This report summarizes the findings of
the various components of this study of
methods for identifying facilities and
communities with shortages of RNs. It
documents the strengths and weaknesses
of different methods for assessing the
extent of shortages of RNs. The report
is presented in seven sections, each summarizing
a different aspect of the study:
- Federal Initiatives to Address Nursing
Shortages
- Initial Literature Review
- Data Sets and Compilations
- Methods and Analyses Based on Facility
Data
- Methods and Analyses Based on Geographic
Data
- Preferred Method
- Study Recommendations
In addition to summarizing these research
components of the study, this report presents
a series of conclusions designed to inform
policy makers and other researchers who
may be interested in implementing or adapting
one or more of these methods in the future.
A. Federal
Initiatives to Address Nursing Shortages
In 2004, realizing that the current shortage
designation process was too narrow in
scope and that RN shortages were likely
to worsen over the next 20 years, HRSA
issued a Request for Proposals for a two-year
research project to gather information
and insights in support of the development
of a new methodology for identifying health
care facilities and agencies with critical
shortages of RNs. The New York Center
for Health Workforce Studies at SUNY Albany
was selected to conduct this project.
There is growing recognition and efforts
are underway to increase production of
RNs and use incentives to target new graduates
to facilities and agencies with the most
critical shortages of RNs. However, there
are issues that must be taken into account
when assessing need and demand for RNs
and identifying health care providers
with the most critical shortages of RNs.
These include:
- Should indicators developed to
measure critical shortages of RNs
be based on need for RNs or
demand for RNs?
- Can standard indicators that measure
critical shortages of RNs be applied
to all of the eligible settings included
in this project?
- Can variations in the supply of
and demand for RNs by region, geography
(i.e., rural or urban), setting, or
facility be accounted for in indicators
that measure RN shortages?
- Are there setting-specific data
sets available at the national level
that include the elements needed to
measure critical shortages of RNs?
- Can a process be developed that
identifies facilities with the most
serious shortages of RNs so that Federal
resources can be targeted on the neediest
facilities?
- How can true shortages of RNs be
distinguished from shortages created
by poor management practices?
A careful review of the literature helped
to inform the discussion of these and
other related issues. Through the identification
and review of existing methods and models
for measuring health professional shortages,
information on these issues will be obtained
and shared with each of four expert panels,
who are providing guidance for this project.
It is unlikely that standard data sets
on staffing will be available for all
of the health care settings included in
this project. Rather, data may be available
for only some providers, e.g., the American
Hospital Association nurse staffing data
set for acute care facilities, or the
Centers for Medicare and Medicaid Services
(CMS) Online Survey, Certification and
Reporting (OSCAR) data set for long-term
care providers. The information on staffing
for some types of health care providers
may be less than adequate, or it may not
be available at the national level.
An effective study should take all of
these issues into account while researching
and testing the development of a national
methodology to measure shortages of RNs.
Current methods are inadequate. A better
method would support several government
incentive programs to attract new RNs.
It would also provide a better basis for
monitoring RN shortages locally and nationally.
B. Study Overview
This study was conducted over a two-year
period, starting in the fall of 2004,
during which nine different research components
were carried out. Each component is summarized
in the body of this report in roughly
the chronological order they were conducted
during the study:
The primary goal of this study was to
conduct research on the necessary components
of a comprehensive, nationwide methodology
to identify facilities and communities
with critical shortages of RNs across
the U.S. and its territories in order
to target the placement of Federally-obligated
RN scholars and loan repayers. This research,
which involved statistical analysis supported
by expert opinion, took into account population
needs, practice settings, appropriate
staffing levels, and nursing education,
among other aspects of the supply of and
demand for RNs. As a secondary benefit,
the project revealed important insights
about the differences in the use and distribution
of RNs across the various settings and
geographic areas of the country.
Ultimately, this research will support
the development of a comprehensive method
for identifying the health care facilities
and agencies with the most critical shortages
of RNs. This will permit more effective
targeting of resources to encourage service-obligated
RNs to work in the facilities with greatest
need.
The study was conducted under the guidance
of four expert advisory panels, one for
each of four types of health care organizations:
hospitals, home health agencies, nursing
homes, and public health agencies. The
names of the panelists can be found in
Appendix B.
Project staff worked to achieve the following
objectives in support of the primary goal
of the study:
- Identify and define indicators and
measures that reflect critical RN shortages
for the four types of facilities;
- Assess the availability of data sets
that can be used to determine RN staffing
needs nationally in each of the settings
listed above;
- Develop quantifiable key measures
of nursing shortages based on key indicators
described above as well as the available
data sets that include the necessary
data to calculate the key measure.
- Determine whether these key measures
of shortage can be incorporated into
a comprehensive national methodology
to identify facilities and agencies
with critical nursing shortages based
on the following criteria:
- the measure accurately quantifies
nursing shortages in a specific
health care setting;
- the measure either can be calculated
using an available national data
set or the data can be collected
and validated at the facility level.
- Establish an analytic framework that
can be used for a comprehensive methodology
to determine critical nursing shortages
across a variety of health care settings.
Early in the study a number of characteristics
were identified as especially desirable
for any method to identify facilities
and communities with shortages of RNs.
These characteristics, some of which may
not be attainable, included:
- A common method to be used across
the nation;
- Ease of calculation of the RN shortage
index for individual facilities and
communities;
- Implementation using existing data
sets, with no additional data collection
required;
- Comparison of shortages of RNs both
within and between different types of
facilities;
- Comparison of RN shortages across
different states and other geographic
jurisdictions;
- Consistency of shortage severity
estimates with shortage assessments
by local experts;
- Identification of shortages in facilities
due to poor management; and
- Easy updates to the method to reflect
more recent conditions, situations,
and relationships.
One important Federal response to the
national nursing shortage was the Nurse
Reinvestment Act, which was enacted in
August 2002. The Act reauthorized the
NELRP, which provides loan repayment to
RNs in return for work at facilities or
in communities with a shortage of RNs,
and established the Nursing Scholarship
Program. Eligible placement sites for
these programs were expanded to include:
- Ambulatory surgical centers;
- Federally designated migrant, community
public housing, or homeless health centers;
- Federally qualified health centers;
- Home health agencies;
- Hospice programs;
- Hospitals;
- Indian Health Service centers;
- Native Hawaiian health centers;
- Nursing homes;
- Rural health clinics; and
- State or local health department
clinics or skilled nursing facilities.
The method used for the identification
of qualified placement sites used a combination
of geographic and facility designations.
In 2002, the New York Center for Health
Workforce Studies assisted the Bureau
of Health Professions by developing an
up-to-date list of nursing shortage hospitals
and counties throughout the U.S. and its
territories. The Center used two separate
methodologies, one to identify private,
non-profit hospitals with shortages of
RNs and the second to identify counties
with shortages of RNs.
Because this approach relied on hospital
nursing data to identify facilities with
nursing shortages, it failed to quantify
nursing shortages experienced by any providers
except hospitals. Most of the other types
of facilities included on the list above
were considered categorically eligible
placement sites, based on the premise
that they faced critical shortage of RNs.
C. Initial
Literature Review
The first component of the research involved
a careful review of the literature, focusing
on characteristics of RNs relevant to
the task of understanding current and
future shortages. The discussion that
follows summarizes a variety of relevant
statistics.
The two demographic characteristics most
relevant to shortages of RNs were gender
and age. The gender mix of RNs was important
because it reflected the size of the pool
of potential candidates from which to
recruit new RNs.
The age distribution was important because
it dictated the numbers of existing RNs
who will leave nursing in the future,
creating a need to replace them in the
workforce.
Table 1 provides estimates of the percentages
of active RNs in the U.S. by gender and
age group. Although 6.1% of RNs were men
in 2004, which is higher than in previous
years, nursing remains a female-dominated
profession. This means that, at least
in the near future, recruiting more men
to the profession is not likely to be
an important avenue for increasing the
supply. The table also reveals that by
2014 it will be necessary to recruit more
than 400,000 new RNs just to replace those
RNs older than age 55 who are expected
to retire from active nursing practice.
In fact, the latest estimates developed
by the Bureau of Labor Statistics [BLS,
2006] indicate that the U.S. will require
1.2 million new RNs by 2014 to meet the
nursing needs of the country, 500,000
to replace those leaving practice and
an additional 700,000 new RNs to meet
growing demands for nursing services.
Table
1. Active RNs in the U.S. by Gender and
Age Group, 2004
Age
Group |
Male |
Female |
Percent |
<
25 |
1,731 |
57,843 |
2.5% |
25
to 29 |
10,955 |
148,721 |
6.7% |
30
to 34 |
15,508 |
205,543 |
9.2% |
35
to 39 |
19,217 |
237,693 |
10.7% |
40
to 44 |
23,951 |
336,195 |
15.0% |
45
to 49 |
30,986 |
418,634 |
18.8% |
50
to 54 |
24,098 |
382,650 |
17.0% |
55
to 59 |
13,469 |
257,640 |
11.3% |
60
to 64 |
4,909 |
131,281 |
5.7% |
65
+ |
1,819 |
73,486 |
3.1% |
Percent |
6.1% |
93.9% |
2,396,329 |
Source: 2004 NSSRN
Figure 1 shows that hospitals continued
to be the major employer of RNs in 2004,
although the percentage of RNs working
in hospitals declined from 59.1% in 2000
to 57.4% in 2004. The percentage working
in public or community health organizations
declined from 18.3% in 2000 to 11.0% in
2004.
A fact hidden in these simple employment
statistics was that the day-to-day demands
on many of these RNs, especially those
employed in hospitals, increased dramatically
over the past two decades. In fact, increases
in patient acuity in hospitals and nursing
homes resulted in a corresponding increase
in the stress of nursing practice that
caused a growing number of RNs to leave
active patient care.
Figure
1. RN Employment by Setting, 2000 and
2004
[D]
Source: The Registered Nurse Population,
March 2000. USDHHS, 2001. 2004 NSSRN,
USDHHS, 2006
Between 1980 and 2004, the number of
active RNs in the U.S. grew by nearly
90%. In 2000, there were more than 2.4
million active RNs, an increase of more
than 1.1 million since 1980.
Between 1996 and 2000, the total number
of RNs grew by only 1.3% each year, compared
with average annual growth of 2% to 3%
in earlier and later years (Figure 2).
This slowdown in growth between 1996 and
2000 was attributable to two trends: a
declining number of candidates passing
the RN licensing examination annually
and an increasing number of RNs leaving
the field [1].
This slowdown was temporary, however,
as the growth in the supply of RNs resumed
between 2000 and 2004, more than keeping
up with the growth in the population over
the same period. The number of active
RNs per 100,000 population nationally
decreased from 798 in 1996 to 782 in 2000
(Figure 3). There was also wide variation
in RNs per 100,000 population across the
country. Massachusetts and South Dakota
had the highest number of employed RNs
per capita in 2000, 1,194 and 1,128 per
100,000 population, respectively. California
and Nevada had the smallest number of
employed RNs per capita, 544 and 520,
respectively [1].
The number of candidates passing the
RN licensure examination decreased steadily
since 1995. Between 1995 and 2001, the
number of RNs passing the licensing exam
declined by nearly 28% [2].
Figure
2. Number of Active U.S. RNs, 1980 - 2004
[D]
Source: USDHHS, Findings from the National
Sample Survey of RNs 2000, 2004
Figure
3. Active RNs per 100,000 Population,
U.S., 1980 to 2000
[D]
Sources: USDHHS, National Sample Survey
of RNs, 2004 and earlier; Population Estimates
Program, Population Division, U.S. Census
Bureau.
The number of graduates of RN education
programs in the country also declined
between 1995 and 2001. While RN production
grew steadily in the early 1990s, the
total number of U.S.- educated candidates
taking the RN licensing examination dropped
between 1995 and 2001, with nearly 29%
fewer RNs graduating in 2001 than in 1995
[2]. Bachelor
degree RN graduates (BRN) dropped by 20%
while associate degree RN graduates (AND)
declined by 28%. Although RN enrollments
are increasing and the numbers of RN graduates
in 2002 and 2003 were higher than the
number of RN graduates in 2001 [3,
4], these
figures are not yet back to 1995 levels.
These national estimates and projections
tell only part of the story. The two maps
presented on the next page provide additional
perspective on the supply of RNs in the
U.S. in 2004. Figure 4 shows that the
geographic dispersion of active RNs in
2004 was far from uniform across the country.
In fact the ratio of the highest to lowest
RN per capita ratios was nearly 4:1, with
the highest ratios in the District of
Columbia (2,236 RNs per 100,000 population)
and New Hampshire (1,321), and the lowest
in California (603) and Nevada (612).
The range of ratios by county was even
greater, which highlights one of the challenges
for anyone interested in identifying counties
or facilities with shortages of RNs. It
is essential to have access to detailed
data on RNs in counties in order to develop
accurate estimates.
Figure 5 provides an additional perspective
on this geographic variation, the change
over time in the RN per capita ratios.
This map shows that seven states (Connecticut,
Florida, Idaho, Louisiana, Massachusetts,
Maryland, and Rhode Island) experienced
a decline in the number of active RNs
per capita between 2000 and 2004. On the
other end of the supply change spectrum
were Alaska, District of Columbia, and
New Hampshire, all with increases in active
RNs per capita of over 25%. After discarding
these three outliers, the Pearson correlation
coefficient between the 2004 supply of
RNs and the change in supply between 2000
and 2004 was only -0.039 (NS).
Figure
4. RNs per 100,000 Population in the U.S.,
2004
[D]
Figure 5. Percent Change
in RNs per 100,000 Population in the U.S.,
2000 to 2004
[D]
The National Center for Health Workforce
Analysis at HRSA has projected a growing
shortage of RNs over the next 15 years,
with a 12% shortage by 2010 and a 20%
shortage by 2015 (Figure 6). The projected
shortage is the result of the expected
increase in demand, coupled with a relatively
stable supply of RNs [6].
Figure 7 updates these projections based
in part on the 2004 NSSRN. Total numbers
of RNs may rise until 2016 if age-specific
cohorts follow patterns observed in the
RNSS between 2000 and 2004. This is in
large part because the sizes of birth
cohorts in nursing tend to increase well
into ages 50 to 55, and so a number of
baby boomers (those born between 1947
and 1964) may still enter nursing as a
second career over the next 10 years.
This does not mean that problems will
not be felt until after 2016, however.
Using these projections of numbers of
RNs, total population, and the population
age 65 and older from the U.S. Census
Bureau, Figure 7 shows that the number
of RNs per 100,000 population will peak
in 2012, while the number of RNs per 100,000
population age 65 and older will peak
in 2008 and decline by 5% (to below current
rates) by 2012.
Figure
6. National Supply and Demand Projections
for FTE RNs, 2000 to 2015
[D]
Source: Bureau of Health Professions,
RN Supply and Demand Projections
Figure
7. Indexed Projections of RNs per 100K
Pop, RNs per 100K 65+ Pop, and Projected
Numbers of Active RNs, 2004 to 2024
[D]
Source: CHWS, 2006
A review of the literature revealed a
number of studies examining future shortages
of RNs relevant to this study. Some of
the key findings are summarized briefly
below.
- Health care providers across a variety
of settings reported increasing difficulty
recruiting and retaining RNs, particularly
in hospital settings [7,
8].
- There were indications that the attrition
from clinical settings may be related
to dissatisfaction with working conditions.
The 2004 NSSRN asked RNs about job satisfaction
and found that 76% of RNs employed by
hospitals and 75% of RNs employed by
nursing homes were satisfied with their
jobs, compared to 82% of RNs employed
in nursing education and 83% of RNs
employed in occupational health. Staff
RNs across all settings were less likely
to be satisfied with their jobs, as
were older RNs, with the exception of
those employed in ambulatory care [1].
- Experienced RNs who left clinical
settings identified a variety of reasons
for their decision to leave, including
lack of autonomy, heavy workload, too
much paperwork, lack of opportunity
for professional growth, inadequate
staffing, and concerns about the quality
of care. In some instances, these RNs
went on to become advanced practice
nurses (APNs) and return to clinical
settings with more skills, more autonomy,
and higher wages.
- There is increasing concern about
the impact of RN shortages on the quality
of health care. A growing body of evidence
demonstrates that hospitals with lower
ratios of RNs to patients had more adverse
events than hospitals with higher RN
to patient ratios [9,
10,
11].
- Several states have passed legislation
prohibiting or limiting mandatory overtime
for RNs and one state passed legislation
mandating minimum nurse staff ratios
in hospitals and nursing homes [12].
The current shortage of RNs and concerns
about future shortages have led to new
efforts—including this study—to address
the problem of identifying facilities
and communities with shortages of RNs.
D. Data Sets
Based on suggestions from the study advisory
panels, four steps were implemented to
develop criteria and methods to use for
identifying facilities and communities
with shortages of RNs. The four steps
were:
- Designate data requirements, data
elements, and data sets;
- Acquire data sets to use in pilot
analyses;
- Perform pilot analyses for assessing
different methods;
- Document the analyses for interested
stakeholders.
These indicators were selected for inclusion
based on the extent to which they were
associated with facilities and agencies
that have a shortage of RNs due to factors
beyond their control (e.g., being located
in a geographic area with few RNs). The
advisory panels identified potential indicators
at both the community and facility levels.
Community Indicators provide a
critical context for any nursing shortage
designation process. A number of community
indicators identified by the expert panels
seemed particularly relevant:
- Demographic Context
- Rural or urban;
- Age distribution of population;
- Percent of population using Medicare
or Medicaid;
- Median population income; and
- Percent of population in poverty.
- Nursing Context
- RNs per 100 hospital beds;
- Local nursing wages;
- Numbers of nursing schools and
graduates; and
- Numbers of new RNs passing the
National Council Licensure Examination
for Registered Nurses (NCLEX).
Facility Indicators further refine
and inform the shortage designation process.
Facility indicators suggested by the panels
included:
- Facility Indicators
- Type of facility; and
- Facility size;
- Workforce Statistics
- Turnover rates;
- Vacancy rates;
- Hard-to-fill positions;
- Staffing ratios (e.g., RNs per
100 beds, support staff per RN);
- Poor facility outcomes (e.g.,
bad outcomes per 1,000 admissions);
- Case mix and acuity;
- Worker satisfaction; and
- Turnover of leadership.
Data were compiled for two different
tracks for this study: an “ideal” shortage
designation methodology that incorporates
all essential indicators required to identify
shortages of RNs in either facilities
or communities; and a “fall back” methodology
that represents the best possible solution
based on currently available data.
- Indicators for an “ideal” methodology.
This step required the identification
of facilities and communities that had
data for all of the kinds of indicators
listed above. Potential pilot sites
considered by study staff were the Veterans
Administration, Hospital Corporation
of America, Health and Hospitals Corporation
of New York City, and states such as
North Dakota, North Carolina, Iowa,
Pennsylvania, California, and Delaware.
- Indicators for a “fall-back” methodology.
This step involved identifying data
elements from the lists above that were
available for facilities and communities
of all different types across the U.S.
Two important data sources were used
in this project: the Survey of Nurse Employers
in North Carolina conducted by the North
Carolina Center for Nursing; and the Area
Resource File [ARF, 2004 release]. The
facility variables were obtained from
the Survey of Nurse Employers in North
Carolina, and the community variables
were obtained from the ARF database. The
number of observations used to estimate
the models was 325. There were four types
of facilities estimated in this study:
hospitals (65), home health facilities
(79), long-term care facilities (128),
and public health facilities (53).
Data were also obtained for 141 facilities
in North Dakota (35 hospitals, 28 home
health agencies, 45 long-term care facilities,
and 33 public health agencies). These
data were collected by the Center for
Rural Health at the University of North
Dakota, using questionnaires and definitions
patterned after those used in North Carolina.
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