Nursing Workforce: HHS Needs Methodology to Identify Facilities  
with a Critical Shortage of Nurses (30-APR-07, GAO-07-492R).	 
                                                                 
Registered nurses (RN) are the single largest group of health	 
care providers in the United States, with more than 2.4 million  
people employed as RNs in 2004. Basic RN training may be	 
completed through a 2-year associate's degree, a 3-year diploma, 
or a 4-year bachelor's degree. RNs work in a wide variety of	 
settings, including hospitals, nursing homes, physicians'	 
offices, and public health clinics. Reports by government	 
agencies and others have raised concerns about nurse shortages.  
In 2001, we reported on an emerging shortage of RNs to fill	 
vacant positions across a range of health care settings. The	 
Health Resources and Services Administration (HRSA), an agency in
the Department of Health and Human Services (HHS), estimated that
the supply of RNs nationally fell approximately 111,000 short of 
demand in 2000 (5.5 percent) and projected the gap would widen in
the ensuing years. A shortage of RNs, like general workforce	 
shortages, occurs when the demand for RNs exceeds supply. The	 
supply of RNs, or the number of RNs employed, is influenced by	 
multiple factors, including the size of the overall labor force, 
the number of licensed RNs choosing to work in nursing, the	 
number of new RNs graduating from nursing school, the capacity of
nursing schools, and funding available for higher education.	 
Demand, or the number of RNs that employers would like to hire,  
is also affected by multiple factors, including demographic	 
characteristics and health status of the population, economic	 
factors such as personal income and health insurance coverage,	 
and characteristics of the health care system such as nurse wages
and health care reimbursement rates. Having an adequate supply of
RNs is important because reports have established a positive	 
relationship between the quality of care and RN staffing levels  
in settings such as hospitals and nursing homes. To support the  
recruitment and retention of RNs in health care facilities with a
critical shortage of nurses, Congress passed the Nurse		 
Reinvestment Act of 2002 (NRA). The NRA established the Nursing  
Scholarship Program (NSP) to provide scholarships for individuals
to attend schools of nursing. The NRA also modified an existing  
program, the Nursing Education Loan Repayment Program (NELRP),	 
which was established by Congress in 1992 to help repay education
loans for RNs. Under both programs, awardees must agree to work  
for at least 2 years in a health care facility with a critical	 
shortage of nurses, with preference given to qualified applicants
with the greatest financial need. To implement this, HRSA, which 
administers both programs, designates several types of facilities
as having a critical shortage of nurses for the purposes of the  
NSP and NELRP. The Secretary of HHS is required to report	 
annually to Congress on various aspects of the programs including
the locations where award recipients are fulfilling their service
obligation. The NRA directed us to conduct several studies	 
related to the nationwide shortage of nurses. As discussed with  
the committees of jurisdiction, in this report we are: (1)	 
providing information on how the number of employed RNs and the  
shortage of RNs has changed since 2000, both nationally and	 
across states; and (2) describing characteristics of NELRP and	 
NSP awardees and examining whether these programs have improved  
the supply of RNs in facilities with critical shortages of	 
nurses. 							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-492R					        
    ACCNO:   A68910						        
  TITLE:     Nursing Workforce: HHS Needs Methodology to Identify     
Facilities with a Critical Shortage of Nurses			 
     DATE:   04/30/2007 
  SUBJECT:   Health care facilities				 
	     Health care personnel				 
	     Health care planning				 
	     Labor shortages					 
	     Nurses						 
	     Program evaluation 				 
	     Scholarship programs				 
	     Statistical data					 
	     HHS Nursing Education Loan Repayment		 
	     Program						 
                                                                 
	     HHS Nursing Scholarship Program			 

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GAO-07-492R

   

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April 30, 2007

The Honorable Edward M. Kennedy
Chairman
The Honorable Michael B. Enzi
Ranking Member
Committee on Health, Education, Labor and Pensions
United States Senate

The Honorable John D. Dingell
Chairman
The Honorable Joe Barton
Ranking Member
Committee on Energy and Commerce
House of Representatives

Subject: Nursing Workforce: HHS Needs Methodology to Identify Facilities
with a Critical Shortage of Nurses

Registered nurses (RN) are the single largest group of health care
providers in the United States, with more than 2.4 million people employed
as RNs in 2004.1 Basic RN training may be completed through a 2-year
associate's degree, a 3-year diploma, or a 4-year bachelor's degree. RNs
work in a wide variety of settings, including hospitals, nursing homes,
physicians' offices, and public health clinics. Reports by government
agencies and others have raised concerns about nurse shortages. In 2001,
we reported on an emerging shortage of RNs to fill vacant positions across
a range of health care settings.2 The Health Resources and Services
Administration (HRSA), an agency in the Department of Health and Human
Services (HHS), estimated that the supply of RNs nationally fell
approximately 111,000 short of demand in 2000 (5.5 percent) and projected
the gap would widen in the ensuing years.3

1This includes RNs employed both full-time and part-time. Data for 2004
were the most recent available on the overall RN workforce.

2GAO, Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors,
GAO-01-944 (Washington, D.C.: July 10, 2001).

3HRSA Bureau of Health Professions, Projected Supply, Demand, and
Shortages of Registered Nurses: 2000-2020 (Rockville, Md., 2002).

A shortage of RNs, like general workforce shortages, occurs when the
demand for RNs exceeds supply.4 The supply of RNs, or the number of RNs
employed, is influenced by multiple factors, including the size of the
overall labor force, the number of licensed RNs choosing to work in
nursing, the number of new RNs graduating from nursing school, the
capacity of nursing schools, and funding available for higher education.
Demand, or the number of RNs that employers would like to hire, is also
affected by multiple factors, including demographic characteristics and
health status of the population, economic factors such as personal income
and health insurance coverage, and characteristics of the health care
system such as nurse wages and health care reimbursement rates. Having an
adequate supply of RNs is important because reports have established a
positive relationship between the quality of care and RN staffing levels
in settings such as hospitals and nursing homes.5

To support the recruitment and retention of RNs in health care facilities
with a critical shortage of nurses, Congress passed the Nurse Reinvestment
Act of 2002 (NRA).6 The NRA established the Nursing Scholarship Program
(NSP) to provide scholarships for individuals to attend schools of
nursing.7 The NRA also modified an existing program, the Nursing Education
Loan Repayment Program (NELRP), which was established by Congress in 1992
to help repay education loans for RNs. Under both programs, awardees must
agree to work for at least 2 years in a health care facility with a
critical shortage of nurses, with preference given to qualified applicants
with the greatest financial need.8 To implement this, HRSA, which
administers both programs, designates several types of facilities as
having a critical shortage of nurses for the purposes of the NSP and
NELRP.9 The Secretary of HHS is required to report annually to Congress on
various aspects of the programs including the locations where award
recipients are fulfilling their service obligation.10

4For a recent study of labor shortages, the Department of Labor defined a
shortage as "a market disequilibrium between supply and demand in which
the quantity of workers demanded exceeds the supply available and willing
to work at a particular wage and working conditions at a particular place
and point in time." See The Urban Institute, Skill Shortages and
Mismatches in Nursing Related Health Care Employment (Washington, D.C.,
April 2002).

5See J. Needleman et al., Nurse Staffing and Patient Outcomes in
Hospitals, Final Report for HRSA, Contract No. 230-99-0021, Harvard School
of Public Health (Boston, Mass., 2001). See also M.W. Stanton and M.K.
Rutherford, Hospital Nurse Staffing and Quality of Care, Agency for
Healthcare Research and Quality (Rockville, Md., 2004).

6Pub. L. No. 107-205, 116 Stat. 813 (2002).

7In this report, we consider any RN training program, including 2-year,
3-year, and 4-year programs, to be a school of nursing.

8According to program guidance, for the NELRP, applicants with the
"greatest financial need" are those with nursing educational loans 40
percent or greater than their annualized salary. For the NSP, applicants
with the greatest financial need were defined as those who had zero
expected family contribution on their federal financial aid application.
NSP awardees begin to fulfill their service obligation after graduation
from nursing school. Because NELRP awardees have already completed nursing
school, they begin to fulfill their obligation upon receipt of the award.

9For the NSP, the facility types are: (1) Indian Health Service health
center; (2) rural health clinic; (3) Native Hawaiian health center; (4)
nursing home; (5) home health agency; (6) federally-designated migrant
health center; (7) hospice program; (8) federally-designated community
health center; (9) state or local public health department including a
clinic within the department; (10) federally-designated health care for
the homeless health center; (11) skilled nursing facility; (12)
federally-qualified look-alike health center (a migrant, community, or
health care for the homeless health center meeting federal Public Health
Service grant requirements but not currently receiving such funds); and
(13) ambulatory surgical center; and (14) hospital. The NELRP includes
these facility types but separates hospitals into three subtypes: federal
hospital; disproportionate share hospital (a hospital that receives
supplemental payments through the Medicare or Medicaid programs to
subsidize the costs of caring for a high proportion of low-income
patients); and nonfederal, nondisproportionate share hospital.

The NRA directed us to conduct several studies related to the nationwide
shortage of nurses.11 As discussed with the committees of jurisdiction, in
this report we are: (1) providing information on how the number of
employed RNs and the shortage of RNs has changed since 2000, both
nationally and across states; and (2) describing characteristics of NELRP
and NSP awardees and examining whether these programs have improved the
supply of RNs in facilities with critical shortages of nurses.

To determine how the employment of RNs changed since 2000 and how it
varied across states, we analyzed data on RN employment from the 2000 and
2004 National Sample Survey of Registered Nurses (NSSRN). This survey has
been conducted by HRSA approximately every 4 years since 1977.12 We also
analyzed data on newly licensed RNs from the National Council of State
Boards of Nursing to identify the number of potential new RNs entering the
workforce each year from 2000 through 2005. To determine whether the
nursing shortage has changed since 2000, we conducted interviews of
experts, researchers, HRSA officials, and provider and professional
associations. We also reviewed current literature and research on the RN
workforce. Further, we compared HRSA's most recent state-level shortage
estimates from 2000 to the growth in RN employment from 2000 to 2004;13
examined changes in state-level per capita RN employment from 2000 to
2004; analyzed annual Current Population Survey (CPS) data from 1999
through 2005 on RN earnings growth relative to the overall workforce;14
and examined trends reported by the American Hospital Association (AHA) in
hospital RN vacancy rates--that is, the number of unfilled employment
positions at hospitals.

To describe the characteristics of NELRP and NSP awardees, we analyzed
HRSA administrative data, reviewed published reports on the programs, and
interviewed HRSA officials. We relied on data about the programs from
fiscal year 2004 to make comparisons of the awardees to the overall RN
workforce and RN student and recent graduate populations because data from
2004 were the most recent data on the RN workforce available. Data on
employment location of the programs' awardees for the fiscal years 2003
through 2005 period were obtained from both published reports on the
programs and HRSA officials. To examine whether these programs have
improved the supply of RNs in facilities with a critical shortage of
nurses we reviewed past and current program guidance, reviewed published
reports on the programs, and interviewed HRSA officials and research
contractors.

10HRSA has prepared and provided these reports on behalf of the
department.

11Pub. L. No. 107-205, S 204, 116 Stat. 811, 818-19.

12This survey was first conducted in 1977, again in 1980, and every 4
years thereafter. The most recent survey was conducted in 2004.

13In this report, we use the term "state" to refer to the 50 states and
the District of Columbia.

14The Current Population Survey is a monthly survey of households
conducted by the Bureau of the Census for the Bureau of Labor Statistics
(BLS).

Our review focused only on registered nurses (RN), and our results cannot
be generalized to other types of nurses, such as licensed practical nurses
(LPN). We also did not conduct assessments of projected shortages. We used
the most recent data available, which were from 2004 for some sources and
from 2005 for other sources, as we noted. We assessed the reliability of
data used in our analyses and determined them to be sufficiently reliable
for our purposes. We performed this work from March 2006 through March
2007 in accordance with generally accepted government auditing standards.

Results in Brief

Between 2000 and 2004, the number of employed RNs in the United States
grew by 10 percent, with a total of 2.4 million RNs employed in nursing in
2004. Most of the increase occurred in hospitals and ambulatory care
settings, and the extent of employment growth varied widely among states.
For example, among the 48 states where the number of employed RNs
increased, the growth in employment ranged from 2 percent in Connecticut
to 47 percent in New Hampshire. Despite evidence of growth in RN
employment between 2000 and 2004, there are no data available for
estimating the magnitude of changes in the shortage of RNs over this time
period. Estimating changes in the RN shortage requires data on both the
supply of and the demand for RNs in 2000 and 2004. Although there are data
indicating that the supply or number of employed RNs increased, there are
no data--either nationally or at the state level--on RN demand in 2004,
because demand estimates have not been updated since 2000. However,
several indirect measures suggest that the shortage of RNs has eased since
2000. For example, RN employment growth from 2000 to 2004 was generally
strongest in those states that HRSA designated as having greater shortages
in 2000. In addition, between 2000 and 2004 the number of employed RNs
relative to the size of the general population increased from 782 per
100,000 people in 2000 to 825 per 100,000 people in 2004--reflecting an
increase in RN supply relative to one measure of demand for RNs. Finally,
the rate of unfilled RN positions in hospitals declined nationally from 13
percent in 2001 to 9 percent in 2005.

Recipients of NSP and NELRP awards are more likely to be from a minority
group and are more likely to have received or be pursuing a 4-year
bachelor's degree rather than a 2-year associate's degree when compared to
the overall RN workforce. In both programs, an applicant's minority status
is not used as a criterion in making awards. In 2004, 11 percent of the
overall nursing workforce was minority while minorities made up 36 percent
of NSP awardees and 21 percent of NELRP awardees. NSP and NELRP awardees
are required to be employed in one of the types of facilities identified
by HRSA as having a critical shortage of nurses. However, HRSA does not
have a sound basis for determining the number of RNs needed for that
facility to be considered as one experiencing a critical shortage of RNs.
Consequently, we cannot identify which facilities fall into this category.
Furthermore, awardees may not be serving in facilities actually
experiencing a nursing shortage. HRSA is working to develop an approach
for identifying facilities with critical shortages of RNs, and researchers
contracted by HRSA have produced a report detailing an approach that uses
available county-level data to determine facilities that could be
identified as having critical shortages of RNs. This report is currently
under review, so HRSA's efforts at developing an empirically-based
approach for identifying facilities with critical shortages of RNs have
not been completed.

In order to target funding effectively for the Nursing Education Loan
Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to
nurses working in health care facilities with a critical shortage of
nurses, we recommend that the Secretary of HHS: (1) identify the specific
steps and a time frame for implementing an empirical methodology for
identifying health care facilities with a critical shortage of nurses; and
(2) direct the Administrator of HRSA to include a description of steps
taken and progress on its time frame for implementing such methodology in
HRSA's annual report to Congress on these programs.

In commenting on a draft of this report, HHS provided technical comments,
which we incorporated as appropriate.

Background

Hospitals employ the largest share of the RN workforce with 56 percent of
RNs employed in hospital settings in 2004. After hospitals, 12 percent of
RNs were employed in ambulatory care, 11 percent in public or community
health settings, and 6 percent in nursing homes and extended care
facilities. The remaining 15 percent were employed in a variety of other
settings such as nursing education and insurance companies. Although basic
RN education may be completed through a 2-year associate's degree, a
3-year diploma program, or a 4-year bachelor's degree, the largest
proportion of RNs has an associate's degree, with 44 percent of the
current RN workforce and 61 percent of newly licensed RNs having an
associate's degree.15 (See fig. 1.) Once they have completed their
education, RNs must meet state licensing requirements and pass a national
licensing examination.

Figure 1: Percentage of Employed Registered Nurses by Initial Degree Type,
2004

Note: Data are from HRSA's 2004 National Sample Survey of Registered
Nurses and the National Council of State Boards of Nursing's 2004 National
Council Licensing Examination (NCLEX) statistics.

15RNs may also obtain graduate nursing degrees that may qualify them to
teach in a university setting or work as a nurse practitioner or as other
advanced nursing specialists.

Although numerous reports of an emerging nursing shortage have been
published by researchers, provider associations, and government agencies,
nurse shortages have historically been cyclical, with periods of shortage
alternating with periods of equilibrium or surplus. There is often a time
lag in the adjustment of RN supply to increased demand, in part due to the
time it takes for a new RN to complete the educational requirements for
licensure. Future demand for RNs is expected to increase dramatically as
members of the baby boom generation reach their 70s, 80s and beyond--ages
at which use of health care typically increases. While the population aged
65 and older is expected to double between 2000 and 2030, 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.
The Bureau of Labor Statistics (BLS) projected that in order to
accommodate growth in demand for RNs and to replace RNs leaving the
workforce, 120,000 new nurses will be needed per year from 2004 through
2014.

To support the recruitment and retention of RNs, the NSP and NELRP
programs provide awards to nursing students or working nurses,
respectively, in exchange for a minimum of 2 years service at a health
care facility with a critical shortage of nurses. The NELRP provides loan
repayment awards of up to 85 percent of educational loans and the NSP
provides scholarship awards to individuals attending an accredited school
of nursing. From fiscal years 2003 through 2005, HRSA granted 2,262 loan
repayment awards totaling $51 million and 419 scholarship awards totaling
$18.9 million. (See table 1.) Total funding and the number of awards
granted under both programs have increased since fiscal year 2003. In
fiscal year 2005, HRSA provided NELRP awards to 803 individuals, or 18
percent of applicants, with a median award of $20,925. For the NSP, HRSA
provided awards to 212 individuals, or 6 percent of applicants, with a
median award of $38,078.

Table 1: Nursing Education Loan Repayment Program and Nursing Scholarship
Program Applicants, Awards, and Funding, Fiscal Years 2003-2005

                               2003         2004         2005 2003-2005 Total 
Nursing Education Loan Repayment Program (NELRP)                           
Applicants                 8,231        4,873        4,465          17,569 
Awards                       602          857          803           2,262 
Total Award                             $17.6        $19.0                 
Funding            $14.4 million      million      million   $51.0 million 
Median Award                                                               
Amount                   $20,911      $17,379      $20,925                 
Nursing Scholarship Program (NSP)                                          
Applicants                 4,408        3,476        3,482          11,366 
Awards                        81          126          212             419 
Total Award                                                                
Funding             $3.3 million $5.9 million $9.7 million   $18.9 million 
Median Award                                                               
Amount                   $34,920      $38,387      $38,078                 

Source: HRSA.

Number of Employed RNs Increased since 2000, Although Gains Varied among
States, and Indirect Evidence Suggests Shortage Has Eased

Between 2000 and 2004, the number of employed RNs in the United States
grew by 10 percent. Most of the increase occurred in hospitals and
ambulatory care settings, and the extent of employment growth varied
widely among states. Despite evidence of growth in RN employment between
2000 and 2004, we are unable to estimate the magnitude of changes in the
shortage of RNs over this time period. Estimating changes in the RN
shortage requires data on both the supply of and the demand for RNs in
2000 and 2004. While HRSA's National Sample Survey of Registered Nurses
provides data on the number of employed RNs in 2000 and 2004, HRSA's
estimates of demand for RNs have not been updated since 2000. However,
indirect evidence suggests that the shortage of RNs has eased since 2000.
This evidence includes strong growth in RN employment in the states HRSA
designated as having a shortage in 2000 and increases in the number of
employed RNs relative to the size of the general population. In addition,
after several years of strong relative earnings growth for RNs following
reports of an emerging shortage around 2000, RN earnings have grown at a
rate comparable to the overall workforce in recent years.

Number of Employed RNs Increased between 2000 and 2004, and Gains Varied
by Facility Type and among States

According to data from HRSA's 2000 and 2004 National Sample Survey of
Registered Nurses, the number of employed RNs, either full-time or
part-time, increased 10 percent between 2000 and 2004, with a total of 2.4
million RNs employed in nursing in 2004.16 The number of RNs employed
full-time grew by 8 percent from 2000 to 2004, while those employed
part-time, representing approximately 30 percent of all employed RNs in
2004, grew by 15 percent. In addition, of all licensed RNs, the percentage
who were employed in nursing, either full-time or part-time, increased
from 81.7 percent in 2000 to 83.2 percent in 2004; this compares to 82.7
percent in 1992 and 1996, and to rates at or below 80 percent throughout
the 1980s. Nationally, between 2000 and 2004, the extent of increases in
the number of RNs employed varied by facility type or setting, with the
greatest gains occurring in hospitals and ambulatory care settings such as
physicians' offices, clinics, and ambulatory surgical centers. (See table
2.) These settings accounted for most of the change in the number of
employed RNs over the 4 years. Employment gains also occurred in teaching
positions associated with nursing education, while the number of RNs
employed in public and community health settings declined. Between 2000
and 2004, the number of RNs employed in long-term care facilities remained
essentially unchanged.

16This represents a sizable increase compared to the previous 4 years when
RN employment grew by about 4 percent from 1996 to 2000.

Table 2: Changes in RN Employment by Facility Type or Setting, 2000-2004

                                                                       Change 
Facility type or setting   2000 Employment 2004 Employment       2000-2004 
All facility types or            2,201,813       2,421,351         219,538 
settings                                                                   
Hospitals                        1,300,323       1,360,847          60,524 
Ambulatory care                    209,324         277,774          68,450 
Public/community health            282,618         259,911         -22,707 
Long-term care facility            152,894         153,172             278 
School/student health               83,269          78,022          -5,247 
Nursing education                   46,655          63,444          16,789 
Occupational health                 36,395          22,447         -13,948 
Other and unknown                   90,335         205,736         115,401 

Source: HRSA.

Note: Data are from the 2000 and 2004 National Sample Survey of Registered
Nurses. Numbers represent RNs employed both full-time and part-time.
Estimated numbers may not equal totals due to rounding.

While the number of employed RNs increased nationally from 2000 to 2004,
the growth varied widely among states. According to data from HRSA's 2000
and 2004 National Sample Survey of Registered Nurses, all but three
states--Louisiana, Massachusetts, and Rhode Island--posted gains in RN
employment between 2000 and 2004 (see enc. I). Among the 48 states where
the number of employed RNs increased, the growth in employment ranged from
2 percent in Connecticut to 47 percent in New Hampshire. Growth exceeded
15 percent in 11 states, and ranged from 10 to 15 percent in 15 other
states.

The growth in the number of employed RNs is due in part to an increase in
the number of newly licensed nursing school graduates entering the
workforce.17 The number of newly licensed RNs available to enter the
workforce, as reflected in the annual number of RNs passing the national
licensing examination, grew from approximately 75,000 in 2000 to 101,000
in 2004 and 113,000 in 2005, an increase of 51 percent from 2000 to 2005
(see fig. 2).18 From 2000 to 2005, the number of newly licensed RNs
educated in the United States increased 41 percent from 69,569 to 98,363,
and the number of newly licensed RNs who were educated outside the United
States grew by 182 percent from 5,231 to 14,750.

17To be licensed as an RN in a state, a nurse must graduate from an
approved nursing program and pass a national licensing exam developed by
the National Council of State Boards of Nursing.

18We use the number of nurses passing the national RN licensing exam to
approximate the number of newly licensed RNs. Some states may impose
additional requirements prior to issuing a license.

Figure 2: Number of RNs Passing the National Licensing Exam, by Year,
U.S.- and Foreign-Educated, 2000-2005

Indirect Evidence Suggests Shortage of RNs Has Eased since 2000

Although there are data indicating that the supply of RNs--that is, the
number employed--increased between 2000 and 2004, we are unable to
estimate changes in the shortage of RNs over this time period. Estimating
changes in the RN shortage requires data on both the supply of and the
demand for RNs in 2000 and 2004. While HRSA's National Sample Survey of
Registered Nurses provides data on the number of employed RNs in 2000 and
2004, HRSA's estimates of demand for RNs have not been updated since
2000.19 Furthermore, HRSA's estimates of RN supply and demand are at the
state level and cannot provide information on whether there is a shortage
within states, in rural or urban areas, or among facilities or other
settings.20

Despite the absence of data to assess directly the magnitude of changes in
the RN shortage between 2000 and 2004, indirect evidence suggests that the
overall shortage of RNs has eased since 2000. This evidence consists of
(1) relatively strong growth in the number of employed RNs in the states
designated by HRSA as having shortages in 2000, (2) growth in the number
of employed RNs relative to the size of the general population, (3) growth
in the earnings of RNs that is consistent with the earnings growth for the
overall U.S. workforce in recent years, and (4) reported decreases in the
number of unfilled employment positions for hospital RNs.

19HRSA has a contract to update its model for estimating demand, but the
update is not expected to be available until 2008.

20In our 2001 report, we noted that available national data were not
adequate to describe the nature and extent of nurse shortages across
states or provider types.

First, RN employment growth from 2000 to 2004 was generally strongest in
those states that HRSA designated as having greater shortages in 2000.21
(See fig. 3.) HRSA estimates of RN shortages in 2000 show that 30 states
were estimated to have a shortage; 9 states were estimated to have a
surplus, and 12 states had no clear shortage or surplus in 2000.22 In the
states HRSA estimated as having shortages in 2000, growth in employed RNs
averaged about 14 percent from 2000 to 2004, while states that HRSA
designated as having surpluses in 2000 averaged about 5-percent growth.23
Arizona, the state with the largest estimated shortage in 2000, had almost
a 23 percent growth in RN employment from 2000 to 2004. Montana, the state
with the largest estimated surplus in 2000, experienced a 3 percent growth
in employment between 2000 and 2004. (See enc. II.)

21See HRSA Bureau of Health Professions, Projected Supply.

22Due to uncertainties in the estimation process, only states with a
difference between supply and demand of greater than 3 percent were
considered to have a shortage or surplus.

23Because HRSA calculated state RN shortage estimates based on full-time
equivalents (FTE), we calculated state-level RN employment change in terms
of FTEs for this comparison. An FTE is the percentage of time a staff
member works, represented as a decimal. A full-time person is 1.00, a
half-time person is .50 and a quarter-time person is .25.

Figure 3: Full-time equivalent (FTE) RN Employment Growth by State,
2000-2004

Note: RN employment based on FTEs.

Second, between 2000 and 2004 the number of employed RNs relative to the
size of the general population increased, reflecting an increase in RN
supply relative to one measure of demand. According to HRSA's National
Sample Survey of Registered Nurses, nationally there were 825 employed RNs
per 100,000 people in 2004, compared with 782 per 100,000 in 2000 and 798
per 100,000 in 1996. Between 2000 and 2004, on a per capita basis, the
number of employed RNs increased by 5.5 percent. This followed a 2 percent
decline in per capita RN employment between 1996 and 2000. (See enc. III.)
Changes in the per capita RN employment varied across states between 2000
and 2004. (See fig. 4.)

Figure 4: Change in State Per Capita RN Employment, 2000-2004

Third, after several years of strong relative earnings growth for RNs
following reports of an emerging shortage around 2000, RN earnings have
grown at a rate comparable to the overall workforce during the most recent
period from 2003 through 2005.24 (See fig. 5.) In a period of shortage,
wage or earnings growth for RNs would be expected to exceed the earnings
growth for all workers as employers raise wages to attract more RNs.
Growth in RN earnings lagged behind earnings growth for all workers
through most of the 1990s, and in particular in the mid-1990s period.
During the 2001 through 2003 period, earnings growth for RNs averaged 4.4
percent per year while earnings for all workers grew by an average of 2.5
percent per year. During the most recent period, however, from 2003
through 2005, RN earnings rose at an average annual rate of 2.2 percent,
the same as for all workers.

24According to labor economists, in a condition of shortage, where demand
exceeds the supply of workers, labor market data will generally show
strong employment and wage growth for an occupation relative to the
workforce overall. See C. Veneri, "Can occupational labor shortages be
identified using available data?" Monthly Labor Review, March 1999.

Figure 5: Earnings Growth for Registered Nurses and All Workers, 1999-2005

Note: Data are from the Current Population Survey (CPS) monthly household
survey and represent 3-year annual averages.

Fourth, reports of declines in the percentage of unfilled employment
positions at some facilities that employ RNs are also evidence of an
easing of the RN shortage because they indicate less unmet employer demand
for RNs. Although no comprehensive data exist on how many of these
positions go unfilled each year, some trade associations gather
information on such employment vacancies from member surveys. For example,
the AHA reported a national decline in the rate of unfilled RN positions
in hospitals, from 13 percent in 2001 to 9 percent in 2005. The extent of
the decline varied across regions of the country. For example, AHA
reported that from 2001 through 2005 the greatest decline in the rate of
employment vacancies occurred among hospitals in the West, where the
average rate of RN vacancies fell from 15 to 9 percent. In contrast, the
smallest decline occurred among hospitals in the South, where during the
same time period, the average rate of RN vacancies fell from 13 to 10
percent.

Characteristics of NELRP and NSP Awardees Differ from the Overall RN
Workforce, and GAO Cannot Assess Programs' Effect on Nursing Supply

As a group, NSP and NELRP awardees have a higher percentage of minorities
and are more likely to have received or be pursuing 4-year bachelor's
degrees rather than 2-year associate's degrees than the overall RN
workforce. Although NSP and NELRP awardees are required to be employed in
one of the types of facilities identified by HRSA in order to meet the NRA
requirement intended to address critical nursing shortages, we cannot
assess whether the two programs have improved the supply of RNs in
facilities with critical shortages of RNs. HRSA does not have a sound
basis for identifying critical shortage facilities, and as a result,
awardees of the programs may not be serving in facilities actually
experiencing such shortages. HRSA is working to develop an
empirically-based approach for identifying facilities with critical
shortages of RNs, but these efforts have not yet been completed.

NSP and NELRP Awardees Have a Higher Percentage of Minorities and Obtain
Higher Degrees than Overall RN Workforce

In our comparison of minority status, we found that as a group, awardees
of the NSP and NELRP have a higher percentage of minorities than the
overall nursing workforce, but are similar to current nursing school
students and recent graduates.25 (See fig. 6.) In both programs, an
applicant's minority status is not used as a criterion in making awards.
While minorities made up 11 percent of the overall RN workforce in 2004,
they constituted 36 percent of NSP awardees, 21 percent of NELRP awardees
and 26 and 22 percent of nursing school students and graduates,
respectively.26 (See enc. IV for more detailed data on NELRP and NSP
awardees.)

Figure 6: Percentage of Minorities among Awardees in the NSP and NELRP, RN
Students and RN Graduates, and the Overall RN Workforce, 2004

Note: Minorities include African Americans, Hispanics, American Indians,
Native Hawaiians, Native Alaskans, Asians, and Pacific Islanders. NSP and
NELRP awardee data are for fiscal year 2004.

25Because the NELRP provides awards to RNs with student loan debt, we use
nursing school graduates as the closest comparison group for NELRP
awardees. Similarly, because the NSP provides awards to individuals
entering nursing school, we use nursing school students as the best
comparison for NSP awardees.

26While race and ethnicity are not criteria for awards for the NSP or
NELRP, the Institute of Medicine and the National Advisory Council on
Nurse Education and Practice (NACNEP), an advisory body for HRSA on nurse
workforce issues, have identified the need to increase racial and ethnic
diversity among RNs and other health professionals.

Awardees of the NSP and NELRP programs are also more likely to be pursuing
or have received higher degrees than the overall RN workforce or current
nursing student population. In fiscal year 2004, the percentage of NSP
awardees pursuing a bachelor's degree was higher than it was among the
nursing student population.27 While 49 percent of the nursing student
population was pursuing a bachelor's or graduate degree in 2004, 70
percent of NSP awardees were pursuing this degree. (See fig. 7.)
Similarly, in the NELRP, the majority of awards in fiscal year 2004 were
given to applicants with bachelor's or higher degrees. This is largely due
to the way in which awards are funded, with preference given to those with
greatest financial need. Applicants who obtain higher level degrees
(bachelor's or graduate degrees) are likely to have higher levels of debt
than those with an associate's degree.

Figure 7: Degree Types of NSP and NELRP Awardees Compared to Nursing
School Students, Graduates, and the RN Workforce, 2004

Note: NSP and NELRP awardee data are for fiscal year 2004.

Other characteristics of NSP and NELRP awardees include the type of
facility in which the awardees work. As of fiscal year 2005, 78 of 419 NSP
awardees had completed their education and had begun their service in a
critical shortage facility. Of these, 71 were serving in hospitals, 3 in
Indian Health Service Health Centers, and 1 each in a home health agency,
hospice, nursing home, and skilled nursing facility. As shown in table 3,
the majority of NELRP awardees were completing their service requirement
in disproportionate share hospitals and public health departments as of
fiscal year 2005. In addition, most NELRP awardees were working in
not-for-profit facilities and in facilities located in the South and
West.28

27While the educational degree type is not a criterion for NSP awards, the
NACNEP and the American Association of Colleges of Nursing have called for
increasing the proportion of bachelor's-prepared RNs in the workforce. As
of 2004, 53 percent of the RN workforce held a bachelor's or higher
degree.

Table 3: Work Locations of Nursing Education Loan Repayment Program
Awardees, Fiscal Years 2003-2005

                                                                    Year
                                                               2003 2004 2005 
Total Awardees                                               602  857  803 
Facility type        Disproportionate share hospitala        473  531  663 
                        Public health department                 91  128   85 
                        Nursing home                             38   66   32 
                        Federally-designated community health                 
                        center                                    0    3   19 
                        Hospital                                  0   52    0 
                        Rural health clinic                       0    4    4 
                        Indian Health Service health center       0    1    0 
                        Other not-for-profit health facility      0   72    0 
Facility ownership   Not-for-profit                                        
status                                                       425  411  510 
                        For-profit                              177  446  293 
Region of facilityb  Northeast                                88  103  111 
                        Midwest                                 107  246  160 
                        South                                   243  270  299 
                        West                                    164  238  233 
                        Urban                                   566  770  713 
                        Rural                                    36   87   90 

Source: HRSA.

aDisproportionate share hospitals receive supplemental payments through
the Medicare or Medicaid programs to subsidize the costs associated with
providing care to a high proportion of low-income patients.

bRegions consist of the following: Northeast--Maine, New Hampshire,
Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey,
Pennsylvania; Midwest--Ohio, Indiana, Illinois, Michigan, Wisconsin,
Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas;
South--Delaware, Maryland, District of Columbia, Virginia, West Virginia,
North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee,
Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, Texas; and
West--Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah,
Nevada, Washington, Oregon, California, Alaska, Hawaii.

Effect of NELRP and NSP Cannot Be Assessed Because HRSA Lacks a Sound
Basis for Identifying Facilities with a Critical Shortage of RNs

We cannot assess whether the NELRP and NSP have improved the supply of RNs
at facilities that actually have critical shortages of RNs because HRSA
does not have a sound basis for identifying facilities with critical
shortages of RNs. To meet the requirement established by NRA designed to
help facilities with critical shortages, HRSA uses its list of critical
shortage facility types. HRSA created the list based on the assumption
that the facility types on the list target the underserved and are
generally believed to be facing nursing shortages. In addition, the
Secretary of HHS determined that the NELRP should emphasize serving the
underserved, improving the public health infrastructure, and addressing
needs at nursing homes, so the agency currently gives preference to loan
repayment applicants working in disproportionate share hospitals,
community health centers, rural health clinics, Indian Health Service
health centers, public health departments or clinics, and nursing homes.
Some awardees of the NELRP must submit a letter or other documentation
from their employer that provides support that the awardee is employed at
one of the critical shortage facility types. Although HRSA uses the list
of facility types in making awards to NELRP and NSP applicants, HRSA does
not determine the number of RNs needed for a facility to be considered as
one experiencing a critical shortage of RNs. As a result, HRSA does not
know the extent to which specific facilities served by NELRP and NSP
awardees are actually experiencing critical nursing shortages. Therefore,
we cannot assess whether the two programs have increased the supply of RNs
at facilities with critical shortages.

28HRSA established preference categories to target certain facility types
on the list. For example, priority for NELRP awards in fiscal year 2005
was given to RNs working in disproportionate share hospitals, nursing
homes, state or local public health departments, federally-designated
community health centers, federally-designated migrant health centers, or
rural health clinics.

HRSA began using the current list of facility types after passage of the
NRA. Prior to the NRA, the law required that preference be given to
qualified applicants who agreed to work in certain health facilities
located in geographic areas with a shortage of and need for nurses.29 To
implement this, HRSA considered whether the facility was located in what
was known as a nurse shortage county or in a Health Professional Shortage
Area (HPSA).30 However, HRSA recognized limitations in both the county and
the HPSA definitions. According to HRSA officials, the nurse shortage
county designation was not sufficiently reflective of the entire nursing
workforce because it was based only on hospital data. Similarly, according
to HRSA officials, HPSAs are designed for the placement of primary care
physicians, and RN work settings are both more diverse and more complex
than those of physicians.31 As a result of these limitations to both the
nurse shortage counties and HPSAs, and because the NRA deleted the
requirement that preference be given to applicants serving in certain
facilities located in geographic areas with a shortage of and need for
nurses, HRSA discontinued the use of geographic areas in favor of using
only the list of critical shortage facility types. At the same time, HRSA
officials acknowledged that this new approach did not represent a
scientific or empirical method for identifying actual shortage facilities
and was only intended as an interim approach to meet the short-term needs
of the program.

29These facilities included an Indian Health Service health center, native
Hawaiian health center, public hospital, migrant health center, community
health center, rural health clinic, or public or nonprofit private health
facility determined by the Secretary to have a critical shortage of
nurses. The law also required preference be given to qualified applicants
with the greatest financial need.

30The nurse shortage county designation was developed using AHA hospital
survey data. It was based on the number of full-time equivalent nursing
staff relative to the average daily census among hospitals in a county.
HRSA designates HPSAs based on the ratio of the number of primary care
physicians relative to the population, among other factors. A HPSA can be
a distinct geographic area such as a county, a specific population group
within an area, or a specific health care facility.

31HPSAs are used by HRSA for primary care physicians. See GAO, Health
Professional Shortage Areas: Problems Remain with Primary Care Shortage
Area Designation System, GAO-07-84 (Washington, D.C.: Oct. 24, 2006).

HRSA has efforts underway to develop a new approach for identifying
facilities experiencing critical shortages of RNs, though these efforts
have not been completed. In 2004 HRSA contracted with researchers at the
Center for Health Workforce Studies at the State University of New York
(SUNY) at Albany to develop an empirical, data-driven method for
identifying "health care facilities with a critical shortage of RNs."
According to the SUNY researchers, among the contract's guiding principles
were that the approach had to (1) be practical, that is, not overly
burdensome on facilities or HRSA; (2) be applicable to all facility types;
(3) use data that were easy to access and available over time; and (4) be
easy to update.

The first approach the SUNY researchers developed and tested was a
facility-based model using data from North Carolina and North Dakota, two
states that are recognized as having good facility-level data on RN
staffing, vacancy rates, and turnover. However, the researchers found that
these data were not sufficiently reliable predictors of whether a facility
had an RN shortage. Also, the analysis required data that are not
collected and reported by health care facilities in most states. The SUNY
researchers concluded that the burden and cost of gathering
facility/provider-level data from every health facility or provider in
every state rendered this approach impractical. As a result, the
researchers began work on an approach that could use available
county-level data to determine which geographic areas could be defined as
having critical shortages of RNs, so that the facilities in such areas
could be identified as having critical shortages of RNs.32 HRSA received
the final report on the results of this work from the SUNY researchers in
February 2007. The report contains a recommended method for estimating the
extent of nursing shortages in all counties in the United States. The
advisory committee for this study recommended that before any method is
adopted by HRSA it be validated in a number of states, facilities, and
settings. As of March 2007, the report and its recommendations were under
review, and HRSA officials said they plan to publish the results sometime
in 2007.

Conclusions

HRSA is in its fifth year granting awards under the Nursing Education Loan
Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) since
passage of the Nurse Reinvestment Act. While these two programs are aimed
at encouraging graduating and employed nurses to work in facilities with a
critical shortage of nurses, they may not always be achieving their
intended goals. Because HRSA does not have a sound basis for identifying
facilities with a critical shortage of RNs, HRSA's awardees may be working
in facilities that may not be actually experiencing such shortages. HRSA
received a report from its contractors that identifies available data and
an approach to identify such facilities, and, as of March 2007, the report
and its recommendations were under review. Because these two HRSA programs
are able to support relatively few nurses, it is important that HRSA
ensure that its work to develop a methodology for identifying facilities
with a critical shortage of nurses is completed so that the resources of
these programs can be targeted effectively to meet their intended purpose.

32In contrast to the facility-based methodology initially developed by the
SUNY researchers, this approach considered other sources of data,
including the decennial Census, the American Community Survey, the
National Sample Survey of Registered Nurses, and the Area Resource File.

Recommendations for Executive Action

In order to target funding effectively for the Nursing Education Loan
Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to
nurses working in health care facilities with a critical shortage of
nurses, we recommend that the Secretary of HHS take the following steps:

           1. identify the specific steps and a time frame for implementing
           an empirical methodology for identifying health care facilities
           with a critical shortage of nurses; and
           2. direct the Administrator of HRSA to include a description of
           steps taken and progress on its time frame for implementing such
           methodology in HRSA's annual report to Congress on these programs.

Agency Comments

In commenting on a draft of this report, HHS provided technical comments,
which we incorporated as appropriate.

                                   - - - - -

We are sending copies of this report to the Secretary of HHS, the
Administrator of HRSA, and other interested parties. We will also make
copies available to others on request. In addition, the report is
available at no charge on the GAO Web site at http://www.gao.gov .
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. If you or your staff
members have any questions about this report, please contact Kathleen King
at (202) 512-7119 or [email protected] . Major contributors to this report
are listed in enclosure V.

Kathleen King
Director, Health Care

Enclosures - 5

Enclosure I

Change in Number of Registered Nurses (RN) Employed in Nursing, by State,
                                   2000-2004

                                        2004 RN          Percent change in RN 
State          2000 RN employment employment          employment 2000-2004 
Alaska                      4,914      6,777                          37.9 
Alabama                    34,073     36,538                           7.2 
Arkansas                   18,752     20,115                           7.3 
Arizona                    32,222     39,136                          21.5 
California                184,329    211,531                          14.8 
Colorado                   31,695     34,654                           9.3 
Connecticut                32,073     32,718                           2.0 
Dist. of Col.               9,583     11,583                          20.9 
Delaware                    7,337      8,633                          17.7 
Florida                   125,439    132,758                           5.8 
Georgia                    55,881     66,512                          19.0 
Hawaii                      8,518      9,335                           9.6 
Idaho                       8,230      8,753                           6.4 
Illinois                  101,660    113,779                          11.9 
Indiana                    46,244     54,624                          18.1 
Iowa                       31,020     32,664                           5.3 
Kansas                     23,779     24,869                           4.6 
Kentucky                   33,655     37,631                          11.8 
Louisiana                  37,275     35,369                          -5.1 
Maine                      13,072     15,077                          15.3 
Maryland                   45,323     47,124                           4.0 
Massachusetts              75,795     75,398                          -0.5 
Michigan                   79,353     84,967                           7.1 
Minnesota                  47,102     51,914                          10.2 
Mississippi                21,338     24,009                          12.5 
Missouri                   53,730     57,365                           6.8 
Montana                     7,327      7,914                           8.0 
North Carolina             69,057     76,761                          11.2 
North Dakota                7,039      7,484                           6.3 
Nebraska                   16,399     18,532                          13.0 
New Hampshire              11,321     16,670                          47.2 
New Jersey                 67,280     72,980                           8.5 
New Mexico                 11,932     13,570                          13.7 
Nevada                     10,384     14,095                          35.7 
New York                  160,009    174,208                           8.9 
Ohio                      100,144    112,806                          12.6 
Oklahoma                   21,905     24,433                          11.5 
Oregon                     27,121     30,850                          13.7 
Pennsylvania              123,997    127,013                           2.4 
Rhode Island               11,542     11,368                          -1.5 
South Carolina             29,226     30,711                           5.1 
South Dakota                8,511      9,278                           9.0 
Tennessee                  49,626     54,338                           9.5 
Texas                     126,436    145,336                          14.9 
Utah                       13,229     15,778                          19.3 
Vermont                     5,829      6,444                          10.6 
Virginia                   50,359     56,726                          12.6 
Washington                 43,482     48,421                          11.4 
West Virginia              15,523     16,042                           3.3 
Wisconsin                  47,895     51,679                           7.9 
Wyoming                     3,849      4,079                           6.0 
United States           2,201,813  2,421,351                          10.0 

Source: GAO analysis of Health Resources and Services Administration
(HRSA) data.

Note: Data are from the 2000 and 2004 National Sample Survey of Registered
Nurses, HRSA.

Enclosure II

  Change from 2000 to 2004 in Full-time equivalent (FTE) Registered Nurse (RN)
Employment by Degree of State Shortage in 2000 as Estimated by the Health
                  Resources and Services Administration (HRSA)

                  Percent FTE RN shortage Percent change in FTE RN employment 
State          estimated by HRSA, 2000                           2000-2004 
States with a shortage in 2000
Arizona                          -17.3                                22.6 
Tennessee                        -13.4                                10.3 
New Jersey                       -12.9                                 5.0 
Connecticut                      -12.4                                 1.1 
Maine                            -11.7                                17.0 
Delaware                         -11.1                                19.4 
Nevada                           -10.9                                36.6 
New York                         -10.9                                 8.8 
Colorado                         -10.7                                10.2 
Massachusetts                    -10.5                                -0.9 
Rhode Island                     -10.1                                -2.7 
Virginia                          -9.8                                 9.9 
New Hampshire                     -9.7                                44.7 
Indiana                           -9.6                                20.4 
Hawaii                            -9.2                                 6.1 
Washington                        -9.2                                15.7 
Texas                             -8.9                                11.3 
Utah                              -8.1                                19.3 
Missouri                          -7.9                                 3.9 
Arkansas                          -7.7                                 6.8 
California                        -7.6                                13.8 
New Mexico                        -7.4                                14.7 
Georgia                           -6.8                                18.4 
Ohio                              -5.4                                11.5 
Nebraska                          -5.2                                15.7 
Pennsylvania                      -4.9                                 2.4 
Alaska                            -4.5                                36.9 
Oregon                            -3.8                                13.8 
Iowa                              -3.5                                 6.0 
Minnesota                         -3.5                                 8.3 
States with no clear RN shortage or surplus in 2000a
Alabama                 -2.9                                           2.4
Florida                 -2.8                                           4.2
Dist. of Col.           -2.4                                          14.8
Maryland                -1.4                                           3.7
Michigan                -1.3                                           6.3
Vermont                 -0.5                                           8.9
South Carolina          -0.4                                           4.0
Mississippi              0.0                                          10.8
North Dakota             0.2                                          10.6
North Carolina           1.0                                           9.0
Illinois                 1.6                                           9.2
Wyoming                  2.0                                           4.7
States with a surplus in 2000
Oklahoma                 4.6                                          10.0
Kentucky                 5.9                                          11.2
Wisconsin                6.2                                           6.4
South Dakota             8.1                                           5.3
Idaho                    8.5                                           9.4
Louisiana                9.0                                          -6.7
Kansas                   9.0                                           0.6
West Virginia           10.3                                           2.1
Montana                 14.5                                           3.1
United States           -5.5                                           8.9

Source: HRSA and GAO analysis of HRSA data.

Notes: HRSA's shortage estimates are for 2000. GAO analysis is of data
from the 2000 and 2004 National Sample Survey of Registered Nurses, HRSA.

aDue to uncertainties in the estimation process, only states with a
difference between supply and demand of greater than 3 percent were
considered to have a shortage or surplus.

Enclosure III

  Change in Registered Nurse (RN) Employment per 100,000 Population, by State,
                                   2000-2004

                  Employed RNs per 100,000 persons                          
State                      2000            2004 Percent change 2000-2004 
Alaska                      784            1034                     31.9 
Alabama                     766             807                      5.4 
Arizona                     628             681                      8.4 
Arkansas                    701             731                      4.3 
California                  544             589                      8.3 
Colorado                    737             753                      2.2 
Connecticut                 942             934                     -0.8 
Delaware                    936            1040                     11.1 
Dist. of Col.              1675            2093                     25.0 
Florida                     785             763                     -2.8 
Georgia                     683             753                     10.2 
Hawaii                      703             739                      5.1 
Idaho                       636             628                     -1.3 
Illinois                    819             895                      9.3 
Indiana                     761             876                     15.1 
Iowa                       1060            1106                      4.3 
Kansas                      885             909                      2.7 
Kentucky                    833             908                      9.0 
Louisiana                   834             783                     -6.1 
Maine                      1025            1145                     11.7 
Maryland                    856             848                     -0.9 
Massachusetts              1194            1175                     -1.6 
Michigan                    798             840                      5.3 
Minnesota                   957            1018                      6.4 
Mississippi                 750             827                     10.3 
Missouri                    960             997                      3.9 
Montana                     812             854                      5.2 
Nebraska                    958            1061                     10.8 
Nevada                      520             604                     16.2 
New Hampshire               916            1283                     40.1 
New Jersey                  800             839                      4.9 
New Mexico                  656             713                      8.7 
New York                    843             906                      7.5 
North Carolina              858             899                      4.8 
North Dakota               1096            1180                      7.7 
Ohio                        882             984                     11.6 
Oklahoma                    635             693                      9.1 
Oregon                      793             858                      8.2 
Pennsylvania               1010            1024                      1.4 
Rhode Island               1101            1052                     -4.5 
South Carolina              728             732                      0.5 
South Dakota               1128            1204                      6.7 
Tennessee                   872             921                      5.6 
Texas                       606             646                      6.6 
Utah                        592             660                     11.5 
Vermont                     957            1037                      8.4 
Virginia                    711             760                      6.9 
Washington                  738             781                      5.8 
West Virginia               858             884                      3.0 
Wisconsin                   893             938                      5.0 
Wyoming                     780             805                      3.2 
United States               782             825                      5.5 

Source: Source: GAO analysis of Health Resources and Services
Administration (HRSA) data.

Note: Data are from the 2000 and 2004 National Sample Survey of Registered
Nurses, HRSA.

Enclosure IV

Characteristics of Nursing Education Loan Repayment Program (NELRP) and Nursing
                       Scholarship Program (NSP) Awardees

Table 4: Race and Ethnicity of Registered Nurse (RN) Workforce, Nursing
School Graduates, and NELRP Awardees, 2004

                            2004 RN                                2004 NELRP 
                          workforce  2004 Nursing school graduates   awardees 
Race and ethnicity     (percent)                      (percent)  (percent) 
White (non-Hispanic)        81.2                           73.6       70.1 
Black (non-Hispanic)         4.4                           10.4        9.7 
Asian/Pacific                3.3                            3.6        3.0 
Islandera                                                                  
American Indian/Alaska       0.3                            0.9        0.7 
Native                                                                     
Hispanic (any race)          1.7                            6.0        5.7 
Other/unknownb               9.0                            5.5       10.7 

Source: Health Resources and Services Administration (HRSA), National
League for Nursing, and GAO analysis of HRSA administrative data.

aIncludes Native Hawaiians among the RN workforce and NELRP awardees.

bIncludes 1.5 percent identified as two or more races among the 2004 RN
workforce.

Table 5: Race and Ethnicity of RN Workforce, Nursing School Students, and
NSP Awardees, 2004

                            2004 RN                                  2004 NSP 
                          workforce    2004 Nursing school students  awardees 
Race and ethnicity     (percent)                       (percent) (percent) 
White (non-Hispanic)        81.2                            69.2      61.9 
Black (non-Hispanic)         4.4                            13.0      29.4 
Asian/Pacific                3.3                             5.4       2.4 
Islandera                                                                  
American Indian/Alaska       0.3                             0.8       0.8 
Native                                                                     
Hispanic (any race)          1.7                             5.7       1.6 
Other/unknownb               9.0                             5.9       4.0 

Source: HRSA, National League for Nursing, and GAO analysis of HRSA
administrative data.

aIncludes Native Hawaiians among the RN workforce and NSP awardees.

bIncludes 1.5 percent identified as two or more races among the 2004 RN
workforce.

Enclosure V

                     GAO Contact and Staff Acknowledgments

GAO Contact

Kathleen King, (202) 512-7119 or [email protected]

Acknowledgments:

In addition to the contact names above, Linda T. Kohn, Assistant Director;
Eric Anderson, Krister Friday, Romonda McKinney, Dae Park, Ollie Richie,
and Jessica C. Smith made key contributions to this report.

(290529)

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