The Nursing Workforce Challenge
Public Policy for a Dynamic and Complex Market
Randall R. Bovbjerg
Barbara A. Ormond
Nancy Pindus
The Urban Institute
Report to the
Jonas Center for Nursing Excellence
Understanding the Nursing Workforce
Public Policy for a Dynamic and Complex Market
Randall R. Bovbjerg
Barbara A. Ormond
Nancy Pindus
The Urban Institute
Report to the Jonas Center for Nursing Excellence
August 2009
This report was funded by the Jonas Center for Nursing Excellence under grant 2008-1 (UI
project no. 08277-000-00) and by Urban Institute internal funding, whose support is gratefully
acknowledged. The nonpartisan Urban Institute publishes studies, reports and books on
timely topics worthy of public consideration. Superb research assistance came from Asya
Magazinnik, Paul Masi, Jennifer Pelletier, and Rachel Solnick; and very useful comments
from William Gorham, the Jonas Center, Marilyn DeLuca, and Darlene Curley. However, the
views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders.
Contents
Executive Summary....................................................................................................................................i I. Introduction ........................................................................................................................................ 1 II. Dimensions of the Issue .................................................................................................................... 2 A. The nursing workforce today...................................................................................................... 2 B. A brief retrospective on nursing workforce developments and policy ................................ 3 C. Projections of the future nursing supply and demand for nurses ......................................... 5 III. Responses to the Shortage .............................................................................................................. 10 A. Private responses ........................................................................................................................ 10 B. Public policy responses .............................................................................................................. 13 IV. A Public Policy Agenda for Moving Forward ............................................................................. 17 A. Supply side: address shortcomings in education ................................................................... 17 B. Demand side: promote the business case for nursing and improve understanding ........ 19 C. Research and advocacy .............................................................................................................. 20 Exhibits ...................................................................................................................................................... 22 References ................................................................................................................................................. 28 Executive Summary
T his report reviews major policy issues related to the nursing workforce, drawing upon prior Urban Institute work, new literature review, assessment of federal sur‐
vey data, and key informant interviews. Key Points
•
Nurses constitute the backbone of health services, spending the most time with patients and playing a key role in promoting quality and medical safety. •
Nursing has faced recurrent short‐term labor market shortages as shown by va‐
cancy rates reported by employers. Intermittent shortages vary by state and are normal, as the market is not static but responds to shifting supply and demand. Unpredictable shifts in both supply and demand can also occur, as seen in the current economic downturn. •
However, there are now long‐term structural issues as well. The aging of the population of Americans will increase demand for nursing care while retirements will reduce the nursing workforce available to care for them. The large genera‐
tional bulge of nurses who were educated in the long expansionary period of the late 1960s and 1970s are now nearing retirement age, and the succeeding age co‐
horts of nurses are smaller. •
Nursing wages serve as a signal both to would‐be nurses and to nurse employers and thus affect both supply and demand. • Lower wages reduce the attractiveness of nursing as a profession and so reduce supply. At the same time, they increase demand for nurses by lowering employers’ total wage bill. • Wages that do not accurately reflect the value of nurses’ contributions allow employers to use them at less than their full capabilities. Con‐
versely, higher wages draw more people into nursing and drive employ‐
ers to use the more costly input more efficiently. • Some efforts to combat shortages, such as importation of foreign‐trained nurses, offer temporary relief but may exacerbate the problem by de‐
pressing wages in the short run. •
The frequently cited projections of future large shortages of nurses are based mainly on demographic trends and past patterns in supply and demand. The dif‐
ferent projections produce a broad range of shortage estimates and should not be relied upon to provide policymakers with a precise number of nurses that will be needed at any particular future time. ii •
Moreover, the overall projections do not address the qualifications of nurses needed to respond to shifting demands for various levels of care. Therefore, good data need to be filtered through informed judgment to support workforce planning. •
Projections of nursing supply relative to demand vary across states and across regions within states, particularly between rural and urban settings. Medical personnel, including nurses, tend to work near where they were trained, so the distribution of support for nursing education mat‐
ters. •
Men and racial, ethnic, and language minorities are not well represented in the nursing work‐
force. Language skills are essential for high quality care, and the availability of culturally appro‐
priate care has been shown to improve patient outcomes. In addition, encouraging a broader range of people to go into nursing will expand the labor pool. •
The evidence that nurses contribute greatly to producing high quality care is strong, and nurses’ unique contributions to care teams for expanded access to primary care, coordination across mo‐
dalities of care, and continuity of care merit greater attention as health care reform discussions proceed. •
Educational institutions have shown substantial responsiveness to demand for new paths to li‐
censure and for mid‐career advancement from one nursing status to another or into nursing from another career. Nonetheless, educational bottlenecks and rigidities still impede smooth increases in nursing supply in response to increased demand. •
The educational pipeline is long (5 to 10 years from application to productive entry to the workplace), and some evidence suggests that demand for nursing degrees exceeds available student slots. •
Schools report difficulties in maintaining sufficient faculty. Nurses today tend to obtain their doctorates later in life than during earlier eras and thus will likely have shorter faculty careers. It is hard for schools to staff for fluctuating demand using lifetime‐
tenured positions, and it can be hard to pay differential salaries in times of tight faculty supply. •
Schools face shortages of teaching space and clinical training placements. Current and Recommended Responses and Interventions
•
The market has responded to the recent shortage as it did in previous shortages. Enrollment in nursing programs has risen over the past several years in response to increases in wages and im‐
provements in working conditions. Diverse private initiatives seem helpful but are often limited in scope. Many are also institution‐specific and lack a clear way to bring them to scale. •
Public funding has historically been a mainstay of nursing education with a focus on increasing the number of nurses trained. Going forward, it could be tailored to help address the structural aspects of the current shortage. •
Key federal Title VIII support for nursing education has declined markedly as a share of health spending and on a per‐student basis since the 1970s era of expansion. •
Graduate medical education funding supports hospitals and would have to be retooled to support clinical training for nurses in new roles in a redesigned system. iii •
Further support of educational bridge programs could facilitate access to nursing careers for a broader population. •
Public funding of health coverage through Medicare and Medicaid accounts for over a third of total health expenditures. Payment reforms to these two programs, such as those that fo‐
cus on outcomes rather than on procedures, could serve to recognize the contributions of nurses. They may be easier to achieve today than before as high level policymakers, both public and private, are focusing on reform of health financing and delivery. •
Regulatory reform to address evolving scopes of practice could allow appropriately qualified nurses to contribute at more advanced levels of practice and ancillary personnel to assume some tasks traditionally assigned to nurses. Scope of practice change should be coordinated with educational policy and supported by payment reform. Moving Forward
•
Today’s health care system stands on the brink of great change. Decisions taken under public reform—and in the private sector’s push for better value—will massively influence the future of nursing. Policies under discussion include how to expand health coverage, the scope of benefits to be covered, what providers should participate on what basis, and how services are priced in various delivery modes and for various levels of patient acuity. It is imperative that nurses be constructively involved in policy discussions on the future shape of health care. •
A nursing workforce agenda going forward should expand its focus beyond professional as‐
pirations and advocate more strongly for policy relevance. It may be helpful for nursing ad‐
vocates to emphasize nurses’ positive contributions, such as promoting safety, relative to messages that may seem negative, such as complaints about working conditions. •
Specific advocacy goals could include the following: •
Setting clear and measurable objectives and prioritizing among them. Public and private policymakers need realistic actionable proposals rather than restatement of the dimensions of the problem and the need for action. •
Promoting greater investment in nurse workforce data. Information should be available about developing shortages and surpluses by geographic area. A particu‐
lar emphasis is needed on timeliness and consistency across reporting formats. •
Documenting further the business case for nurses. A greater understanding of nurses’ contributions to improving access and promoting quality of care is critical as the health system is redesigned. Such information can help promote payment and other reforms that encourage institutions to enhance nursing capabilities in the interest of better and more cost‐effective patient care. •
Broadening the focus of policy emphasis. Focusing simply on the number of nurses trained or in the educational pipeline without paying attention to how they are paid and used once in practice does not serve the long‐term interests of either nurses or nurses’ employers. Policies that better match nurses’ wages to their con‐
tribution to care will both encourage an adequate supply of nurses and promote their efficient use. Professional Nurse Workforce Dilemmas: Understanding and
Responding to a Dynamic and Complex Market
Introduction
C oncerns about nursing shortages have existed for decades, and there is evidence that the labor market adjusts for cyclical, short‐term shortages. Demographic trends and ongoing changes in the health care delivery system suggest that structural issues in this market now dominate cyclical concerns. However, there are now long‐term structural is‐
sues as well. The large generational bulge of nurses who were educated in the long expan‐
sionary period of the late 1960s and 1970s are now nearing retirement age, and the suc‐
ceeding age cohorts of nurses are smaller, even as population aging will increase demand for care. These issues will require solutions beyond the traditional labor‐market responses of improving wages and working conditions or simply graduating more nurses without regard to their likely career trajectories or the system’s long‐term needs. The current inter‐
est in broad reform of the U.S. health care system provides an opportunity to consider solutions that take a long view. Scopes of practice, payment mechanisms, and the organi‐
zation of care delivery are all on the table, and the decisions made will substantially affect the nursing profession. This paper aims to deepen understanding of the issues affecting the nursing work‐
force for general health policy audiences. We emphasize the need for thoughtful action and describe available and appropriate policy responses. This paper focuses on registered nurses (RNs, sometimes called registered profes‐
sional nurses, as in New York). Registered nurses receive two, three, or four years of for‐
mal education, depending on their background and which pathway they choose to licen‐
sure (box). This report does not address issues associated with other nursing personnel, such as nurse’s aides or licensed practical or vocational nurses, who have less education and more limited scope of practice. And it touches only briefly on nurse practitioners, who have more education and a broader scope of practice, when considering emerging roles for nurses, especially in health systems reform. RNs outnumber all other health professionals (HRSA 2006; BLS 2008a) and provide the vast bulk of patient care. They work in a broad range of settings from nursing homes to insurance companies. Most practice in hospital inpatient settings, but hospitals’ domi‐
nance in nurse employment is declining. Nurses are involved in all aspects of health care, and, as health care delivery has changed, so have nurses’ practice settings. Further evolu‐
tion in health care delivery will continue to change the distribution of personnel across sites. Changing delivery modes and the aging population are increasing the number of nurses needed per U.S. resident. Demographics and the nature of the delivery system are the largest (but not the only) determinants of how many nurses the country will demand (or need) in the future. Demo‐
graphics and the nursing education system will be the largest (but, again, not the only) 2 determinants of how many nurses the country will have available to meet that demand. This paper starts by providing descriptive background on nursing employment and shortages. We then look at predicted trends in both the demand for and the supply of nurses in the coming years, to assess the likely dimensions of the mismatch between future supply and demand that is seen as a looming nurs‐
ing shortage. We next look at interventions that re‐
spond to recent shortages. We end by discussing what can be done to address longer‐term shortages and the role of nurses and their contributions to effective and economical care. We rely upon a scan of the relevant literature, readily available work‐
force data, and key‐informant interviews (Pindus and Greiner 1997; Pindus et al. 2002)1. Education for RN Licensure
“There are three major educational paths to registered nursing—a bachelor’s of science degree in nursing (BSN), an
associate degree in nursing (ADN), and a diploma. BSN programs, offered by colleges and universities, take about 4
years to complete. In 2006, 709 nursing programs offered
degrees at the bachelor’s level. ADN programs, offered by
community and junior colleges, take about 2 to 3 years to
complete. About 850 RN programs granted associate degrees. Diploma programs, administered in hospitals, last
about 3 years. Only about 70 programs offered diplomas.
Generally, licensed graduates of any of the three types of
educational programs qualify for entry-level positions. Many
RNs with an ADN or diploma later enter bachelor’s programs
to prepare for a broader scope of nursing practice. ... In all
States, the District of Columbia, and U.S. territories, students
must graduate from an approved nursing program and pass a
national licensing examination, known as the NCLEX-RN, in
order to obtain a nursing license.” —Bureau of Labor Statistics (2008b)
ingly, nurses are also playing new roles in health care, working in advanced‐practice settings or out‐
side of direct care. Hospitals have long employed the majority of nurses (figure 3). However, even surgery can now II. Dimensions of the Issue
take place on an outpatient basis, and hospitals’ A. The nursing workforce today
share of overall medical spending has fallen, along with their share of nursing employment. Between Nurses are the basic building blocks of health 1984 and 2004, the proportion of nurses working in care. The most recent estimate puts the number of hospitals fell from 68.2 to 57.4 percent, while em‐
registered nurses in the United States in “the functions of ployment in ambulatory care rose from 8.7 2006 at 2.3 million (Buerhaus et al. 2009). to 11.7 percent. A growing share of RNs are strikThe number of RNs has been rising stead‐
ingly diverse” — nurses—6.6 percent, up from 1.4 percent in Institute of Medi- 1984—work outside of health care institu‐
ily since 1980 (figure 1). The share of all cine (1983,
nurses that work and the share that work tions, for example, in insurance jobs, edu‐
cation, policy or regulatory positions, or full‐time has also risen. Of course, popula‐
health care information technology. The number of tion growth alone calls for more nurses, and popu‐
nurse educators is important, since these nurses lation aging increases health care needs, but the train future nurses. Their ranks are again rising af‐
number of nurses has grown at a faster rate than ter relative declines through the 1980s (figure 3). either the total population or the over‐65 population Trends in demographics, employment setting, (figure 2). and education all affect the balance between supply The number of nurses has always risen in step and demand for nurses. Other factors, including with overall health spending (Buerhaus et al. 2009). population health, the organization of care, the in‐
Most nurses primarily work in direct patient care— creasing complexity of care, and payment for care, within hospitals, nursing homes, or ambulatory also play a role. A short look backward provides care settings. The range of their practice settings useful perspective on today’s issues and planning and responsibilities attests to registered nurses’ for the future. broad knowledge, skill set, and flexibility. Increas‐
1 Note
that the supply and demand for nurses is a very broad topic. In focusing here on the number of nurses, this report gives much less attention to other important aspects of the nursing workforce. Most notably, we do not address how composition of the workforce affects cultural and
language appropriateness, nor do we provide detail on the distribution across states and by rural/urban location within states. Finally, space
allows only a sampling of states’ and institutions’ responses to workforce problems. For a broader discussion of diversity issues, see New York
Academy and Jonas Center (2006).
3 B. A brief retrospective on nursing
workforce developments and policy
In one way, current concerns are not new. Nurs‐
ing shortages have come and gone over many years, in eras of very different scopes and structures of the health care delivery system. In other ways, concerns are now different. They involve long‐term rather than immediate market conditions, and the health policy environment has changed substan‐
tially since the last major change in workforce pol‐
icy that began in the mid‐1960s. or by a mismatch in desired and offered mixes of skills and experience. They can appear national in scope but generally reflect local conditions. Hires are usually site specific, most nurses do not readily migrate across state lines, and fiscal circumstances can vary considerably by market and even by insti‐
tution. The strains of the imbalance between supply and demand are felt on both sides. In times of short‐
age, hospitals have to do more to recruit and retain nurses—pay them more, improve their work envi‐
ronment, and take other measures—and to use them more efficiently (May et al. 2006). Nurses ex‐
Recurring shortages over time
perience demands for longer shifts or more over‐
Since at least the 1930s, nursing shortages have time, to cover more patients per shift, and other in‐
periodically attracted public attention and creased workloads (Buerhaus et al. 2007b). Short‐
prompted discussions of reform (see, for example, ages are most commonly reported by hospitals, but Leroy 1982). The most re‐
ambulatory care, education, and “In measuring labor shortages, it is escent such period arguably sential to use a combination of labor mar- other settings also feel the effects, began in 1999 and lasted ket indicators, to realize the complexity of as practice settings compete for longer than in earlier years the concept, and not to hastily conclude
nurses. (Buerhaus et al. 2004). The that a shortage exists and then quickly
generate solutions.” —Pindus et al., 2002 Shortages are typically declared historical pattern suggests based upon immediate employer that market forces played the dominant role in ame‐
experience rather than long‐term measures of sup‐
liorating this and earlier shortages. Observers ply and demand. Indicators include job positions across different eras have commented on the key unfilled, increased use of contract nursing services, role of increases in nurses’ wages relative to the need to pay bonuses, and reports of difficulty in costs of living and of other occupations (Aiken hiring. In normal markets, shortages are inherently 1982, 1989; Buerhaus et al. 2004). In addition, hospi‐
temporary, corrected by some mix of increase in tals report undertaking at least a thousand local ini‐
supply and decrease in demand. However it is tiatives to improve the conditions of nursing work measured, studies and news accounts suggest that (AHA 2002). They have “The key factor is prevailing wage. As wages the short‐term shortage of the also come to depend on increase, supply often increases. ... Econoearly 2000s is waning (Buerhaus nursing temporary employ‐ mists define shortage as a situation in which
et al. 2004, 2007c; Dougherty ment agencies to supple‐ demand exceeds supply and a surplus as a
2008). ment employed nurses. In situation in which supply exceeds demand.
We in health care muddy the water by sayThe opposite of a shortage is a addition, foreign‐educated ing there aren't enough RNs.” —Kovner
surplus, a time when employers nurses now constitute a (1999, p.2).
can readily obtain the numbers much larger share of the and capabilities of nurses they want at accustomed workforce, albeit concentrated in relatively few ar‐
wages. Surpluses seem mainly to go unremarked, eas (Polsky et al. 2007). although in the mid‐1990s, the Pew Commission Shortages are periods of imbalance in nursing (1995) explicitly foresaw an emerging surplus ow‐
labor markets. At such times, hospitals and other ing to an expected downsizing of hospitals from prospective employers want to buy more nursing better overall coordination of health care. This sur‐
services than nurses are willing to sell given the plus did not in fact occur, as in the latter 1990s pri‐
wages and working conditions on offer. Shortages vate and public health plans did more to hold down can be caused by shifts in either demand or supply payments for hospital care than to discourage use 4 of hospital care. All projections need frequent revi‐
sion, but particularly those made in eras of rapid change. Short‐term imbalances of supply and demand send useful signals to sellers and buyers about the need for changes in wage levels and roles for labor. A long‐term shortage in a vital profession like nurs‐
ing, on the other hand, is a substantial concern for public policy (GAO 2001, AACN 2009e; IOM 2008; Buerhaus et al. 2007b; NLN 2009b). Federal policy and large workforce shifts
starting in the mid-1960s
1983). This surge produced a historically large co‐
hort of nurses. Today, this baby boom generation of nurses is nearing traditional retirement age (figure 4). Also in the 1960s, the American Nurses Association (ANA) and others pushed to raise nurses’ educa‐
tional credentials. They were responding to a per‐
ceived shortage of skills, not of numbers. Their ra‐
tionale was that greater professional autonomy and more advanced education in science were needed to perform well within an ever‐advancing clinical en‐
vironment (Donley and Flaherty 2008). Before 1965, over three‐quarters of nurses were educated within Two major federal policy interventions of the hospitals, while only a minority had baccalaureate mid‐1960s greatly affected the nursing workforce. First, the Nurse Training Act of 1964 created Title degrees (BSNs) (IOM 1983; Donley and Flaherty VIII of the Public Health Service Act to subsidize 2008). By the mid 1970s, not only were there far the supply side of nursing more nurse graduates per year, “Nurses’
salaries,
which
historically
had
through grants and loans but also a large majority were lagged behind other women’s occupafrom the Health Resources tions, [after Medicare] increased dramati- college educated, somewhat and Services Administration cally” —Aiken (1982, p.32)
more often in new community (HRSA) to nursing schools college programs granting associate degrees and nursing students (IOM 1983). The Act ad‐
dressed immediate concerns of shortage, but was a (ADNs) than in BSN programs (IOM 1983). Di‐
long‐term intervention to increase both the num‐ ploma‐granting programs within hospitals were on bers and the level of training of nurses. Its funding the decline, and many hospital programs started to peaked a decade later, as discussed below. move toward offering their graduates community Second, Medicare and Medicaid created mas‐
sive new demand for health services. Federal and state spending rose from zero in the enactment year of 1965 to over $24 billion in 1974, about 55 percent for care in hospitals (CMS 2008). Moreover, hospi‐
tals enjoyed cost‐based reimbursement, so that they were simply repaid for spending more on nurses. This increase in demand then helped attract more students into nursing. These huge boosts for nursing education and employment coincided with two broader social trends: higher education was expanding to serve the baby boom cohort of Americans, then just start‐
ing college, and women were becoming more likely to enter and remain in the labor force than their postwar mothers had been. As a result, the number of nursing graduates soared between 1965 and 1975, from about 30,000 to about 70,000 a year (IOM college degrees through joint programs. Diploma‐
granting programs within hospitals were on the decline, and many hospital programs started to move toward offering their graduates community college degrees through joint programs. During 1980‐2004, the share of nurses whose initial nursing education was a bachelorʹs or associate degree ap‐
proximately doubled, while that of diploma nurses halved (Figure 5). Changes in the Policy
Environment over Time
and
Economic
This historical overview lends support to the concerns of observers who feel that future imbal‐
ances between supply and demand may be more difficult to surmount than past ones. Since the 1960s 5 and 1970s, for example, the population has aged, and new workers no longer greatly outnumber re‐
tiring ones. Moreover, professions other than nurs‐
ing also need to replace aging workforces (Council on Competitiveness 2008). Support for public plan‐
ning has been in decline since the high‐water mark of the National Health Planning Act of 1974. Both public and private payers have moved away from cost‐based hospital reimbursement—with pro‐
spective payment for hospital care in the 1980s and a general shift in insurance toward managed care in the 1990s—and nurses’ services cannot normally be separately billed, apart from certain advanced prac‐
tice nurses. Leaps in federal and state funding achieved in the past appear unlikely in an era of large deficits and financial crisis. At the same time, new concerns are arising about the level of educa‐
tion and training and sophistication needed for nurses to be able to play larger and more independ‐
ent roles within an evolving health system. These and other shifts are considered further in the fol‐
lowing sections. C. Projections of the future nursing supply
and demand for nurses
ous short‐run indicators are cited. The lack of agreed‐upon, objective standards is exacerbated by the need to project demand forward in time, where there are many unknowns, notably new technolo‐
gies and changing modes of care delivery. On the supply side, projections must take into account not only the size of the age cohorts entering the labor force over time, but also the attractiveness of nurs‐
ing as a profession—wages, schedules, working conditions, and prestige—relative to competing professions, and how the perception of the relative merits of different careers will change over time. These difficulties notwithstanding, researchers regularly make projections because health care workforce planning needs such estimates. Three sets of projections are commonly cited—HRSA (HRSA 2004), the Bureau of Labor Statistics (BLS 2008b), and Buerhaus et al. (2004). Each of these sources has built its own model to generate projec‐
tions of future nursing employment levels. HRSA and BLS project both supply and demand, while Buerhaus and colleagues project supply only and compare this estimate with the HRSA demand pro‐
jection. The models have some assumptions in com‐
mon, but other assumptions differ, including how far to the future the projections look. As a result, both supply and demand projections differ across the models as do the predictions of shortage. The nursing workforce could grow rapidly dur‐
ing the 1960s and 1970s expansions of health cover‐ Supply, demand, and shortage projections
age because maturing baby boomers were swelling The HRSA model predicts that there will be the labor force. Now, the aging of boomers will si‐
multaneously shrink the nursing workforce and about 2.7 million nurses in 2020, of whom 2.1 to 2.3 swell the elderly population that needs the most million will be “active in the nursing field.” Based nursing care. There is widespread agreement in the on current patterns of workforce participation (full‐
time or part‐time, age at en‐
nursing literature that a serious “available data on supply and demand
try, age at retirement), these shortage of nurses looms ahead for RNs are not adequate to determine
estimates imply that the (HRSA 2004; CCNA 2008; NLN the magnitude of any current imbalance
2009b; ANA 2008; IOM 2008; Buer‐ between the two with any degree of pre- number of full‐time equiva‐
cision.” —-US Government Accountabil- lent (FTE) nurses will de‐
haus et al. 2009). However, there is ity Office (2001)
cline from about 1.9 million much less agreement on the size in 2000 to about 1.8 million in 2020. In contrast, the and timing of the shortage. BLS model predicts that there will be 3.1 million The concept of a shortage is straightforward active nurses in 2016. Under the same participation but, in practice, it is difficult to quantify. On the de‐
patterns, this model suggests about 2.5 million FTEs mand side, there is no standard for how many (authors’ calculations). In 2000, Buerhaus and col‐
nurses are needed (Goldfarb et al. 2008), and vari‐
leagues estimated that the number of FTE nurses 6 would fall from a peak of 2.2 million in 2012 to just over 2 million in 2020. On the demand side, HRSA’s baseline model projects demand for nurses at 2.8 million FTEs in 2020, while BLS estimates that there will be 3.1 million jobs for nurses in 2016, a figure unadjusted for part time work (BLS 2008b). A com‐
parison of these demand estimates to the various estimates of supply yields shortage predictions of some 300,000 to 1,000,000 FTEs. All of the models assume that past trends on both the supply and the demand sides will gener‐
ally continue into the future. HRSA’s demand model extrapolates current national patterns of health care use and assumes that future demand will be driven largely by population characteristics. (It does make separate estimates for alternative sce‐
narios of wages, HMO enrollment rates, inpatient and outpatient surgery rates, insurance coverage status, and other factors.) On the supply side, both HRSA and Buerhaus and colleagues assume that the behavior of each age cohort will follow patterns seen historically in entry into nursing by new graduates from nursing programs; thus, the pro‐
jected number of graduates from nursing programs, like the demand for nurses, is driven largely by population growth. The share of students attracted to nursing and workforce participation rates by age and education level are also assumed to remain relatively stable into the future. Exit from the nurs‐
ing workforce due to mortality, retirement, disabil‐
ity, and other reasons likewise are assumed to fol‐
low past patterns. The models do allow for some deviations from the past. For example, the HRSA model considers the effect of upgrades in nursing education levels. However, the models do not con‐
trol for factors other than wages that affect the at‐
tractiveness of the nursing profession. The BLS model takes into account broader economic trends—labor force participation rates by age, sex, and race/ethnicity; total economic performance; and industry‐level employment in the health sector—
and generates estimates that are between the other two models. Basing projections on past trends makes sense. But the resulting projections should be viewed in light of the assumptions that produced them and revised when these assumptions are no longer war‐
ranted. In 2007, Buerhaus and colleagues revised their supply estimates upwards to 2.5 million in 2020 (Auerbach et al. 2007) when the number of working nurses grew six times faster than had been predicted between 2000 and 2004 (Kuehn 2007). This revision in light of newly available data is an indication of how difficult it is to project supply. The authors cite a later age at first entry into nursing and an overall increase in interest in nurs‐
ing as a profession as the key drivers of the change. The likely evolution of health care delivery in the coming decade suggests that revisions will also be needed in projections of demand. Regional differences
Although the market for nurses can appropri‐
ately be considered to be national, shortage esti‐
mates differ across states and across regions within some states (GAO 2001). A recent study concludes that nurse shortages are “significantly greater” in rural areas than in urban ones (Cramer et al. 2006). Research has shown that the geographic distribu‐
tion of shortages of nonphysician providers, which includes nurses, follows the distribution of short‐
ages of physicians, and that these shortages are more frequent in states with lower educational ca‐
pacity for each provider type (Cooper et al. 1998). These studies suggest that simply producing more nurses may not be effective in alleviating areas’ shortages if attention is not paid to where the nurses are produced. Underlying factors affecting supply
Among the most important factors in the sup‐
ply models are the influence of teaching capacity, tuition costs, working conditions, and RN compen‐
sation. Considerable anecdotal evidence suggests that teaching capacity is strained, tuition costs have outpaced federal aid, working conditions have de‐
clined as compared with other employment options available to nurses, and growth in compensation has been relatively stagnant. These factors may be amenable to change, and so their effects are worth considering in greater depth. 7 Nursing education
ity to charge differential tuitions to students based Overall, nurses have a higher rate of labor force on their declared field of study. As a consequence, participation than other college‐educated women although nursing courses are more expensive to (figure 6); retention within the profession is rela‐ conduct, nursing students generally pay the same tively high. Hence, there is less scope for increasing tuition as, say, liberal arts majors who require little the number of FTEs from within the existing pool of special equipment or materials, although nursing trained nurses and greater need for increasing the students may, however, face some specific labora‐
number of nurses being trained. Nursing tory charges. educational capacity is, therefore, an important key Faculty constraints are the most frequently cited to future nursing supply. bottleneck. Universities may find it difficult to offer The number of students entering nursing has nursing faculty higher salaries than other faculty been growing since 2001, following several years of members even though they do for professional decline (figure 7). The number of nursing students schools including law, medicine, and engineering is almost 50 percent higher than it was in 1996 where outside salaries are much higher than in when the decline began, although the rate of nursing (Joynt and Kimball 2008). Faculty need ad‐
growth has slowed recently. There are indications, vanced nursing degrees as well as clinical experi‐
however, that nursing educational capacity may be ence, both of which are time‐consuming and expen‐
straining to accommodate all of the potential enrol‐ sive to acquire. The share of nurses receiving ad‐
lees. The National League for Nursing reports that vanced degrees, particularly PhDs, has been in‐
almost 100,000 applications were rejected in the creasing steadily since at least 1980 (figure 8), which most recently surveyed year, not because the appli‐ should provide a base for expanding nursing edu‐
cants were unqualified but because there were no cation once physical capacity and other constraints places available for them (NLN 2009a). Because have been addressed. Although, as noted above, the share of nurses in education many applicants submit mul‐
“With
rising
salaries
and
the
promise
of
a
has recently rebounded af‐
tiple applications, it is not bright long-term employment outlook, individuter several years of decline, clear how many individuals als are clamoring to enter nursing training prothe age of doctorally pre‐
are represented by these ap‐ grams.” — Kuehn (2007, p. 1623)
pared nurses is rising and, plications. In the face of a projected shortage, however, the rejection of any compared with other disciplines, nurses seek ad‐
qualified applicants suggests a need to examine vanced training later in their careers and tend to retire earlier (Yordy 2006). educational bottlenecks. The production of nurses takes several years, so there is a lag between market signals of a need for more nurses and when the nurses can be available. Constraints on producing more nurses include physical capacity at nursing schools, faculty, and opportunities for clinical experience (AACN 2008a). In addition, there is a lack of mentors available to help new nurses make the transition from student to practicing nurse in a clinical setting. Physical capacity constraints are seen in general classrooms but more strongly in laboratory space. Expansion of nursing school capacity can be costly for schools since building and stocking science labs is expensive. Such costs can be difficult to recoup through tuition; universities often have limited abil‐
Opportunities for clinical experience is the most pressing other constraint for nurses in training and for newly licensed nurses transitioning to practice (AACN 2008a). Nursing vacancies in hospitals mean that nursing staff have little time for the addi‐
tional duties of mentoring new nurses. Cost con‐
tainment efforts have put pressure on health care facilities at all levels to reduce staff and seek higher productivity than new nurses are likely to be capa‐
ble of meeting on first entering practice. Working conditions and compensation
Tuition support, which has declined substan‐
tially over time, and educational capacity influence how many people become nurses; working condi‐
8 tions and wages influence how many stay in prac‐
tice over time. Earnings of nurses increased by 4.9 percent in 2002 following a decade of stagnation (Buerhaus et al. 2004) and have been rising slowly since that time, easing this constraint somewhat (Spetz and Given 2003). Working conditions, how‐
ever, remain an issue. choice for recent college graduates (Buerhaus et al. 2004). Nursing is still largely a female profession, al‐
though men now represent about 5 percent of nurses (HRSA 2006). Some of the decline in the share of women going into nursing is attributable to the increasing openness of other professions to women. The aging of the population that will increase the need for nurses also implies a reduc‐
tion in the share of the population that is of school age. Teaching, particularly in K–12 schools, is also dominated by women. Some women who would have chosen teaching may choose nursing instead as teaching jobs dwindle and demand for nurses rises. The same cost containment and efficiency fac‐
tors that have affected facilities’ willingness to par‐
ticipate in nurse training have contributed to a re‐
ported deterioration in working conditions for nurses (Buerhaus et al. 2009). For 56 percent of nurses leaving the workforce, the top reason, after retirement, was finding a less stressful and less physically exhausting work environment (Hart 2001), although there are indications that some im‐
provements have been made recently in working Economic conditions
Buerhaus et al. (2009) have established a link conditions (Buerhaus et al. 2009). Staff shortages have led many facilities to institute mandatory between employment growth among RNs and eco‐
overtime for nurses or extra shifts. Nurses note the nomic conditions. Employment of RNs grew faster increase in the number and acuity of the patients in between 2001 and 2003 than at any time in over their charge and have expressed real fears about three decades. At the same time, the already high quality of care and the safety of their patients, fears workforce participation of nurses grew by 1.5 per‐
that have been documented in the literature cent increase between 2000 and 2004. During this (Altman et al. 2004). Nurses time, the American econ‐
omy was slowing down and see greater autonomy and "We face an impending crisis as the growing
number
of
older
patients,
who
are
living
longer
unemployment was unusu‐
flexibility in the delivery of ally high. Older women ac‐
care as one way to alleviate with more complex health needs, increasingly
outpaces the number of health care providers
some of these concerns as with the knowledge and skills to care for them
counted for much of the well as improve working capably.” — John W. Rowe, chair of the IOM
growth in 2002 and 2003, Committee
on
the
Future
Health
Care
Workforce
conditions (Kovner et al. many of whom were reen‐
for Older Americans, quoted in National Acad2007). tering the workforce; hospi‐
emies (2008)
tal employment of RNs Demographic factors
older than fifty rose 15.8 The average age of nurses is rising, and many percent in 2002 (Buerhaus et al. 2004). Because most nurses will reach retirement age within the next of these RNs were married and living in states two decades. Unless a much larger share of new where unemployment had risen faster than aver‐
workers choose nursing, the shortage could be se‐ age, Buerhaus and colleagues concluded that the vere. The recent increase in nursing enrollment has earnings and job security of RNs’ spouses, as deter‐
begun to influence the age distribution of nurses. In mined by the broader economic climate, are power‐
2002, employment of nurses under age 35 grew by ful factors driving nurses’ work decisions in the 90,000, reaching the highest level of younger RNs short run (Buerhaus et al. 2007b). The current reces‐
since 1987. However, about half of the growth was sion is keeping more nurses in the workforce, pro‐
concentrated in the 30‐ to 34‐year‐old cohort, sug‐ viding short‐term relief on the supply side even as gesting that nursing is still not a popular career insurance coverage contracts and demand for some 9 services falls (see, for example, Dougherty 2008, Alltucker 2009, and Halsey 2009). Underlying factors affecting demand
Defining staffing needs
There are different standards for what consti‐
tutes adequate nurse staffing and, by extension, de‐
mand for nurses. Goldfarb et al. (2008) discuss stan‐
dards in hospitals, but their argument transfers easily to other settings where nurses practice. De‐
mand may be based on the number of nurses needed to meet professional standards, that is, how many nurses the facility would like to have without taking cost into account. Alternatively, demand may be based on how many nurses the facility can afford to hire given likely revenue and competing costs. A large share of health care is delivered in response to emerging or urgent needs and so is not predictable on a day‐to‐day basis, so facilities must also take into account staffing for peak demand as well as periods of low demand. Changing demand for services
However demand is defined, it is rising. The increase comes from several sources, including changes in the population and changes in payment for health services. The aging of the population means rising service use to meet the increase in health problems that often comes with age. Over‐
weight and obesity are also correlated with in‐
creased health problems, particularly chronic dis‐
eases such as diabetes and heart disease that call for intensive case management (Finkelstein et al. 2008). The so‐called “obesity epidemic” puts additional pressure on health services use. Finally, technologi‐
cal innovations have made more conditions treat‐
able so more people get treatment. The shift to prospective payment as the domi‐
nant form of reimbursement for hospitals affected nurses in two major ways. First, it created incen‐
tives for hospitals to discharge patients as soon as they were no longer in need of acute care. Second, it meant that hospitals no longer received separate reimbursement for each element of their costs, in‐
cluding nursing costs. Hospitals thus had incentives to decrease all inputs to the level needed to permit the earliest possible discharge. The resulting in‐
creases in average patient acuity and decreases in average length of stay mean that nurses in hospitals are taking care of more patients on average and that, on average, their patients are sicker. Payment reform discussions include mecha‐
nisms that emphasize payment for quality. Recogni‐
tion of nurses’ contribution to increasing quality of care is growing (Needleman et al. 2002; Aiken et al. 2002; Stanton and Rutherford 2004; Kane et al. 2007), so demand for nurses may rise if quality‐
based reimbursement mechanisms, such as pay‐for‐
performance, become more widely accepted. Changing scope or location of practice
While the majority of nurses practice in hospi‐
tals, many work in other areas of care delivery that have been affected by the changing delivery system. The past two decades have seen tremendous growth in ambulatory care, including ambulatory surgical care, with the accompanying need for pa‐
tient follow‐up. Homecare is one of the fastest growing areas of health care delivery, and nurses account for a large share of the projected increase in needed homecare personnel (Berman 2005). Nurses have a broad range of skills, and in many areas their expertise overlaps with that of other professionals. Nurses, particularly advanced practice nurses, can and do provide primary care, with good results and reports of high patient satis‐
faction. The emerging shortage of primary care physicians likely will increase the demand for more nurses to serve as primary care providers and may create pressures to change the boundaries of tradi‐
tionally licensed scopes of practice, as discussed further below. Current practice limitations con‐
strain the autonomy of nurse practitioners (Christian et al. 2007) and reduce incentives to enter the field (Kalist and Spurr 2004). Where both physi‐
cians and nurses are in short supply, as is increas‐
ingly the case in many regions of the country, nurses may be in greater demand as primary care providers, potentially exacerbating shortages in their more traditional areas of practice. 10 Discussion
Prediction of future shortages depends on what the predictor believes will happen to all of the vari‐
ous factors affecting supply and demand. The exist‐
ing supply and demand models all assume that the future will be not substantially different from the past. None foresaw a wholesale change in how care is delivered or paid for, a likely outcome if current reform currents continue. The recent economic tur‐
moil combined with the growing consensus on the need for health care reform suggest that it might be time to reassess this assumption. On the supply side, there is recent evidence that market signals of a shortage combined with declin‐
ing prospects in other fields and/or increasing un‐
employment among nurse spouses have led to the hoped‐for supply response among the existing nurse workforce as well as renewed interest in nursing as a career. Demand for places in nursing schools has risen and, after some lag, there are indi‐
cations of an increase in the number of places avail‐
able, as enrollment surged in the early 2000s, peak‐
ing at a 17 percent annual rate in 2002–03 (AACN 2009c). The limits of increased enrollment given current educational capacity may be near, as enroll‐
ment growth has slowed, but new federal support in 2009 as well as initiatives to address educational shortages in many states, described below, are en‐
couraging. On the demand side, the picture is much less clear. The health sector has grown rapidly through many economic ups and downs. Despite the large national job loss in the year through April 2009, for example, employment in hospitals has not dropped and has risen in ambulatory care (BLS 2009). The rate of increase in overall health care costs has ex‐
ceeded general inflation for years on end, and con‐
sensus is building that this pattern is not sustain‐
able. Greater attention to quality suggests that the limits to cost‐cutting by simply doing more with less within the current system may have been reached. At the same time, the call for expanding health insurance coverage to a much broader range of the population is growing louder. The drive to insure more people is being coupled, in the interest of affordability, with a drive to discover new ways to control costs. Care management, care coordina‐
tion, and primary prevention, all of which would increase demand for nurses in the short run, are among the leading candidates. Expanding scopes of practice for nurses to help address the shortage of primary care providers would also increase de‐
mand for nurses under a reformed health care sys‐
tem. The design of health system reform—in both delivery and payment for care—could affect both demand for and supply of nurses. The success of the changes in improving care while containing costs will determine whether the changes are sus‐
tainable. Nurses are central in health care delivery, and health reform is certain to change demand for their services. Involving nurses in the redesign of care strategies will take the participation of more nurses at the policy level but could contribute to the long‐term success of the measures proposed. Fur‐
thermore, the improvement in working conditions that would be associated with giving nurses more flexibility and autonomy could itself affect the sup‐
ply of nurses through its effect on the attractiveness of nursing as a career. It is impossible to say whether continuing busi‐
ness as usual or making the types of changes identi‐
fied here would result in a larger increase in de‐
mand. It is also difficult to imagine a future where demand will be lower, making immediate attention to understanding bottlenecks in supply imperative. III. Responses to the Shortage
Numerous responses to workforce problems have been implemented or suggested. This section de‐
scribes past responses—initiatives that have actu‐
ally been implemented—not as recommendations, but as illustrations of what has been done. The next section covers future policy—including proposals not yet implemented, at least not sufficiently. A. Private responses
Among hospital responses, short‐run recruit‐
ment is of little policy import. Simply offering sign‐
ing bonuses, for example, reported by 44 percent of hospitals in 2005 (May et al. 2006), may shift nurses from one state or hospital to another. But it does 11 nothing to address systemic or long‐term problems. Far more significant are increasing pay relative to other careers or changing how nurses work with patients and other caregivers. These steps may per‐
manently increase satisfaction, improve patient care, or enhance career attractiveness. Improving working conditions may also create a virtuous cy‐
cle, in which greater satisfaction enhances staff sta‐
bility, which bolsters quality of care, which im‐
proves “financial outcomes,” which supports the enhancements (Pricewaterhouse 2007, 32). Thou‐
sands of employer efforts have been documented (AHA 2002, 2008; Health Workforce Solutions 2008). The following examples are illustrative. Supplementing the workforce
Hospitals’ use of independent nursing agencies for temporary help has long been cited as proof of shortage (LeRoy 1982; AHA 2002; Kimball and O’Neil 2002). However, it may also improve overall efficiency. Hospitals can use nonemployees to even out imbalances between fluctuating demand for services and a fixed supply of employed nurses. Agencies may give their own nurses greater pay and flexibility, but overreliance on agencies may hurt a client hospital’s continuity of care and organ‐
izational culture. Their contributions and draw‐
backs under different circumstances seem too little studied (an exception is Goldfarb et al. 2008). The hiring of foreign‐educated nurses has emerged as a longer‐term solution to shortfalls in the domestic supply of nurses (Aiken et al. 2004). Some 15.3 percent of new RNs in the 1990s were trained internationally, versus 8.8 percent in the 1980s. In the 1990s, real wages were rising steadily for the foreign nurses, but almost not at all for do‐
mestic nurses (Polsky et al. 2007). Ethical and prac‐
tical concerns about reliance on other countries’ nurses have been advanced. However, the United States is not alone in seeking to import nurses, con‐
ditions in “exporting” countries encourage nurses to leave (Buchan et al. 2003), and the large‐exporter Philippines actively educates nurses to work abroad. More practically, this approach may have reached its realistic limit, as concerns about short‐
age are worldwide (Simoens et al. 2005). Improving compensation and workplace
conditions
Wage or benefit increases are the most straight‐
forward marketplace response; they end shortages by not only increasing supply but also reducing de‐
mand while encouraging more careful use of re‐
sources. Wage hikes are certainly the solution that economic theory expects. At least one experienced observer has noted their role in ending nursing shortages (Aiken 1982, 1989), and lack of real wage increases in the 1990s likely helped precipitate shortages starting in 1999 (Buerhaus and Staiger 1999; Buerhaus et al. 2004). Higher wages immedi‐
ately encourage nursing dropouts to re‐enter active nursing or work longer hours. Over time, higher wages also encourage more new entrants, after a lag due to the length of the educational pipeline. Higher wages, of course, presuppose sufficient demand to support them, not merely generalized need or desire for care giving, but also higher reve‐
nues for hospitals and other employers or manage‐
ment willingness to raise nursing’s share of existing revenues. The early 2000s shortage followed 1990s constraints on both hospital revenues and nursing wages, and began to lessen after subsequent in‐
creases in wages enabled by improved hospital margins. Future changes in the levels and methods of hospital payment would also affect demand and wages, as considered more below. Many new initiatives seek to improve work‐
place conditions, broadly defined: More flexible scheduling and lower demands for overtime increase nurses’ control over their profes‐
sional lives (GAO 2008). About a third of hospitals used some form of flexible scheduling as of 2005, including self‐scheduling (May et al. 2006). Others have created special “parent shifts” for nurses with small children. Finally, some are experimenting with allowing nurses to “bid” for traditionally un‐
popular shifts (Tarkan 2004). Stress reduction to avoid burnout of nurses may be responding to a side effect of raising nurse‐
patient ratios. Other initiatives target stress directly, such as weekly massages, optional time in a “healing garden” to rejuvenate and reflect, and for‐
12 mation of a staff softball team or other staff social events. Such programs have been found to raise satisfaction rates (RWJF 2006). Better assimilation of new nurses more narrowly targets dropouts in the first year. Informal help may come from experienced nurse mentors or “retention coordinators” (Lillibridge 2007). Formal residency programs allow new nurses to share their experiences, receive advice from seasoned nurses, and work on continuing education (Krugman et al. 2006; Rosenfeld et al. 2004; Williams et al. 2007). Improving nursing careers together with
patient care
Beyond such add‐ons to traditional workplaces, more fundamental changes address how nurses care for patients, their role within their institutions, and their career paths. Most seek not just to make nurses’ lives easier but also to streamline and im‐
prove patient care and outcomes. Empirical docu‐
mentation of effectiveness seems scant, but anecdo‐
tal evidence suggests that elevating nurses’ status can increase their satisfaction and retention rates. sions that directly affect their work, such as patient‐
staff ratios and equipment acquisitions. The “magnet hospital” approach combines many such initiatives. Seeking to understand why some hospitals do better in recruiting and retaining nurses, early research identified factors attractive to nurses, including high quality nursing leadership, competitive personnel policies and programs, sus‐
tained quality improvement, autonomy for nurses consistent with practice standards, and positive im‐
age of nursing (McClure et al. 1983). In 1994 the ANA began conferring Magnet Recognition® status on qualifying hospitals and other organizations.2 Only about 5 percent of institutions nationally have received recognition, but many others are in the pipeline (ANCC 2009; Triolo et al. 2006). A halo ef‐
fect may also influence other entities that observe the results obtained by the designated facilities. Magnet status recognizes good workplace con‐
ditions and correlates with lower turnover and likely higher quality of care (Havens and Aiken 1999; McClure and Hinshaw 2002). There may, however, be selection bias in such observations, and at least one study finds that Greater integration of nurses "Autonomy is a big thing," says [Jennifer] some as yet unrecognized hos‐
into care teams has increasingly Dimmick, who has been at Inova Fairfax
Hospital for 7 1/2 years. "It's important for pitals do even better (Ulrich et drawn attention as a way to me to know that what I do matters."
al. 2007). This effort to improve improve quality of care -Haynes (2008)
will benefit from learning more (Alliance for Health Reform about which elements of 2008). For example, Transforming Care at the Bed‐ “magnetism” are most influential, how much they side seeks to create a “supportive environment that cost, and what offsetting savings may occur. Other nurtures professional formation and career devel‐ efforts also seek to create cultures that value nurs‐
opment” within which “effective care teams” of ing more highly (e.g., AONE 2004). nurses and others “continually strive for excel‐
Improved support systems can promote nursing lence” (IHI 2004, 5). efficiency. One way to free up nursing time for pa‐
Improving nurses’ autonomy may take the form of tient care is to have support staff perform some giving nurses a greater voice in patient care stan‐ tasks—such as addressing personal care needs or dards and planning or encouraging them to con‐ transporting patients—although nurses often use duct their own research project, especially on ways any interaction with a patient to help assess patient to improve quality of care (Haynes 2008). Private status. More help in managing paperwork also ad‐
employers have also worked to elevate the status of dresses a frequent complaint of nurses; electronic nurses. Some hospitals have made organizational health records are often touted as helpful (Haynes changes to give nurses more power in their hierar‐ 2008). Improved work flow and supply manage‐
chies. Others have sought to include nurses in deci‐
2 The full set of institutional characteristics considered is extensive (ANCC 2009) and incorporates by reference the ANAʹs separate standards for nursing administration (ANA 2004). 13 ment can also improve efficiency (JCAHO 2002; Feldstein 2008). Education-related initiatives
even international, in scope. Local governments may also play a role, especially where they see a thriving educational or health care sector as central to their economic stability and development. This section describes four key types of public initiatives, often partnering with private actors. Many hospitals have provided forms of tuition support for current or prospective nursing staff or refresher courses for nurses returning to the Education—expanding capacity of the
workforce (AACN 2002, 2003; Tarkan 2004; May et pipeline
al. 2006; Wood 2009). Other employers have formed Many scholarship or loan programs support partnerships with nursing schools to give students the opportunity to obtain nursing experience in a nursing students, some general, others need‐based clinical setting and also provide additional educa‐ or targeted to specific needs, including increased tion to current nursing staff (May et al. 2006). Other diversity3 (NCSL 2001; HRSA 2005). Loan forgive‐
strategies for supporting nursing education include ness often rewards graduates who work in areas of rigorous orientation programs to acquaint new need. Good data on the numbers and scope of stu‐
nurses to hospital settings, specialized training in dent assistance from all sources appear to be lack‐
ing (CHPRE 2002). Most specialty clinical areas, and pre‐
nurses are educated in state ceptor programs that pair new Teamwork and Nursing
schools, including community One new model for inpatient and outpatient
nurses with more experienced care emphasizes a leadership role for nurses
colleges; and state schools are nurses mentors (e.g., Wolak et al. in designing care plans for patients, while bol2009). Nurse residency programs stering teamwork and interdependence among the central public policy lever (noted above) also provide such staff. The “nurse caring delivery model” makes available for building nursing teams of nurses responsible for collaborative
workforces (HRSA 2005). support at the start of a career. delivery of care. They share information on all
patients during multiple daily meetings. Early
However, the most recent Employers have sometimes results included greater feelings of support,
also bolstered nursing faculties— professionalism, and satisfaction among nurse decade of budget austerity participants, easier recruitment thereafter, and
has seen regular state appro‐
by directly subsidizing faculty decreased RN turnover rates. —RWJF (n.d.)
priations for higher education salaries, lending master’s‐
decline in competition with prepared nursing staff members to serve as faculty, and assisting in faculty searches other needs (Goodman 2009). and recruitment (RWJF 2007; May et al. 2006). In addition, some new schools have opened in re‐
sponse to higher demand for education. Their abil‐
ity to meet educational standards has at times been questioned, however (Shishkin 2008). B. Public policy responses
States are the central public actors. They tradi‐
tionally support state colleges and universities, op‐
erate licensure and quality regulation, and adminis‐
ter the joint state‐federal Medicaid programs (NCSL 2001). Medicare and Medicaid make the federal government the biggest single purchaser of health care, however, and workforce issues are national, Since professionals tend to begin practicing near their place of final education, numerous states and some localities have undertaken special initia‐
tives, especially when seeing a severe shortage and often seeking private partners (RWJF 2005a). Such initiatives typically target funding to perceived ca‐
pacity needs, including lack of space, faculty, and clinical rotation options (AACN 2006), often trying to partner with private funders (Pennsylvania De‐
partment of Labor and Industry 2008, Pennsylvania Office of the Governor 2008). Student scholarships are a similar target (Tampa Bay Business Journal 2004). Such limited efforts may be very helpful in the short term, but may do little to change general 3 Enhancing diversity in the nursing workforce is a goal in its own right, quite apart from its impact on the supply and demand for nurses, the focus here. As AACN (2008c) has noted, “Nursing’s leaders recognize a strong connection be‐
tween a culturally diverse nursing workforce and the ability to provide quality, culturally competent patient care.” The topic warrants its own publications (e.g., Grumbach et al. 2003). 14 perceptions of how desirable nursing and nursing education are as career choices. A contrasting exam‐
ple comes from Maryland, which has generated multi‐year funding by adding 0.1 percent to the rates of all Maryland hospitals—some $18 million per year (HSCRC 2008, Tan 2007‐08). This strategy is uniquely available in Maryland because of its comprehensive hospital rate regulation. Another strategy has been to start wholly new nursing programs, both full baccalaureate programs and a variety of new, accelerated degree‐granting programs that expand career pathways for already licensed nurses (Raines and Taglaireni 2008; AACN 2008d, 2009b). The latter programs create pathways for already licensed practitioners to upgrade their credentials—such as nurses with diplomas gaining bachelors of science in nursing degrees or RNs be‐
coming advanced practice nurses. Similarly, accel‐
erated BSN or masters programs “fast track” hold‐
ers of college degrees into a nursing degree. Non‐
traditional programs are growing rapidly, but re‐
main small relative to traditional pathways (AACN 2008d). Some observers within the profession ques‐
tion the desirability of such proliferating degree programs (compare AACN 2004 with Dracup et al. 2005). Title VIII of the Public Health Service Act con‐
tinues grant support for nursing education that dates back to the Nurse Training Act of 1964. The most striking thing about this support is how greatly its magnitude has varied over time. An all‐
time high of $777 million was reached after one dec‐
ade (1973 level in 2008 dollars, figure 9), but de‐
clined over the next decade to about $100 million, not rising again until increases began again in the early 2000s. As a percentage of health care spending the drop is even more striking—from about 0.16 to 0.007 percent. There is an association between fund‐
ing and enrollment—the low funding of the 1990s coincided with a period of low nursing enroll‐
ment—although causality cannot be discerned from the data. The types of support have also changed over time, including scholarships and loan repayment programs for nursing students; loans for nursing faculty; grants for education, practice, and reten‐
tion; and funding for advanced nursing education, as well as smaller amounts for supporting specific needs such as geriatric education and nurse work‐
force diversity. The Health Manpower Amendments of 1981 ended the formerly large capi‐
tation payments to institutions, leaving student aid as the main focus. Under current law, the Nurse Reinvestment Act of 2002, the focus is on support for advanced nursing students and building of ca‐
reer ladders (AACN 2005). The proposed Nurse Education, Expansion, and Development Act, repeatedly introduced in the 2000s, aims to re‐create the former type of substan‐
tial capitation grant funding (AACN 2009a). The Nurse Faculty Education Act (S. 1575) would have funded a small set of demonstration projects. It is not clear whether giving capitation aid directly to institutions creates different outcomes from giving aid to students that can only be used to pay institu‐
tions. Targeting project funds to institutions, espe‐
cially through capital grants, could more effectively create needed classroom and clinical space. How‐
ever, given that money is fungible and that nursing programs exist within much larger institutions, new public funding in one area may to some extent be offset by shifts elsewhere. The funding picture may be changing. The American Recovery and Reinvestment Act of 2009 (the “stimulus bill”) provided large, new one‐time fund‐
ing to support nursing education (Pub. Law 111‐5, Feb. 17, 2009; AACN 2009f). Moreover, President Barack Obama’s first budget calls for a 54 percent increase in total Title VIII funding (USDHHS 2009; AAMC 2009). Sizeable federal funds also flow via Medicare payment for graduate medical education (GME). GME mainly funds hospitals that educate physi‐
cians, but also supports those that train nurses and other health practitioners, paying some $300 million 4 MedPAC, the Medicare Payment Advisory Commission, is an independent federal body that advises Congress on Medicare. 15 a year, according to MedPAC sources.4 GME does not support today’s larger needs for baccalaureate and higher training nor for community‐based prac‐
tice. The Institute of Medicine and leaders in the nursing profession have suggested changes in this regard (IOM 1997; Thies and Harper 2004; Aiken and Gwyther 1995). Regulation of Nurses’ Scopes of Practice and
of Employers’ Use of Nurses
Licensure and Payment Policy
Workforce supply and demand reflect the changing roles of nurses over time, as noted above. Those roles in turn are influenced by the nursing scopes of practice enforced by licensure agencies for each recognized category of health professional within a state (Christian et al. 2007), as well as by private and public health plans’ payment policies (Cromwell and Rosenbach 1988; Blumenreich 1991). Buyers cannot demand what is not legally allowed or paid for. Advanced practice nursing of various kinds can allow nurses to help meet unmet health care needs as well as to utilize their full professional skills, but licensure and payment rules must permit this practice to attract nurses into such practice (Kalist and Spurr 2004). Two substantial and growing health care needs are to deliver primary health care services of good quality and to improve care coordination and man‐
agement, especially for chronic disease (see, for ex‐
ample, Laurant et al. 2005, Mundinger et al. 2000, Tringali et al. 2008, and Boville et al. 2007). In both areas, nurses are seen as adding great value to a physician workforce increasingly dominated by specialists and subspecialists. Expanding the scope of practice and autonomy of nurses in the delivery of primary care can help improve access to care, encourage care‐seeking at earlier stages of an ill‐
ness, and reduce unnecessary emergency room use. To complement or supplement physician ser‐
vices requires nurses able and authorized to prac‐
tice more independently. Achieving greater flexibil‐
ity in utilization of the various health care work‐
forces in turn requires new regulatory attitudes about scopes of practice and sometimes statutory amendment as well. Political and intra‐institutional conflicts must also be managed over the increas‐
ingly porous boundary between primary care phy‐
sician and nursing scopes of activity. Registered nurses also routinely perform some tasks that could usefully be delegated to others with less training, licensure rules permitting. How to improve flexibil‐
ity of practice so as to get the most value from the varied health care workforces and to change over time as needs and technology change merits much more attention from health care payers and licen‐
sure authorities. Hospital staffing ratios
California enacted the first minimum hospital nurse staffing ratios, responding to nursesʹ com‐
plaints of overwork and reduced quality of care (CNA 2009). Enacted in 1999 and implemented in phases starting in 2004, the law was touted as a quality measure and also a solution to the nursing shortage, evidently on the theory that hospitals would be forced to attract more nurses through im‐
proved wages or working conditions. The measure also had potential to exacerbate the shortage, how‐
ever, by increasing demand without increasing sup‐
ply. To its credit, California also increased Medicaid funding for hospitals to facilitate more hires and soon embarked upon a broad‐based effort to boost nursing education (box below). Wages and staffing ratios increased after the law, but evidence about quality appears to be mixed, and both negative and positive assessments have appeared (compare Bol‐
ton et al. 2007 and Sochalski et al. 2008 with Mark et al. 2009 and Spetz et al. 2009). Moreover, numerous other in‐state and national trends have also affected California experience. The effectiveness of this approach remains con‐
troversial. Fixed legal ratios do not account for pa‐
tient acuity, nor for the circumstances within which nurses work—both of which affect staffʹs ability to take good care of a patient population (Welton 2007). Moreover, implementation of the new regula‐
tions was only completed in 2008 and compliance seems mixed, so that California’s experience is nei‐
ther final nor yet completely understood. Finally, the staffing‐ratio approach takes no note of differ‐
ences in educational levels or the mix of staffing at 16 any given institution. There is more general evi‐ data from neighboring states and similar regions dence that hospitals with a higher proportion of elsewhere in the country, as can be seen in the work of HRSA‐initiated, typi‐
baccalaureate nurses cally regional health work‐
have better outcomes The California Example of Multifaceted Intervention
force centers (see, for exam‐
(Aiken et al. 2003; Nee‐
Given the many influences on any state’s workforce,
dleman et al. 2006; Kane multiple, coordinated interventions might plausibly do most to ple, Martiniano and Moore increase the number and educational attainment of nurses,
et al. 2007), but substan‐ as proposed by a number of state task forces (Moskowitz 2009, Southeast Regional tially more information is 2007b,; Pennsylvania Department of Labor and Industry. Center for Health Work‐
2008). California targeted five areas starting in April 2005—
needed to judge the rela‐ expanding educational capacity, partnering with private in- force Studies 2007, and tive effectiveness of staff‐ dustry on faculty, developing new avenues to nursing ca- University of Texas 2007). reers, and coordinating with federal and other funding
ing ratios and other inter‐ sources (CA Dept of Labor 2006). It enhanced existing state Moreover, there may be ventions in improving roles and also provided funds to localities and other entities. economies of scale and cited include increased school capacity
care. Nonetheless, the Accomplishments
synergies in analysis if and new rural clinical simulation laboratories. Some indefixed‐ratio approach pendent observers credit state action with ameliorating the nursing workforce issues seems likely to attract early 2000s extreme shortage (Goldeen 2008).
are considered in the same state interest for the fore‐
center with other parts of the health workforce, as seeable future (Larkin et al. 2007; Cortez 2008). in New York. For example, having corresponding Workforce data collection and analysis
data on the circumstances and performance of the major employers of nurses (hospitals, visiting nurse services, and nursing homes) is useful for consider‐
ing the feasibility of various interventions to bolster the nursing workforce. Institutionally, public part‐
nering with a university or a foundation may en‐
able a center to attract and retain more talented data management capabilities, although perhaps at some cost in control over operations. However config‐
ured and focused, efforts to generate more consis‐
tent and timely data would greatly assist in policy development and evaluation. A consistent theme in analysis of workforce is‐
sues is that good, timely data are often lacking. Pro‐
duction of information is a classic public good that requires public support, and HRSA’s quadrennial survey is the major source of national and even state‐specific data. Federal support for this and other workforce efforts has grown only slowly if at all, as interest in many forms of health planning has waned. In about two thirds of states, including New York, state‐level data centers focus on workforce issues for nurses or all practitioners (RWJF 2005b; “Nursing is rendered fiscally invisible
when it comes to hospital income but
CHWS 2009; Forum of State continues to figure prominently when
Nursing Workforce Centers examining operating costs, making nurs2009; HWIC 2009). If suffi‐ ing a periodic target for budget cuts.” —
ciently funded and staffed, Keepnews (2006, p. 237)
such centers can generate pol‐
icy‐relevant information more geared to state pol‐
icy‐making needs and budget cycles, but funding can be hard to maintain (NC Center for Nursing 2008; Schalin 2008). Consensus seems lacking on what data to col‐
lect, at what geographic level, or within what insti‐
tutional structure. State‐level operations plausibly improve credibility and policy relevance within each state, but some states are likely too small to operate effectively. It is useful to have comparable Cutting across all of the initia‐
tives just discussed, states may take a multifaceted approach. Such coordinated interventions have intuitive appeal and have often been recommended by task forces (box). Funding for nursing services
Most writing and discussion of nursing‐
shortage‐oriented interventions is incomplete, in that it focuses almost exclusively on the supply side of nursing—attracting students, producing nurses, and retaining them in practice. Full understanding of shortages calls for examination of the demand side as well, including, as already noted, how pri‐
17 vate and public health plans and programs pay for services involving nurses. Few if any interventions have paid more for more or better nursing, much less to support expan‐
sion and upgrading of nursing capabilities in the future. Pay for performance initiatives might re‐
ward hospitals that use nurses more effectively to improve quality during a hospital stay, if properly designed, and suggestions for such initiatives are being heard (e.g., Aiken 2008). One tenet of quality improvement is the importance of a team approach to patient‐centered and evidence‐based care (IOM 2003 and 2004; Commonwealth Fund 2009). Nurses are a key team member and spend the most time with patients, but all must work together. Beyond pay for performance for episodes of care lie broader quality improvements that nurses can help to achieve, such as reducing hospital stays or better managing chronic conditions. Going forward, it is very important to continue to document the value added by nurses and ways that funding flows can recognize and incentivize attainment of greater value, as discussed next. IV. A Public Policy Agenda for Moving
Forward
Concerns about the nursing shortage have been coming from many quarters—employers, educa‐
tional institutions, foundations, industry organiza‐
tions, and nursing associations, each with their own perspective. At the same time there is growing awareness of nursesʹ ability to improve the delivery of care. Our perspective is that this moment offers an opportunity to recast workforce concerns as sys‐
tems design issues and to gather broad support for constructive change. This section suggests action items for such an agenda. A. Supply side: address shortcomings in
education
As documented in this brief, addressing the nursing shortage involves far more than attracting more people to the profession and training them all as quickly and cheaply as possible. Funding, re‐
quired skill levels, and institutional and profes‐
sional barriers are all factors to be considered (see also Joynt and Kimball 2008). Funding
Past shortages have often encouraged increased federal and state funding for nursing education, but in todayʹs economy a very strong case is needed to win such increases. While it is encouraging that there has been more foundation and private sector engagement in nursing workforce issues, these sup‐
porters will likely be facing difficult financial cir‐
cumstances as well, at least in the near term. Addressing nursing supply issues in this envi‐
ronment requires • A strategic and coordinated effort to increase grant and GME‐like funding to nursing educational institutions, with attention to differences in regional and local capacity, building on recent changes in federal policy. • Continued experimentation and expan‐
sion of new ways to share educational resources, including funds, facilities, and faculty, within educational institu‐
tions and across health professions. A strategic effort to increase funding means tar‐
geted approaches, bolstered by a strong case that resonates with health providers, policymakers, and consumers. An example would be focusing on par‐
ticular educational levels and/or specialties within nursing that are directly related to documented need for those types of nurses or educational capac‐
ity. A persuasive case for targeted funding also re‐
quires clarity in distinguishing between the capital/
capacity needs of educational institutions and fi‐
nancial assistance for students. The consensus among nursing leaders is that institutional capacity is a significant limiting factor. This view sees the bottleneck less as a lack of student financial aid and more as shortages of qualified faculty, classroom and laboratory space, and/or clinical placements. It is important to draw these distinctions in order to assure that the best use is made of the limited re‐
sources available to address the problem. 18 One cautionary note is that, even within the nursing profession, there is some disagreement re‐
garding the best educational paths for addressing nurse workforce needs. For example, there are tradeoffs between shorter, more intensive training programs that may offer more limited exposure to a range of clinical settings, and longer programs that are more costly and perhaps less attractive to more mature students making a career change. Another concern is that new educational entrants may not meet standards. These issues require further re‐
search and open dialogue in order to promote a comprehensive, coordinated response. Bottlenecks and Inflexibilities in Education
If capacity is the binding constraint even in the face of projections of increasingly severe shortages and long waiting lists of students, then why do in‐
stitutions not raise tuition, raise salaries, and find more space? There are several reasons why the so‐
lution is not so simple. Academic institutions have rigidities in their fiscal structures that make it diffi‐
cult to raise tuitions or faculty salaries selectively in response to changing demand across programs. Schools also seem reluctant to hire more tenured staff in response to an increase in students because past drop‐offs have sometimes left them with ex‐
pensive overcapacity. This lack of flexibility is more pronounced in public institutions, where state gov‐
ernments or regents must authorize higher tuition or spending. And, in the current economic environ‐
ment, educational and political leaders are unlikely to suggest increasing the financial burdens on fami‐
lies through tuition increases.5 Given such institutional barriers, now is the time to further explore and promote new and crea‐
tive ways to expand capacities and share burdens—
between hospitals and universities, within universi‐
ties, and through public‐private partnerships. Within each school, many facilities and faculties could be shared for health professions training. While some collaboration does occur within univer‐
sities for basic science courses, such efforts can be Outside provider organizations (including hos‐
pitals) and universities already collaborate for clini‐
cal placements, but additional partners may be needed to help encourage provider organizations to spend time supervising and mentoring students. Foundations can play such a role (Davis and Napier 2008), but likely not indefinitely nor nationwide. Similarly, private funding and collaborative ar‐
rangements with hospitals may enable universities to offer incentives to attract and retain faculty, such as joint appointments, opportunities to continue clinical practice, class assignments at hospitals, or reduced teaching loads for clinical mentors. A number of these innovative approaches are being tried around the country, but funding is needed to bring some of these programs to scale. Publicizing well‐documented evidence of the effec‐
tiveness of such programs must be an important part of the agenda (section C. below). Finally, it is clear that simply graduating more nurses will not address many of the workforce problems summarized in this report. In the absence of reimbursement and regulatory changes to sup‐
port the effective use of nurses once graduated, a simple boost in the supply of nurses will tend to hold down wages, perhaps to the short‐run benefit of employers, but it will also tend to encourage low‐
value uses of highly trained staff and feed back negative signals about nursing careers to prospec‐
tive future students. Other types of rigidity have also been cited as impediments to improved workforce policy—including rigidities of state line‐by‐
line budgeting, the lack of budgetary and programmatic independence for nursing degree‐granting programs, the hierarchical na‐
ture of educational structures, the lag time between educational interventions and outputs, and the split of state policymaking among departments of labor, economic development, health, and education, as well as with boards of licensure. Full consideration of such issues goes beyond the scope of this brief. How best to enable leaders in nursing education to flexibly respond to profes‐
sional and market signals is an important issue for further work going forward. So is how funders can best support those efforts. 5 expanded, perhaps to include sharing between edu‐
cational institutions within close proximity. States can help to broker the arrangements, at least within public college systems. One new form of collabora‐
tion is centralized applications to nursing schools, which should facilitate multiple submissions, and help assure that available slots do not go unfilled (AACN 2009d). 19 B. Demand side: promote the business
case
for
nursing
and
improve
understanding
As already noted, current nurse workforce plan‐
ning models project demand imperfectly because they largely assume a static health system, so that an aging population is the main factor underlying future demand as modeled. However, changes are occurring in the health care system that can and should affect the future demand for nurses, and further changes seem likely. It is important to improve traditional workforce planning, but even more important to address how nursesʹ roles and remuneration could be optimized under a reformed system of health delivery and financing. Health re‐
form will reshape future demand, the time to influ‐
ence reform is now, and nurses need to claim a place in designing reform because, as the backbone of patient care, they will surely be asked to imple‐
ment much of it. As action items for reform, two elements stand out: (1) health insurance reimbursement and (2) scopes of practice. Reimbursement Policy
A growing body of research associates hospital nursing care with reductions in complications, lengths of stay, medical errors, and the likelihood of subsequent readmission, as summarized above. One thorough assessment found further that there is a business case for hospitals to achieve such im‐
provements by using a higher proportion of RNs because the savings exceed costs. However, al‐
though hiring more nurses improves quality, it is not cost effective for hospitals under current reim‐
bursement policies that do not pay more for better quality (Needleman et al. 2006). Existing payment policies are the main problem, not just in hospitals, but also in other care settings, where improved pa‐
tient management and care coordination are unrec‐
ognized. Willingness to pay more, or differently, for care is a key to using nurses more effectively in sys‐
tems reform. Current health care reform discussions include payment reform (MEOHHS 2009, Rosenthal 2008) so the time is ripe to emphasize the importance of nurses in care teams. Part of the nursing policy agenda needs to be to understand the implications of such options for nurses and to help educate re‐
formers about how each option would recognize the contributions of nurses—or fail to do so. Nurses’ Scopes of Practice
Settings of care and roles of nurses have been shifting, but regulatory and payment restrictions inhibit nurses’ capacities to serve patient interests in new ways. It may prove easier to address such changes as part of health reform than in the tradi‐
tional contexts of licensure and payment policy separately. Reform naturally considers payment, licensure, and other topics as interrelated parts of change. Reform also creates a natural constituency for making care more cost effective, as nurses can help to do, in order to make expansions of cover‐
age, an enhanced benefit package, and other quali‐
tative improvements affordable. Finally, broader alliances for change seem possible for overall re‐
form than for narrower regulatory modifications. Health reform’s expansion of coverage will in‐
crease the demand for care in many settings. In or‐
ganizing to meet that new demand cost‐effectively, and to improve service for all, nurses’ scopes of practice need re‐assessment in light of emerging evidence about their capabilities—within outpatient surgery centers, long‐term care facilities, and reha‐
bilitation facilities, as well as in primary care. Nurses could usefully assume increased clinical or management responsibilities in these settings, where often there is no full‐time physician. The role of nurses in each setting needs to be clearly defined, the value of the nurse in these settings (e.g., manag‐
ing post‐operative care, supervising care teams, prescribing medications) needs to be documented, and scope of practice regulation and educational preparation of RNs needs to fit the models for cost effective, quality care. Support for rigorous research needs to continue for all health care settings, as dis‐
cussed below. 20 C. Research and advocacy
Two action items seem most important. The first is improving information, especially by target‐
ing further research on nursing trends and accom‐
plishments. The second is continuing advocacy to raise public awareness of nursing’s value and build patient‐oriented coalitions. • • Improving the knowledge base
A key resource both for workforce planning and for health systems redesign is better and more timely workforce data. Consistency or at least comparability in definitions and reporting periods across national and regional data sources, and, where applicable, consistency in reporting across health care professions will facilitate planning. Ad‐
ditional support for collecting and analyzing local and regional workforce data will help in under‐
standing variation in local labor markets, in de‐
bunking “one size fits all” planning, and in formu‐
lating short‐term policy recommendations. Addressing the limitations in longer‐run projec‐
tions of nursing workforce needs is also important, especially on the demand side and particularly to include changes in health care delivery. Improve‐
ments in modeling clearly seem possible, yet the complexity and ever‐changing nature of supply as well as local variations caution against placing undo emphasis or resources on developing the “perfect” model as the best solution in workplace policymaking. As Nichols (2002, 6) points out, “quantitative work is not a substitute for expert judgment.” Beyond better data and modeling, more research is needed on the use and contributions of nurses throughout health care that can better in‐
form such judgment going forward. Specifically, the reform agenda should encourage research on • The value‐added of nursing—cost and benefit impacts on care in different set‐
tings • Patterns of nurse staffing in various set‐
tings and conditions; especially instruc‐
tive might be comparisons of nursing scopes of practice (and value added) between traditional institutions and • • • population‐oriented systems like the Kaiser Permanente health plans and the Veterans Agency health system, which internalize costs for the entire contin‐
uum of care Substitutability across types of nurses, and between nurses and other providers Understanding the production function for hospital care, including the role of contract nurses in addressing variable demand at hospitals The role of nurses under different ap‐
proaches to producing care, considering not only different labor inputs, but also capital, such as changes in architectural design, location of services within an institution, health information technol‐
ogy, and bar coding of drugs and sup‐
plies How different payment methods influ‐
ence choice among those approaches Classifying acuity levels/care needs in order to staff accordingly and pay ap‐
propriately Advocacy and use of evidence
Good data and research evidence alone will not be enough to promote the changes in supply and demand noted above. Research findings need to be made accessible in ways that engage employers, the public, and private and public health plans in pro‐
moting willingness to restructure payment methods that affect nursing care. Old modes of thinking about nurses need to be altered, for example, to overcome hospital leaders and physicians insuffi‐
cient appreciation for nurses’ contributions to pa‐
tient safety (Buerhaus et al. 2007a). All of these goals call for an approach to advocacy that is grounded in policy analysis in addition to profes‐
sional aspirations. Health reform poses some danger that budget hawks will favor low payment levels above other goals, including better care from better nursing in‐
volvement. Similarly, some employers of nurses may prefer above all else to have more nurses pro‐
duced (at others’ expense) so as to hold down 21 wages and make it easier to maintain accustomed modes of delivering care. Nurses could do well to find and partner with patient‐oriented proponents with whom to make common cause in assuring that nurses can practice so as to optimize access, quality, and affordability for patients—and for Americans seeking to maintain healthy lives outside of clinical settings. Nurses also need to hone their skills in evi‐
dence‐based advocacy and to present findings not only from a nursing perspective (e.g., improved quality of life for the patient, more effective use of nursing skills, higher career aspirations), but from economic and policy analytic perspectives as well, even when such perspectives seem at odds with the institutions in which they work. It also seems helpful to empha‐
size nursesʹ many positive contributions to patient health and patient care rather than complaints about working conditions or professional status that may seem negative. Employers, insurers, and policymakers need to be convinced that resources spent on better nursing care will be money well spent, offering more value for their money, and that system evolution based on changing incentives to achieve optimal nursing input to the health produc‐
tion function is preferable to increased regulation of nursing roles or reimbursement. About
the Authors
Randall R. Bovbjerg, a senior fellow in the Urban Institute’s Health Policy Center, is a policy analyst and lawyer. His specialties include health insurance and reform, reinsurance, the safety net for the uninsured, and administrative and legal issues in health care, particularly relating to medical injury. Barbara A. Or‐
mond, a senior research associate in the Health Policy Center, is a health economist. Her primary research interest is the effect of health system change on access to care by uninsured and publicly insured popula‐
tions, which she has studied in many states and localities across the United States as well as overseas. Nancy Pindus, a senior research associate, is the acting director of the Instituteʹs Center on Metropolitan Housing and Communities. She specializes in program evaluation, organizational behavior, cost analysis, and service delivery and takes particular interest in how workforces are affected by regional context, eco‐
nomic development, and training initiatives. 22 Exhibits
Figure 1. Number of Registered Nurses in the United States
by Employment Status, 1980–2004
3000
2500
2000
1500
1000
500
0
1980
1984
1988
1992
total
total employed
employed part-time
not employed
1996
2000
2004
employed full-time
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
23 Figure 2a. Registered Nurses per 1,000 U.S. Residents
by Employment Status, 1980–2004
12
10
8
6
4
2
0
1980
1984
1988
1992
1996
2000
2004
Figure 2b. Registered Nurses per 1,000 U.S. Residents
Age 65+ by Employment Status, 1980–2004
80
60
40
20
0
1980
1984
1988
1992
total
total employed
employed part-time
not employed
1996
2000
2004
employed full-time
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
24 Figure 3. Registered Nurses by Practice Setting, 1980–2004
2500
6.6
2000
1500
8.0
8.1
1000
7.7
8.7
1.7
3.8
1.4
2.7
8.1
7.0
2.7
6.5
9.5
11.7
17.2
18.3
15.2
66.7
60.1
59.3
57.4
1992
1996
2000
2004
7.0
7.8
2.6
2.7
6.6
9.8
3.0
2.0
3.9
2.3
3.7
2.1
13.5
8.5
11.1
11.3
12.6
500
65.9
68.2
68.0
1984
1988
0
1980
hospital
public/community health
ambulatory care
nursing homes/extended care
education
other
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered
Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
Figure 4. Age Distribution of Registered Nurse Population,
1980–2000
25%
20%
15%
10%
5%
0%
25–29
30–34
35–39
1980
40–44
1988
45–49
50–54
1996
55–59
60–64
65+
2004
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
25 Figure 5. Registered Nurses by Initial Nursing Degree, 1980–2004
100%
80%
60%
40%
20%
0%
1980
1984
1988
diploma
1992
1996
associate
2000
2004
bachelor's
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered
Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
Figure 6. Civilian Labor Force Participation by Age,
Female College Graduates and Nurses, 2004
95
85
75
65
55
45
35
25-29
30-34
35-39
40-44
college-educated women
45-49
50-54
55-59
60-64
nurses
Sources: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered
Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm; Urban Institute calculations of the 2004 Annual Social and
Economic Supplement of the Current Population Survey.
26 Figure 7. Index of Enrollment in BSN Programs
(Relative to Base Year 1994)
150
140
130
120
110
100
90
80
70
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Source: authors' calculations using data presented in American Association of Colleges of Nursing 2007.
Figure 8. Registered Nurses, by Highest Nursing Degree,
1980 to 2004
100%
80%
60%
40%
20%
0%
1980
diploma
1984
1988
associate
1992
1996
bachelor's
2000
2004
master's/PhD
Source: HRSA. 2006. “The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses.” http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm.
27 Figure 9. Funding for Title VIII Nursing Workforce Development Programs
$900
(in $millions)
$800
$700
$600
CPI adjusted, $2008
$500
$400
$300
$200
Nominal $
$100
$1964
1968
1972
1976
1980
1984
1988
1992
1996
2000
2004
Source for Title VIII funding: Appendix A https://www.ncsbn.org/NrsgConsensusDocMarch08.pdf Note: CPI adjustment
made using BLS estimate of price growth in Medical Care and Medical Care Services: http://data.bls.gov/cgi-bin/
surveymost?su
2008
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