HRSA - U.S Department of Health and Human Services, Health Resources and Service Administration U.S. Department of Health and Human Services
Order Publications
Grants Find Help Service Delivery Data Health Care Concerns About HRSA
Toward a Method for Identifying Facilities and Communities with Shortages of Nurses, Summary Report

In 2004, the Health Services and Resources Administration (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 communities with critical shortages of registered nurses (RNs). HRSA’s decision to support this research was based in large part on their concern that its current method for identifying facilities and communities with shortages of RNs was too narrow in scope and that RN shortages were likely to worsen over the next 20 years. The New York Center for Health Workforce Studies at SUNY Albany was selected to conduct this study.

This report summarizes the findings of the various components of this empirical research study. It describes a number of methods for identifying facilities and communities with shortages of nurses. It documents the strengths and weaknesses of different methods for assessing the extent of shortages of RNs in facilities and communities. 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. Additional details about the different methods, including estimates of the supply and demand for RNs in different jurisdictions, can be found in the technical report prepared as part of the larger study.

A. Federal Initiatives to Address Nursing Shortages

The Federal government has had a long-standing interest in the nursing workforce. For more than two decades, through its National Center for Health Workforce Analysis, Division of Nursing and the Shortage Designation Branch of HRSA has collected data on nurses in the U.S. and developed quantitative models to estimate the current and future supply of and demand for RNs. Several programs to encourage new RNs to practice in facilities and communities with severe shortages of RNs, including the Nursing Education Loan Repayment Program (NELRP) and the Nursing Scholarship Program, have been operating for many years. These programs help to alleviate persistent shortages of RNs.

In framing the parameters for this research study, HRSA identified a number of issues that needed resolution including:

    • 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 [1] included in this study?
    • 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 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 to the neediest facilities?
    • How can true shortages of nurses be distinguished from shortages created by poor management practices?

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 nurses. It would also provide a better basis for monitoring RN shortages locally and nationally.

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 included 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 nurses and the second to identify counties with shortages of nurses. Appendix C of the full technical report provides a brief description of the methodologies used for the designation of hospitals and areas with nursing shortages.

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, based on the premise that they faced critical shortage of nurses.

B. Study Overview

In the general context described above, this study was conducted over a two-year period, starting in the fall of 2004. After a brief summary of the study goals, objectives, and other characteristics of the study, the ten study components are summarized below.

1. Project Goals and Objectives

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.

The study’s 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; and
    • 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.

Ultimately, this research will support the development of a comprehensive method for identifying the health care facilities and agencies with critical shortages of RNs. This will permit more effective targeting of Federal and other resources to encourage service-obligated RNs to work in the facilities and communities with the greatest needs.

2. Expert Advisory Panels

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 of the full, technical report.

These panels met face-to-face twice. The first meetings were held separately early in the study to discuss preliminary findings and agree on strategies for accomplishing study goals and objectives. The second meeting convened all the panels together toward the end of the study to gain the benefit of cross-fertilization of ideas. In between these meetings the panelists were invited to participate in two conference calls in which interim progress reports were provided to solicit feedback and suggestions.

An important outcome of the initial meetings of the advisory panels was agreement on a list of “guiding principles” to inform and direct our efforts. These principles can be roughly classified as relating to theoretical, practical, or fairness concerns. The list also included some specific recommendations about methodology.

The theoretical principles and ideals included:

  • Context: facility within community. Both facility and community characteristics must be considered, but community characteristics are more important than facility characteristics.
  • Demand over need. Analyses should primarily focus on employer demand for RNs (e.g., what the local labor market will actually support) rather than the health needs of the population. High-need areas that have no resources or infrastructure to employ additional RNs would find little benefit in the NELRP program.
  • Identify standards for data. Ultimately, it will be important to upgrade Federal, state, and local data systems to support better planning for the nursing workforce, including the designation of facilities and communities with shortages of RNs.
  • Consider facility culture. Some facilities may experience high RN vacancies not because of difficulties recruiting RNs, but because of persistent RN turnover due to problems of organizational culture within the facility (e.g., poor management). This is not a “shortage” issue, and the NELRP program is not intended to address such problems.
  • Define shortage based on outcomes. Theoretically, a facility can be said to have “too few” RNs when there are not enough RNs for the facility to effectively function. This will be observed in certain outcome measures relating to quality of care and facility functioning.

The principles and ideals relating to practical concerns included:

  • Low administrative burden on facilities and HRSA. Data used in the final methodology should not require a large-scale data collection or manipulation.
  • Applicable to all facility types. The final shortage methodology should be applicable to and appropriate for all facility types.
  • Readily available data over time. Ideally, the final methodology should be supported by existing data that are easy to access and available over time for updating.
  • Commonly accepted data elements and indicators. Using established indicators of supply, demand, and shortage is preferable to developing new ones.
  • Easy to update to reflect changing environment. Data used for identifying shortages should be easy to update so that designations can be periodically reexamined.

The principles and ideals relating to fairness included:

  • Attention to rural and urban differences. The shortage designation method should not systematically disadvantage either rural or urban facilities.
  • Special needs of some facilities. The shortage designation method should recognize extenuating circumstances (e.g., facing critical problems, serving special populations).
  • Case mix of patients. The method should recognize that some facilities have higher patient acuity than others, which may signify that some facilities require more intensive staffing.
  • Accommodate data manipulation. The method should minimize opportunities for facilities and communities to “game” the system to achieve a shortage designation.

Specific recommendations for the method included:

  • Look beyond clinical care. It should be recognized that overall demand for RNs extends beyond just those at the bedside to those in non-clinical positions.
  • Consider overall staff mix. Some employees may substitute for RNs with other personnel. This may be more or less appropriate depending upon the facility type.
  • Consider RN staff mix (e.g., specialty, education). Facilities with enough RNs overall may still have a shortage of RNs with certain credentials or in some services (e.g., ICUs).
  • Separate out different units within hospital care. Different units have different staffing needs (e.g. intensive care units will require more RNs than general medical-surgical units).

Most of these guiding principles were addressed in at least some of the analyses, either directly or indirectly, and many are incorporated into the Preferred Method proposed by the study.

3. Characteristics of an Ideal Shortage Designation Method

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.

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.

1. Characteristics of RNs

  • Table 1 shows that 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.
  • 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.
  • 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 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
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 +

Source: 2004 NSSRN

2. Employment Settings

  • In 2004, more than 57% of RNs worked in hospitals, 11% worked in public or community health, nearly 12% worked in ambulatory care settings, and almost 7% worked in nursing homes and extended care facilities (Figure 1).

Figure 1. RN Employment by Setting, 2004


Source: The Registered Nurse Population, March 2004. USDHHS, Bureau of Health Professions, Division of Nursing, November 2005.

3. Trends in Supply

  • 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 over 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 years (Figure 2). This slowdown in growth between 1996 and 2000 is 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 of early years resumed between 2000 and 2004, more than keeping up with the growth in the population over the same period.
  • The number of candidates passing the RN licensure examination has decreased steadily since 1995. Between 1995 and 2001, the number of RNs passing the licensing exam declined by nearly 28% [2].

Figure 2. Active RNs per 100,000 Population, U.S., 1980 to 2004


Sources: U.S. Department of Health and Human Services, National Sample Survey of RNs, 2004 and earlier; Population Estimates Program, Population Division, U.S. Census Bureau.

  • Between 1995 and 2001, the number of graduates of RN education programs in the U.S. declined. Nearly 29% fewer RNs graduated in 2001 than in 1995 [2]. The numbers of RN graduates have been steadily increasing since 2002 and in some states, including New York, they are now higher than the previous peak number in 1996 [3, 4]. There is evidence capacity limits in many nursing education programs (due to such factors as the inability to recruit enough faculty) are limiting the ability of the system to accept all qualified nursing school applicants.

4. Geographic Distribution

The geographic dispersion of active RNs in 2004 was far from uniform across the U.S. In fact, Figure 3 shows that 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).

Figure 3. RNs per 100,000 Population in the U.S., 2004


5. Projections of Future Supply

  • A growing shortage of RNs has been projected over the next 15 fifteen years, with a 12% shortage by 2010 and a 20% shortage by 2015 (Figure 4). The projected shortage is the result of the expected increase in demand coupled with a relatively stable supply of RNs [5].
  • Figure 5 updates these projections based in part on the 2004 National Sample Survey of Registered Nurses (NSSRN). Total numbers of RNs may rise until 2016 if age-specific cohorts follow patterns observed in the NSSRN between 2000 and 2004. This is in large part because the sizes of birth cohorts in nursing tend to increase well into ages 50-55, and so a number of baby boomers (currently ages 43 to 60) 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 and projections of the total population and the population age 65 and older from the U.S. Census Bureau, Figure 5 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% (falling below current rates) by 2012.

Figure 4. National Supply and Demand Projections for RNs, 2000 to 2015


Source: Bureau of Health Professions, RN Supply and Demand Projections

Figure 5. Indexed Projections of RNs per 100K Population, RNs per 100K Age 65+ Population, and Projected Numbers of Active RNs, 2004 to 2024


Source: CHWS, 2006

6. Nursing Shortages

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 [6, 7].
  • 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.
  • There is growing 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 [8, 9, 10].