Nursing Workforce: Emerging Nurse Shortages Due to Multiple	 
Factors (10-JUL-01, GAO-01-944).				 
								 
Health and long-term care systems in the United States rely	 
heavily on the services of nurses, the largest group of health	 
care providers. Concerns have recently been raised about the	 
adequacy of both the current and projected supply of nurses to	 
meet the nation's needs. In this report, GAO reviews (1) whether 
there is evidence of a current nursing shortage, (2) the reasons 
for current nurse recruitment and retention problems, and (3)	 
what is known about the projected future supply of and demand for
nurses. GAO found that (1) national data are not adequate to	 
describe the nature and extent of nurse workforce shortages, nor 
are data sufficiently sensitive or current to compare nurse	 
workforce availability across states, specialties, or provider	 
types, (2) the multiple factors that affect recruitment and	 
retention problems include the aging of the nurse workforce	 
resulting from reduced entry of younger people into the 	 
profession as well as nurses' job dissatisfaction, and (3) a	 
serious shortage of nurses is expected in the future as 	 
demographic pressures influence both demand and supply. 	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-944 					        
    ACCNO:   A01418						        
  TITLE:     Nursing Workforce: Emerging Nurse Shortages Due to       
             Multiple Factors                                                 
     DATE:   07/10/2001 
  SUBJECT:   Health care personnel				 
	     Health services administration			 
	     Labor force					 
	     Labor supply					 
	     Personnel recruiting				 
	     Projections					 
	     Job satisfaction surveys				 
	     Medicare Prospective Payment System		 

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GAO-01-944
     
Report to the Chairman, Subcommittee on Health, Committee on Ways and Means,
House of Representatives

United States General Accounting Office

GAO

July 2001 NURSING WORKFORCE

Emerging Nurse Shortages Due to Multiple Factors

GAO- 01- 944

Page i GAO- 01- 944 Emerging Nurse Shortages Letter 1

Results in Brief 1 Background 2 Evidence Suggests Emerging Shortages of
Nurses 3 Multiple Obstacles to Increasing Supply of Nurses 6 Demand for
Nurses Will Continue to Grow As the Supply Dwindles 11 Concluding
Observations 13

Appendix I Change in RN Employment, per 100,000 Population by State, 1996-
2000 14

Figures

Figure 1: Age Distribution of the Registered Nurse Population, 1980 and 2000
8 Figure 2: Cumulative Annual Increase in Median RN Earnings and

the Consumer Price Index, 1989- 2000 11 Figure 3: Decline in Elderly Support
Ratio Expected, 2000 to 2040 12 Contents

Page 1 GAO- 01- 944 Emerging Nurse Shortages

July 10, 2001 The Honorable Nancy L. Johnson Chairman Subcommittee on Health
Committee on Ways and Means House of Representatives

Dear Madam Chairman: The health and long- term care systems in the United
States rely heavily on the services of nurses, the largest group of health
care providers. Recent media reports and other accounts have raised concerns
about the adequacy of both the current and projected supply of nurses to
meet the nation?s needs. Over the last few months, several congressional
hearings have been held on this issue, including two at which we testified
on nurse recruitment and retention problems. 1

In response to your request, we are providing information on (1) whether
there is evidence of a current nursing shortage, (2) the reasons for current
nurse recruitment and retention problems, and (3) what is known about the
projected future supply of and demand for nurses. 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) and the Department of Labor?s Bureau of Labor
Statistics (BLS). We also reviewed the relevant professional and research
literature and interviewed industry and professional association
representatives, researchers, union officials, and other experts. We
performed our work during May and June 2001 in accordance with generally
accepted government auditing standards.

National data are not adequate to describe the nature and extent of nurse
workforce shortages, nor are data sufficiently sensitive or current to
compare nurse workforce availability across states, specialties, or provider
types. Nonetheless, current evidence suggests emerging

1 See Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides
Is a Growing Concern (GAO- 01- 750T, May 17, 2001) and Nursing Workforce:
Multiple Factors Create Nurse Recruitment and Retention Problems (GAO- 01-
912T, June 27, 2001).

United States General Accounting Office Washington, DC 20548

Results in Brief

Page 2 GAO- 01- 944 Emerging Nurse Shortages

shortages of nurses available or willing to fill some vacant positions in
hospitals, nursing homes, and home care. The number of employed registered
nurses (RN) per capita has declined in recent years while the national
unemployment rate for RNs has declined to 1 percent in 2000. In addition,
providers from around the country are reporting growing difficulty
recruiting nurses to work in a range of settings, and surveys of providers
in several states and localities indicate rising RN vacancy rates.
Furthermore, there has been an increase in public sector activities related
to nurse workforce issues in many states.

While shortages emerge because of an imbalance of demand and supply, there
are insufficient data to measure how each may be affecting the current
situation. The multiple factors that affect recruitment and retention
problems include the aging of the nurse workforce resulting from reduced
entry of younger people into the profession as well as nurses? job
dissatisfaction. Sources of dissatisfaction include working conditions such
as inadequate staffing, heavy workloads, the increased use of overtime, a
lack of sufficient support staff, and the adequacy of wages. A serious
shortage of nurses is expected in the future as demographic pressures
influence both demand and supply. The future demand for nurses is expected
to increase dramatically as the baby boomers reach their 60s, 70s, and
beyond. Moreover, the nurse workforce will continue to age, and, by 2010,
approximately 40 percent will likely be older than 50.

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, historically, have worked predominantly in hospitals; in
2000, 59.1 percent of RNs were employed in hospital settings. 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 a home health care setting, managing and
directing complex nursing care in an intensive care unit, or supervising the
provision of long- term care in a nursing home. 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. Background

Page 3 GAO- 01- 944 Emerging Nurse Shortages

Once they have completed their education, RNs are subject to state licensing
requirements. 2

The U. S. healthcare system has changed significantly over the past 2
decades, affecting the environment in which nurses provide 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 care from traditional
inpatient settings to ambulatory or community- based settings, nursing
facilities, or home health care settings. The number of hospital beds
staffed declined as did the patient lengths of stay. While the number of
hospital admissions declined from the mid- 1980s to the mid- 1990s, they
increased between 1995 and 1999. At the same time, the overall acuity level
of the patients increased as the conditions of those patients remaining in
hospitals made them too medically complex to be cared for in another
setting. The transfer of less acute patients to nursing homes and community-
based care settings created additional job opportunities and increased
demand for nurses.

Current evidence suggests emerging shortages of nurses available or willing
to fill some vacant positions in hospitals, nursing homes, and home care.
Some localities are experiencing greater difficulty than others. National
data are not adequate to describe the nature and extent of these potential
nurse workforce shortages, nor are data sufficiently sensitive or current to
allow a comparison of the adequacy of the nurse workforce size across
states, specialties, or provider types. However, total employment of RNs per
capita and the national unemployment rate for RNs have declined, and
providers from around the country are reporting growing difficulty
recruiting and retaining the number of nurses needed in a range of settings.
Another indicator that suggests the emergence of shortages is a rise in
recent public sector efforts related to nurse workforce issues in many
states.

The national unemployment rate for RNs is at its lowest level in more than a
decade, continuing to decline from 1.5 percent in 1997 to 1.0 percent in

2 Licensed practical nurses (LPN) make up the second- largest group of
licensed health care givers, accounting for 23 percent of the nurse
workforce. LPNs primarily provide direct patient care under the direction of
a physician or RN. Unless otherwise specified, our discussion of nurse
workforce issues in this report generally refers only to RNs. Evidence
Suggests

Emerging Shortages of Nurses

Page 4 GAO- 01- 944 Emerging Nurse Shortages

2000. At the same time, total employment of RNs per capita declined 2
percent between 1996 and 2000, reversing steady increases since 1980.
Between 1980 and 1996, the number of employed RNs per capita nationwide
increased by 44 percent. At the state level, changes in per capita nurse
employment from 1996 to 2000 varied widely, from a 16.2 percent increase in
Louisiana to a 19.5 percent decrease in Alaska. (See appendix I.) Overall a
decline in per capita nurse employment occurred in 26 states and the
District of Columbia between 1996 and 2000. Declining RN employment per
capita may be an indicator of a potential shortage. It is an imprecise
measure, however, because it does not account for changes in care needs of
the population or how many nurses relative to other personnel providers wish
to use to meet those needs. Moreover, total employment includes not only
nurses engaged in clinical or patient care activities but also those in
administrative and other nondirect care positions. Data on how much nurse
employment may have shifted between direct care and other positions are not
available.

Recent studies suggest that hospitals and other health care providers in
many areas of the country are experiencing greater difficulty in recruiting
RNs. 3 For example, a recent survey in Maryland conducted by the Association
of Maryland Hospitals and Health Systems reported a statewide average
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. A
survey of providers in Vermont found that hospitals had an RN vacancy rate
of 7.8 percent in 2001, up from 4.8 percent in 2000 and 1.2 percent in 1996.
For 2000, California reported an average RN vacancy rate of 20 percent, and
for 2001, Florida reported nearly 16 percent and Nevada reported an average
rate of 13 percent.

Concerns about retaining nurses have also become more widespread. A recent
survey reported that the national turnover rate among hospital staff nurses
was 15 percent in 1999, up from 12 percent in 1996. 4 Another industry
survey showed turnover rates for overall hospital nursing

3 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 budgeted full-
time RN positions, not all studies identify the method used to calculate
rates.

4 The Nursing Executive Center, The Nurse Perspective: Drivers of Nurse Job
Satisfaction and Turnover (Washington, D. C.: The Advisory Board Company,
2000).

Page 5 GAO- 01- 944 Emerging Nurse Shortages

department staff rising from 11.7 percent in 1998 to 26. 2 percent in 2000.
5 Nursing home and home health care industry surveys indicate that nurse
turnover is an issue for them as well. 6 In 1997, an American Health Care
Association survey of 13 nursing home chains identified a 51- percent
turnover rate for RNs and LPNs. 7 A 2000 national survey of home health care
agencies reported a 21- percent turnover rate for RNs. 8

Increased attention by state governments is another indicator of concern
about nurse workforce problems. According to the National Conference of
State Legislatures, as of June 2001, legislation to address nurse shortage
issues had been introduced in 15 states, and legislation to restrict the use
of mandatory overtime for nurses in hospitals and other health care
facilities had been introduced in 10 states. A variety of nurse workforce
task forces and commissions have recently been established as well. For
example, in May 2000, legislation in Maryland created the Statewide
Commission on the Crisis in Nursing to determine the current extent and
long- term implications of the growing shortage of nurses in the state.

Available data on supply and demand for RNs are not adequate to determine
the magnitude of any current imbalance between the two with any degree of
precision. Both the demand for and supply of RNs are influenced by many
factors. Demand for RNs not only depends on the care needs of the
population, but also on how providers- hospitals, nursing homes, clinics,
and others- decide to use nurses in delivering care. Providers have changed
staffing patterns in the past, employing fewer or more nurses relative to
other workers such as nurse aides. For example, following the introduction
of the Medicare Prospective Payment System (PPS), hospitals increased the
share of RNs in their workforces. However, in the early 1990s, in an effort
to contain costs, acute care facilities restructured and redesigned staffing
patterns, introducing more non- RN caregivers and reducing the percentage of
RNs. While the number of RNs

5 Hospital and Healthcare Compensation Service, Hospital Salary and Benefits
Report, 2000- 2001 (Oakland, N. J.: Hospital & Healthcare Compensation
Service, 2000). 6 Like vacancy rates, caution must be used when comparing
turnover rates from different studies. While nurse turnover rates are
typically the number of nurses that have left a facility divided by the
total number of nurse positions, there is no standard method for calculating
turnover, and methods used in different studies vary.

7 American Health Care Association, Facts and Trends 1999, The Nursing
Facility Sourcebook (Washington, D. C.: AHCA, 1999). 8 Homecare Salary and
Benefits Report, 2000- 2001, 2000.

Page 6 GAO- 01- 944 Emerging Nurse Shortages

employed by hospitals remained relatively unchanged from 1995 to1997,
hospitals reported significant growth in RN employment in 1998 and 1999.

Supply depends on the size of the pool of qualified persons and the share of
them willing to work. Current participation by licensed nurses in the work
force is relatively high. Nationally, 81.7 percent of licensed RNs were
employed in nursing in 2000. 9 Although this represents a slight decline
from the high of 82.7 percent reported in 1992 and 1996, this rate of
workforce participation remains higher than the 76.6 to 80. 0 percent rates
reported in the 1980s. Moreover, some RNs are employed in nonclinical
settings, such as insurance companies, reducing the number of nurses
available to provide direct patient care.

Current problems with the recruitment and retention of nurses are related to
multiple factors. The nurse workforce is aging, and fewer new nurses are
entering the profession to replace those who are retiring or leaving.
Furthermore, nurses report unhappiness with many aspects of the work
environment including staffing levels, heavy workloads, increased use of
overtime, lack of sufficient support staff, and adequate wages. In many
cases this growing dissatisfaction is affecting their decisions to remain in
nursing.

The decline in younger people, predominantly women, choosing nursing as a
career has resulted in a steadily aging RN workforce. Over the last 2
decades, as opportunities for women outside of nursing have expanded the
number of young women entering the RN workforce has declined. 10 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
Reductions in nursing program enrollments within the last decade attest to
this narrowing pipeline. According to a 1999 Nursing Executive Center
Report, between 1993 and 1996, enrollment

9 In 2000, workforce participation rates by RNs vary across states, from a
high of 92 percent in North Dakota and Louisiana to a low of 75 percent in
Pennsylvania and 76 percent in Virginia, Indiana, and Arizona.

10 Peter I. Buerhaus, Douglas O. Staiger, and David I. Auerbach,
?Implications of an Aging Registered Nurse Workforce,? JAMA, Vol. 283, No.
22 (June 14, 2000). 11 Peter I. Buerhaus, Douglas O. Staiger, and David I.
Auerbach, ?Policy Responses to an Aging Registered Nurse Workforce,? Nursing
Economic$, Vol. 18, No. 6 (Nov.- Dec. 2000). Multiple Obstacles to

Increasing Supply of Nurses

Nurse Workforce Is Aging

Page 7 GAO- 01- 944 Emerging Nurse Shortages

in diploma programs dropped 42 percent and enrollment in associate degree
programs declined 11 percent. Furthermore, between 1995 and 1998, enrollment
in baccalaureate programs declined 19 percent, and enrollment in master?s
programs decreased 4 percent. 12 The number of individuals passing the
national RN licensing exam declined from 97,679 in 1996 to 74,787 in 2000, a
decline of 23 percent.

The large numbers of RNs that entered the labor force in the 1970s are now
over the age of 40 and are not being replenished by younger RNs. Between
1983 and 1998, the number of RNs in the workforce under 30 fell by 41
percent, compared to only a 1- percent decline in the number under age 30 in
the rest of the U. S. workforce. 13 Over the past 2 decades, the nurse
workforce?s average age has climbed steadily. While over half of all RNs
were reported to be under age 40 in 1980, fewer than one in three were
younger than 40 in 2000. As shown in figure 1, the age distribution of RNs
has shifted dramatically upward. The percent of nurses under age 30
decreased from 26 percent in 1980 to 9 percent 2000, while the percent age
40 to 49 grew from 20 to 35 percent.

12 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- and 49 for associate
professors.

13 ?Policy Responses to an Aging Registered Nurse Workforce,? Nursing
Economic$.

Page 8 GAO- 01- 944 Emerging Nurse Shortages

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.

Job dissatisfaction has also been identified as a major factor contributing
to the current problems of recruiting and retaining nurses. 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.
14 Over one- fourth (28 percent) of RNs responding to a 1999 survey by The
Nursing Executive Center described themselves as somewhat or very
dissatisfied with their jobs, and about half (51 percent) were less or much
less satisfied with their jobs than they were 2 years

14 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 Cited

As a Major Factor

0 5

10 15

20 25

30 35 Percent

<= 29 30- 39 40- 49 50- 59 >= 60 Age distribution

1980 2000

Page 9 GAO- 01- 944 Emerging Nurse Shortages

ago. 15 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 jobs. According to a survey conducted by the
American Nurses Association, 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 discourage someone close to them
from entering the profession. 16

Inadequate staffing, heavy workloads, and the increased use of overtime are
frequently cited as key areas of job dissatisfaction among nurses. According
to the recent FNHP survey, of those RNs responding who had considered
leaving the patient- care field for reasons other than retirement over the
past 2 years, 56 percent indicated that they wanted a less stressful and
less physically demanding job. 17 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 jobs. Another survey
found that 36 percent of RNs in their current job more than 1 year were very
or somewhat dissatisfied with the intensity of their work. 18 Some providers
report increased use of overtime for employees. Twenty- two percent of
nurses responding to the FNHP survey said they were concerned about
schedules and hours. A survey of North Carolina hospitals conducted in 2000
found significant reliance on overtime for staff nurses. Nine percent of
rural hospitals reported spending more than 25 percent of their nursing
budget on overtime, and, among urban hospitals, 49 percent expected to
increase their use of overtime in the coming year. 19 The trend toward
increasing use of overtime is currently a major concern of nurse unions and
associations.

15 The Nurse Perspective: Drivers of Nurse Job Satisfaction and Turnover,
2000. 16 American Nurses Association, Analysis of American Nurses
Association Staffing Survey (Internet survey of self- selected participants
compiled by Cornerstone Communications

Group for the American Nurses Association)( Warwick, R. I., 2001). 17 The
Nurse Shortage: Perspectives from Current Direct Care Nurses and Former
Direct Care Nurses, April 2001.

18 The Nurse Perspective: Drivers of Nurse Job Satisfaction and Turnover,
2000. 19 North Carolina Center for Nursing, Nursing Shortage Areas in North
Carolina Hospitals (February 2001).

Page 10 GAO- 01- 944 Emerging Nurse Shortages

Nurses have also expressed dissatisfaction with a decrease in the amount of
support staff available to them over the past few years. More than half the
RNs responding to the recent study by the American Hospital Association
(AHA) did not feel that their hospitals provided adequate support services.
20 RNs, LPNs, and others 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. 21

Some nurses have also expressed dissatisfaction with their wages. While
surveys indicate that increased wages might encourage 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 over the past 2 years, 18 percent wanted more money, versus 56
percent who were concerned about the stress and physical demands of the job.
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 jobs. Another study indicated that 39 percent of RNs who had been in
their current jobs 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 employers. 22 AHA recently reported on a survey
that found that 57 percent of responding RNs said that 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 administrations
listened and responded to their concerns. 23

Wages can have a long- term impact on the size of a workforce pool as well
as a short- term effect on people?s willingness to work. After several years
of real earnings growth following the last nursing shortage, RN earnings
growth lagged behind the rate of inflation from 1994 through 1997. In 2 of
the last 3 years, however, 1998 and 2000, RN earnings growth exceeded the
rate of inflation. The cumulative effects of these changes are such that RN

20 AHA and The Lewin Group, ?The Hospital Workforce Shortage: Immediate and
Future,? TrendWatch, Vol. 3, No. 2 (June 2001). 21 Analysis of American
Nurses Association Staffing Survey, 2001. 22 The Nurse Perspective: Drivers
of Nurse Job Satisfaction and Turnover, 2000 . 23 ?The Hospital Workforce
Shortage: Immediate and Future,? 2001.

Page 11 GAO- 01- 944 Emerging Nurse Shortages

earnings have just kept pace with the rate of inflation from 1989 to 2000 as
shown in figure 2.

Figure 2: Cumulative Annual Increase in Median RN Earnings and the Consumer
Price Index, 1989- 2000

Source: GAO analysis of median weekly earnings for RNs employed full- time
as reported by the Bureau of Labor Statistics (BLS) using data from the
Current Population Survey. Consumer Price Index data for each year represent
annual averages as reported by BLS.

A serious shortage of nurses 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 between 2000 to
2030. During that same period the number of women between 25 and 54 years of
age, who have traditionally formed the core of the nurse workforce, is
expected to remain relatively unchanged. This potential mismatch between
future supply of and demand for caregivers is Demand for Nurses

Will Continue to Grow As the Supply Dwindles

0 5

10 15

20 25

30 35

40 45

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year Percent
change

Median RN Earnings Consumer Price Index

Page 12 GAO- 01- 944 Emerging Nurse Shortages

illustrated by the change in the expected ratio of potential care providers
to potential care recipients. As shown in figure 3, the ratio of the
workingage 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, the cohort most
likely to be working either as nurses or nurse aides, to the population age
85 and older will decline from 16.1 in 2000 to 8. 5 in 2030, and 5.7 in
2040.

Figure 3: 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.

Unless more young people choose to go into the nursing profession, the nurse
workforce will continue to age. By 2010, approximately 40 percent of the
workforce will likely be older than 50. By 2020, the total number of full
time equivalent RNs is projected to have fallen 20 percent below HRSA?s
projections of the number of RNs that will be required to meet demand. 24

24 ?Implications of an Aging Registered Nurse Workforce,? JAMA.

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 13 GAO- 01- 944 Emerging Nurse Shortages

Providers? current difficulty recruiting and retaining nurses may worsen as
the demand for nurses increases with the aging of the population. Impending
demographic changes are widening the gap between the numbers of people
needing care and those available to provide it. Moreover, the current high
levels of job dissatisfaction among nurses may also play a crucial role in
determining the extent of current and future nurse shortages. Efforts
undertaken to improve the workplace environment may both reduce the
likelihood of nurses leaving the field and encourage more young people to
enter the nursing profession. While state governments and providers have
begun to address recruitment and retention issues related to the nurse
workforce, more detailed data are needed to assist in planning and targeting
corrective efforts.

As we agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after
its issue date. At that time, we will send copies to interested parties and
make copies available to others upon request.

If you or your staff have any questions, please call me on (202) 512- 7119
or Helene Toiv, Assistant Director, at (202) 512- 7162. Other major
contributors were Eric Anderson, Connie Peebles Barrow, Emily Gamble
Gardiner, and Pamela Ruffner.

Sincerely yours, Janet Heinrich Director, Health Care- Public Health Issues
Concluding

Observations

Appendix I: Change in RN Employment, per 100,000 Population by State, 1996-
2000

Page 14 GAO- 01- 944 Emerging Nurse Shortages

Employed RNs per 100,000 population State 1996 2000 Percent change 1996-
2000

Alabama 756 766 1.3% Alaska 974 784 -19.5% Arizona 721 628 -12.9% Arkansas
683 701 2.6% California 566 544 -3.9% Colorado 806 737 -8.6% Connecticut
1,029 942 -8.5% Delaware 1,046 936 -10.5% District of Columbia 1,710 1,675
-2.0% Florida 800 785 -1.9% Georgia 712 683 -4.1% Hawaii 733 703 -4.1% Idaho
583 636 9.1% Illinois 863 819 -5.1% Indiana 780 761 -2.4% Iowa 989 1,060
7.2% Kansas 806 885 9.8% Kentucky 748 833 11.4% Louisiana 718 834 16.2%
Maine 1, 053 1,025 -2.7% Maryland 842 856 1.7% Massachusetts 1,190 1,194
0.3% Michigan 816 798 -2.2% Minnesota 945 957 1.3% Mississippi 701 750 7.0%
Missouri 932 960 3.0% Montana 771 812 5.3% Nebraska 925 958 3.6% Nevada 580
520 -10.3% New Hampshire 985 916 -7. 0% New Jersey 844 800 -5.2% New Mexico
663 656 -1.1% New York 911 843 -7.5% North Carolina 794 858 8.1% North
Dakota 1,072 1,096 2.2% Ohio 893 882 -1.2% Oklahoma 581 635 9.3% Oregon 791
793 0.3% Pennsylvania 1, 019 1,010 -0.9% Rhode Island 1,128 1,101 -2.4%

Appendix I: Change in RN Employment, per 100,000 Population by State, 1996-
2000

Appendix I: Change in RN Employment, per 100,000 Population by State, 1996-
2000

Page 15 GAO- 01- 944 Emerging Nurse Shortages

Employed RNs per 100,000 population State 1996 2000 Percent change 1996-
2000

South Carolina 693 728 5.1% South Dakota 1,059 1,128 6.5% Tennessee 856 872
1.9% Texas 629 606 -3.7% Utah 632 592 -6.3% Vermont 911 957 5.0% Virginia
790 711 -10.0% Washington 776 738 -4.9% West Virginia 794 858 8.1% Wisconsin
876 893 1.9% Wyoming 787 780 -0.9%

United States 798 782 -2.0%

Source: GAO analysis of data from the 1996 and 2000 National Sample Survey
of Registered Nurses, HRSA?s Bureau of Health Professions, Division of
Nursing.

(290081)

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