Nursing Workforce: Multiple Factors Create Nurse Recruitment and 
Retention Problems (27-JUN-01, GAO-01-912T).			 
								 
Health care providers' current difficulty recruiting and	 
retaining nurses may worsen as the demand for nurses increases	 
with the aging of the population. Certain changes in the labor	 
market are similar to those that occurred during past nurse	 
shortages. However, impending demographic changes are widening	 
the gap between the numbers of people needing care and available 
caregivers. Moreover, the current high levels of job		 
dissatisfaction among nurses due to management decisions to	 
restructure health care delivery and staffing may play a crucial 
role in determining the extent of future nurse shortages. Efforts
undertaken to improve the areas of the workplace environment that
contribute to job dissatisfaction may reduce the likelihood of	 
nurses leaving or considering leaving the profession, and of	 
fewer people considering entering it. More data that can describe
the exact scope and nature of the current problem are needed to  
assist in planning and targeting corrective efforts. As 	 
providers, states, and the federal government focus on the	 
nursing workforce, they have the opportunity to collect and	 
analyze critical information on changes in the supply of and	 
demand for nurses.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-912T					        
    ACCNO:   A01267						        
  TITLE:     Nursing Workforce: Multiple Factors Create Nurse	      
             Recruitment and Retention Problems                               
     DATE:   06/27/2001 
  SUBJECT:   Health care personnel				 
	     Personnel recruiting				 
	     Labor supply					 
	     Job satisfaction surveys				 
	     Medicaid Program					 
	     Medicare Program					 

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GAO-01-912T
     
Testimony Before the Subcommittee on Oversight of Government Management,
Restructuring and the District of Columbia, Committee on Governmental
Affairs, U. S. Senate

United States General Accounting Office

GAO For Release on Delivery Expected at 10: 00 a. m. Wednesday, June 27,
2001 NURSING WORKFORCE

Multiple Factors Create Nurse Recruitment and Retention Problems

Statement of Janet Heinrich Director, Health Care- Public Health Issues

GAO- 01- 912T

Page 1 GAO- 01- 912T

Mr. Chairman and Members of the Subcommittee: I am pleased to be here today
as you discuss issues related to the current difficulties in the recruitment
and retention of nurses and concerns about their future supply. The health
and long- term care systems in the United States rely heavily on the
services of nurses, the largest group of health care workers. Nursing
shortages have been reported around the country, and providers and provider
associations have been studying the issue. In addition, both state
legislators and members of the Congress have proposed legislation to address
the problem.

To assist the Congress as it considers the impact of nurse recruitment and
retention issues on federally funded health programs, including Medicare and
Medicaid, my remarks will focus on (1) what is known about the current
supply of nurses, (2) factors contributing to current recruitment and
retention difficulties, (3) and factors that will affect the supply of and
demand for nurses in the future.

While comprehensive data are lacking on the nature and extent of current
difficulties recruiting and retaining nurses, current evidence suggests an
emerging shortage. Several factors, including nurses? decreased levels of
job satisfaction, are combining to constrain the current supply of nurses.
Furthermore, 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. Additionally, enrollments in registered nursing programs have
declined over the past 5 years, shrinking the pool of new workers to replace
those who are leaving or retiring. The problem is expected to become more
serious in the future as the aging of the population substantially increases
the demand for nurses.

Registered nurses 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 are 77 percent of the nurse workforce. 1 Historically, RNs
have worked predominantly in hospitals; in 2000, 59.1 percent of RNs worked
in hospitals. A smaller number of RNs work in other settings, such as
ambulatory care, home health care, and nursing homes. Their responsibilities
may include providing direct patient care in a hospital or home health care
setting, managing and directing complex nursing care in

1 Bureau of Labor Statistics Data, 1999 Occupational Employment Statistics
data. Background

Page 2 GAO- 01- 912T

an intensive care unit, or supervising the provision of long- term care in a
nursing home. In 1999 licensed practical nurses (LPN) composed 23 percent of
the nurse workforce. LPNs provide patient care under the direction of
physicians and registered nurses, with 32 percent working in hospitals, 28
percent working in nursing homes, and the rest working for doctors? offices,
home health agencies, residential care facilities, schools, temporary help
agencies, and government agencies.

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. As of 2000, 40.3 percent of nurses had received their training
through an associate program, while 29.6 percent and 29.3 percent had
received their training in a diploma or baccalaureate degree program,
respectively. 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. Once they have completed their
education, RNs and LPNs must meet the licensing requirements of their state
to be allowed to practice.

The U. S. health care system has changed significantly over the past two
decades, affecting the environment in which nurses provide patient care.
Advances in technology and greater emphasis on cost effectiveness have led
to changes in the structure, organization, and delivery of health care
services. While hospitals traditionally were the primary providers of acute
care, advances in technology, along with cost controls, shifted some care
from traditional inpatient settings to ambulatory, community- based, nursing
facility, or home health care settings. The transfer of less acute patients
to nursing homes and community- based care settings created additional job
opportunities and increased demand for nurses in these settings. This change
in service settings has also resulted in decreased lengths of patient stay
in hospitals and a decline in the numbers of beds staffed. At the same time,
the acuity of patients increased as those patients remaining in hospitals
were those too medically complex to be cared for in another setting. In an
additional effort to contain costs in the early 1990s, acute care facilities
restructured and redesigned staffing patterns, introducing more non- RN
caregivers and reducing the number of RNs on staff.

Recent studies have identified a relationship between the level of nurse
staffing and the quality of patient care. A recent Health Resources and

Page 3 GAO- 01- 912T

Services Administration (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. 2 Furthermore, a
Health Care Financing Administration (HCFA) report to the Congress last year
found a direct relationship between nurse staffing levels in nursing homes
and the quality of resident care. 3

Current evidence suggests emerging shortages of nurses available or willing
to fill some vacant positions in hospital, nursing home, and home health
care settings. National data are not adequate to describe the full nature
and extent of nurse workforce shortages, nor are data sufficiently sensitive
or current to allow a comparison of the degree of nurse workforce shortages
across states, specialties, or provider types.

The nationwide unemployment rate for RNs, which has been low for many years,
has recently declined further from 1.5 percent in 1997 to 1.0 percent in
2000, the lowest level in more than a decade. 4 Rising vacancy rates
reported by providers provide another indicator of possible excess demand. 5
A survey recently conducted by the Association of Maryland Hospitals and
Health Systems reported a statewide average RN vacancy rate for hospitals of
14. 7 percent in 2000, up from 3.3 percent in 1997. The Association reported
that the last time vacancy rates were at this level was during the late
1980s, during the last reported nurse shortage. As of a June 2001 American
Hospital Association survey, 17 state hospital associations reported
statewide RN vacancy rate data for 2000 or 2001, and 11 of these states
reported vacancy rates of 10 percent or higher. For 2000, California
reported an average RN vacancy rate of 20 percent, while in 2001 Florida and
Delaware reported nearly 16 percent, and Alabama and Nevada reported an
average rate of 13 percent. Other surveys indicate that the difficulty
recruiting RNs appears to be affecting a variety of provider types.

2 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).

3 HCFA is now known as the Centers for Medicare and Medicaid Services (CMS).
4 A Shortage of Registered Nurses: Is It On the Horizon or Already Here?,
2001. 5 Caution must be used when comparing vacancy rates from different
studies. While nurse vacancy rates are typically the number of budgeted
full- time RN positions that are unfilled divided by the total number of
total budgeted full- time RN positions, not all studies identify the method
used to calculate rates. Evidence Suggests

Emerging Shortages of Nurses

Page 4 GAO- 01- 912T

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. A 2000 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).

Job dissatisfaction is reported to be high among nurses. Nurses report
unhappiness with a variety of issues, including staffing, respect and
recognition, and wages, and this dissatisfaction is affecting their decision
to work in nursing. Furthermore, the nurse workforce is aging and fewer new
nurses are entering the profession to replace those who are retiring or
leaving.

Job dissatisfaction may play a significant role in both current and future
recruitment and retention problems. A recent Federation of Nurses and Health
Professionals (FNHP) survey found that half of the currently employed RNs
who were surveyed had considered leaving the patient- care field for reasons
other than retirement over the past 2 years. 6 Over onefourth (28 percent)
of RNs in a 1999 study by The Nursing Executive Center described themselves
as somewhat or very dissatisfied with their job, and about half (51 percent)
were much less satisfied with their job than they were 2 years ago. 7 In
that same survey, 32 percent of general medical/ surgical RNs, who
constitute the bulk of hospital RNs, indicated that they were dissatisfied
with their current job. According to a survey conducted by the American
Nurses Association (ANA), 54.8 percent of RNs and LPNs responding would not
recommend the nursing profession as a career for their children or friends,
while 23 percent would actively

6 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.: April 2001). 7 The Nurse Perspective: Drivers of Nurse
Job Satisfaction and Turnover, 2000. Job Dissatisfaction,

Demographic Changes, and Declining Interest in The Nursing Profession
Contribute to Recruitment and Retention Problems

Nurses Report Dissatisfaction with Current Work Environment

Page 5 GAO- 01- 912T

discourage someone close to them from entering the profession. 8 Almost half
(49 percent) of current RNs surveyed in another study said that if they were
younger and just starting out, they would pursue a different career, rather
than becoming a registered nurse. 9

Inadequate staffing, heavy workloads, and the use of overtime to address
staffing shortages are frequently cited as key areas of job dissatisfaction
among nurses. Seventy- nine percent of nurses responding to the FHNP survey
said they had seen a rise in acuity of patients. 10 When adjusted to reflect
the rise in acuity levels, the number of hospital employees on staff for
each patient discharged, including nurses, declined by more than 13 percent
between 1990 and 1999. This increases the work intensity for individual
nurses. According to one survey, of those RNs responding who had considered
leaving the patient- care field for reasons other than retirement, 56
percent indicated that they wanted a less stressful and physically demanding
job and 22 percent said they were concerned about schedules and hours. 11
The same survey found that 55 percent of current RNs were either just
somewhat or not satisfied by their facility?s staffing levels, while 43
percent of current RNs surveyed indicated that increased staffing would do
the most to improve their job. Another survey found that 36 percent of RNs
in their current job more than one year were very or somewhat dissatisfied
with the intensity of their work. 12 Officials of unions representing nurses
told us the issues of staffing and overtime have been important for their
nursing members during recent negotiations. State legislators have also
indicated concern- in the first half of 2001 alone, legislation designed to
limit mandatory overtime or protect nurses who refuse to work additional
hours has been introduced in 10 states.

Registered nurses have also cited the lack of respect and recognition given
them, along with their perceived lack of authority, as areas of

8 American Nurses Association, Analysis of American Nurses Association
Staffing Survey (Internet survey compiled by Cornerstone Communications
Group for the American Nurses Association)( Warwick, RI, 2001). 9 The Nurse
Shortage: Perspectives From Current Direct Care Nurses and Former Direct
Care Nurses, April 2001.

10 The Nurse Shortage: Perspectives From Current Direct Care Nurses and
Former Direct Care Nurses, April 2001. 11 The Nurse Shortage: Perspectives
From Current Direct Care Nurses and Former Direct Care Nurses, April 2001.
12 The Nurse Perspective: Drivers of Job Satisfaction and Turnover, 2000.

Page 6 GAO- 01- 912T

dissatisfaction. In a survey conducted by The Nursing Executive Center, 48
percent of RNs surveyed who had held their current job more than one year
indicated that they were very or somewhat dissatisfied with the recognition
they receive, while 35 percent were dissatisfied with their level of
participation in decision- making. 13 Over half (53 percent) of RNs
responding to a survey from the FNHP were either just somewhat or not
satisfied by the degree to which they had a voice in decisions, while 47
percent were either just somewhat or not satisfied by the support and
respect they received from management. 14

While surveys indicate that increased wages might encourage registered
nurses to stay at their jobs, money is not always cited as the primary
reason for job dissatisfaction. According to the FNHP survey, of those RNs
responding who had considered leaving the patient- care field for reasons
other than retirement, 18 percent wanted more money, versus 56 percent who
were concerned about the stress and physical demands of the job. 15 However,
the same study reported that 27 percent of current RNs responding cited
higher wages or better health care benefits as a way of improving their job.
Another study indicated that 39 percent of RNs who had been in their current
job for more than 1 year were dissatisfied with their total compensation,
but 48 percent were dissatisfied with the level of recognition they received
from their employer. 16 The American Hospital Association (AHA) recently
reported on a survey that found that 57 percent of responding RNs said their
salaries were adequate, compared to 33.4 percent who thought their facility
was adequately staffed and 29.1 percent who said that their hospital
administration listened and responded to their concerns. 17

Nurses have also expressed dissatisfaction with a decrease in the amount of
support staff available to them over the past few years. Fewer than half the
RNs responding to the recent study by the AHA agreed that their

13 The Nurse Perspective: Drivers of Job Satisfaction and Turnover, 2000. 14
The Nurse Shortage: Perspectives From Current Direct Care Nurses and Former
Direct Care Nurses, April 2001.

15 The Nurse Shortage: Perspectives From Current Direct Care Nurses and
Former Direct Care Nurses, April 2001. 16 The Nurse Perspective: Drivers of
Nurse Job Satisfaction and Turnover, 2000. 17 AHA and The Lewin Group, ?The
Hospital Workforce Shortage: Immediate and Future? Trend Watch, Vol. 3, No.
2 (June 2001)

Page 7 GAO- 01- 912T

hospital provided adequate support services. 18 Nurses responding to a
survey by the ANA also pointed to a decrease of needed support services.
Current nurse workforce issues are part of a larger health care workforce
shortage that includes a shortage of nurse aides. 19 Nurse aides support
nurses and assist patients with activities of daily living such as dressing,
feeding, and bathing. 20 Several state and local- level studies cite nurse
aide recruitment and retention as a problem for many providers. The shortage
among nurse aides may be linked to difficult work conditions as well as
dissatisfaction with wages and benefits. Studies have cited low wages and
few benefits as factors contributing to nurse aide turnover. Our recent
analysis of national data from the Bureau of Labor Statistics indicated
that, on average, nurse aides receive lower wages and fewer benefits than
workers generally; this is particularly true for those working in nursing
homes and home health care. 21 In 1999, the national average hourly wage for
nurse aides working in nursing homes was $8.29, compared to $9.22 for
service workers and $15.29 for all workers. For nurse aides working in home
health care agencies, the average hourly wage was $8.67, and for nurse aides
working in hospitals, $8.94. Our analysis indicated that many nurse aides
have sufficiently low earnings and family incomes to qualify for public
benefits such as food stamps and Medicaid.

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, and have one of the
highest rates of workplace injury, 13 per 100 employees in 1999, compared to
the construction industry rate of 8 per 100 employees. Additional factors
that affect turnover include workloads and staffing levels, respect from
administrators, organizational recognition, and participation in decision-
making- all very similar to areas of dissatisfaction identified by nurses.

18 AHA and The Lewin Group, ?The Hospital Workforce Shortage: Immediate and
Future?. 19 Analysis of American Nurses Association Staffing Survey, 2001.
20 We use the term ?nurse aide? to refer to all paraprofessional nursing
staff working in health care settings. 21 See Nursing Workforce: Recruitment
and Retention of Nurses and Nurse Aides is a Growing Concern (GAO- 01- 750T,
May 17, 2001).

Page 8 GAO- 01- 912T

While job dissatisfaction is a primary reason cited for nurse retention
problems, demographic changes are also a contributing factor. As shown in
figure 1, there has been a dramatic shift upward in the age distribution of
registered nurses in the past 10 years. The average age of the RN population
in 2000 was 45, almost 1 year older than the average in 1996. Over half (52
percent) of all RNs were reported to be under the age of 40 in 1980; by 2000
fewer than 1 in 3 were younger than 40.

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.

While the current nurse population continues to age, fewer young people are
choosing nursing as a profession. Over the past 25 years, career
opportunities available to women have expanded significantly, and there has
been a corresponding decline of interest by women in nursing as a The Nurse
Workforce Is

Aging Fewer People Have Chosen to Enter the Nursing Profession

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 9 GAO- 01- 912T

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. 22 The decline in nursing program enrollments in recent years
reflects this development. According to a 1999 Nursing Executive Center
Report, enrollment in diploma programs dropped 42 percent between 1993 and
1996, and enrollment in associate degree programs declined 11 percent. 23
Furthermore, between 1995 and 1998, enrollment in both baccalaureate and
master?s programs also dropped.

In addition to the reduced number of students entering 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. Both Arkansas and
California have reported that qualified applicants have been turned away
from basic RN education because of a lack of institutional resources,
including faculty and facilities.

Growth in the number of new RNs has slowed in recent years. The number of
new RNs passing the licensing examination declined steadily from 1996 to
2000; in 2000 it was 23 percent lower than in 1996, falling from 96,679 to
74,787. Although the total number of licensed RNs increased 5.4 percent
between 1996 and 2000, to a total of 2,696,540- this was the lowest increase
ever reported in HRSA?s periodic survey of RNs. In contrast, the highest
increase in the RN population occurred between 1992 and 1996, when the total
number of RNs increased by an estimated 14.2 percent, from 2,239,816 to
2,558,874. 24

22 Buerhaus, Peter I. et al., ?Policy Responses to an Aging Registered Nurse
Workforce,? Nursing Economics Vol. 18, No. 6 (Nov.- Dec. 2000). 23 The
Nursing Executive Center, A Misplaced Focus: Reexamining the Recruiting/
Retention Trade- Off (Washington, D. C.: The Advisory Board Company, Feb.
11, 1999). 24 The Registered Nurse Population: National Sample Survey of
Registered Nurses, Mar. 2000.

Page 10 GAO- 01- 912T

A serious nurse shortage is expected in the future, as pressures are exerted
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 age 65 years and older will double from 2000 to 2030.
During that same time period the number of women between 25 and 54 years of
age, who have traditionally formed the core of the nursing workforce, is
expected to remain relatively unchanged. This 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 working age population, age 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 age
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.

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.

Demand for Nurses Will Continue to Grow As the Supply Dwindles

0 5

10 15

20 25

30 35

40 45

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

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

Page 11 GAO- 01- 912T

Unless more young people choose to go into the nursing profession, the nurse
workforce will continue to age. By 2010, the average age of nurses will be
45.4, while approximately 40 percent of the workforce will be older than 50.
By 2020, the total number of full- time equivalent RNs is projected to have
fallen 20 percent below requirements. 25

Providers? current difficulty recruiting and retaining nurses may worsen as
the demand for nurses increases with the aging of the population. Certain
changes in the labor market are similar to those that occurred during past
nurse shortages. However, impending demographic changes are widening the gap
between the numbers of people needing care and available caregivers.
Moreover, the current high levels of job dissatisfaction among nurses due to
management decisions to restructure health care delivery and staffing may
play a crucial role in determining the extent of future nurse shortages.
Efforts undertaken to improve the areas of the workplace environment that
contribute to job dissatisfaction may reduce the likelihood of nurses
leaving or considering leaving the profession, and of fewer people
considering entering it. More data that can describe the exact scope and
nature of the current problem are needed to assist in planning and targeting
corrective efforts. As providers, states, and the federal government focus
on the nursing workforce, they have the opportunity to collect and analyze
critical information on changes in the supply of and demand for nurses.

Mr. Chairman, this concludes my statement. I would be happy to answer any
questions that you or Members of the Subcommittee may have.

For more information regarding this testimony, please contact me at (202)
512- 7118 or Helene Toiv at (202) 512- 7162. Eric Anderson, Connie Peebles
Barrow, Emily Gamble Gardiner, and Pamela Ruffner also made key
contributions to this statement.

(290091) 25 American Organization of Nurse Executives, Perspectives on the
Nursing Shortage: A Blueprint for Action, October 2000. Concluding

Observations GAO Contacts and Staff Acknowledgments
*** End of document. ***