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Denise H. Geolot, PhD, RN, FAAN
Director, Division of Nursing
Bureau of Health Professions
Health Resources and Services Administration
On
Finding a Cure to Keep Nurses on the Job
before the
Subcommittee on Oversight of Government
Management, Restructuring and the District of Columbia
Senate Committee on Government Affairs
June 27, 2001

Mr. Chairman and Members of the Subcommittee:

I am pleased to appear before you today to discuss issues related to the nursing workforce. In my statement, I will provide an overview of the characteristics of the nursing workforce based on data from our National Sample Survey of Registered Nurses, speak about the extent of current and projected nursing staffing levels and review what HRSA is doing to plan for future nurse staffing needs.

Characteristics of the Registered Nurse Workforce

In March 2000, the Division of Nursing, BHPr, HRSA conducted the National Sample Survey of Registered Nurses, the seventh in a series of surveys on the characteristics of the nursing workforce; the previous survey was completed in 1996. This survey provides the latest and most comprehensive data on the characteristics of the registered nurse workforce. The preliminary findings were released in February 2001 and the full report is to be released this summer. Preliminary findings show the following:

  • There are an estimated 2,696,540 registered nurses (RNs) in the US today. The overall number of registered nurses (RNs) increased by an estimated 137,666 between 1996 and 2000. This represents a 5.4 percent increase between 1996 and 2000 and is a substantial drop from the 14.2 percent increase in the nursing workforce seen between 1992 and 1996.
  • An estimated 2,115,815 (81.7 percent) of the total licensed RN population reported being employed in nursing.
  • When asked about job satisfaction, 73 percent of nurses employed in nursing indicated that they were satisfied; however, only 68 percent of staff nurses working in hospital settings indicated that they were satisfied with their jobs.
  • An estimated 71.6 percent of RNs in the nursing workforce reported working full-time and 28.4 percent reported working part-time in nursing.
  • A breakout by highest educational preparation of RNs in 2000 revealed that 23 percent had a diploma in nursing, 34 percent had an associate degree in nursing, 33 percent had a baccalaureate degree, and 10 percent had a masters or higher degree in nursing.
  • The RN population is aging. The average age of the RN is 45.2 years, up from 44.5 years in 1996. Nine percent of the nurses are under the age of 30, and 51 percent are over the age of 45.
  • The average age of the employed RN is 43.3 years, up from 42.3 in 1996.
  • The average age at graduation from basic nursing education programs has increased over time. Between 1995 and 2000, the average age of a graduate from a baccalaureate program was 27.5 years; from an associate degree program was 33.2 years; and from a diploma program was 30.8 years.
  • An estimated 12.3 percent of the RN population reported being in one or more of the identified racial and ethnic minority groups, up from 10.3 percent in 1996. Of these RNs, 4.9 percent reported being Black/African American (non-Hispanic); 3.5 percent reported being Asian; 2.0 percent reported being Hispanic; 0.5 percent reported being American Indian/Alaska Native; 0.2 percent reported being Native Hawaiian/Pacific Islander; and 1.2 percent reported being of two or more racial backgrounds.
  • Asian, Native Hawaiian/Pacific Islander, and Black/African American RNs were more likely than Hispanic and white (non-Hispanic) nurses to have at least baccalaureate preparation in nursing.
  • An estimated 5.4 percent of the RN population are men, up from 4.9 percent in 1996.
  • Five major employment settings for RNs were identified: hospitals (59.1 percent), community and public health settings (18.3 percent), ambulatory care settings (9.5 percent), nursing homes and extended care facilities (6.9 percent), and nursing education (2.1 percent).
  • The average annual earning for RNs employed full-time was $46,782. Salaries have remained relatively flat since 1992.
  • An estimated 7.3 percent of the total RN population reported being prepared as advanced practice nurses (clinical nurse specialists, nurses practitioners, nurse-midwives and nurse anesthetist); this was up from 6.3 percent in 1996.
  • A breakout of advanced practice nurses revealed that an estimated 44.9 percent reported being nurse practitioners; 27.7 percent reported being clinical nurses specialists; 7.5 percent reported being both a nurse practitioner and clinical nurse specialist; 15.2 percent reported being a nurse anesthetist; and 4.7 percent reported being a nurse-midwife.
  • The New England area had the highest concentration of employed RNs in relation to the area’s population with 1,075 employed RNs per 100,000 population. The Pacific area had the lowest concentration with 596 per 100,000 population. The average number of RNs employed per 100,000 population in the country is 782.

The Nursing Shortage – What We Know

There are pockets of nursing shortages throughout the country, especially for RNs with clinical expertise and specialty preparation. Some hospitals are reporting that they must close beds and divert patients to other hospitals because of nursing shortages. The American Hospital Association (AHA) survey of 715 hospitals across the country released earlier this month indicated that of the nearly 168,000 overall hospital job vacancies identified, 126,000 (75 percent) were for registered nurses.

The aging of the nursing population, declining student enrollments in nursing schools, and current working conditions may have an effect on future nursing staffing needs. The average age of the RN is 45.2 years. Enrollments in all nursing programs have declined. Enrollment data from the American Association of Colleges of Nursing reveal that baccalaureate nursing program enrollments fell 4.6 percent in fall 1999 - the fifth straight year of declining enrollments. Figures for 2000 revealed a slowing of this decline to 2.1 percent. Graduation data from the National League for Nursing indicated that there was a 13.6 percent decrease in RN graduates between 1995 and 1999. Increased workloads, low staffing levels, mandatory overtime, limited career opportunities and low pay have been identified as reasons for increased turnover of staff in many settings.

The Nursing Shortage – What the Data Show

The answer to whether there is a national nursing shortage is complex. No single direct measure exists for indicating a shortage of nurses at the national level. The Division of Nursing, BHPr, HRSA has historically used a comparison of the projected supply of nurses and the projected demand (requirements) for nurses to assess imbalances.

However, it is important to note that the national picture, based on data from the sample survey, coupled with our supply and demand forecasting models, is significant for national health workforce policy analysis, not for predicting local disruptions in workforce needs. A balance at the national macro level may mask significant workforce imbalances at the local level in various health care settings and for needed specialties.

The March 2000 National Sample Survey of Registered Nurses shows that the supply of RNs has continued to increase, although at a slower rate than ever reported for a four-year period since the surveys began in 1977. The Division of Nursing uses its Supply and Requirements Forecasting Models with the sample survey data to provide projections on the nursing workforce that serve as the basis for shaping policies designed to assure an adequate workforce.

Ideally, the number of nurses available to provide services in a given setting should be in balance with the requirements for nursing services in that setting. Based on outputs from the supply projection model and the demand projection model published in the mid-1990s, the supply of and requirements for full time equivalent (FTE) RNs is expected to be roughly in balance until the year 2010 at the national level. A projected leveling off of supply and steep increases in demand over the years between 2010 and 2020 result in a widening gap between the number of nurses expected to be required and the number of nurses expected. By the year 2020, the model indicates a shortfall in the number of needed RNs. However, because of recent rapid changes in the health care system, it is difficult to make precise predictions about what the demand for nursing services will be in the future.

Preliminary estimates from the revised demand forecasting model indicate requirements for 1,892,000 FTE RNs in 2000. Comparing this estimate with the 2000 FTE supply of 1,889,244 estimated from the 2000 sample survey indicates that, at the national level, there is roughly a balance. However, this does not negate reports from other sources of current shortages in specific geographic areas, health care sectors, or types of RNs.

The demand forecasting model identifies a systematic problem that will continue to increase through 2020. If these current trends continue, all health care settings, all geographic areas, and all needed specialty nurses may experience nursing supply challenges, but there may also be advances in technology that may reduce future demands. HRSA will continue to monitor nursing data to chart future nursing staffing needs.

When we look at RN to population ratios for the Nation as a whole, data from the National Sample Survey of Registered Nurses show that the overall ratio of employed RNs per 100,000 population has varied from 688 in 1988 to 798 in 1996 and 782 in 2000. After more than a decade of increases, the rate appears to be dropping at a time when the population is aging. Data from the 2000 sample survey show that the variation among states is considerable. The numbers range from a low of 520 employed RNs per 100,000 population in Nevada to a high of 1,675 employed RNs per 100,000 population in Washington, DC with an average of 782 for all jurisdictions.

Although we recognize that the ratio of RN to population may be useful as indicators on the national availability of nurses and how well such availability meets demand requirements ratios, the Division of Nursing, BHPr, HRSA does not advocate the use of fixed ratios. This data may be useful in identifying State trends, but it has little meaning unless related to such factors as specific population characteristics, types of services provided, patient acuity, the types of nursing specialties available, and the educational preparation of the nursing workforce.

What HRSA is doing to Address the Nursing Shortage

HRSA administers programs authorized under Title VIII of the Public Health Service Act, often referred to as the Nurse Education Act. Title VIII was instituted by the Nurse Training Act of 1964 in response to a quantitative and qualitative shortage of nurses as a key vehicle for federal support for nursing workforce development. Title VIII programs are primarily administered by the HRSA Bureau of Health Professions’ Division of Nursing. Specific activities helping to mitigate the shortage of nurses include support for (1) basic and advanced nursing education programs, (2) diversity programs targeting minority and disadvantaged students, (3) scholarship, traineeships and loans, and (4) nursing workforce analysis.

The FY 2001 budget for Division of Nursing programs is $76.5 million: $59 million (77 percent) for Advanced Education Nursing; $4.7 million (6 percent) for Nursing Workforce Diversity; and $12.8 million (17 percent) for Basic Nurse Education and Practice. The FY 2002 budget increases funding for HRSA's nursing programs by $5 million. The Advanced Education Nursing program supports projects to educate nurse practitioners, clinical nurse specialists, nurse anesthetists, nurse midwives, nurse administrators, public health nurses, nurse educators and other specialty nurses for advanced practice. Funds from this program will support advanced education projects enrolling approximately 4550 students and provide traineeship support for 5800 graduate level students. The Nursing Workforce Diversity program provides support to projects targeting 1800 minority and disadvantaged students in elementary and secondary schools, pre-nursing programs, and nursing schools. The Basic Nurse Education and Practice program supports academic and continuing education projects designed to strengthen the basic nursing workforce. Funds from this program will support projects to expand enrollments in baccalaureate programs and support basic entry level career ladder programs for licensed practical nurses, innovative academic distance learning projects for rural RNs, and faculty-run nurse managed centers caring for underserved populations.

The Bureau of Health Professions’ Division of Student Assistance provides $12.7 million in support to 3,600 nursing students through the Scholarships for Disadvantaged Students Program and $22 million in support for 10,000 nursing students through the revolving Nursing Student Loan Program. In addition, two nursing faculty receive support from the Faculty Loan Repayment Program.

Within the Bureau of Primary Health Care, the Nursing Education Loan Repayment Program provides $2.3 million to assist 200 registered nurses by repaying up to 80 percent of their qualified educational loans in return for their commitment to provided services at health facilities in shortage areas. In addition, the National Health Service Corp Scholarship and Loan Repayment Programs provides $6.3 million to support 94 nurse practitioners and 29 nurse-midwives providing services to people in underserved areas.

HRSA has been working with the Centers for Medicare and Medicaid Services (CMS) to examine workforce issues. We routinely comment on proposed regulations, which include references to nursing. Currently one of our nurse consultants is serving on the regulation team on final hospital conditions of participation to address nursing issues. Recently, HRSA and CMS collaborated with the Agency for Health Research and Quality and the National Institute for Nursing Research, National Institutes of Health to produce the Nurse Staffing and Patient Outcomes in Hospitals study completed by the Harvard School of Public Health.

Conclusion

In conclusion, Mr. Chairman, I appreciate the opportunity to share with you the latest information on the characteristics of the nursing workforce, the status of what the data show from a national perspective, and the types of activities being undertaken at HRSA to address the needs of the nursing workforce.

I would be happy to answer any questions you may have.

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Last revised: July 2, 2001