Pursuing a four-year degree as a registered nurse means embracing a world of exams.

It means years of study groups and practical evaluations. It means passing an eight-week course to be a licensed nursing assistant before even entering a college program, and racing to pass the National Council Licensure Examination in the months after.

It means hours of academic sacrifice in preparation for a medical career that offers little respite.

Jaclyn Seagren is familiar with the challenges. On a blustery December morning, Seagren and three of her peers, all freshmen, huddled at the Keene campus of River Valley Community College. They had just finished the last of their final exams for the semester; four over six days. Winter break was minutes away. One semester down, seven and a half to go.

“This semester I feel like I learned so much,” Seagren, of Keene, said. “And at the same time I had no idea what I was getting into.”

Plenty of slots

The nursing industry in New Hampshire, and across the nation, is in free fall. Hospitals and care facilities, feeling the effects of a workforce fall-out across the health care profession, have suffered as fewer people go into nursing, and positions remain unfilled.

Among 16 Monadnock Region facilities, 229 places for nurses are empty, according to a survey by a local task force dedicated to solving the crisis.

And preferences for registered nurses mean that some facilities are starving for people who can’t or choose not to complete the grueling four-year program and shoulder the tuition expenses.

For many of the freshmen nursing students at River Valley, entering study as registered nurses is a natural extension of their life experiences.

Seagren, 24, got interested upon seeing an ad in a newspaper, after odd jobs in care positions. Her classmate Elizabeth Moers, 23, of Keene, had worked in child care and day care, and sought the level of public service the nursing profession offers.

Sarah Woodman, 20, another classmate, always wanted to be a doctor. At 14, her ambitions changed. Her father passed away after a battle with cancer. There were many days spent by bedsides and in hospital waiting rooms.

“I didn’t remember the doctors,” she said, recalling the experience. “I remembered the nurses. They were always there, always present.”

On one of those hospital days, one of the nurses turned to her and told her she would be a great nurse one day.

Woodman says the nursing profession offers a chance at touching the lives of those in crisis. “We’re able to provide care in dignity,” she said; “people at their lowest moments, whether they’re coming into the world or leaving it.”

But Woodman says the demands of the job provide natural limitations to entry.

“You need to have a sense of compassion to be successful in this field or you’re not going to love it,” she added. “You’re not going to make the impact that you wish to.”

Benefits and drawbacks

These students are aware of the shortage across the state. But they say in many ways it’s not surprising, given what nursing entails. The hours are long; it isn’t a 9-to-5 job, they point out. Some of the work is gritty and painstaking. And many of the benefits involved are emotional, not monetary.

“People just know that it’s really hard,” said freshman Laura Hansen, 26. “And so I think people are really like, ‘Wow, that’s really great, good for you; I’m glad someone’s doing it.’ ”

Getting through the education is also a trial. Passing the exams, which come regularly, is a continual challenge. In the weeks ahead of finals, the students band together into study groups, determined to get to the end together.

It used to be that eight-week LNA and one-year licensed practical nurse (LPN) degrees were seen as an easy and attractive foothold into a care-based industry with good pay and job security.They were regarded as launching points for a career as a registered nurse (RN).

But lowered pay, increased tuition costs and scarcer education and training programs have contributed to a significant dent in nursing entrants.

Now, the diminishing interest from potential students means that that pipeline, or what exists of it, is drying up. Local care facilities such as Maplewood, the county nursing home, benefited from the infusion of LPNs in years past.

William Shafer, 53, of Keene, followed that ideal track, working as an LPN for years and graduating with an RN bachelor’s degree this year. But the process wasn’t easy, he says.

Shafer jumped into nursing late in his career, originally working for a software development company in Cambridge, Mass. After a post-9/11 economic downturn, the company imposed mass layoffs, and Shafer moved to Vermont, scraping by on minimum-wage jobs.

A decade ago, after nearly hitting rock bottom, he did some research into alternative careers. Nursing in Vermont, with its low tuition and high entry-level salary, seemed a safe bet. He found an LPN program at Vermont Technical College and set to work getting in.

But the way in was not exactly comprehensive. Shafer needed prerequisite college course credits to be eligible for the degree, which he collected only after a year of education at the Community College of Vermont. He faced strong competition — 500 applicants for 24 places — and found a challenge in getting back into a college mindset.

But in two years Shafer had his LPN, soon finding well-paying jobs in private nursing homes across Vermont. Eight years later, he was ready to study for the RN degree.

The competition for an RN program proved to be even higher. Shafer found himself looking in states beyond Vermont, searching far and applying wide. Even after finding a program at Keene State College, the entry bar was high. Applicants needed a 3.5 grade point average; Shafer had a 3.4. He went back to classes, this time at Keene State, to raise his average.

“You’re being held to a much higher grade standard than other majors; it’s so easy to blow a class,” he said.

After two and a half more years, Shafer graduated with a bachelor’s RN from Keene State in August 2016. He’s waiting to take his National Council Licensure Examination sometime before this February.

Shafer is surprised how quickly things have changed in the educational landscape. Where once entry into a program was a rat race, the applicant pool is now anemic; River Valley only filled 15 of its 16 spots in its RN program in 2016, after already reducing admission to every other year, according to Patricia Shinn, chairwoman of the nursing department.

The college cut its local LPN program several years ago during a re-accreditation process, citing insufficient interest.

Shafer is happy to be in the profession — “It’s not the most glamorous job at times, but it’s a very satisfying job.” But he says the effects of the nursing shortage affect his daily life.

He works at a private nursing home in Keene — he declined to identify it by name — and he says the lack of staffing makes it difficult to give any one patient quality care.

“It’s a war zone,” he said. “It’s hell, it’s hard, it’s ugly. And it’s not right. We’re dealing with our fellow humans here.”

Ethan DeWitt can be reached at 352-1234, extension 1439, or edewitt@keenesentinel.com. Follow him on Twitter at @EDeWittKS