shannon Firth to the show.

Shannon Firth: Hi, Rachael, thanks for having me on the podcast.

Robertson: Thanks for being here. We're gonna get into your reporting on a few case studies of for-profit nursing programs in just a minute. But let's start with the bigger picture. Who chooses for-profit nursing programs? And what about those programs appeals to them?

Firth: First things first, it is not easy to get into a high-quality nursing program. In 2022, nearly 80,000 qualified nursing applications were turned down from four-year colleges and universities due to a shortage of nursing faculty, preceptors, and clinical sites. That's according to the American Association of Colleges of Nursing. Many public and nonprofit private programs have a years-long wait list. But for a lot of for-profit nursing programs, there's no waiting at all. Their programs are flexible and faster. Students can take classes on nights and weekends. Most programs are hybrid. And while they may cost more than public schools, many are cheaper than nonprofit private schools. Plus, students are told they can earn their degree in one and a half years or less if they have previous clinical certifications.

These factors make for-profit programs especially attractive to non-traditional students, like single mothers, immigrants, and veterans. Many can't afford to take 4 years away from other responsibilities. But for 1 to 2 years, they figure look, I can study at night work in the day, take classes online, hire a babysitter during my clinicals. ... I can make this work! And for many people that does work, but not for everyone. Not every for-profit program is set up to ensure student success.

Let me back up a bit. So in order to become a registered nurse, nursing school graduates must pass the board exam. It's called the National Council Licensure Examination, or NCLEX for short. A published in the Journal of Nursing Regulation looked at more than 14,000 nursing programs and analyzed their NCLEX pass rates according to each school's ownership status. The pass rates for graduates of for-profit programs were on average 20 percentage points lower than for graduates of public nursing programs across all degree types.

Robertson: Wow, 20 points -- that is a lot. But let's backtrack just a little bit more. What is a for-profit nursing program? How is it different from nonprofit and public programs?

Firth: The main difference between for-profit and nonprofit colleges has to do with ownership. Nonprofits can be public, meaning state funded, or private, while for-profit schools are run by private companies and represent shareholder interests. The goal of a for-profit college or university is to make a profit, while the goal of nonprofits is to provide a public service, meaning education or research. David Halperin, a lawyer and author who's an expert on for-profit schools, summed up their goals on his blog, the "Republic Report" in four words, saying, "They exist to enroll" -- meaning they care more about future students than current ones.

In 2007, there were only about 60 for-profit nursing programs. But by 2016, there were over 300 -- a 5-fold jump -- and the number of students graduating these programs grew even more exponentially, according to the same 2019 study I mentioned earlier. So while there are still tons more public and private nonprofit nursing programs, the for-profit nursing programs are growing. But what I learned in my reporting is often these programs aren't delivering on the promises they made to their students, leaving some students to drop out and others saddled with mountains of debt.

Robertson: You said earlier that some for-profit nursing programs are not setting students up for success. And it sounds like that can have really devastating consequences. Can you tell us more about what that looks like?

Firth: Sure, Rachael. In addition to perhaps your high school transcript or GED, many nursing programs require an admissions exam. Colleen Auer, a litigator in Arizona who's filed lawsuits against some of these schools, told me that the minimum scores for passing these exams can be "all over the map." Some schools look for an 80% but for others 60% -- a D minus -- is enough. But once they're enrolled, students are expected to make A's and B's in the program. Lawyers I spoke with in three different states who have sued the schools all agree: that's predatory.

For-profit programs intentionally target low-income prospective students -- anyone eligible for federal student loans, like the GI Bill, or Pell grants, or Title IV loans. For programs, loan eligibility equals access to essentially guaranteed dollars. Auer told me their main goal is "just to get butts in seats." What so many students I spoke to were unaware of is that if a for-profit program winds up closing, or even if a student independently chooses to transfer to another program, often their credits are not transferable, meaning those students may have to start all over completely from scratch.

The important thing to know is there are plenty of legitimate high-quality for-profit nursing programs. Some individual for-profit programs have even performed as well as the top public and nonprofit programs. But the demand to grow the nursing pipeline has drawn out bad actors who prioritize shareholders over students. Each of the three case studies I'll share illustrates a different problem with these schools. The first looks at a university that by all signs is struggling financially, while keeping its students in the dark. The second spotlights a school that was failing, but got a second life by branding itself as a new program. And the third looks at the thorny question of what to do with a failing program.

Robertson: Wow, there are a lot of factors at play here. Let's move into your first case study to see how these higher level issues played out in Virginia.

Case Study 1: Stratford University

Robertson: You reported on several case studies in your series, but let's start with Stratford University, which was a for-profit program in Virginia that suddenly shuttered in September of 2022. Can you tell me more about what happened there?

Firth: Sure, Rachael. Stratford is an example of a school that was struggling financially but wasn't always transparent with students about its problems. Accreditation is key to unlocking access to federal financial aid. If a school is high performing and financially stable, finding a new accreditor might not be that difficult. But based on appearances, Stratford appeared to be neither. I spoke with one former student, Lizette Scupal, a single mom working in retail who had always wanted to be a nurse. She enrolled in Stratford, but only 2 weeks into her core program, students were invited to a Zoom call with the Virginia Board of Nursing to investigate student complaints. Students described professors showing favoritism and some who would read off PowerPoints rather than teach the material. Students also complained about not getting enough hands-on experience. According to Scupal, one student described the challenge of finding a clinical rotation as "like The Hunger Games."

Robertson: Jeez, that is not a good sign. What happened after that Zoom call?

Firth: So unfortunately, the students' warnings were pretty spot on. Scupal couldn't find the pediatric clinical rotation, which along with other factors, delayed her expected graduation date. Amethyst Whitaker, another student, told me when she arrived at the site of one of her clinical rotations -- a nursing home -- it quickly became clear no one was expecting students. When the clinical instructor arrived an hour and a half late, she complained about not having been paid. Whitaker said it felt like the school was "scrambling to keep up the illusion that things were okay."

In hindsight, Scupal said she wished she'd paid attention to the school's NCLEX pass rates, which for one Stratford campus at the time, were only about 52%, meaning only about half of Stratford graduates took the board exam to get their license and actually passed. But there were other red flags, too. Beginning in the late spring into the early fall of 2022, the WiFi was disabled for weeks, the library closed, and an important software license lapsed. Financial Services stopped responding to emails and a number of custodial staff were fired or quit en masse. Students were told to clean up the bathrooms after themselves and professors were now responsible for replacing toilet paper in the bathrooms. Students told me at one point professors started leaving back to back. Then on September 12, 2022, dozens more staff were terminated.

Robertson: Obviously, hindsight is 20/20. But what were students thinking at the time? Did they see that Stratford was a sinking ship?

Firth: Well, the students were definitely not clueless. I had access to a group chat where students were going back and forth about whether or not they thought the school might be closing. Some were reading online that Stratford's accreditor might go under. And that was another concern. Again, colleges and universities must be accredited if they want to be able to receive federal loan dollars. Stratford had an accreditor, just not a very good one.

Every time a student flagged a problem with the school, someone would reassure the students that the school had things under control. For example, in June 2021, when concerns were first raised about Stratford's accreditor potentially losing its status, the university's president Richard Shurtz said the school had implemented a "preemptive plan of action" and was well on its way in the process of applying with a new accreditor. And that day in September 2022, when dozens of professors and other staff were fired, the Stratford student council president sent a text in all caps saying she'd spoken with the dean and "THE SCHOOL IS NOT CLOSING." The very next day, students received emails from the registrar encouraging them to enroll for their next round of classes. A lot of students were nervous, and were looking for a way out. But when you're enrolled at a nursing school with a bad reputation and low NCLEX pass rates, there aren't a lot of open doors.

Robertson: To wrap up this case study on Stratford, I'm sure listeners want to know: what happened to Stratford in the end?

Firth: Stratford officially closed in December 2022 and declared bankruptcy in 2023. In late September 2022, about 2 weeks after that all-caps message saying that school was not closing, the students received a very different email from the university's president, again, Richard Shurtz. He said Stratford's accreditor ACICS, which stands for the Accrediting Council for Independent Colleges and Schools, had been stripped of its recognition by the Department of Education. When I said ACICS was not a very good accreditor, that was an understatement. ACICS once rubber-stamped a university that had no students and no faculty, . Without accreditation, the Department of Education said Stratford could no longer accept new students. And without new students, the university's president said the school financially couldn't stay afloat. Here's Lizette Scupal sharing her reaction to the email about the school's closure.

Lizette Scupal: I'm telling you it is hard when you have to get up, you go to work at 10 at night til 7 in the morning, lift boxes, do so much work. And then you come home and you can't go to bed. You have to do assignments, you have to study. There are days I didn't even get to sleep. And then it was just an email that said Stratford will cease operations. The most hurtful thing I can tell you, so many times, to be honest, is we asked, 'Is Stratford closing? Are they doing a teach-out? Is Stratford losing accreditation?' And every time they told us no, no, no.

Robertson: So what happened to Scupal and Whitaker and the other students you spoke with?

Firth: So when the school closes abruptly, students are eligible to have their loans forgiven. But at the time of my reporting, only one of the students I'd spoken with who requested loan forgiveness had actually received it. Whitaker had a job lined up as an operating room nurse, but without a degree and a license, the offer became void. Scupal transferred to a large public university. She likes the program, but because Stratford didn't provide this new school with the correct documentation, she has no proof of the clinical rotations she's completed. That means Scupal is essentially having to repeat the entire curriculum. Here's Scupal:

Scupal: Yes, we had to literally start all over again. I can sincerely tell you when I went back to clinical the first day, we had to learn you know, like the basic stuff, wash dentures and all that stuff and just making a bed -- and I literally just started to cry.

Firth: Scupal also told me she feels lucky to have a chance to start over, but she's maxed out her student loans like a lot of other students. Next term, she might have to pick up extra hours at her job to pay out of pocket if scholarships she's applied to don't come through. Nearly a dozen students, including Whitaker and Scupal, have filed a lawsuit against Stratford University. But that lawsuit is currently stuck in bankruptcy court.

Robertson: Yikes. That is so alarming that someone can work so hard and come so close to their goal only to have it move further out of reach. Thank you for your reporting on this Shannon.

That's it for today's special episode of MedPod Today. Shannon and I will be back soon with part two of our deep dive into for-profit nursing schools. Stay tuned.

Also a quick note -- this special episode is based on Shannon's reporting for her series "What's the Matter With For-Profit Nursing Programs?" That series made Shannon a at the National Institute for Health Care Management (NIHCM) awards this year. Links to all the stories in her nursing series are in the show notes.

This episode was hosted and produced by Rachael Robertson. Sound engineering by Greg Laub. Our guest was 番茄社区app's Washington Correspondent Shannon Firth. If you liked what you heard, leave us a review wherever you listen to podcasts, and please hit subscribe if you haven't already (, ).

MedPod Today is a production of 番茄社区app. For more information about the show, check out medpagetoday.com/podcasts.

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