Preface

The Health Resources and Services Administration (HRSA) is the key Federal agency responsible for nursing workforce analysis and development in the United States. The Bureau of Health Professions (BHPr) within HRSA provides national leadership to assure an adequate supply and distribution of qualified nursing personnel to meet the health needs of the Nation. This responsibility includes examination of the supply, composition, and distribution of nurses on the national and State levels in order to assure an adequate supply of qualified nursing personnel against requirements. For several decades, the Division of Nursing (DN) had primary responsibility for the assessment and examination of the Nation's nursing workforce. Since 2001, the analytical aspects of these efforts on the nursing workforce have resided in BHPr's Evaluation and Analysis Branch (EAB). These activities of the EAB have included leadership and direction in the administration of the 2004 National Sample Survey of Registered Nurses (NSSRN), the reporting of findings from the Survey, and analytic support in short-term and long-term assessments of both the supply of nurses in the workforce and the requirements for nurses in the workforce. In pursuing these analytical efforts on the nursing workforce, BHPr has worked with other agencies within the Federal Government, as well as with various State agencies and private nursing organizations, in the development of methods for the study and acquisition of data on the RN population.

The NSSRN is the Nation's most extensive and comprehensive source of statistics on all individuals with active registered nurse licenses to practice nursing in the United States whether or not they are employed in nursing. It provides information on the number of registered nurses, their educational background and practice specialty areas, their employment settings, position levels, job satisfaction and salaries. It also provides information on their geographic distribution and personal characteristics including gender, racial/ethnic background, age, and family status.

The development of a design for collecting data through national sample surveys of registered nurses originated in July 1975 in a contract with Westat, Inc. Subsequently, reports for seven studies, conducted in September 1977, November 1980 and 1984, and March 1988, 1992, 1996, and 2000 have been published and made available to people and organizations involved in health care planning and evaluation as well as to the public. This publication is the report of the eighth study, conducted in March 2004.

The 2004 NSSRN benefited from a wide range of professional nurse associations and organizations with large or diverse memberships of individual RNs that endorsed the study and encouraged their members to participate in it. The organizations included the American Academy of Nurse Practitioners, American Association of Critical-Care Nurses, American Association of Nurse Anesthetists, American Nurses Association, American College of Nurse-Midwives, Asian American Pacific Islander Nursing Association, Association of Perioperative Registered Nurses, Association of Women's Health Obstetric and Neonatal Nurses, Emergency Nurses Association, National Alaska Native/American Indian Nurses Association, National Association of Hispanic Nurses, National Black Nurses Association, and the National Council of State Boards of Nursing.

The 2004 NSSRN survey application, including survey administration, data collection, and reporting, was carried out by The Gallup Organization through a contract with the U.S. Department of Health and Human Services (USDHHS), HRSA, and administered by the EAB. Under a subcontract with The Gallup Organization, Insight Policy Research, Inc. led the data analysis, sample design, and the development and writing of the final report. Funding for the 2004 NSSRN was provided by the Division of Nursing. EAB staff were responsible for overseeing the study (Dr. Christine Hager, Steve Tise, Louis A. Kuta, William Spencer, and Marshall Fritz). In addition, other HRSA staff including, Dr. Denise Geolot, Donna English, Dr. Annette Debisette, Dr. Joan Weiss, and other members of their staff in the Division of Nursing provided guidance on nursing education and practice during the review of the questionnaire drafts, the interpretation of the raw response data, and the preparation of the Findings Report. Members of the Interagency Collaborative on Nursing Statistics (ICONS) also reviewed the questionnaire draft and offered suggestions prior to finalization. The report was authored by Darby Miller Steiger of the Gallup Organization and Sara Bausch, Bryan Johnson, and Dr. Anne Peterson of Insight Policy Research. Zac Arens of the Gallup Organization programmed and summarized the data into tables. HRSA's BHPr is pleased to make this important information on the Nation's RNs population available to the public through this report.

Introduction

The Health Resources and Services Administration (HRSA) is the key Federal agency responsible for nursing workforce analysis and development in the United States. The Bureau of Health Professions (BHPr) within HRSA provides national leadership to assure an adequate supply and distribution of qualified nursing personnel to meet the health needs of the Nation. This responsibility includes examination of the supply, composition, and distribution of nurses on the National and State levels in order to assure an adequate supply of qualified nursing personnel against requirements. For several decades, the Division of Nursing (DN) had primary responsibility for the assessment and examination of the Nation's nursing workforce. Since 2001, the analytical aspects of these efforts on the nursing workforce have resided in BHPr's Evaluation and Analysis Branch (EAB). These activities of the EAB have included leadership and direction in the administration of the 2004 National Sample Survey of Registered Nurses (NSSRN), the reporting of findings from the Survey, and analytic support in short-term and long-term assessments of both the supply of nurses in the workforce and the requirements for nurses in the workforce. In pursuing these analytical efforts on the nursing workforce, BHPr has worked with other agencies within the Federal Government, as well as with various State agencies and private nursing organizations, in the development of methods for the study and acquisition of data on the RN population.

Early Registered Nurse Workforce Studies

National studies to determine the number and characteristics of the Nation's registered nurses were initiated in 1949 when the American Nurses Association (ANA) conducted the first Inventory of Registered Nurses¹. Data were collected through postcard questionnaires mailed by the licensing entity in the States and territories that require renewal of registration to each registrant on record at the time of the study. In Maryland and Ohio, where renewal and registration was not required, questionnaires were distributed through State nurses' associations and employing agencies. About 62 percent of all questionnaires sent to nurses by the States were returned. The number of nurses who had licenses to practice in 1949 was estimated by eliminating duplication resulting from nurses having licenses in more than one State, and accounting for those nurses who did not respond to the survey.²

The ANA conducted a similar study in 1951, but decided to mail the questionnaires with the license renewal notices to RNs in each State. About 71 percent of the questionnaires were returned. This change in data collection methodology improved the response rate but lengthened the data collection period because of variation in renewal dates from State to State. The number of nurses who had licenses to practice in 1951 was estimated using the same procedures used in the 1949 inventory: elimination of duplication due to RN licensure in more than one State, and accounting for nonrespondents to the inventory.

In the mid-1950s, the ANA promoted the inclusion of a uniform set of questions about RNs' characteristics on each State's licensing application form rather than using a postcard or a separate questionnaire. An Inventory of Registered Nurses was initiated in 1956 using this data collection process. The length of time it took to include the questions in the licensing process and the limited funds available for compiling and analyzing the data resulted in an extended time frame for both the data collection and analysis. The actual data summary for the 1956-1958 inventory was published in 1963³.

The ANA conducted four subsequent inventories of registered nurses^{4, 5, 6, 7}. HRSA was instrumental in providing Federal financial support to the ANA to defray the costs of obtaining and processing the data for these studies. This support ensured a more centralized approach to data collection and processing as well as greater use of automated procedures to summarize the data.

Development of NSSRN Methodology

Originally, the nursing inventories were based on data collection at the State level using the licensing mechanism as an opportune time for asking registered nurses to complete the questionnaires. This data collection process, although logical and potentially comprehensive, encompassed some serious limitations. The size of the questionnaire had to be limited and follow-up on forms not returned, missing data, or ambiguous data were not part of the data collection process. Moreover, the wide variation in renewal dates from State to State led to a lengthy data collection period. It took as long as 3 years to present a national picture through analysis of data from all States.

The need for more comprehensive data on the nursing workforce, concerns about the limitations of the nursing inventories, and the enactment of Public Law (P.L.) 94-63 were the impetus for the development of the present methodology for collecting data on the nursing workforce. Section 951 of P.L. 94-63 called for the collection of information on a continuous basis regarding the current and future supply, distribution, and educational requirements for nurses, nationally and within each State. The data acquisition requirements listed in the law were very specific. For example, the law required data on the number of nurses with advanced education or graduate degrees by specialty, and data on average rates of compensation by type of employment and location of practice.⁸

In the mid 1970s, the Department of Health, Education and Welfare (DHEW) contracted with Westat Inc., a survey research firm with expertise in complex survey design, to develop a comprehensive survey plan. Westat worked with the ANA and the DN to develop a survey plan to implement the data element requirements in section 951 of P.L. 94-63: 1) to provide baseline data for the development of estimates and projections regarding the registered nurse population both nationally and for each State; and 2) to provide data on nurse characteristics needed for program planning, administration, monitoring, and evaluation by Congress, State legislators, and Federal and State agencies and associations.⁹  A complex sample survey was developed using licensure listings from each of the 50 States and the District of Columbia. A single questionnaire was designed and data collection and data follow-up processes were established. The data collection was to be done by mail with telephone follow-up for nonrespondents.

The first study using this survey methodology was conducted in September 1977, under contract to the ANA with a subcontract to Westat. During the conduct of that study, the design and data processing procedures were refined¹⁰.  Subsequent studies using the same design were carried out in 1980, 1984, 1988, 1992, 1996 and 2000^{11, 12, 13, 14, 15, 16} .

References

1. Inventory of Professional Registered Nurses 1949, American Nurses Association, Inc., New York.
2. Inventory of Professional Registered Nurses 1951, American Nurses Association, Inc. New York.
3. “Nurses ….Numbers and Characteristics”, American Journal of Nursing, Vol. 63, Jan 1963.
4. Marshall,  Eleanor D. and Moses, Evelyn B. The Nation's Nurses, the 1962 Inventory of Professional Registered Nurses, American Nurses Association, New York, 1965.
5. Marshall, Eleanor D. and Moses, Evelyn B. RNs 1966….An Inventory of Registered Nurses.  American Nurses Association, New York, 1965.
6. Roth, Aleda V. and Walden, Alice R. The Nation's Nurses, 1972 Inventory of Registered Nurses. American Nurses Association, Kansas City, 1981.
7. Schulte, Duane C. Inventory of Registered Nurses 1977-1978. American Nurses Association, Kansas City 1981.
8. First Report to Congress, February 1, 1977, Nursing Training Act of 1975. Health Resources and Services Administration, Public Health Service, USDHEW, DHEW publication No. HRA 78-38, 1977. (Available through NTIS, Access Number HRP-0900501.)
9. Sample Survey for the National Survey of Registered Nurses, Technical Report (Volume I), and Appendices (Volume II). Westat Inc. and the American Nurses Association, 1976 (unpublished).
10. Roth, Aleda, Graham, Deborah, and Schmittling, Gordon. 1977 National Sample Survey of Registered Nurses and Factors Affecting their Supply. American Nurses Association, Kansas City, 1978. (Available through NTIS, Access Number HRP-0900603.)
11. The Registered Nurse Population, An Overview from the National Sample Survey of Registered Nurses, November 1980. Office of Data Analysis and Management, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 1982. (Available through NTIS, Access Number HRP-0904551.)
12. Moses, Evelyn B., 1984. The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, November 1984. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 1986. (Available from NTIS, Access Number HRP-0904551.)
13. Moses, Evelyn B. 1988. The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, March 1988. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 1990. (Available from NTIS, Access Number PB91-145391.)
14. Moses, Evelyn B. 1992. The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, March 1992. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 1994. (Available from NTIS, Access Number PB97- 108187.)
15. Moses, Evelyn B. 1996. The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, March 1996. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 1997.
16. Spratley, Ernell, Johnson, Ayah, Sochalski, Julie, Fritz, Marshall, and Spencer, William. 2000. The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, March 2000. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, PHS, USDHHS, 2001.