Nursing Workforce: Recruitment and Retention of Nurses and Nurse 
Aides Is a Growing Concern (17-MAY-01, GAO-01-750T).		 
								 
This testimony discusses the recruitment and the retention of	 
nursing staff, including both nurses and nurses aides, and	 
concerns about the future supply of these workers. The health and
long-term care systems in the United States rely heavily on the  
services of both nurses and nurses aides, the two largest groups 
of health care workers. GAO found that the recruitment and the	 
retention of both nurses and nurses aides are major concerns for 
health care providers. Experts and providers have reported a	 
shortage of nurses, partly as a result of patients' increasingly 
complex care needs. This shortage is expected to become more	 
serious as the population ages and increases the demand for	 
nurses. Several factors combine to constrain the current and	 
future supply of nurses. Like the population in general, the	 
nurse workforce is aging; the average age of a registered nurse  
(RN) rose from 37 years in 1983 to 42 years in 1998. Enrollments 
in nursing programs have declined during the last five years,	 
shrinking the pool of new workers available to replace those who 
are retiring. Many studies also report less job satisfaction	 
among nurses, which could cause them to pursue other occupations.
Demographic changes over the coming decades may also worsen the  
shortage of nurse aides in hospitals, nursing homes, and home	 
health care settings.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-750T					        
    ACCNO:   A01018						        
  TITLE:     Nursing Workforce: Recruitment and Retention of Nurses   
             and Nurse Aides Is a Growing Concern                             
     DATE:   05/17/2001 
  SUBJECT:   Health care personnel				 
	     Labor statistics					 
	     Labor supply					 
	     Personnel recruiting				 
	     BLS Current Population Survey			 
	     BLS Occupational Employment Statistics		 
	     Survey						 
								 

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GAO-01-750T
     
Testimony Before the Committee on Health, Education, Labor and Pensions, U.
S. Senate

United States General Accounting Office

GAO For Release on Delivery Expected at 9: 30 am Thursday, May 17, 2001
NURSING WORKFORCE

Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern

Statement of William J. Scanlon Director, Health Care Issues

GAO- 01- 750T

Page 1 GAO- 01- 750T

Chairman Jeffords, Ranking Member Kennedy, and Members of the Committee:

I am pleased to be here today as you discuss issues related to the current
recruitment and retention of nursing staff, including both nurses and nurse
aides, and concerns about the future supply of these workers. The health and
long- term care systems in the United States rely heavily on the services of
both nurses and nurse aides, the two largest groups of health care workers.
Considerable attention has been given to the nurse workforce, and several
witnesses recently testified before this committee?s Subcommittee on Aging
about nursing shortages throughout the country. Very little attention,
however, has been given to the characteristics and supply of nurse aides,
who provide most of the direct care for persons in nursing homes and those
receiving home health care services.

To assist the Congress as it considers a range of possible federal efforts
to ensure that consumers receive quality health and long- term care
services, you requested that we review current data on the nurse workforce
and examine in more detail the nurse aide workforce in hospitals, nursing
homes, and home health care. Accordingly, my remarks will focus on (1)
factors contributing to the current and anticipated shortage among nurses,
(2) what is known about the current and projected supply of nurse aides and
the factors contributing to the current and anticipated shortage, and (3)
government and private efforts to improve recruitment and retention of nurse
aides. In addition, you requested that we provide a detailed demographic,
employment, wage, and benefit profile of nurse aides in the different
employment settings. This information is presented in appendix I.

To provide information on the nurse workforce, we relied primarily on
published reports and data from the Department of Health and Human Services?
(HHS) Health Resources and Services Administration (HRSA), industry and
professional associations, researchers, and other experts. To develop
information on the nurse aide workforce, we (1) analyzed recent data from
the Bureau of Labor Statistics? (BLS) Current Population Survey (CPS) and
Occupational Employment Statistics (OES); (2) interviewed experts, industry
and professional association representatives, and federal and state agency
officials; and (3) conducted a review of the relevant professional and
research literature. We performed our work from January through May 2001 in
accordance with generally accepted government auditing standards.

Page 2 GAO- 01- 750T

In summary, recruitment and retention of both nurses and nurse aides are
major concerns for health care providers. Experts and providers are
reporting a current shortage of nurses, partly as a result of patients?
increasingly complex care needs. While comprehensive data are lacking on the
nature and extent of the shortage, it is expected to become more serious in
the future as the aging of the population substantially increases the demand
for nurses. Moreover, several factors are combining to constrain the current
and future supply of nurses. Like the general population, the nurse
workforce is aging, and the average age of a registered nurse (RN) increased
from 37 years in 1983 to 42 in 1998. Enrollments in nursing programs have
declined over the past 5 years, shrinking the pool of new workers to replace
those who are retiring. In addition, numerous studies report decreased
levels of job satisfaction among nurses, potentially leading to their
pursuing other occupations.

Demographic changes over the coming decades may also worsen the shortage of
nurse aides in hospitals, nursing homes, and home health care settings. With
the aging of the population, demand for nurse aides is expected to grow
dramatically, while the supply of workers who have traditionally filled
these jobs will remain virtually unchanged. According to the Institute of
Medicine (IOM), advocacy groups, and provider associations, a serious
shortage of nurse aides already exists. Retention of nurse aides is a
significant problem for many providers, with some studies reporting annual
turnover rates for aides working in nursing homes approaching 100 percent.
Several factors contribute to providers? difficulty in both hiring and
retaining nurse aides, including relatively low wages and few benefits. In
addition, research has found that the physical demands of the work and other
aspects of the workplace environment lead to difficulties in retaining nurse
aides. In 1999, 30 states indicated that they were addressing nurse aide
recruitment and retention through task forces, initiatives, and research.
The federal government and provider groups also have begun to address this
issue. However, few studies have evaluated the effectiveness of these
efforts.

RNs and licensed practical nurses (LPN) are responsible for a large portion
of the health care provided in this country. RNs make up the largest group
of health care providers, and, historically, have worked predominantly in
hospitals; a smaller number of RNs work in other settings such as ambulatory
care, home health care, and nursing homes. (See table 1.) Their
responsibilities may include providing direct patient care in a hospital or
a home health care setting, managing and directing complex nursing care in
an intensive care unit, or supervising the Background

Page 3 GAO- 01- 750T

provision of long- term care in a nursing home. LPNs make up the
secondlargest group of licensed health caregivers and primarily provide
direct patient care under the direction of a physician or RN. Nurse aides
augment the care nurses provide by performing routine duties of caring for
hospital patients or long- term care residents under the direction of an RN
or LPN. 1 Most nurse aides work in nursing homes, where they provide
assistance with activities of daily living such as dressing, feeding, and
bathing.

Table 1: Number of RNs, LPNs, and Nurse Aides Working in Three Employment
Settings, 1999

Hospital Nursing home Home health care

RNs 1,280,510 150,230 108,310 LPNs 200,030 208,030 43,460 Nurse aides
388,280 695,570 344,200

Source: 1999 Employment and Wages for Selected Health Care Occupations and
Industries, Bureau of Labor Statistics (BLS), Occupational Employment
Statistics (OES).

Both RNs and LPNs are subject to state licensing requirements. Individuals
usually select one of three ways to become an RN- through a 2- year
associate degree, 3- year diploma, or 4- year baccalaureate degree program.
LPN programs are 12 to 18 months in length and generally focus on basic
nursing skills such as monitoring patient or resident condition and
administering treatments and medications. Federal law requires states to
certify nurse aides who provide care in nursing homes and for home health
care agencies that receive Medicare and Medicaid reimbursement. 2 This
certification can be obtained through either a nurse aide training program
and a competency evaluation- a written or oral test and skills
demonstration- or competency evaluation alone. A state- approved nurse aide
training program must require a minimum of 75 hours of training, including
at least 16 hours of supervised practical training under the direct
supervision of an RN or LPN. Approximately half of the states require the
nursing aide training programs to go beyond the 75- hour minimum, with
several requiring over 120 hours. 3 Federal law also requires states to

1 We use the term ?nurse aide? to refer to all paraprofessional nursing
staff working in hospitals, nursing homes, or home health care. 2 42 U. S.
C. Section 1395i- 3 (b)( 5)( A)( i)( I), 42 U. S. C. Section 1396r( b)( 5)(
A)( i)( I), and Section 1395bbb( a)( 3)( A)( i). 3 This information was
obtained through interviews with state officials and a survey conducted in
Oct. 2000 by the Paraprofessional Healthcare Institute and the National
Citizens? Coalition for Nursing Home Reform.

Page 4 GAO- 01- 750T

maintain a registry of nurse aides working in nursing homes who have passed
their competency evaluations; no such requirement exists for aides working
in home health care. 4 For nurse aides working in hospitals, there are no
federal requirements related to certification, training, competency
evaluations, or a registry.

The nation?s health care providers are reporting a shortage of nurses in a
range of settings. Although comprehensive data are lacking to describe the
nature and extent of the current shortage, there is evidence of a growing
demand for nurses with skills to treat patients with complex care needs.
Furthermore, shortages can affect the quality of care. The shortage is
expected to worsen as the aging population increases demand and fewer people
enter the nurse workforce. Job dissatisfaction among nurses may further
reduce the strength of the nursing supply.

Providers and experts around the country have reported that the nation is
currently facing a shortage of nurses. There is a lack of comprehensive
national data to describe the full nature and extent of the shortage, but
several types of information point to an existing shortage. For example,
California reported an RN vacancy rate of 8.5 percent for all employers in
1997, with hospitals reporting a rate of 9.6 percent, nursing homes 6.9
percent, and home health care 6.4 percent. The Dallas- Fort Worth Hospital
Council reported vacancy rates for 2000 of 9.3 percent for RNs in emergency
departments and 16.9 percent for RNs in critical care units. A recent survey
of providers in Vermont found that nursing homes and home health care
agencies had RN vacancy rates of 15.9 percent and 9.8 percent, respectively,
while hospitals had an RN vacancy rate of 4.8 percent (up from 1.2 percent
in 1996).

An important factor in the current shortage is the higher proportion of
patients having more complex care needs, which increases the demand for
nurses with training for specialty areas such as critical care and emergency
departments. In addition, the increased use of technology in care settings
has increased the demand for a higher skill mix of RNs. Furthermore, the
expansion of care delivery settings- such as home health care and community-
based health care delivery systems- has increased the job opportunities
available and demand for these workers.

4 42 U. S. C. Section 1395i- 3 (e)( 2)( A) and 42 U. S. C. Section 1396r(
e)( 2)( A). Demographic and Job

Satisfaction Factors Could Worsen Shortage of Nurses

Current Nurse Shortage Is Due to Several Factors

Page 5 GAO- 01- 750T

A nursing shortage may have serious implications for the quality of patient
care. A recent HRSA study found a relationship between higher RN staffing
levels and the reduction of certain negative hospital inpatient outcomes,
such as urinary tract infection and pneumonia. 5 Furthermore, a recent
Health Care Financing Administration (HCFA) report to Congress found a
direct relationship between nurse staffing levels in nursing homes and the
quality of resident care. HCFA?s analysis of three states? data demonstrated
that, after controlling for case mix, there is a minimum nurse staffing
threshold below which quality of care may be seriously impaired. 6 However,
23 percent of the facilities in the three states were not staffing at the
combined RN and LPN minimum staffing threshold level, and 31 percent of the
facilities were not staffing at the RN minimum staffing threshold level. 7

The nursing shortage is expected to worsen in the future, with pressures
expected on both demand and supply. The future demand for nurses is expected
to increase dramatically when the baby boomers reach their 60s, 70s, and
beyond. The population aged 65 years and older will double from 2000 to
2030. Moreover, the population aged 85 and older is the fastest growing age
group in the U. S. At the same time, the number of persons who have
traditionally worked in the nursing workforce- women between 25 and 54 years
of age- is expected to remain relatively unchanged over the period from 2000
to 2030. 8 Over the past decade, the nurse workforce?s average age has
climbed steadily, while fewer young persons are choosing to enter the
nursing profession. The average age of the RN population in 2000 was 45,
almost 1 year older than the average in 1996. While over half (52 percent)
of all RNs were reported to be under the age of 40 in 1980,

5 Harvard School of Public Health, Vanderbilt University School of Nursing,
and Abt Associates, Nurse Staffing and Patient Outcomes in Hospitals,
contract No. 230- 99- 0021, HRSA (Washington, D. C.: HHS, 2001).

6 The states included in the analysis were New York, Ohio, and Texas for
calendar years 1996 and 1997. The minimum staffing threshold for RNs and
LPNs combined was 0.75 hours per resident day. For RNs alone, the minimum
staffing threshold level was 0.20 hours per resident day.

7 Phase II of the HCFA Study is currently under way to analyze additional
states? data to identify alternative minimum thresholds and optimal case-
mix adjusters and to assess relative costs and benefits of such thresholds.
According to HCFA officials, more research will be required to assess the
feasibility of implementing minimum ratio requirements.

8 Few men currently work in nursing. As of 2000, only 5.9 percent of RNs
employed in nursing were men. The Nursing Shortage Is

Likely to Worsen

Page 6 GAO- 01- 750T

fewer than one in three were younger than 40 in 2000. During the same
period, the percentage of nurses under age 30 dropped from 25 to 9 percent.
As shown in figure 1, the age distribution of RNs has shifted dramatically
upward. The number of nurses aged 25 to 29 decreased from about 296,000 in
1980 to about 177,000 in 2000, while the number aged 45 to 49 grew from
about 153,000 to about 465,000.

Figure 1: Age Distribution of the Registered Nurse Population, 1980 and 2000

Source: HRSA, The Registered Nurse Population: National Sample Survey of
Registered Nurses, March 2000.

The total number of licensed RNs increased 5.4 percent between 1996 and
2000- the lowest increase ever reported in HRSA?s periodic survey of RNs. 9
Nursing program enrollments further indicate a narrowing of the

9 HRSA, The Registered Nurse Population: National Sample Survey of
Registered Nurses, Mar. 2000.

0 100

200 300

400 500

<25 25- 29 30- 34 35- 39 40- 44 45- 49 50- 54 55- 59 60- 64 >= 65 Age Number
of nurses (in thousands)

1980 2000

Page 7 GAO- 01- 750T

pipeline. According to a 1999 Nursing Executive Center Report, between 1993
and 1996, enrollment in diploma programs dropped 42 percent and enrollment
in associate degree programs declined 11 percent. 10 Furthermore, between
1995 and 1998, enrollment in baccalaureate programs declined 19 percent, and
enrollment in master?s programs decreased 4 percent. Over the past 25 years,
career opportunities available to women have expanded significantly, while
there has been a corresponding decline of interest by women in nursing as a
career. A recent study reported that women graduating from high school in
the 1990s were 35 percent less likely to become RNs than women who graduated
in the 1970s. 11

In addition to the lack of students entering and graduating from nursing
programs, there is concern about a pending shortage of nurse educators. The
average age of professors in nursing programs is 52 years old, and 49 years
old for associate professors. The average age of new doctoral recipients in
nursing is 45, compared with 34 in all fields. From 1995 to 1999,
enrollments in doctoral nursing programs were relatively stagnant.

Job dissatisfaction may play a crucial role in determining the extent of
future nurse shortages. Recent surveys of nurses have found decreased job
satisfaction, and a high portion of respondents have reported increased
pressure to accomplish work, the need to work overtime, and stressrelated
illness. A recent Federation of Nurses and Health Professionals survey found
that half of the currently employed nurses who were surveyed had considered
leaving the patient- care field for reasons other than retirement over the
past 2 years. 12 Of this group, 56 percent indicated that they wanted a less
stressful and physically demanding job, 22 percent said they were concerned
about schedules and hours, and 18 percent wanted more money. Over one-
fourth (28 percent) of nurses in a 1999 study by the Nursing Executive
Center described themselves as somewhat

10 The Nursing Executive Center, A Misplaced Focus: Reexamining the
Recruiting/ Retention Trade- Off (Washington, D. C.: The Advisory Board
Company, Feb. 11, 1999). 11 Buerhaus, Peter I. et al., ?Policy Responses to
an Aging Registered Nurse Workforce,? Nursing Economics Vol. 18, No. 6
(Nov.- Dec. 2000). 12 Federation of Nurses and Health Professionals, The
Nurse Shortage: Perspectives from Current Direct Care Nurses and Former
Direct Care Nurses (opinion research study conducted by Peter D. Hart
Research Associates)( Washington, D. C.: 2001). Job Dissatisfaction May Be

a Major Factor in Future Nurse Shortages

Page 8 GAO- 01- 750T

or very dissatisfied with their job, and about half (51 percent) were much
less satisfied with their job than they were 2 years ago. 13

Job dissatisfaction is a primary reason cited for nurse retention problems.
As of March 2000, 18.3 percent of RNs reported not being employed in
nursing, up slightly from 17.3 percent in 1992. A recent survey reported
that the national turnover rate among hospital staff nurses was 15 percent,
up from 12 percent in 1996. 14 Nursing home and home health care industry
surveys indicate that nurse turnover is an issue for them as well. In 1997,
a survey sponsored by the American Health Care Association (AHCA) of 13
nursing home chains identified a 51- percent turnover rate for RNs and LPNs.
15 A 2000 national survey of home health care agencies reported a 21percent
turnover rate for RNs and 24- percent turnover rate for LPNs. 16

Demographic changes over the coming decades may also worsen the shortage of
nurse aides. With the aging of the population, demand for nurse aides is
expected to grow dramatically, while the number of persons who have
traditionally filled these jobs will change very little. Retention of nurse
aides is currently a significant problem for many hospitals, nursing homes,
and home health care agencies, with some studies reporting annual turnover
rates for aides working in nursing homes approaching 100 percent. Low wages,
few benefits, and difficult working conditions contribute to recruitment and
retention problems for nurse aides. High turnover can contribute to both
increased costs to the facility and problems with quality of care.

Several factors have contributed to growing demand for nurse aides to
provide health and long- term care services. In the decade between 1988 and
1998, the number of employed nurse aides increased 40 percent. Medical
advances that have allowed people with chronic illnesses and

13 The Nursing Executive Center, The Nurse Perspective: Drivers of Nurse Job
Satisfaction and Turnover (Washington, D. C.: The Advisory Board Company,
2000). 14 The Nurse Perspective: Drivers of Nurse Job Satisfaction and
Turnover. 15 American Health Care Association, Facts and Trends 1999, The
Nursing Facility Sourcebook (Washington, D. C.: AHCA, 1999).

16 Hospital & Healthcare Compensation Service, Homecare Salary & Benefits
Report, 2000- 2001 (Oakland, N. J.: Hospital & Healthcare Compensation
Service, 2000). Demographic

Changes, Low Compensation, and Difficult Working Conditions Contribute to
Shortage of Nurse Aides

Demographic Trends Will Continue to Increase Demand for Nurse Aides

Page 9 GAO- 01- 750T

disabilities to live longer, advances in technology that have allowed people
with significant care needs to receive care in their homes or other
community- based settings, and increased funding for in- home services,
particularly from the Medicare and Medicaid programs, are factors increasing
demand for nurse aide services. In addition, the growing number of elderly
will have a significant effect on demand in the future. The number of
persons over age 85, those most in need of health and long term care
services, will more than double from 4.3 million in 2000 to 8.9 million in
2030, when the baby boomers first begin to reach age 85.

At the same time, the supply of workers to fill these jobs will remain
virtually unchanged. Between 2000 and 2030, the total working- age
population- persons aged 18 to 64- is expected to grow by only 16 percent.
The number of women aged 20 to 54- the traditional pool of nurse aides- will
increase by only 9 percent from 2000 to 2030. The potential mismatch between
future supply and demand for caregivers is illustrated by the change in the
expected ratio of potential care providers to potential care recipients. As
shown in figure 2, the ratio of the workingaged population, aged 18 to 64,
to the population over age 85 will decline from 39.5 workers for each person
85 and older in 2000 to 22.1 in 2030 and 14.8 in 2040. The ratio of women
aged 20 to 54 to the population age 85 and older will decline even more
dramatically, from 16.1 in 2000 to 8.5 in 2030 and 5.7 in 2040.

Page 10 GAO- 01- 750T

Figure 2: Decline in Elderly Support Ratio Expected, 2000 to 2040

Source: GAO analysis of U. S. Census Bureau Projections of Total Resident
Population, Middle Series, December 1999.

Over the next several years, even before the baby boomers begin retiring,
nurse aide jobs are expected to be among the fastest growing in the
workforce. The 40- percent increase in nurse aide employment from 1988 to
1998 is in contrast to the 19- percent increase in the number of persons
employed in the overall labor market. From 1998 to 2008, the overall number
of nurse aide jobs is projected to grow an additional 36 percent- from 2.1
million to 2.9 million jobs- compared to the 14- percent projected growth in
all jobs. Jobs for nurse aides working in home health care are projected to
increase even faster, namely by 58 percent, from 746,000 in 1998 to 1. 2
million in 2008.

Numerous reports and media accounts in recent years have described the
inability of a range of providers to hire and retain adequate numbers of
nurse aides. However, little analytical work has been conducted to assess
the nature or overall magnitude of the paraprofessional nursing staff
Recruitment and Retention

of Nurse Aides Is Widely Reported To Be a Problem

0 5

10 15

20 25

30 35

40 45

2000 2010 2020 2030 2040 Year Workers per person 85 and older

Women aged 20- 54 to each persons 85 and older Working- aged population 18-
64 to each person 85 and older

Page 11 GAO- 01- 750T

shortage. 17 Nonetheless, the IOM and other experts agree that we are facing
a shortage of nurse aides throughout the country. 18 The current
lowunemployment economy has increased competition for workers and
exacerbated the shortage of nurse aides. With a low national unemployment
rate, higher paying jobs with better working conditions have opened up for
women who have traditionally held nurse aide jobs.

Recent national analyses demonstrate the growing concern over the supply of
these workers. In a 1999 survey of state long- term care ombudsmen, the
respondents from more than 40 states reported ?critical?

shortages of direct care staff. 19 In another recent survey of states,
officials from 42 of the 48 states responding reported that nurse aide
recruitment and retention were currently major workforce issues in their
states. 20 More than two- thirds of these states (30 of 42) reported that
they were actively engaged in efforts to address these issues.

Several state or local level studies cite nurse aide recruitment as a
problem for many providers. In a 2000 study of the nurse aide workforce in
Pennsylvania, staff shortages were reported by three- fourths of nursing
homes and more than half of all home health care agencies. 21 Over half (53
percent) of private nursing homes and 46 percent of certified home health
care agencies reported staff vacancy rates higher than 10 percent. Nineteen
percent of nursing homes and 25 percent of home health care agencies
reported vacancy rates exceeding 20 percent. The Dallas- Ft. Worth Hospital
Council reported a hospital vacancy rate for nurse aides of

17 Some policymakers and planners have expressed concerns about the quality
and timeliness of data currently available on these workers. HRSA is
currently funding a project to assess trends, issues, and projections of
supply and demand for nurse aides. It is expected that this work will be
completed by late 2001 and will include identifying, comparing, and
assessing the adequacy of existing data sources for assessing the scope and
scale of current workforce shortages.

18 Institute of Medicine, Improving the Quality of Long- Term Care
(Washington, D. C.: National Academy Press, 2000). 19 Submitted to the
Domestic Strategy Group of the Aspen Institute by the Paraprofessional
Healthcare Institute, Direct- Care Health Workers: The Unnecessary Crisis in
Long- Term Care (Bronx, N. Y.: Paraprofessional Healthcare Institute, Sept.
2000).

20 North Carolina Division of Facility Services, Comparing State Efforts to
Address the Recruitment and Retention of Nurse Aide and Other
Paraprofessional Aide Workers (Raleigh, N. C.: Sept. 1999). 21 Leon, Joel et
al., Pennsylvania?s Frontline Workers in Long Term Care (Jenkintown, Pa.:
Polisher Research Institute at the Philadelphia Geriatric Center, 2001).

Page 12 GAO- 01- 750T

17 percent in 2000, up from 11 percent in 1999. A recent survey of providers
in Vermont found high vacancy rates for nurse aides, particularly in
hospitals and nursing homes; as of June 2000, the vacancy rate for nurse
aides in nursing homes was 16 percent, in hospitals 15 percent, and in home
health care 8 percent.

Providers also face problems with retention of nurse aide staff. Available
data indicate nurse aide turnover in nursing homes and home health care
agencies is much higher than the labor force in general (13 to 18 percent)
or the service workforce (20 percent). 22 Annual turnover rates among aides
working in nursing homes are reported to be from about 40 percent to more
than 100 percent. In 1998, a survey sponsored by AHCA of 12 nursing home
chains found 94- percent turnover of nurse aide positions. 23 A recent
national study of home health care agencies identified a 28- percent
turnover rate among aides in 2000, up from 19 percent in 1994. 24

Studies have cited low wages and few benefits as factors contributing to
nurse aide turnover. Our analysis of national wage and employment data from
BLS indicates that, on average, nurse aides receive lower wages and have
fewer benefits than workers generally; this is particularly true for those
working in nursing homes and home health care. 25 In 1999, the national
average hourly wage for aides working in nursing homes was $8.29, compared
to $9. 22 for service workers and $15.29 for all workers. For aides working
in home health care agencies, the average hourly wage was $8.67, and for
aides working in hospitals, $8.94. Aides working in

22 Comprehensive national data on nurse aide turnover are not available, and
caution must be used when comparing turnover rates from different studies.
While nurse aide turnover rates are typically the number of nurse aides that
have left a facility divided by the total number of nurse aide positions,
there is no standard method for calculating turnover and methods used in
different studies vary. It is generally agreed that staff who leave after a
very short tenure on the job contribute most to high turnover rates. Some
nurse aide positions may turn over several times during a given year, while
others may not turn over for several years.

23 AHCA, Staffing of Nursing Services in Long Term Care: Present Issues and
Prospects for the Future (Washington, D. C.: AHCA, 2001). 24 Hospital &
Healthcare Compensation Service, Homecare Salary & Benefits Report 2000-
2001 (Oakland, N. J.: Hospital & Healthcare Compensation Service, 2000) and
Hospital & Healthcare Compensation Service, Homecare Salary & Benefits
Report 1994- 1995 (Oakland, N. J.: Hospital & Healthcare Compensation
Service, 1994).

25 Detailed demographic, employment, and wage data on nurse aides in
hospitals, nursing homes, and home health care are presented in app. I.
Lower Wages, Fewer

Benefits, and Difficult Work Conditions Linked to Nurse Aide Turnover

Page 13 GAO- 01- 750T

hospitals are much more likely than aides in nursing homes and home health
care to have employer- provided health and retirement benefits. Aides in
nursing homes and home health care are similar to other service workers in
that they are less likely to have employer- provided health insurance or
pension coverage than workers in general. Most nursing homes and home health
care agencies do not offer pension coverage, and only 21 to 25 percent of
aides in these settings are covered.

Our analysis of CPS data indicates that many nurse aides have sufficiently
low earnings and family incomes to qualify for public benefits such as food
stamps and Medicaid. While 11 percent of all workers had family incomes
below poverty, 18 percent of aides working in nursing homes and 19 percent
of aides working in home health care had incomes below that level. One in
three aides working in nursing homes earned less than $10,000 per year, and
36 percent reported family incomes below $20,000. In addition, aides working
in nursing homes and home health care are more than twice as likely as other
workers to be receiving food stamps and Medicaid, and they are much more
likely to lack health insurance. One- fourth of aides in nursing homes and
one- third of aides in home health care are uninsured compared to 16 percent
of all workers.

Studies have also identified the physical demands of nurse aide work and
other aspects of the workplace environment as contributing to retention
problems. Nurse aide jobs are physically demanding, often requiring moving
patients in and out of bed, long hours of standing and walking, and dealing
with patients or residents who may be disoriented or uncooperative. Nursing
homes have one of the highest rates of workplace injury, 13 per 100
employees in 1999, compared to the construction industry with 8 per 100
employees.

The 2000 IOM study of quality in long- term care identified several
environmental and job design factors that directly affect nurse aide
turnover, including

 adequacy of training;

 methods for managing workload and schedules;

 opportunities for career advancement;

 respect from administrators;

 organizational recognition;

 workloads and staffing levels;

 clarity of roles; and

 participation in decisionmaking.

Page 14 GAO- 01- 750T

In another study, the degree of nurse aide involvement in resident care
planning was superseded only by the condition of the local economy as a
factor affecting turnover. 26 For example, in facilities where nursing staff
were perceived to accept aides? advice and suggestions or simply discussed
care plans with aides, the turnover was lower than in those facilities where
aides were not involved in care planning.

Negative effects- related to both costs for the facility and quality of
patient care- have been associated with high turnover. Direct provider costs
of turnover include recruitment, selection, and training of new staff,
overtime, and use of temporary agency staff to fill gaps. Indirect costs
associated with turnover include an initial reduction in the efficiency of
new staff and a decrease in nurse aide morale and group productivity.

High turnover can disrupt the continuity of patient care- that is, aides may
lack experience and knowledge of individual residents or clients.
Furthermore, when turnover leads to staff shortages, nursing home residents
may suffer harm because of the increased number of residents the remaining
staff must care for, resulting in less time to care for each resident. The
recent HCFA report to Congress that found a direct relationship between
nurse staffing levels in nursing homes and quality also found a direct
relationship between nurse aide staffing levels and the quality of resident
care. HCFA?s analysis of the three states? data demonstrated that, after
controlling for case mix, there is a minimum nurse aide staffing threshold
below which quality of care may be seriously impaired. 27 Moreover, 54
percent of the facilities in the three states were not staffing at that
minimum threshold level. 28

26 Banaszak- Holl, Jane and Marilyn A. Hines, ?Factors Associated with
Nursing Home Staff Turnover?, The Gerontologist, Vol. 36, No. 4 (1996), pp.
512- 17. 27 The states included in the analysis were New York, Ohio, and
Texas for calendar years 1996 and 1997. 28 Nurse aides had a minimum
staffing level of 2.00 hours per resident day. High Nurse Aide Turnover

May Lead to Higher Provider Costs and Quality of Care Problems

Page 15 GAO- 01- 750T

Most initiatives and research efforts to address nurse aide recruitment and
retention have been undertaken by states and provider groups. In 1999, 30
states indicated that they were addressing nurse aide recruitment and
retention, primarily in nursing homes and home health care agencies, through
task forces, initiatives, and research. HHS has also recently begun to focus
on the supply and demand of this workforce through research and planning
efforts. (See appendix II.)

Initiatives intended to improve nurse aide recruitment and retention can be
categorized under three major themes: (1) improved wages and benefits; (2)
the development of additional training and opportunities for career
advancement; and (3) additional employee supports, including improved work
environments, job skills, and social supports. In addition, many initiatives
are multifaceted, addressing two or more of these areas. The programs
discussed below illustrate the types of initiatives under way. Appendix II
provides additional information on selected initiatives.

States have taken steps to improve the wages or benefits of nurse aides by
increasing reimbursement rates, primarily for aides working in nursing homes
and home health care. As of 2000, 26 states had established some form of a
wage pass- through, wage supplement, or related program for nurse aides and
other direct care staff. 29 Methods of wage pass- throughs vary from state
to state; participation by providers can be voluntary or mandatory, and
states use different formulas to calculate the amount of money provided.
According to the 2000 North Carolina Division of Facility Services survey, 4
out of 12 states that had implemented a wage passthrough reported that it
had had some positive effect on recruitment and retention of nurse aides,
although little data exist to substantiate this view. While some states have
reported that they are satisfied with their accountability procedures to
ensure that pass- through dollars are reaching

29 North Carolina Division of Facility Services, Results of a Follow- Up
Survey to States on Wage Supplements for Medicaid and Other Public Funding
To Address Aide Recruitment and Retention In Long- term Care Settings
(Raleigh, N. C.: Nov. 4, 2000) and Nursing Homes: Sustained Efforts Are
Essential to Realize Potential of the Quality Initiatives (GAO/ HEHS- 00-
197, 2000). Wage pass- throughs provide a specific amount or percentage
increase in reimbursement, earmarked typically for nurse aides? salaries
and/ or benefits. Government and

Private Initiatives Seek to Address Nurse Aide Retention and Recruitment,
but Few Have Been Evaluated

Page 16 GAO- 01- 750T

aides, concerns have been raised that funds may not always be used as
intended. Few states have addressed the issue of benefits for nurse aides.
According to a 1999 study, only three states had considered or taken action
to require any form of benefits for nurse aides and other workers. 30

Initiatives to improve training and opportunities for career advancement
have been undertaken by states as well as providers. States and providers
are experimenting with specialized training for nurse aides in targeted
patient care areas, such as treatment of persons with dementia, and are
developing career ladders that offer aides a chance to improve their skills
while also advancing their careers. For example, according to Massachusetts
officials, the Massachusetts? Nursing Home Quality Initiative provides $5
million in fiscal year 2001 specifically to develop competitive nurse aide
career ladder grants and to encourage the development of partnerships of
concerned groups, including community colleges and workforce investment
boards. 31

Initiatives that focus on workplace and social supports for nurse aides fall
into two categories. The first type of support targets the structure of the
aides? work environment, focusing on issues such as nurse aide participation
in care planning and the empowerment of nurse aides to act on their special
knowledge of their clients. For example, the Wellspring Program in Wisconsin
is an alliance of 11 providers whose approach is based on the idea that
management should foster quality of care with appropriate policies, but
decisions on policy implementation should be left to the front- line workers
who are most familiar with residents? needs.

The second type of support focuses on general work skills and social
supports for nurse aides. For example, the Iowa Caregivers Association, a
nonprofit organization representing nurse aides, received state funding to
develop a pilot project to determine the effect on nurse aide recruitment
and retention of employee supports such as workshops on teamwork and

30 The states identified in the study were Hawaii, Idaho, and Maine. See
North Carolina Division of Facility Services, Comparing State Efforts to
Address the Recruitment and Retention of Nurse Aide and Other
Paraprofessional Aide Workers (Raleigh, N. C.: Sept.

1999). 31 The federal Workforce Investment Act of 1998 required states and
localities to develop workforce investment boards. The state board works
with the governor to develop a statewide workforce development plan and
helps develop statewide workforce investment systems and labor market
information systems. Local boards are responsible for implementing the
system in their local area.

Page 17 GAO- 01- 750T

communication and an aide- mentoring program. Additionally, the California
Caregivers Training Initiative is a state- funded effort to improve nurse
aide recruitment and retention and includes providing supportive services
such as childcare and transportation. Other state and provider initiatives
have addressed general work skills through programs such as general
educational development diploma preparation or courses in English as a
Second Language.

HRSA?s Division of Nursing is charged with providing national leadership to
ensure an adequate supply and distribution of qualified nursing
professionals. HRSA has generally focused on licensed nursing professionals,
rather than nurse aides, but has recently undertaken a study of the supply
of and demand for aides. Along with HRSA, HCFA and the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) are also focusing
attention on the nurse aide workforce. HCFA plans to address issues that
affect nurse aide recruitment and retention in Phase II of the Report to
Congress on Appropriateness of Minimum Nurse Staffing Ratios in Nursing
Homes, while ASPE?s research is designed to identify successful recruitment
and retention programs for nurse aides.

To date, most research on initiatives to address the nurse aide shortage has
been largely nonevaluative. Providers cite reduced turnover rates as
evidence of effectiveness. Some efforts are now under way to determine the
effectiveness of various interventions. Two states, Kansas and Michigan,
have gathered longitudinal data on the impact of their wage pass- throughs
on turnover. Michigan?s data indicate that since the implementation of the
nursing home wage pass- through in 1990, turnover rates have decreased from
75 percent to 68 percent, while in Kansas turnover has declined slightly,
from 120 percent to 116 percent, since implementation in 1998, but these
measures may not account for other factors that affect the aide workforce.
Some states and providers have also begun to realize the importance of
formal evaluations and have implemented evaluation efforts as a component of
their initiatives. Further information on these and other evaluations is
included in appendix II.

Recruitment and retention of nursing staff- both nurses and nurse aides-
pose a problem today that will likely worsen as demand for these workers
increases in the future. Demographic forces are widening the gap between the
numbers of people needing care and the nursing staff available to provide
care. As a result, the nation will face a shortage of different dimensions
than those of the past. The private sector and state governments have taken
the lead in trying to address recruitment and Concluding

Observations

Page 18 GAO- 01- 750T

retention issues for nurse aides. Additional evaluation is needed to
determine which initiatives are most effective. More detailed data are also
needed to delineate the extent and nature of nurse and nurse aide shortages
to assist in planning and targeting corrective efforts. As the federal
government focuses more on the nursing workforce in hospitals, nursing
homes, and home health care, support for the evaluation of efforts to
increase the supply of nurses and nurse aides may also help identify more
effective steps to ameliorate the shortage.

Chairman Jeffords and Ranking Member Kennedy, this concludes my statement. I
would be happy to answer any questions that you or Members of the Committee
may have.

For more information regarding this testimony, please contact me or Janet
Heinrich at (202) 512- 7118, or Helene Toiv at (202) 512- 7162. Eric
Anderson, Connie Peebles Barrow, Paula Bonin, Emily Gamble Gardiner, and
Nila Garces- Osorio also made key contributions to this statement GAO
Contacts and

Staff Acknowledgments

Page 19 GAO- 01- 750T

Nurse aides work for a variety of employer types and in a variety of
settings. Of the approximately 2.2 million nurse aides employed in 1999,
most work either in nursing homes, hospitals, or home health care. (See fig.
3.) Nurse aides compose a much smaller percentage of total employees in
hospitals than they do in either nursing homes or home health care. (See
fig. 4.) In contrast, nurses make up the largest portion of hospital
employees, and a smaller share of workers in nursing homes and home health
care.

Figure 3: Nurse Aide Employment by Setting, 1999

Note: ?Other? includes a range of employment settings such as residential
care, social services, and temporary staffing agencies.

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational
Employment Statistics data.

Appendix I: Demographic and Employment Characteristics of Nurse Aides

Home health Hospital Nursing home Other 35%

16% 18% 32%

Page 20 GAO- 01- 750T

Figure 4: Nurses and Nurse Aides as a Percentage of all Employees in
Hospitals, Home health care, and Nursing homes, 1999

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational
Employment Statistics data.

The number of nurse aides in the workforce increased by 40 percent between
1988 and 1998 (see fig. 5), more than twice the rate of growth of the
overall workforce. The greatest growth was among aides working in home care,
with their numbers more than doubling from 1988 to 1998. According to BLS
projections, these trends are expected to continue into the next decade.
While total employment in the workforce is projected to grow by 14 percent
from 1998 to 2008, projections for nurse aide employment call for a 36-
percent increase over the period, and a 58percent increase in the numbers
working in home care.

8

0 10

20 30

40 50

60 70

80 90

Hospital Home health Nursing home Percentage of total employees

Nurse aides Nurses

54 38 30

24 20

Page 21 GAO- 01- 750T

Figure 5: Growth in Nurse Aide Employment, 1988- 1998 and Projected to 2008

Source: Bureau of Labor Statistics, Monthly Labor Review.

Compared to the workforce in general, nurse aides are more likely to be
female, non- white, unmarried, and with children at home. (See table 2.)
While half of all workers and about two- thirds of service workers are
women, 80 to 90 percent of nurse aides are women. In addition, nurse aides
tend to be somewhat younger than the overall workforce, and a high
proportion are minorities. About half of nurse aides are non- white,
compared to only one- quarter of all workers. Aides in hospitals have
slightly higher rates of employer- provided health and pension benefits than
the general workforce. However, aides in nursing homes and home health care
are less likely than other workers to have employer- provided health
insurance and much less likely to be covered by a pension.

0.00 0.50

1.00 1.50

2.00 2.50

3.00 3.50

1988 1990 1992 1994 1996 1998 2008 proj. Year Number of nurse aides (in
millions)

Page 22 GAO- 01- 750T

Table 2: Characteristics of Nurse Aides and Other Workers Nurse Aides
working in Nursing homes Home health care Hospitals Service workers All
workers

Mean age 37.0 41.3 38.7 37.3 44.8 Age ranges (percent) <25 21.3 11.8 13.4
23.7 13.0 25- 34 26.8 20.4 27.2 22.7 19.3 35- 44 24.7 29.0 27.9 24.0 22.4
45- 54 15.1 21.2 17.4 16.2 17.7 55+ 12.2 17.8 14.1 13.3 27.6 Gender
(percent) Male 9.1 10.8 20.4 32.5 48.0 Female 90.9 89.2 79.6 67.5 52.0 Race/
Ethnicity (percent) White, non- Hispanic 56.6 48.5 53.5 60.3 73.8 Black,
non- Hispanic 31.8 33.8 33.0 18.1 11.5 Hispanic and other 11.5 17.6 13.5
21.6 14.7 Immigration (percent) Native born 88.9 79.6 86.9 80.9 87.8
Immigrant 11.1 20.4 13.1 19.1 12.3 Education Less than high school 22.6 21.4
10.1 24.8 17.4 High school 50.0 40.7 43.8 42.3 33.1 Some college 27.3 37.9
46.2 32.8 49.5 Marital Status (percent) Married 39.4 43.5 43.7 43.7 57.2
Never married 36.8 26.9 32.6 37.3 23.8 Widowed, divorced or separated

23.8 29.5 23.7 19.0 19.0 Children (percent) None 43.7 49.9 54.8 53.9 61.8
Any under 18 years 56.3 51.1 45.2 46.1 38.2 Unmarried with children
(percent) 32.4 24.6 20.2 20.8 11.0

Source: GAO analysis of combined 1998, 1999, and 2000 Current Population
Survey, March Supplements.

Many nurse aides are among the working poor. Aides working in nursing homes
and home care are much more likely than other workers to be uninsured,
living below the poverty level, and receiving public benefits such as food
stamps and Medicaid. (See table 3.) Nursing home and home health care aides
are also two to three times more likely as other workers to be unmarried and
have children at home. Among single parent nursing home and home health care
aides, 35 to 40 percent are below poverty, and 30 to 35 percent receive food
stamps.

Page 23 GAO- 01- 750T

Table 3: Income, Earnings, and Poverty Status of Nurse Aides and Other
Workers Nurse Aides working in Nursing homes Home health care Hospitals
Service workers All workers

Family income (percent) Under $10,000 12.4 16.1 6. 8 13.0 9. 3 $10,000-
19,999 23.8 21.6 16.7 19.7 13.3 $20,000- 29,999 18.2 19.6 16.9 15.9 12.9
$30,000- 39,000 14.6 13.2 14.9 12.7 11.7 $40,000- 49,999 11.3 9. 5 11.6 10.1
10.0 $50,000 + 19.7 20.0 33.2 28.5 42.8 Family income Mean $33,982 $33,653
$43,832 $40,712 $56,020 Median 26,970 25,908 36,080 30,769 42,400 Individual
earnings Mean $14,723 $13,501 $17,834 $13,412 $22,313 Median 13,287 12,265
16,608 10,795 13,500 Individual earnings (full- time, full- year workers)
Mean $19,416 $19,216 $21,432 $19,515 $39,672 Median 17,000 17,002 20,000
16,608 30,663 Poverty status (percent) Below poverty 17.8 18.8 8. 1 16.1
10.5 100 -149 13.2 15.9 10.4 12.8 8. 4 150 -199 15.0 11.4 11.9 12.6 8. 9
Above 200 54.1 53.9 69.6 58.4 72.3 Health insurance (percent) Uninsured 25.2
32.1 14.2 31.2 16.4 Employer coverage 57.5 47.3 77.9 51.7 61.6 Medicaid 9.9
11.1 2. 1 6.9 3. 9 Pension coverage Percent covered 25.2 21.2 51.3 21.3 44.4
Food stamps Percent receiving 13.5 14.8 5. 3 9.3 5. 5

Note: All reported income and earnings have been adjusted to constant 1999
dollars using the Consumer Price Index, U. S. city average, for all urban
consumers.

Source: GAO analysis of combined 1998, 1999, and 2000 Current Population
Survey, March Supplements.

Page 24 GAO- 01- 750T

Nationally, the mean hourly wage for a nurse aide in all settings was $8.59
in 1999, yet wages vary widely across states. (See table 4.) The
competitiveness of nurse aide wages with those of other service or
production jobs where they might be likely to find employment also varies
widely across states, as does the relative economic standing of nurse aides
compared to other workers. As a percentage of state per capita income, the
mean annual earnings of a nurse aide in 1999 ranged from a high of 85
percent in Alaska to a low of 48 percent in the District of Columbia. (See
table 5.)

Table 4: Nurse Aide Wages Compared to Other Occupations, by State, 1999 Mean
hourly wage, 1999 Nurse aide a Factory worker b Fast food cook Housekeeper

Alabama $7.24 $10.45 $5.90 $6.35 Alaska 11.63 11.12 9.05 9.09 Arizona 8. 26
9. 85 6. 39 6. 66 Arkansas 6.78 8.98 6.09 6.30 California 8. 93 10.18 6.86
7.82 Colorado 8.56 9.67 6.40 7.42 Connecticut 11.32 12.36 7.14 8.69 Delaware
9.01 9.37 6.81 7.45 District of Columbia 9.29 c 7.54 10.33 Florida 8. 25 8.
82 6. 90 7. 07 Georgia 7. 40 10.03 6.56 6.80 Hawaii 9.57 9.94 7.60 10.96
Idaho 7.71 9.61 6.40 6.67 Illinois 8. 16 12.64 6.74 7.29 Indiana 8. 22 11.06
6.59 7.01 Iowa 8.17 11.71 6.65 7.07 Kansas 7.86 10.51 6.70 6.82 Kentucky
7.77 11.40 6.25 6.80 Louisiana 6. 53 10.40 5.96 6.32 Maine 8. 01 9. 43 6. 78
7. 61 Maryland 8.98 11.60 6.50 7.85 Massachusetts 9.96 11.13 7.71 8.45
Michigan 8.76 12.43 6.55 7.59 Minnesota 9. 27 11.21 6.82 8.05 Mississippi
7.19 9.20 6.32 6.46 Missouri 7. 45 12.08 6.35 6.88 Montana 7.47 10.18 5.93
6.45 Nebraska 8.37 10.24 7.02 6.96 Nevada 9.66 10.07 6.62 8.66 New Hampshire
9. 32 10.43 7.21 7.71

Page 25 GAO- 01- 750T

Mean hourly wage, 1999 Nurse aide a Factory worker b Fast food cook
Housekeeper

New Jersey 9.85 11.17 6.83 7.98 New Mexico 7.35 9.57 6.09 6.69 New York 9.27
10.26 6.69 9.71 North Carolina 7. 77 10.45 6.38 7.06 North Dakota 7.48 9.38
6.40 6.56 Ohio 8.34 11.11 6.52 7.27 Oklahoma 7. 17 11.91 6.08 6.53 Oregon
8.58 10.44 7.23 7.68 Pennsylvania 8. 82 10.82 6.34 7.66 Rhode Island 9.51
8.78 6.84 8.28 South Carolina 7.54 11.66 6.39 6.93 South Dakota 7.66 8.74
6.42 6.60 Tennessee 7.77 10.18 6.53 6.79 Texas 8. 63 9. 19 6. 24 6. 40 Utah
8.10 9.11 6.70 7.08 Vermont 8.30 10.24 7.52 7.42 Virginia 7.67 10.19 6.26
7.05 Washington 8.59 11.13 6.74 7.87 West Virginia 6.83 8.60 5.99 6.57
Wisconsin 8. 66 10.56 6.59 7.37 Wyoming 7. 74 8. 95 6. 34 7. 09

U. S. 8.59 10.67 6.54 7.46 a Wage data for nurse aides represent the
combined total of workers in three OES occupational categories: (1) nursing
aides, orderlies, and attendants; (2) home health care aides; and (3)
personal and home care aides. b Factory workers consist of the occupational
category ?team assemblers,? persons who work as part

of a team having responsibility for assembling an entire product or
component of a product. Team assemblers compose the largest single category
of production worker, accounting for just over 10 percent of all production
employees. c Wage data for factory workers in the District of Columbia were
not available.

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational
Employment Statistics data.

Page 26 GAO- 01- 750T

Table 5: Nurse Aide Earnings as a Percentage of State Per Capita Income,
1999 State Mean annual earnings a Per capita income Aide earnings as
percentage of

state per capita income

Alabama $15,068 $22,987 66 Alaska 24,199 28,577 85 Arizona 17,185 25,189 68
Arkansas 14,101 22,244 63 California 18,569 29,910 62 Colorado 17,811 31,546
56 Connecticut 23,544 39,300 60 Delaware 18,750 30,778 61 District of
Columbia 19,323 39,858 48 Florida 17,154 27,780 62 Georgia 15,383 27,340 56
Hawaii 19,898 27,544 72 Idaho 16,028 22,835 70 Illinois 16,967 31,145 54
Indiana 17,105 26,143 65 Iowa 16,986 25,615 66 Kansas 16,355 26,824 61
Kentucky 16,164 23,237 70 Louisiana 13,592 22,847 59 Maine 16,655 24,603 68
Maryland 18,685 32,465 58 Massachusetts 20,715 35,551 58 Michigan 18,216
28,113 65 Minnesota 19,286 30,793 63 Mississippi 14,945 20,688 72 Missouri
15,501 26,376 59 Montana 15,537 22,019 71 Nebraska 17,401 27,049 64 Nevada
20,094 31,022 65 New Hampshire 19,377 31,114 62 New Jersey 20,481 35,551 58
New Mexico 15,289 21,853 70 New York 19,279 33,890 57 North Carolina 16,172
26,003 62 North Dakota 15,553 23,313 67 Ohio 17,348 27,152 64 Oklahoma
14,921 22,953 65 Oregon 17,850 27,023 66 Pennsylvania 18,339 28,605 64 Rhode
Island 19,788 29,377 67 South Carolina 15,681 23,545 67

Page 27 GAO- 01- 750T

State Mean annual earnings a Per capita income Aide earnings as percentage
of state per capita income

South Dakota 15,923 25,045 64 Tennessee 16,153 25,574 63 Texas 17,961 26,858
67 Utah 16,852 23,288 72 Vermont 17,260 25,889 67 Virginia 15,954 29,789 54
Washington 17,877 30,392 59 West Virginia 14,204 20,966 68 Wisconsin 18,022
27,390 66 Wyoming 16,105 26,396 61

U. S. 17,866 28,542 63 a Mean annual earnings are for a full- time, full-
year worker (2,080 hours) earning the mean hourly wage. Sixty- seven percent
of all workers are employed full- time for the full year compared to 68
percent of hospital aides, 60 percent of aides in nursing homes, and 53
percent of aides in home health care.

Source: GAO analysis based on earnings data from Bureau of Labor Statistics,
1999 Occupational Employment Statistics data and per capita income data from
the Bureau of Economic Analysis, U. S. Department of Commerce.

Two primary sources of data were used to describe the demographic and
employment characteristics of nurse aides- the Current Population Survey
(CPS) conducted by the Census Bureau for the Bureau of Labor Statistics
(BLS) and the Occupational Employment Statistics (OES) survey conducted by
BLS and State Employment Security Agencies.

The CPS is a monthly survey of approximately 47,000 households and is the
source of official government statistics on employment and unemployment. The
monthly CPS contains basic demographic and labor force data, while the March
CPS survey contains additional data on work experience, income, benefits,
and migration. For our analysis, we used the March CPS files. Although the
overall sample size of the monthly CPS is large, nurse aides represent a
relatively small portion of the overall workforce. In order to obtain a
sample of aides large enough to support our statistical analysis, we
combined the 3 most recent years of data from the March CPS in 1998, 1999,
and 2000. We ended with a weighted sample of 766 hospital aides, 1,230
nursing home aides, and 1, 073 home health care aides.

Paraprofessional nursing aide workers may be classified under several
occupational and industry categories in the CPS. We selected two
occupational categories: health aides, except nursing (occupational code
446) and nursing aides, orderlies, and attendants (code 447). We cross
Technical Notes on

Analysis

Page 28 GAO- 01- 750T

tabulated these two occupational codes (446, 447) by industry codes to
identify the settings where these workers are employed. We included
hospitals (industry code 831) and nursing and personal care facilities (code
832). We identified nurse aides working in home health care as those
employed in private households (code 761), social services (code 871), and
health services, not elsewhere classified (code 840). We considered service
workers to be those classified in private household occupations (codes 403-
407) and service occupations (codes 433- 469) regardless of industry.

The OES program surveys approximately 400,000 establishments per year,
taking 3 years to fully collect the sample of 1.2 million establishments.
The OES collects data on wage and salary workers in nonfarm establishments
and produces employment and wage estimates for over 700 occupations by
geographic area and by industry. Employment and wage data for nurse aides
were based on three occupational categories in the OES: (1) nursing aides,
orderlies, and attendants (standard occupational code 31- 1012), (2) home
health care aides (31- 1011), and (3) personal and home care aides (39-
9021). We compared data across three employment settings: hospitals
(standard industry code 806), nursing and personal care facilities (805),
and home health care services (808). For comparison purposes we chose three
other occupational categories: team assemblers (51- 2092), fast food cooks
(35- 2011), and maids and housekeeping cleaners (37- 2012).

Page 29 GAO- 01- 750T

Initiatives and research efforts to address nurse aide recruitment and
retention focus primarily on improved wages and benefits (table 6),
opportunities for additional training and career advancement (table 7), and
additional employee supports, including improved work environments, job
skills, and social supports (table 8). Many initiatives are also
multifaceted, addressing two or more of these areas (table 9). While states
and providers have undertaken most initiatives and research efforts, the
federal government has recently begun to focus on the supply and demand of
this workforce. The Department of Health and Human Services, through HRSA,
HCFA, and ASPE, has undertaken research and planning efforts focused on
nurse aide issues (table 10). The tables describe selected examples of
initiatives and research efforts, and are not meant to be comprehensive.

Table 6: Wages and Benefits State wage pass- throughs Affected provider type
Nursing homes and home health care agencies

Description States with wage pass- throughs require that some portion of a
long- term care reimbursement increase from a public funding source be used
specifically to increase wages and/ or benefits for nurse aides. In some
states, only facilities that apply may participate in the pass- through
programs. As of September 2000, 26 states have established a wage pass-
through, wage supplement, or related program to provide supplemental wages
or benefits.

Funding source Varies (funds are usually from Medicaid, but may also include
Older Americans Act funds, state appropriations, and other sources)

Start date Varies from state to state. Some states have had pass- throughs
in place since the early 1980s to deal with episodic worker shortages; most
pass- throughs are relatively recent.

Evaluation findings Data collected in Michigan indicate that between 1990
and 1998, the aide turnover rate dropped from 74. 5 percent to 67. 45
percent, which the state attributes to a pass- through that has been in
place since 1990. Kansas? aide turnover rate in facilities participating in
the 1999 pass- through went from 120 percent in 1998 to 116 percent in 1999.
There have been no evaluations examining short- or long- term effects of the
wage passthrough strategy and differences in outcomes based on state
variations in methodology.

Appendix II: Examples of Government and Private Initiatives to Address Nurse
Aide Recruitment and Retention

Page 30 GAO- 01- 750T

Table 7: Training and Career Ladders Massachusetts Nursing Home Quality
Initiative Affected provider type Nursing homes (other provider types may be
included in one component of the

initiative, provided a nursing home is the primary applicant)

Description The initiative grants state funds to providers, and includes $35
million for a wage pass- through for nurse aides, $1 million for a
scholarship program to attract new aides, $5 million for a career ladder
grant program for aides, and $1.1 million in education and job supports for
current or former welfare recipients interested in a career as a nurse aide.
The career ladder grant program includes a component targeting the culture
of nursing homes; this component also requires applicants to collaborate
with other providers, the workforce development community, community
colleges, and other interested groups to increase program impact.

Funding source Funded by a $42 million appropriation from the state.

Start date Implemented in 2000.

Evaluation findings No evaluation has been conducted to date. Grantees in
the career ladder program are required to participate in an evaluation that
will be conducted by The Commonwealth Corporation. The scheduled deadline
for this evaluation is June 30, 2002.

Virginia Nursing Assistant Institute Initiative Affected provider type
Nursing homes, home health care agencies, hospitals

Description The Institute was developed by local officials, associations,
and providers to offer comprehensive free or low- cost aide training;
conduct workforce needs assessments; provide technical assistance to
providers interested in promoting best practices management; facilitate aide
recruitment; provide networking and peer support; and increase community
awareness of the aide shortage. The initiative is a joint effort of seven
agencies in the western Virginia area. a

Funding source Private funds, private and public grants

Start date 1999

Evaluation findings No overall evaluation conducted to date. a The agencies
are Charlottesville Albemarle Technical Education Center, the Jefferson Area
Board for the Aging, Monticello Area Community Action Agency, Martha
Jefferson Hospital, Piedmont Virginia Community College, University of
Virginia Health Systems, and Williamson?s Health Care Network.

Page 31 GAO- 01- 750T

Table 8: Employee Supports The Wellspring Program Affected provider type
Nursing homes

Description The Wellspring Program is a collaborative of 11 providers and is
based on the idea that while top levels of management should create quality
of care through appropriate policy, decisions on how to implement the policy
should be made by the front- line workers who are most familiar with the
needs of the residents. To implement this policy, the facilities who compose
the Wellspring Program have created ?care

resource teams? which receive specialized job training and are empowered to
train other workers and develop, implement, and evaluate facility level care
and structural changes. Nurse aides play a prominent role in these
interdisciplinary teams. Additionally, clinical experts, including a
geriatric nurse consultant, are available to the teams, and the geriatric
nurse consultants regularly visit each facility to provide assistance and
support.

Funding source Private

Start date 1994

Evaluation findings The Institute for the Future of Aging Services, with
funding from The Commonwealth Fund, is conducting an evaluation of the
Wellspring Program. However, turnover rates for aides across the 11
facilities have dropped from 110 percent (1994) before the implementation of
the Wellspring Program to a current rate of 23 percent (2001).

California Caregivers Training Initiative Affected provider type Nursing
homes, home health care agencies, hospitals

Description The state of California?s Caregiver Training Initiative (CTI) is
designed to develop and implement proposals to recruit, train, and retain
caregivers, including nurse aides and other entry level staff. Initiatives
undertaken with funds from CTI must be regional in scope and may include
supportive services such as childcare, transportation, and personal growth
workshops. Participants in the regional initiatives must meet the
eligibility requirements of the two funding sources, the federal Workforce
Investment Act and Welfare to Work Grant Program state matching funds. In
order to receive money from CTI, applicants must develop collaborations with
representatives of the health care industry, public agencies, labor
organizations, and public education. As of January 31, 2001, 12 grants,
ranging in size from $400,000 to just over $2. 5 million, were awarded.

Funding source $25 million ($ 15 million from Workforce Investment Act
funds, and $10 million from State General Fund match dollars)

Start date 2000

Evaluation findings No evaluation has been conducted to date. However, an
evaluation is required . The evaluation will address the implementation,
process, and outcomes of each funded program. Programs are required to
collect and maintain data on an ongoing basis, and to provide regular
progress reports to the evaluation staff.

Page 32 GAO- 01- 750T

Iowa Caregivers Association CNA Recruitment and Retention Pilot Project
Affected provider type Nursing homes

Description The goal of the CNA Recruitment and Retention Pilot Project was
to assess and address the needs of direct care workers in order to reduce
staff turnover in nursing facilities. After conducting a needs assessment of
nurse aides in the state, the Iowa Caregivers Association recruited three
facilities to participate in the pilot as tracking facilities and three to
act as control facilities (with two additional urban facilities recruited
during the second year of the pilot). They then implemented a series of
interventions, including training on conflict resolution, workshops in
communication and team building, and a nurse aide mentoring training
program.

Funding source Funded through the Iowa Department of Human Services

Start date 1998

Evaluation findings An evaluation by the National Resource Center for Family
Centered Practices at the University of Iowa School of Social Work found
that the average length of service over the 2- year pilot period was 18.96
months in the intervention facilities versus 10. 01 months in the control
facilities. Significantly lower turnover rates occurred in the treatment
facilities than in the control facilities (34 percent vs. 82 percent) in the
first year. Additionally, treatment facilities scored significantly better
than control facilities on several indicators of job satisfaction.

Page 33 GAO- 01- 750T

Table 9: Multifaceted Cooperative Home Care Associates Affected provider
type Home health care agencies

Description Cooperative Home Care Associates (CHCA) is a worker- owned home
health care provider in the Bronx, New York. It currently employs 550
minority women, and was developed on the premise that home health care
clients would receive higher quality of care if home health care workers
were offered higher quality jobs. Over 75 percent of women who work for CHCA
were previously dependent on public assistance. Wages at CHCA are among the
area?s highest, and the provider offers a full range of benefits, including
health care and a retirement plan. CHCA provides 4 weeks of classroom
training plus 90- days of on- the- job training, and offers continuing
development to staff. Employees are given the opportunity to become owners
of the company, and senior staff are also guaranteed a minimum of 30 hours
per week.

Funding source Private

Start date 1985

Evaluation findings No formal evaluation has been conducted. However, CHCA
reports that its annual turnover of aides is less than 25 percent, and
within the last 2 years 82 percent of aides remained with CHCA at least 180
days.

Providence Mount Saint Vincent Affected provider type Nursing home

Description Providence Mount Saint Vincent (PMSV) is a long- term care
facility in Seattle, Washington that offers a range of services, including a
nursing center and adult day services. In 1991, PMSV restructured itself to
provide ?resident directed care.? The organization defines resident directed
care as care directed by residents, including choosing the daily routines
and services the resident wishes to receive. Front- line staff were given
the power to make decisions related to patient care, and certain middle
management positions were eliminated to provide resources for more
directcare staff. All employees received cross- training in multiple tasks,
which, according to PMSV, gave them greater opportunity for advancement.
Aides also received pay increases with each year of service, bonuses for
staying with PMSV, and a full benefit plan, including health care and a
pension.

Funding source Private

Start date 1991

Evaluation findings No formal evaluation has been conducted. However, since
the implementation of the changes, turnover at PMSV is lower than the
industry standard. In 1994, PMSV?s turnover rate was 54 percent, in 1995 it
was 39 percent, and in 1996 it was 37 percent.

Page 34 GAO- 01- 750T

Wisconsin?s Community Links Workforce Project Affected provider type Nursing
homes, home health care agencies (and other long- term care providers)

Description The state Bureau of Aging and Long Term Care Resources allowed
counties to apply for funds to support local initiatives designed to
strengthen or expand the community long- term care workforce. Thirty- two
grants from 28 counties were funded, and included multidisciplinary
collaborations to address the issue of aide recruitment and retention,
efforts to tap nontraditional sources of workers, and programs to provide
wrap- around services for aides, such as the establishment of emergency
funds for unexpected car repairs and assistance with children?s school
supplies.

Funding source Community Options Program and Community Options Program-
waiver funds

Start date 1999

Evaluation findings No evaluation conducted to date.

Page 35 GAO- 01- 750T

Table 10: Federal Research and Data Collection Initiatives Report to
Congress on Appropriateness of the Minimum Nurse Staffing Ratios in Nursing
Homes, Phase II- Health Care Financing Administration, HHS Affected provider
type Nursing homes

Description Phase II of the Staffing Ratio study will examine the costs and
benefits associated with establishment of staffing minimums and further
explore the findings of Phase I. Additionally, Phase II will examine issues
that affect the recruitment and retention of nurse aides, including turnover
rates, amount of staff training, and management of staff resources.

Funding source Federal

Start date 2000, with an expected completion date of late 2001

Evaluation findings No evaluation has been completed.

National Study of Nursing Home Nurse Aides and Home Health Workers- Health
Resources and Services Administration, HHS

Affected provider type Nursing homes and home health care agencies

Description The Health Resources and Services Administration recently began
a national study of the current and future supply of and demand for front-
line long- term care workers. The study will include analysis of existing
databases and interviews of long- term care workers, providers,
associations, and interested state agencies. The interviews will be
conducted by the Center for Health Workforce Studies at State University of
New York, University at Albany?s School of Public Health, and other health
workforce centers around the country. A report is expected in late 2001.

Funding source Federal

Start date 2000

Evaluation findings No evaluation has been completed.

Frontline Workers in Long- Term Care- Office of Disability, Aging, and Long-
Term Policy, Office of the Assistant Secretary for Planning and Evaluation,
HHS

Affected provider type All long- term care workers

Description This project is designed to heighten the awareness of federal,
state, and local policymakers about issues related to the development of a
quality long- term care workforce. The project will identify successful
recruitment and retention models for frontline long- term care workers and
will suggest policy and research activities to promote a quality
paraprofessional long- term care workforce. ASPE is collaborating with the
Robert Wood Johnson Foundation. HCFA, HRSA, Administration on Aging, the
Department of Education, Agency for Healthcare Research and Quality, and the
Department of Labor are also involved.

Funding source Federal and private

Start date 2000

Evaluation findings No evaluation has been completed.

(290008)
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