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INTRODUCTION
Project Goals and Design
Overview of the Report
States are taking various steps to stem the tide of a worsening
nurse shortage. This report examines the different ways
States are funding and otherwise assisting nursing education
programs and the extent to which State aid is helping to
expand the nursing workforce and keep up with current and
future demand.
States are not alone, however, in this effort. The Federal
government, health care employers, educational institutions
and others are working to close the gap. States play a prominent
role in shaping the workforce, since they are responsible
for the following:
-
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;
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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.
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