Florence Nightingale would be amazed.
Since she founded the first nursing school in 1860, education for nurses -- and the demand for well-educated nurses -- has expanded dramatically.
Nursing now is the third most popular college major in the nation, according to the Princeton Review.
In Pennsylvania, enrollment in professional registered nursing programs has nearly doubled since 1999, from 9,859 in 1999 to 19,411 in 2006.
"Nursing has reached the time where it is one of the most valued and desired professions," said Pamela Klauer Triolo, chief nursing officer of UPMC, which offers nursing diploma programs at Shadyside, St. Margaret and Mercy hospitals.
There are several ways to begin and enhance a nursing career.
Future nurses can earn a diploma at a hospital-based school, an associate degree at a community college or a bachelor's degree at a four-year college or university.
In Pennsylvania, there are 22 diploma schools, 35 schools offering bachelor's degrees and 27 offering associate degrees, according to the state Health Department. Allegheny County alone has 14 nursing programs.
For those who don't start in a four-year program, colleges offer special programs to help registered nurses finish a bachelor's or master's degree.
For those who have earned bachelor's degrees, master's degree programs in a range of specialties and doctoral programs can widen career opportunities.
Some schools tailor programs for working nurses, offering online, weekend or evening classes.
Al Rundio, 55, of Egg Harbor, N.J., who already had three master's degrees and a Ph.D., finished a doctor of nursing practice through Chatham University's online program in August while working as a nurse practitioner at an addiction treatment center in New Jersey. He and his classmates began the program the previous August.
In some cases, working nurses can receive tuition reimbursement from their employers. A federal program provides student loan forgiveness for some who practice in areas where there is a critical shortage.
"The more education you get, the more doors are open to you," said Diane Anderson, 49, of Irwin, who now teaches at the Shadyside Hospital School of Nursing.
Ms. Anderson has become a nurse one step at a time. She graduated from the licensed practical nurse program at Westmoreland County Community College in 1978, became a registered nurse through the Shadyside Hospital School of Nursing in 1984, and earned a bachelor's degree in nursing in 2006 and a master's in nursing in August, both from Chatham University. Next planned stop: a doctor of nursing practice at Chatham.
Ms. Anderson believes the diploma program gave her a strong clinical background.
"I'm glad I grew in nursing the way I did. Every time I go back to school, I feel really good about what I've done and what I've learned," she said.
Clare Hopkins, interim associate dean and director of the Carlow University School of Nursing, advises taking the "direct route" to nursing via a bachelor's degree.
Dr. Hopkins, who started her career with a bachelor's degree in nursing from the University of Michigan, said many students in diploma or associate degree programs end up spending longer working on getting a bachelor's degree than they would have otherwise because life events often intervene, forcing them to go part-time or take time off.
Increasingly, the bachelor's degree is becoming more important in nursing, with only a small number of states offering diploma programs.
Jacqueline Dunbar-Jacob, dean of the University of Pittsburgh School of Nursing, said research shows that registered nurses with a bachelor's degree produce better patient outcomes for hospitals on average.
Noting that hospital patients tend to be sicker than those of years ago, Dr. Dunbar said, "The level of complexity in managing nursing care of patients has increased substantially."
In addition, the roles of nurses, such as nurse practitioners and nurse anesthetists, have expanded.
Kathryn Yecko, director of the School of Nursing at Washington Hospital, which has about 50 graduates a year, believes that diploma schools play an important role.
The 28-month Washington Hospital program is affiliated with Waynesburg University, which provides college courses in the sciences for students. Some students later finish their bachelor's degree in nursing at the university.
Mrs. Yecko, who started her career with a bachelor's degree in nursing from Penn State University, said the hospital school attracts largely nontraditional students.
"We do get some of the traditional students out of high school. We tend to get more second-career people, single parents, people with families who lost their jobs, the mill shut down, a mine shut down," she said.
"Through job retraining, they have to get a good career as quickly as possible to be able to support their families. They can't do that with a four-year program."
Getting into many nursing programs has become more competitive over the years.
Pitt received 970 applications for this fall's freshman nursing class, which was limited to 110 students. About 200 were admitted, with 107 enrolled. The university has about 1,000 students studying nursing at the graduate and undergraduate level.
Community College of Allegheny County has an open admissions policy overall, but not for its associate degree program for nurses, which has about 940 students.
CCAC applicants must have a 3.0 grade point average or higher in high school if coming directly from high school or a 2.5 GPA or higher for at least 12 college credits. They must also pass a nursing entrance test, which focuses on math and reading.
With the right background in science and math, students can complete the CCAC nursing program in two years, but three years is more common.
Maureen Pavlik, associate dean of nursing at Community College of Allegheny County, said there is a big need for nurses. But schools are limited in how many nurses they can prepare by the number of available faculty as well as lab space, she said.
Nursing programs are demanding. Statewide, about a quarter of those who start a nursing program do not finish, more than half for academic failure, according to the state Health Department.
Carla Daw, a 2001 Penn Hills High School graduate who earned a bachelor's degree from Gannon University before enrolling in nursing last fall at CCAC, said, "It's a lot of hard work in a short amount of time, but it's worth it in the end and you'll never be out of a job."
Kristen Aikens, a Robert Morris University senior and 2005 graduate of Center Area High School in Beaver County, said, "It's not your typical four-year college degree. There are days we are just so swamped it's almost like we're not college students. We're in our careers. We have classes and tests. We have clinical hours."
Wherever they attend, students still must pass the NCLEX-RN exam -- a national exam that state boards of nursing use in the licensure process -- to become a registered nurse. This exam focuses primarily on the entry-level skills of a hospital nurse.
Pass rates vary by individual school, not necessarily the type of school.
The pass rates for first-time candidates by school can be found by using Google to search for "Pennsylvania State Board of Nursing" and then clicking on licensure information, followed by NCLEX performance.
A strong job market and favorable pay have helped to make nursing attractive. The median pay for a registered nurse was $62,480 last year, according to the U.S. Bureau of Labor Statistics.
Lynda Davidson, dean and professor in the School of Nursing and Health Sciences at Robert Morris, where there are about 170 nursing students, said graduates of the relatively new program are getting multiple job offers. Officials from some hospitals have come to talk with freshmen, in the hopes the students will choose them four years later.
When Greg Hites graduated from Robert Morris in December, he had six job offers. Mr. Hites, 31, chose the Veterans Administration Hospital in Oakland.
"It's the best job I've ever had in my life," he said. "I find it very fulfilling to help people in their time of need."
Brianne Morris, who graduated from Hopewell High School in 2004 and from Robert Morris' nursing school in May, interviewed only at Children's Hospital, her top choice. She had a job offer in February.
"I love it," she said. "I knew that's what I wanted."
Education writer Eleanor Chute can be reached at firstname.lastname@example.org or 412-263-1955.