cities still have local health departments, the trend is toward decreasing duplication and cost by merging city and county units (Martin, 2002). RNs employed in public health and community health settings increased by 155 percent between 1980 and 2000 (Spratley et al., 2000).

During the 1990s, various factors, such as substance abuse and its impact on high-risk pregnancies and newborns and the incidence of HIV/AIDS, stimulated growth in the public health sector and caused these agencies to reassess their mission and purpose. An earlier IOM study found that the public health system was in disarray and incapable of fulfilling the fundamental core functions of assessment, policy development, and assurance (IOM, 1988). Following the events of September 11, 2001, and associated concerns about bioterrorism, the public health infrastructure began receiving additional attention.

Problems with Recruitment and Retention of Nursing Staff Across Clinical Settings

Hospitals, nursing homes, home health agencies, and other community-based long-term care organizations all report difficulties in securing enough RNs and NAs to provide needed patient care (AHA Commission on Workforce for Hospitals and Health Systems, 2002; GAO, 2001b; Stone and Wiener, 2001). For 2001, the American Organization of Nurse Executives (AONE) reported nationwide hospital RN vacancy rates11 of 10.2 percent, with the highest rates being in critical (14.6 percent), medical–surgical (14.1 percent), and emergency room (11.7 percent) care (The HSM Group, 2002). Similarly, an AHCA national survey of long-term care facilities found vacancy rates of 18.5 percent for staff RNs, 14.6 percent for LPNs/LVNs, and 12 percent for NAs (AHCA, 2002). Some have expressed the view that this inability to attract and retain a sufficient number of nurses is the result of inhospitable working conditions. Others assert that, while work conditions may not be favorable, recruitment problems are due to an underlying shortage of nursing personnel. Evidence indicates that both factors are at work.

A Nationwide Nursing Shortage

The national employment of RNs per capita and the national unemployment rate for RNs have both declined. The national unemployment rate for RNs in 2000 (1.0 percent) was at its lowest level in more than a decade. At the same time, total employment of RNs declined by 2 percent


The vacancy rate is calculated as the average number of vacant full-time equivalent (FTE) positions divided by the average number of budgeted FTE positions.

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