Preferred Method

Assumption: Current staffing patterns at the national level reflect a balance of supply and demand.

Assumption: Differences within types of care in factors such as patient acuity do not vary substantially across counties.

Assumption: RN commuting patterns are similar to the commuting patterns of other workers in terms of county inflow and outflow.

This method reflects an effort to create a more “realistic” model with which to assess the extent of nursing shortages in counties across the U.S. It incorporates elements of several of the models described above.

A. Estimating Health Care Utilization

Demand for RNs was estimated for 14 different settings. In eight of these settings (short-term inpatient, long-term inpatient, hospital outpatient, emergency department, psychiatric inpatient, hospital nursing home unit, other nursing home, and home health), demand was estimated based on actual or estimated use of services at the county level. In the other six settings (nurse education, public/community health, school health, occupational health, ambulatory care, and all other settings), estimates of demand were based on the size of the population.

Short-term inpatient days (non-psychiatric hospitals): Data on inpatient days in short-term general hospitals by county was available from the ARF.

The ARF does not separate inpatient days in short-term non-general and long-term hospitals, but does separate several specific types of short-term non-general and long-term hospitals: short-term psychiatric, short-term rehabilitation, short-term children’s psychiatric, long-term general medical and surgical, long-term psychiatric, long-term rehabilitation, and long-term children’s psychiatric. This allowed the division of many of the most common hospital types into short-term non-general and long-term. Short-term non-general and long-term inpatient days that fell outside of these categories were categorized as short-term non-general and long-term based upon whether hospitals in the county that did not fall into any of the specific categories were short-term non-general or long-term hospitals.

Only 34 counties had both short-term non-general and long-term hospitals that fell outside the seven categories above, so in most cases it was easy to determine whether the remaining inpatient days were either short-term non-general or long-term. In the remaining 34 counties, the unidentified inpatient days were assigned as either short-term non-general or long-term based upon the proportion of hospital beds in the county falling into either of those categories.

This produced reasonable estimates of short-term non-general inpatient days by county, but these estimates included inpatient days spent in nursing home units. ARF provided estimates of nursing home unit inpatient days for short-term non-general and long-term hospitals, but did not separate the two. Once again, however, nursing home unit beds were separated into short-term non-general versus long-term, and this proportion was used to assign nursing home unit inpatient days to the two categories of hospitals. Inpatient days spent in nursing home units in short-term non-general hospitals were subtracted from the total number of inpatient days in short-term non-general hospitals, and are dealt with separately. The same was done for short-term general hospitals.

Days in short-term psychiatric and children’s psychiatric hospitals were also then subtracted from total short-term non-general hospital inpatient days. These will also be treated separately. In a few cases, it was apparent that nursing home unit days in short-term non-general hospitals were being reported by short-term psychiatric hospitals (e.g., because the only short-term non-general hospital in the county was psychiatric, leaving this as the only explanation ^[3]), and in those cases subtracting both nursing home inpatient days and psychiatric inpatient days would have resulted in double subtraction and negative values. This was handled by subtracting only short-term psychiatric inpatient days in the counties where this occurred.

Long-term inpatient days (non-psychiatric hospitals): As described above, inpatient days in long-term hospitals were separated from those in short-term non-general hospitals using information about inpatient days in specific types of long-term hospitals and information about other hospitals in the county. Once again, however, these estimates contained nursing home unit days, which were subtracted as described for short-term non-general inpatient days. Days in long-term psychiatric and children’s psychiatric hospitals were also then subtracted from total long-term hospital inpatient days.

As with short-term non-general inpatient days, it was evident that a small number of long-term psychiatric hospitals had reported nursing home unit days ^[4]. Because subtracting both nursing home inpatient days and psychiatric inpatient days would result in double subtraction and negative values, this was handled by only subtracting long-term psychiatric inpatient days in the counties where this occurred.

Psychiatric hospital inpatient days: Because inpatient days in both short-term and long-term psychiatric and children’s psychiatric hospitals were separated out in the ARF for all counties, psychiatric hospital inpatient days were not difficult to count. The only complexity was that 18 of these hospitals, as discussed above, appeared to report nursing home unit days. Because this seemed improbable, the decision was made to ignore the nursing home days rather than subtracting them from the totals for psychiatric inpatient days and adding them to the total for hospital nursing home unit days ^[5].

Nursing home unit inpatient days: Nursing home unit inpatient days were presented in ARF for both short-term general and short-term non-general and long-term hospitals. The data was clear except for the issue discussed above of a small number of psychiatric hospitals (both short-term and long-term) apparently reporting nursing home unit days. These nursing home days were removed from the nursing home days total for short-term non-general and long-term hospitals.

Outpatient visits (non-emergency): Outpatient visits to hospital non-emergency departments for short-term hospitals and short-term non-general and long-term hospitals were available in ARF. The sum of these two figures was used to produce the figure for total non-emergency hospital outpatient visits.

Emergency department visits: Visits to hospital emergency departments for short-term hospitals and short-term non-general and long-term hospitals were available in ARF. The sum of these two figures was used to produce the figure for total hospital emergency department visits.

Non-hospital nursing home population: The 2000 U.S. Census has data by county for those living in specific types of group quarters, including nursing homes.

Home health patients: The number of home health patients per county was estimated using the age and gender distribution of the population, based upon national age-specific and gender-specific utilization rates taken from a CDC report available online at: www.cdc.gov/nchs/data/nhhcsd/curhomecare00.pdf.

Other nursing care: The use of other types of nursing care (nurse education, public and community health, school health, occupational health, non-hospital ambulatory care, and other) was estimated based upon population ratios as described below.

B. Estimating Current National RN Staffing

Using data from the NSSRN, it was possible to estimate RN staffing by setting at the national level.

Short-term inpatient (non-psychiatric hospitals): The RNs included as employed in this category of care were all those working in hospital units other than emergency department, outpatient, home health, radiologic, or dialysis in non-federal, non-psychiatric short-term hospitals, federal government hospitals ^[6], and other types of hospitals.

Long-term inpatient (non-psychiatric hospitals): The RNs included as employed in this category of care were all those working in hospital units other than emergency department, outpatient, home health, radiologic, or dialysis in non-federal non-psychiatric long-term hospitals.

Psychiatric inpatient (non-federal): The RNs included as employed in this category of care were all those working in hospital units other than emergency department, outpatient, home health, radiologic, or dialysis in non-federal psychiatric hospitals.

Nursing home unit inpatient: The RNs included as employed in this category of care were all those who reported working in a “nursing home unit in hospital.”

Outpatient (non-emergency): The RNs included as employed in this category of care were all those who reported working in outpatient, radiologic, or dialysis units in any type of hospital.

Emergency outpatient: The RNs included as employed in this category of care were all those who reported working in emergency departments in any type of hospital.

Non-hospital nursing home: The RNs included as employed in this category of care were all those who reported working in a nursing home other than a hospital nursing home unit.

Home health: The RNs included as employed in this category of care were all those who reported working in a home health unit in a hospital of any type or any type of home health agency.

Nurse education: The RNs included as employed in this category of care were all those who reported working in any type of nursing care education program, including LPN and CNA programs.

Public and community health: The RNs included as employed in this category of care were all those who worked in state or local health departments, community mental health and substance abuse facilities, any kind of community health clinic (CHC, family planning clinic, RHC), or a day care, hospice, or other community health setting.

School health: The RNs included as employed in this category of care were all those who worked in public or private school health services, elementary through high school. Those working in college or university health services were not included.

Occupational health: The RNs included as employed in this category of care were all those who worked in private, government, or other occupational health services.

Non-hospital ambulatory care: The RNs included as employed in this category of care were all those who worked in physician or nurse practices, clinics, HMOs, or other non-hospital ambulatory settings.

Other nursing care: The RNs included as employed in this category of care were all those who worked in any setting not included in the above, including facilities for the mentally retarded, college health services, insurance companies, state boards of nursing, and professional associations.

C. Estimating RN Demand by Setting

The national estimates for utilization and current RN staffing were combined to produce ratios of RNs to units of care, as shown in Table 41 below. These ratios were then applied to utilization and population counts at the county level to estimate how many RNs would be needed to achieve these ratios.

Table 41. RNs per Unit of Care in Fourteen Health Care Settings in Selected Years

D. Estimating Supply of RNs

The only nationally available figures for RNs by county were from the 2000 Census, and were based on county of residence. For a substantial portion of the RN workforce, however, county of residence was different from county of employment. To adjust for this, county-to-county commuting flows were obtained from the U.S. Census Bureau, and RN estimates were adjusted based upon the ratio of workers living in the county to workers working in the county. This methodology assumed that the commuting patterns of RNs did not differ substantially from the commuting patterns of the civilian workforce overall.

E. Estimating RN Shortages

The estimation of RN shortages was based upon the difference between estimated demand for RNs and the number of RNs in the county (adjusted for commuting patterns). Raw shortage numbers were then standardized as a percent of demand. This methodology did not assess shortages at the national level because it theoretically redistributed the current number of RNs into counties according to patterns of health care utilization. While a small national shortage occurred using our procedures, this may have been an artifact of using data from different years for different types of care (hospital ratios used 2004 nurse data and 2003 hospital data, while ratios for other types of care used 2000 nurse and hospital data).

At the state level, however, some interesting patterns emerge (Table 42, below). Half of the states were not seen to have shortages, and those with the largest relative supplies of RNs were Vermont, New Hampshire, and Alaska. On the other hand, the District of Columbia had a 49% shortage, while Louisiana had a 25% shortage, and Oklahoma had a 20% shortage.

Table 42. Estimated Percentage Shortages of RNs in the U.S.

Eighteen counties in the U.S. had a 100% shortage (all of these counties had no RNs), but a handful more counties had shortages of more than 90%.

When counties were aggregated into metropolitan and micropolitan areas (shown below), the MSA with the greatest shortage was the Boone, Iowa micropolitan area (80%). Relatively few major metropolitan areas had serious shortages -- the notable exceptions were Las Vegas (with a 25% shortage), New Orleans (22%)^[7], and New York (also 22%). Oklahoma City, Los Angeles, Topeka, and Honolulu also had shortages (16%, 14%, 13%, and 12%, respectively). Despite the serious shortage estimated for the District of Columbia proper, the Washington-Arlington-Alexandria MSA (which included counties in Maryland, Virginia, and West Virginia, as well as D.C.) had a shortage of only 2%.

[3] It was not clear why psychiatric hospitals would report nursing home unit days. As this occurred in only 10 of the 3,140 counties it was possible that this was simply due to a reporting error.

[4] This occurred in eight of the 3,140 counties, and may be due to reporting errors.

[5] The potential result of this, if these reports were not in error, could be to overestimate demand for RNs in psychiatric hospitals if some of these hospitals did indeed contain nursing home units. RN staffing in psychiatric hospitals is typically more intensive than in nursing home units, so misclassifying nursing home days as psychiatric days could inflate the demand figures for RNs.

[6] Federal government hospitals include some long-term and psychiatric hospitals, but these were not distinguished in the NSSRN. Most federal hospitals are VAs, which tend to provide short-term general care, and so RNs in federal government hospitals will be included in this category rather than another.

[7] This was using data from before Hurricane Katrina in 2005. New Orleans may currently have a much greater shortage.