INTRODUCTION

Project Goals and Design

Overview of the Report

• Financing and governing health professions education;
• Licensing and regulating health professions practice and private health insurance;
• Purchasing services and paying providers under the Medicaid program; and
• Designing a variety of subsidy and regulatory programs to provide incentives for health professionals to choose certain specialties and practice locations. ^[1]

This report assesses the nursing pipeline in five States—California, Georgia, Indiana, Texas and Utah—and examines the strategies the States are pursuing to expand their nursing workforce. Specifically, the report examines the following:

• Supply of nurses, including those in the nursing pipeline and those currently in the workforce.  Chapter One includes comparative data on the pipeline—including applications, enrollment and graduation trends—as well as the current nursing workforce.  Together, these two components comprise the current and future nursing supply.
• State support and funding strategies for nursing programs, including State appropriations, grants and other forms of State aid.  Chapter Two describes trends in State funding of higher education and examines State aid and its effect on the nursing pipeline.
• Policy options in place in the five focus States, as well as promising practices in other States.  Chapter Three analyzes various policy options aimed at alleviating the nurse shortage.  In addition, this section summarizes policy recommendations by prominent organizations and experts in the field. 

In sum, the report examines the relationship between State aid—in its various forms—and workforce development in five States. The objective is to create options and strategies to help States and their partners in the public and private sectors to more effectively address nurse shortages.

Study Methodology

Selection of States

The National Conference of State Legislatures (NCSL) worked with staff from the United States Department of Health and Human Services, (HHS) Health Resources and Services Administration (HRSA) and an expert advisory panel to select five States. The method for selecting States included, but was not limited to, the following criteria:

• States in the lowest quartile of all States for the number of nurses per capita; (Indiana was the only State that ranked above the bottom quartile)
• States that have a majority of public nursing schools;
• States with a mix of school sizes and degree programs; and
• States that are geographically dispersed. Every selected State is located in a different region.

Data Collection

NCSL used the following data collection methods:

• Site visit interviews with nursing program representatives and others. These interviews provided quantitative and qualitative information about State financing of nursing education programs, training program capacity and other factors;
• Analysis of National and State-level data collected from organizations such as the National League for Nursing, the American Association of Colleges of Nursing and HRSA’s Bureau of Health Professions (BHPr);
• Analysis of interviews and focus groups during the one-day summit of nurse educators and State policymakers;
• Phone and e-mail communications with nursing program and higher education officials to define key funding strategies;
• Other recent data, reports and presentations from online sources; and
• Guidance from the expert advisory panel.

Introduction: Snapshot of Nursing Workforce Issues

The nurse shortage that already has impacted many areas is estimated to worsen in the coming years. The Bureau of Labor Statistics (BLS) estimates that, by 2020, the nation will have a shortfall of up to one million nurses, which includes new jobs and “replacement” jobs that are open when today’s nurses retire and leave the field. ^[2]  Moreover, the BLS estimates that the demand for nurses will increase at almost twice the rate of all occupations between 2000 and 2010.

Aside from answering the basic question of who will care for us in the future, policymakers and others are engaged in the issue for other reasons, including growing evidence that demonstrates a link between nurse staffing levels and quality of care and health outcomes.  Recent research concludes the following about nurse staffing.

• One-fourth of all unexpected events leading to patient death, injury or permanent loss of function are the result of inadequate staffing, according to a 2002 report by the Joint Commission on Accreditation of Healthcare Organizations. ^[3]  
• The risk of hospital deaths would increase by 31 percent—or roughly 20,000 avoidable deaths each year—if all hospitals staffed eight patients per nurse instead of four, according to a 2002 study published in the Journal of the American Medical Association.  Moreover, the odds of nurse burnout increased with an increased number of patients. ^[4]
• Improved RN staffing cut down on pneumonia, urinary infections, cardiac arrest, shock and other adverse health outcomes, according to a 2002 study published in the New England Journal of Medicine. ^[5]

The reasons for the nurse shortage are complex and belie a simple solution. Demographic changes—chief among them a rapidly aging population—are driving demand.  During the next 25 years, the over-age-65 population will increase at five times the rate of those under age 65.  Moreover, the fastest growing population group is the over-85 segment.  Advancements in technology and medical treatment are helping people live longer, often with chronic conditions that require nursing care. ^[6]  

According to the U.S. General Accounting Office, between 2000 and 2030, the number of women between the ages of 24 and 54, traditionally the foundation of the nurse workforce, is not expected to change, while the over-65 population will double.  Compounding this problem is the fact that the nursing profession itself is growing older and nearing retirement and the number of new, replacement nurses is not sufficient to fill the gaps.  The average age of RNs is 45 years, and among nurse educators the mean age is almost 52 years.  The implications are serious, with 75 percent of current faculty expected to retire by 2019. ^[7]   This shortfall of educators prohibits nursing programs from accepting the number of nursing students needed to meet tomorrow’s needs.  In 2004, the American Association of Colleges of Nursing reported that schools across the country turned away more than 26,000 qualified applicants, primarily due to faculty shortages. ^[8]

Finally, as they address the nurse shortages, many States and educational institutions are scrambling to reverse years of declining applications, enrollments and graduates from nursing programs. 

In short, demand for health care services is increasing faster than the supply of the health care workforce, particularly in high-demand professions such as nursing.  Although interest in nursing education is on the rise—as seen in increased applications and enrollment (see Chapter One)—there are still too few nurses entering the pipeline to meet future demand.  Moreover, in the midst of a worsening faculty shortage, it is a daunting task to expand nursing programs’ capacity.

In response, policymakers, along with health care employers, researchers and others, are attempting to stem the tide by increasing the supply and improving the distribution of qualified nurses.  Despite the numerous challenges facing them, States and their partners in the private and academic sectors are, indeed, making progress, offering hope that prudent policy and funding decisions can help to alleviate this potential crisis.  This report examines the interaction between supply and demand in five States and analyzes the effect that State policies and funding have on expanding the nursing pipeline to meet tomorrow’s needs. 

[1]. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, The Health Care Workforce in Ten States: Education, Practice and Policy (Washington, D.C.: HRSA, 2001).

[2].  Georgia Department of Community Health, What’s Ailing Georgia’s Health Care Workforce?, a report prepared by the Healthcare Workforce Policy Advisory Committee (Atlanta: GDCH, August 2002).

[3].  Joint Committee on Accreditation of Healthcare Organizations, Healthcare at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis (Washington, D.C.: JCAHO, 2002).

[4].  Linda H. Aiken, et al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” Journal of the American Medical Association 288, no. 16 (October 23, 2002): 1987-1993.

[5].  Jack Needleman, Peter Buerhaus, Soeren Mattke, Maureen Steward and Katya Zelevinsky, “Nurse Staffing Levels and the Quality of Care in Hospitals,” New England Journal of Medicine 346, no. 22 (May 30, 2002):1715-1722.

[6].  Indiana Nursing Workforce Development Steering Group, The Nursing Workforce Shortage in Indiana: Current Status and Future Trends (Indianapolis: Indiana Nursing Workforce Development Steering Group, 2002).

[7].  U.S. General Accounting Office, Emerging Nurse Shortage (GAO-01-944)(Washington, D.C.: U.S. GAO, July 2001).

[8].  American Association of Colleges of Nursing, Enrollment Increases at U.S. Nursing Schools are Moderating While Thousands of Qualified Students Are Turned Away, Press Release, December 15, 2004, http://www.aacn.nche.edu/Media/FactSheets/DegreeCompletionProg.htm.