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CHAPTER }} Meedng Current and Future Needs for Nurses The Congress asked the Institute of Medicine to consider the present and future need for nurses under existing arrangements for providing health care, and under specified modifications of health care organization and financing that may influence such needs in the future. The committee debated whether to interpret the charge primarily in terms of the current and anticipated market demand for nurses, or whether to base its recommendations on professional perceptions of the supply of nurses needed to fully staff all health care settings at all times. This was not just an exercise in semantics around the word "need"; conclusions that could be reached by employing these different interpretations could be widely divergent. Because both concepts of need were thought to be important, the committee decided to work with both, and to distinguish clearly in each case the concept from which estimates were derived. The committee has answered the congressional questions in the context of effective economic demand--i.e., on the basis of observed utilization, reflecting present and probable future willingness and ability of hospitals and other health service providers to employ nursing personnel of various types. It assumed that it would be wasteful to society and unfair to individuals to encourage the educational system to produce more graduates than historical evidence indicates would be likely to be employed. However, it is important that policymakers see the potential magnitude and characteristics of the supply that would be required if one were, instead, to adopt professional criteria of nursing "need." This report, thus, also sets out estimates that have been made and published on the basis of judgments by nursing leaders as to what the demand should be to meet staffing standards they believe to be either minimally necessary or desirable to provide nursing services to patients in different settings of care. In this framework, the chapter presents the committee's observations and conclusions as to the immediate and long-tenm prospects for a sufficient overall national supply of registered nurses (RNs) and licensed practical nurses (LPNs) to meet the nation's 51

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52 needs for their services. It also deals with planning for meeting nursing needs at the state and local level. Current Supply and Demand During the 1970s there were widespread reports of a shortage of RNs to staff the nation's hospitals and nursing homes. If one defines shortage as an unfavorable balance between supply and demand, the phenomenon was not new; it has been present almost continuously since World War II. In the popular view, nurse shortages are extensive and stem from low salaries and stressful working conditions that lead nurses to desert nursing for more rewarding work and influence potential nursing students to choose other careers. However, notwithstanding the acute nature of shortages in many localities and studies and testimony to the committee that many RNs are dissatisfied with their professional status and working conditions, the recent shortages have not been caused by a failure of nurses to work in their profession. On the contrary, the number of employed RNs more than doubled during the past two decades, rising from 550,000 in 1962 to an estimated 1,360,000 in 1982. Expressed as a population ratio, the supply increased from 298 per 100,000 population in 1962 to an estimated 572 per 100,000 in 1982.1~2 Moreover, except for one brief interval, graduations from RN education programs also rose steadily during the 1970s.3 The dramatic increases in supply were largely in response to labor market interactions, including improved compensation, more flexible hours, and other incentives to nurse employment. Thus, nurse shortages did not develop from a drop or leveling off of the supply, but rather from dramatic growth in the demand for nursing services in hospitals and nursing homes during the decade of the 1970s--a growth that, until the economic recession in 1982, consistently outstripped the marked growth in supply. Therefore, to address the problem of present and potential future shortages, at both national and state levels, requires that as much attention be paid to the demand side of the equation as to the supply. This, and the particularly local character of nursing shortages, have important implications for the support of nursing education. The Supply of Nurses Registered Nurses Our study estimates that at the end of 1982 there were some 1.36 million RNs in the nation's active nurse supply.* The estimate is based on the most recent national sample *The "supply" of KNs is used to mean those who are employed or in practice. The "population" of KNs used includes all living graduates of United States schools whether or not currently licensed, plus all foreign graduates who have been licensed in the United States.

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53 survey that found a total of 1.27 million employed KNs in November 1980.4 These nurses constituted 77 percent of the 1.66 million RNs holding licensure as of the survey date. The study estimates that there were another 200,000 graduates who had not maintained their licenses.5 This total estimated population in 1980 of 1.86 million graduates from programs preparing for KN licensure is depicted in Figure 4 by age and by type of basic educational preparation. It points up the skewed age distribution of RNs, and the dramatic shift from diploma graduates at older ages to those with associate and baccalaureate degrees at the younger end of the age range. 50 Coo 40 000 30.000 of CC 20 000 In hoe 700 0 - 1 1 1 i 1 crew I =1 I rents /\ it// at_ / he' ~ ~>. ,. 65 60 55 50 45 40 AGE IN 1980 cloma 35 30 FIGURE 4 The 1980 population of nurses graduated from basic programs preparing for registered nurse licensure, by age. Between 1970 and the end of 1980 the number of employed RNs rose from 722,000 to 1,273,000.6 This represented an increase from 356 RNs per 100,000 population in 1970 to 558 at the end of 1980. The increase was supplied both by increased labor force participation of RNs and by a sharp rise in the number of graduates of RN programs. The rate of labor force participation of RNs has been increasing substantially over several decades. To the employer or potential employer of RNs, labor force participation must be looked at in terms of the proportion of currently licensed RNs who are employed. In 1980, this proportion was 76 percent. This is the rate cited throughout this report, unless otherwise indicated. However, in this section, for purposes of historical comparisons and for making supply projections, the base used is the ratio of employed KNs to the total

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54 number of living graduates of RN programs.* On this base, the participation rate in 1980 was 68 percent. In 1927, one-third of all graduates (whether or not registered) were employed in nursing. By 1950 the proportion had risen to 40 percent, by 1970 to about 60 percent, and by 1980 to 68 percent. Between 1950 and 1960 the greatest increases were among older nurses; more recently, the greatest increases have been among RNs in the earlier childbearing years.7 Figure 5 depicts the levels of labor force participation of RNs at these intervals. 100 80 111 o ~ 60 LL in ~ 40 AL 20 O - 1980 i 1 960 - 1 949 50 60 70 1 1 ~ Do. 1 ~ I I. I ~i 1` ~ _ ~ 1 " 1 ~ 1 ~i I ~'' 1 l l l l 0 20 30 1 1 'N_ .: . . _ ~ ~ 1' a' 40 AGE FIGURE 5 Registered nurse labor force participation, by age, 1949, 1960, and 1980; all graduates of programs preparing for registered nurse kc ensure. The changing employment pattern of RNs reflects the changing working patterns of women generally. These patterns vary not only over time, but also at any one time by level of educational preparation. Women having higher academic preparation participate in the labor force at a higher rate than do those with less education. Today, the labor force participation of RNs is very much like that of all women with some college education.8 New graduates from the three types of basic programs preparing for RN licensure--diploma, associate degree (AD), and baccalaureate--rose from 43,639 in 1970 to 76,415 in 1980--an increase of 75 percent in 10 years. The number of graduations dropped slightly in 1981, to 74,890. Figures on 1980-1981 admissions, on the other hand,- indicate _ *This method is discussed in more detail in West, M.D. The projected supply of registered nurses 1990: Discussion and methodology (see ~ , _ Reference 2 for complete citation).

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55 an expected further increase in the proportion of AD graduates as well as numerical increases over the previous year admissions for each of the three types of program. As noted in Chaper I, there was a dramatic shift during the past decade from diploma graduates, half of the total in 1970, to AD graduates, who made up almost half of the 1980 graduates (Table 6~. The proportion of baccalaureate graduates has grown steadily during this period, from one-fifth the annual total in 1970 to one-third in 1981. Basic RN programs are drawing from a widening age base (Table 7~. This change has helped to offset the decline in enrollment which was expected to follow the current decline in the number of young people. TABLE 6 Graduations From Basic Registered Nurse Programs, 1970, 1980, and 1981 1970 1980 1981 Program type Number Percent Number Percent Number Percent Diploma 22,856 52.4 14,495 19.0 12,903 17.2 Associate 11,678 26.7 36,509 47.8 37,183 49.7 Baccalaureate 9,105 2009 25,411 33.2 24,804 33.1 TOTAL 43,639 100.0 76,415 100.0 74,890 100.0 NOTE: "Basic" programs include baccalaureate, AD, and diploma programs preparing students for initial RN licensure. Graduations do not inc. Jude those of RNs from post-RN programs which grant baccalaureate degrees, nor do they include those from master's and doctoral programs. SOURCE: NLN nursing data book 1982, Table 36, and earlier years (see Reference 32 for complete citation). Licensed Practical Nurses The supply of LPNs also has grown substantially. From 370,000 employed LPNs in 1970 the number rose to an estimated 549,000 in 1980. This represents a growth in the ratio of LPNs to population from 183 per 100,000 population in 1970 to an estimated 248 per 100,000 in 1980.9~10 The most recent survey of state boards of nurse licensure found that approximately 800,000 licenses were held by LPN s in 1981-1982.11 Adjusted for some duplication (persons licensed in more than one state), the total number probably is close to 700,000. The estimate of the 1980 active supply cited above was made by the DHHS on the basis of data contained in the 1974 Inventory of Licensed Practical Nurses, which showed 406,000 employed LPNs in 1974. The DUBS estimates that the number of employed LPNs increased by 143,000 between 1974 and 1980, or an average of 24,000 per year. The annual number of graduates of practical nurse (PN) programs

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56 TABLE 7 Proportions of Graduations From Basic Registered Nurse Programs at Age 25 or Older, by Program Type, Selected Years Year of Graduat ion a b Program Type 1960-1974 1975 1979-1980 Diploma As sac late Baccalaureat e 4.0 14.0 25.7 26.0 48.O 63.8 7.0 14.0 27.0 aSOURCI:: Study group analysis of Am, 1977 national sample survey of registered nurses: A report on the nurse population and factors affecting their supply (see Reference 47 for complete citation). bSOURCE: NLN nursing data book 1981, Table 130, p. 132 . (see Reference 3 for complete citation). increased from 37,128 in 1970 to 48,081 in 1976. Since then it has declined to 41,868 in 1981. The proportion of PN graduates who were prepared in junior or community colleges increased from about 21 percent in 1970 to almost 30 percent in 1981, while PN graduates of technical or vocational schools remained at about a constant level, and those of hospital programs decreased.l2,13 The pool of LPNs is one on which KN programs are drawing to offset the recent drop in high school graduates. The Demand for Nurses Registered Nurses The 1970s witnessed fundamental changes in the way health care was provided to the United States population. Most important in creating increased demand for nursing services was the population's increasing access to health care during that decade, made possible by liberalization of many aspects of health care financing. Per capita, community hospital admissions rose by 10 percent (Table 8~. There were other, more specific, spurs to nurse demand. One example is the growth in the life-support monitoring systems of hospital intensive care units (ICUs). In 1971, there were only 3,200 beds in such units; by 1980, the number had increased twentyfold to more than 68,000.14,15 The effect of this increase in ICU beds on demand for nurses is evidenced by the fact that the recommended staffing of nurses over a 24-hour period in ICUs is one nurse for each patient (or three nurses per patient day, each for an 8-hour shift), compared with a recommended standard of one nurse to six patients in conventional medical-surgical unitS.16 The increasingly complex technology employed in hospitals also can be illustrated by changes in the it'd e:< of service intensity developed by the American Hospital Association (AHA), a measure that takes into

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57 account quantities of 37 types of hospital services per patient day, including laboratory tests, X-rays, prescriptions, visits to the operating room, and the like, weighted by base~ear cost . This index rose by more than 55 percent between January 1970 and October 1979.17 Such increased intensity means more work for nurses, whether in direct care, coordinating services, recordkeeping, or ac tivities such as teaching and supervising. Al so during the 19 70s, 312, 000 beds were closed in nonfederal psychiatric hospitals, a s i tuat ion p lac ing on c ommunity ho sp it al s an increased load of pat lent s with conditions requiring intensive treatment for acute psychiatric illness, alcoholism, and drug abuse and posing a greater need for psychiatric nursing service. 18 In addition to increased rates of admission to hospitals, shorter patient stays during the 1970s (Table 8) also increased the amount and intensity of work for nurses because the f irst days of stay necessitate the most nursing service. Further, there was a tremendous growth in ambulatory care provided in hospital outpatient departments and emergency rooms. The number of hospital outpatient visits in short- term general and allied special hospitals increased from approximately 134 million in 1970 to 207 million in 1980, the increase thus creating additional demands for nurses. TABLE 8 Beds, Inpatient Utilization, and Outpatient Visits in Nonfederal Short-Term General and Allied Special Hospitals, 1970 and 1980 Measure 1970 1980 Percent Change Beds ~ thousands ~848 Admis signs ~ thousand s)29, 252 Admissions per thousand populat ion145 160 Average length of stay (days)8.2 7 .6 Outpatient visits (thousands) 133,545 206,752 992 36, 198 +17 .0 +23 .7 +10.3 -7. 3 +54.8 SOURCE: AHA. Hospital statistics, 1981, Table 1, p. 4 (see Reference IS for complete c itation) . Implementation and rapid expansion of Medicaid in the 1960s resulted in an explosive growth of nursing homes . Between 19 73 1978, however, the number of nursing home beds in the United c_ stabilized while the number of patients continued to rise. Although the approximately 1.3 million patients in nursing homes on any one day now outnumber patients in hospitals, and although most need active nursing care, there is at present a low effective demand for RNs in these settings. This can be attributed to a variety of causes, including minimal private insurance and Medicare coverage, restrictive Medicaid payment systems, and shortages of state funds (Chapter VI) ~ and ~ ~ nt ~ .~

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58 By contrast, cost-based reimbursement to hospitals by Blue Cross, Medicare, and Medicaid and payment of charges by private insurance allowed community hospitals to adopt more liberal staffing policies in response to the technological developments reviewed above. These hospitals employed almost 63 percent more full-time equivalent (FTE) RNs in 1980 than in 1970.19,20 More federal funds for primary care nursing in community health centers, mental health centers, and rural health clinics probably also contributed to increasing demand for RNs in such settings. Although recent figures are not available, the number of RNs employed in public health work and school nursing in state and local agencies increased almost 40 percent between 1972 and 1979.21 The number of visiting nurses (treated as a subcategory of public health/community health nurses) also increased during the period.22 In short, the 1970s were a time of tremendous increase in the effective demand for RNs, particularly in hospitals. Because almost identical national surveys of RNs were conducted in 1977 and in 1980, the extraordinary growth in numbers of employed nurses that occurred during even this short period of time has been charted. A comparison of these two sample surveys of RNs, both using the same group of work settings, shows that the employment of RNs increased in all settings except private duty nursing (Table 9~. Eighty percent of the total increase took place in hospitals, where about two-thirds of all RNs are employed today. As the table shows, hospitals employed almost 40 percent more RNs at the end of 1980 than TABLE 9 Employed Registered Nurses, by Work Setting, 1977 and 1980 Number Employed b 1977-1980 Change Work Setting 1977 1980 Number Percent Hospital 601,011835,647 234,636 39.0 Nursing home 79,647101,209 21,562 27.1 Public/community health 77,13983,440 6,301 8.2 Physicians/dentists office 69,26371,974 2,711 3.9 Student health service 41,36544,906 3,541 8.6 Nursing education 37,82646,504 8,678 22.9 Occupational health 24,31729,164 4,847 19.9 Private duty 28,56320,240 -8,323 -29.1 Other and unknown 19,10239,768 20,666 108.2 TOTAL 978,2341,272,851 294,617 30.1 aSOURCE: Roth, A., et al. 1977 national sample survey of registered nurses: A report on the nurse population and factors affecting their supply, Table 51, p. 183 (see Reference 47 for complete citation). bSOURCE: DHHS, BRA. The registered nurse population, an overview. From national sample survey of registered nurses, November, 1980, Table 5, p. 13 (see Reference 4 for complete citation).

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59 TABLE 10 Registered Nurses and Licensed Practical Nurses (FTE) in Hospitals, 1972 and 1980 _ Year Percent Nurses (FTE) Type of Hospital 1972 1980 Change Registered nurse All hospitals and licensed practical nurse Registered nurse Licensed practical nurse All hospitals Communityb Psychiatric Other All hospitals Co'~unity a Psychiatric Other 641,400 425, 700 369, 700 21, 100 34,900 215, 700 184, 300 17,000 14,400 951, 800 693,400 623, 100 25, 400 44,900 258,400 228, 500 14,200 15, 700 48.4 +62.9 +68. 5 +20. 4 +28.7 +19.8 +24.0 -16 .5 + 9.0 §The number of full-time equivalent nurses (FTE) is calculated by adding half of the number of nurses employed part time to the number of those employed full time. "Nonfederal short-term general and allied special hospitals. SOURCES: ADA. Hospital statistics, 1972, Table 3, p. 27 (see Reference 14 for complete citation); Hospital statistics, 1981, Table 3, p. 13 (see Reference 15 for complete citation). they had 3 years previously, and the numbers in nursing homes, nursing education, and occupational health also rose substantially.* This growth rate in demand appears to have slackened somewhat by 1982. Although no national data are yet available, the committee has received reports from many states that indicate lessened desire and ability of hospitals to add to their overall nursing staff positions. States hit hardest by the 1982 economic recession appeared to have the most reduction in demand for nurses, partly because of a drop in hospital utilization as health insurance benefits ran out for the unemployed. Licensed Practical Nurses The greit majority of practicing LENS - also work in hospitals. There was a slow but steady r~se in the demand for LPN s on hospital staffs between 1972 and 1980, with the number in all hospitals increasing by 20 percent, and in community hospitals by 24 percent. The number of LPN s in psychiatric hospitals dropped by 17 percent, but the number of RNs increased by 20 percent, as is shown in Table 10. The increase in LPN staffing, however, has been proportionately less than the increase in RN staffing, so that *For further detail, see background paper, Levine, E. The registered nurse supply and nurse shortage (see Reference 48 for complete citation).

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60 LPNs made up 33.6 percent of the nurse staffing in hospitals in 1972, but the proportion dropped to 27.1 percent in 1980. Extent and Nature of Supply-Demand Imbalances The dimensions of the nursing shortage during the 1970s have been only partially defined and documented. Available measures include the extent of RN and LPN unemployment and vacancy rates. The Bureau of Labor Statistics reports a consistently low rate of unemployment for nurses. During the period 1971-1981, the median annual rate for KNs was 1.9 percent and for LPNs 3.5 percent. Both were well below the 6 percent median rate for all United States civilian workers during that period. But the median unemployment rate for ancillary nursing personnel--aides and orderlies--was 7.5 percent.23 The AMA's 1980 annual survey reported approximately 62,000 unfilled positions for RNs and approximately 18,000 for LPNs.* This translated to vacancy rates of 10 percent of all budgeted positions for staff RNs and 7 percent for LPNs.24 At the same time, 28 percent of hospitals had no staff RN vacancies, and 53 percent had no LPN vacancies.25 The AHA survey showed considerable variation in vacancy rates among the states. Vacancies for RN staff nurses ranged from a high of 15 percent in Louisiana to a low of 5 percent in Vermont. The corresponding range for LPNs was from 11 percent in Delaware to a low of 2 percent in Idaho.26 Vacancy rates also varied greatly according to hospital type. General hospitals reported average vacancy rates of 9 percent for RN staff nurses and 6 percent for LPNs, but the corresponding rates in chronic disease hospitals were 30 and 26 percent, respectively.27 There is no comparable survey to provide current vacancy rates for nursing homes. However, in testimony before the Select Committee on Aging of the House of Representatives in 1980, the executive vice president of the National Council of Health Centers cited a recent national survey that reports a national shortage of 53 percent.28 In 1981, the AHA conducted a nursing personnel survey of a 20-percent sample of United States hospitals. It found that vacancies occurred very unevenly within the same institution, according to type of nursing unit and work shifts. For example, intensive care units experienced high vacancy rates.29 Several state studies of nursing report that a large proportion of all vacancies occurred on night and evening shifts. For example, among hospitals in New Jersey, more than 50 percent of the vacancies occurred on the night and evening shifts. *Numbers of vacant budgeted positions do not necessarily give a true picture of actual staffing deficiencies. Vacancies can occur because of job turnover, which, although a problem in itself (Chapter VII), does not necessarily indicate an insufficient supply. Also, the number of positions budgeted may or may not reflect employers' actual willingness to hire.

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61 Studies in Rhode Island showed that 80 percent of hospital vacancies occurred on these shifts and also found that patterns of vacancies in nursing homes were similar.30 In summary, for purposes of planning specific actions to redress imbalances between the supply of nurses available and the demands of the population for direct nursing care, indicators of national shortages have only limited usefulness. Nursing shortages appear to be phenomena of local markets, within which there is great variability both among institutions and within such institutions. Thus, as will be discussed in Chapter VII, decisions that influence the attractiveness of nursing employment, as well as the more efficient use of nurses already employed, are ones that need to be made locally by individual institutions that employ nurses. The Distribution of Nurses The ratio of RNs to population is rising in all parts of the country (Figure 6), but wide differences among the regions and states still exist. On a regional basis, the ratio of RNs to population is highest in New England and lowest in the south central states. In contrast, the ratio of LPNs to population is highest in the south, particularly in the west south central states, and lowest in the west. Among individual states the ranges are very wide (Figure 7~. In 1977 there were six states and the District of Columbia in which the supply of RNs and LENS, taken together, provided more than 700 FTE 7004 a 0 500 To o o 400 o ~ 300 z cc ~ 200 LLJ J ~ 100 LL 0 ° 600 ~ south ! _-_ ~ ~ ~1 OTT TV= ~ 1 962 1' ~ ~ 1972 1977 1980 YEAR FIGURE 6 Employed registered nurses per 100,000 population by regions of the United States, 1962, 1972, 1977, and estimated 1980.

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78 The number of nurses with diplomas or ADs who go on to receive baccalaureate degrees is growing steadily, the number of post-RN baccalaureates granted rising from 2,337 in 1972 to 8,416 in 1981 and projected to reach 14,000 in 1990.41,42 Thus, about 100,000 of the 257,000 "baccalaureate or higher" additions to this supply component by 1990 are expected to come from post-RN graduations. The number of active XNs with diplomas probably will have decreased somewhat by 1990 but still will make up a large group--over 600,000--and will constitute slightly over one-third of the total active supply. Associate degree graduates are expected to have increased by about 220,000 and will account for 28 percent of total. The younger nurses added to the supply primarily will have associate and baccalaureate degrees; deaths and retirements primarily will be among diploma graduates who make up the largest proportion of the older RNs. A cross section of the study's intermediate projections of the 1990 supply of active RNs is shown in Figure 11 to indicate the effect of changing age and educational patterns. Here it can be seen that in 1990 the largest numbers of active RNs will be in their thirties. Graduates with diplomas will be older, with a median age of 45. The median age of those with associate degrees will be 35 years, and that for graduates with baccalaureate degrees will be 32 years. This figure also shows, in the narrow bands, the numbers who are expected to have attained their current level of preparation by moving from diploma or associate degree to a post-RN baccalaureate degree (D-B and A-B), and from each type of basic preparation to a master's level us, LL a) 50t z LL > 40- _ 11 ~ o z CD - - .~n 20 - _ _ I .._ I I I ~I i ~ ./ ~ ~ccolclurecte ~ A- - -I -.:.:-. '' ~' / - A-B A-M = _ · D-B D-M . , . Diploma ......... ,,,--~ \1 o . . . . 1920 1925 1930 1935 1940 1945 1950 YEAR BORN 70 65 60 55 50 45 40 AGE IN 1990 195519601965 1970 353025 FIGURE 11 Supply of active registered nurses, 1990, by age and educational preparation (study's intermediate projection).

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79 (D-M, A-M, and B-M). All nurses with doctorates are shown in the band labeled B-D. The study's intermediate projected supply of RNs for the end of 1990 by highest educational preparation has already been shown in Table 16. This distribution is quite unlike that resulting from the WICHE panel's judgment-of-need projections for the beginning of 1990. Our supply projection estimates that there will be a much higher proportion of diploma and associate degree graduates than the WICHE (lower bound) judgment-of-need projection anticipates. Conversely, our study foresees that by 1990 the educational system will have produced a much lower supply of RNs with baccalaureate and advanced degrees than the WICHE process projected through its panel's judgment of need (Table 17~. TABLE 17 Percent Distribution of Active Registered Nurses in 1990, by Highest Educational Preparation, Study's Intermediate Projection, Compared With DHHS WICHE Lower Bound Projection of Need Highest Educational Preparation Study's Judgment-of-Need Intermediate a Projectiont Supply Projection (Lower Bound) (December 1990) (January 1990) Diploma/associate degree 63.7 Baccalaureate and higher 36.3 TOTAL 100.0 43.0 57.0 100~0 aSOURCE: Table 16. tSOURCE : Secretary, DHHS . Third Report to Congress, February 17, 1982: Nurse Training Act of 1975 ~ see Reference 10 for complete citation). The implications of this table are that if the nation were to adopt the WICHE panel's goals, immediate massive shifts in educational distribution would be required--i.e., away from AD preparation of nurses toward preparation of greatly increased numbers at the baccalaureate and higher levels. In addition to greatly increased admissions and graduations from generic baccalaureate programs, dramatic acceleration of graduation rates from post-RN programs would also be required to advance large numbers of AD and diploma graduates to higher levels. The committee had no reliable basis for estimating the large additions to higher education budgets that would be entailed in implementing such shifts, or how they would be financed. The study also found no basis for disaggregating its projections of employer demand for RNs in 1990 according to level of educational preparation. In view of the evidence noted in the preceding chapter on the diverse ways in which employers currently staff their

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80 facilities and agencies, and the lack of agreement among many who are professionally and managerially involved in the production and utilization of the nurse supply, the committee did not attempt to disaggregate its demand projections at the level of different types of educational preparation of generalist KNs. In projecting the likely configuration of the RN supply during the balance of the decade on these dimensions, the committee foresees that by 1990 the numbers of baccalaureate prepared nurses will have increased about 70 percent even in the absence of large shifts of educational resources (Table 16~. State and Local Planning for Generalist Nurse Education Both the specific demands for generalist RNs and the specific nature of the educational distributions that help to determine nurse supply are for the most part highly localized. Imbalances, if any, in supply and demand of RNs vary greatly from state to state and require assessment at subnational levels. Most decisions affecting the allocation of resources for nurse education take place at institutional and state levels. State and local governments through their postsecondary and vocational education systems, private universities and colleges, and to some extent hospitals, are involved in planning and paying for a substantial portion of the educational preparation of both RNs and LPNs. Many groups and agencies in states have strong interests in these matters--professional, bureaucratic, and economic. At the state level, the official agencies typically having interest in nursing and nursing education include boards and commissions of higher education, departments of vocational education, state university systems, boards of nursing, statewide health planning agencies, and state health departments. Private organizations include state nursing associations, hospital and nursing home associations, third-party payers, and unions of hospital employees and of nurses. A range of perspectives and interests are represented in local and state planning efforts. Hospitals and other potential employers like to have nurse education programs available in their localities to assure new recruits to their nursing staffs because, as will be described further in Chapter VI, the majority of newly licensed RNs, especially those with associate degrees and diplomas, as well as LPNs, begin their careers in the communities in which they were educated.43 Legislators may be attuned to special problems of nurse shortages in their particular districts. Nurse educators and nursing service directors may hold strong but not necessarily similar views on the types of nurse education preparation that should receive priority. Furthermore, because the distribution of nurses with different levels of licensure and/or educational preparation found most appropriate for a particular patient caseload varies considerably according to geographic region, setting of care, and type and size of hospital, nursing service directors themselves may send mixed signals to educational planners. Finally, university systems and independent

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81 4-year and 2-year colleges must balance the demand for nurse education against the competing demands of other programs. State Studies Few states have organizational mechanisms for reconciling these interests in a continuing manner that can be related systematically to decisions on allocating resources for future nursing education. A common response to the problem is to conduct a special study. Our project analyzed reports of 75 statewide studies of nursing conducted in 45 states between 1977 and mid-1982. Mbst were sponsored by a state agency or by the state university system; 9 were conducted under the auspices of state nursing associations and 15 by state hospital associations. The sheer volume and rate of replication of these studies suggests broad concern with nursing issues at the state level. Both the importance and the difficulties of attempts to plan nursing education are apparent in the reports. A summary of information from the recent studies and a listing of major reports are included in Appendix 3. Twenty-two of these state level studies present analyses and projections of future supply and needs. A variety of methodologies and data were employed. Most studies estimated both needs and supply. For RNs, 14 projected a potential deficit and 4 a potential surplus; in four cases the balance included both positive and negative results, depending upon the assumptions applied. For LPNs, five states projected that the supply would be adequate, eight that there would be a deficit, and one had mixed results. Seven did not estimate needs for LPNso RN needs by educational level were estimated in 15 of the 22 studies. In these analyses, 13 studies projected an adequate or more than adequate future supply of RNs with diplomas or associate degrees, and the same number projected a deficit of kNs with baccalaureate and master's degrees. The judgment-of-need process employed at the state level (WICHE model) parallels that of the national panel, described earlier. State panels, including nurses in leadership positions in nursing education and nursing service and other health profesionals, adopted assumptions about potential and desirable changes in health care conditions and practices, and about appropriate mixes of staff and levels of educational preparation required to handle anticipated responsibilities in different settings of care. These groups had the benefit of locally available information concerning health care needs and patterns of service, although deficiencies in needed data were usually encountered. Sometimes public hearings were held at which differing views could be expressed. The state projections based on judgments of need adopted widely differing assumptions as to appropriate staffing levels and mix of nurses (by type of educational preparation) and of other nursing service personnel. Differences in assumptions resulted in substantial ranges of estimated nursing staff needed per 100 patients from one state to another, for similar practice settings. To illustrate the wide variations in expert opinion among different states, Table 18 displays the results of the criteria adopted by the national WICHE

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83 panel for inpatient services in short-term hospitals with more than 100 beds (lower bound) and compares them with the results of the WICHE panels in eight states.44 When the outcomes of local panels' judgments in these states are compared to the conclusions of the national panel, wide differences are evident. Judgments about requirements in hospitals for RN staff ratios per 100 patients, levels of RN educational preparation, and ratios of LPN s and aides to RNs vary considerably. Another striking difference is in the total number of hours of nursing services the panels assumed were needed per patient day. These differences among the eight state panels of experts, compared to the national criteria, are summarized in an analysis by Kearns and her associates as follows: Five states increased the total hours of direct care a patient receives per day. Three states increased registered nurses and licensed practical nurses and eliminated or significantly decreased aide staff. One state increased the number of registered nurses and aides and eliminated the licensed practical nurses staff. One state decreased the number of registered nurses but increased both the licensed practical nurses and aide staff. Two states were slightly lower in the total hours of care which was reflected by a slight increase in the number of registered nurses, a decrease in the number of aides and an increase in the number of licensed practical nurses. One state significantly decreased the number of total hours of care. This state decreased the number of registered nurses, eliminated the aide staff and increased the licensed practical nurse staff. The one state that identified a separate pediatric category recommended an increase in the number of hours of care by dramatically increasing registered nurses and licensed practical nurses and decreasing aide staff. For the educational preparation of the registered nurse, most states were comparable to the National Panel or above, except three indicated 75 to 80 percent of the registered nurses at less than baccalaureate.45 Such differences among panelists' judgments indicate that a wide range of opinions exist among professional experts concerning appropriate and necessary nurse staffing goals in different parts of the nation. To the extent that these judgments are influenced by existing wide variations among states in health care expenditures, utilization of services, and manpower, they may also reflect realities of living standards, societal perspectives, and per capita financial resources. Those who allocate resources to initiate or maintain support for different types of nursing education programs at the state level frequently do not have sufficient reliable information at hand on the probable future market demand for their graduates and on the relative ability of those graduates to satisfy the needs of various types of employers. Information on hospital and nursing home vacancies provides little guidance, because when the qualifications for desired applicants for generalist nurse positions are specified, they usually are expressed in terms of required clinical nursing experience rather

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84 than the type of basic nursing education that candidates for employment are expected to have. Hospitals (and nursing homes) rarely maintain their personnel records in ways that permit analysis of the proportions of RNs employed according to type of basic nurse education received. Administrators rarely have a sufficient statistical base to analyze how education may correlate with promotions, turnover, or other empirical measures of performance. Results from hospital opinion surveys indicate a range of views. Many administrators indicate preferences for either baccalaureate or diploma graduates. This viewpoint corresponds to the empirical evidence about average ratings in standard examination scores discussed in Chapter VIII. Available reports indicate that state nursing studies have had diverse impacts on decision making in the states. In same cases, follow-up efforts have been organized to implement their recommendations. However, an earlier review of state studies, in 1978, showed that at that time 28 states had developed master plans for nursing education, but their provisions were rarely implemented.46 In some states when the results of a study by one sponsoring group have been unacceptable to other groups within the state, alternative studies have been undertaken. As noted, few states have continuing mechanisms to monitor and consider changing needs and resources. Nonetheless, it is clear that recent studies have placed issues of educational differentiation squarely on the agenda of nursing education policy discussion at the state level. They also have spurred a widespread interest in educational mobility, as will be discussed in Chapter IV. The consideration being given to reorganizing health services planning activities in the states and at the national level also is relevant. Planning for health services must, of course, take into account nursing resources and needs. Many state health planning agencies have conducted and contributed to nursing studies in recent years. Future planning efforts for health services in general, and nursing resources in particular, should be closely coordinated. Conclusion Although fully cognizant that substantial changes in political, economic, and professional activities at the state level rarely are the direct result of the development of master plans, the committee nevertheless believes continued efforts are needed in the states to coordinate the planning and resource allocation decisions for nursing education and the development of nursing personnel. It is evident that in most states, serious attempts have been undertaken to better understand the nursing shortage problem and to identify possible solutions. The committee has noted the apparent inefficiency of efforts within many of these states as they struggle to ascertain their current and future needs for registered and practical nurses and to identify related nursing education priorities. In reviewing large numbers of state studies of nursing, the committee found that many official state agencies seek the participation of various interested parties in seeking agreement on

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85 goals for basic nursing education. A broadly representative commission format appears to be useful in planning policy or stimulating program development. However, in many cases, studies and actions are not effectively coordinated, arrangements for follow-up are inadequate, or agreement is not reached among those responsible for resource allocation decisions. Closer and continuing communication between those who design state and local education programs and local employers will encourage accommodation between education and practice goals. Projections of needed future supply appear to be hampered by the absence of continuing processes to consider systematically the potential future estimated market demand for registered nurses and licensed practical nurses by hospitals and other employers. The committee concluded that a relatively small outlay of federal technical assistance dollars employed to develop demand forecasting techniques better suited to state uses would yield benefits in strengthened state planning efforts. As a further means of overcoming these problems, the committee considered the possibility of federal nursing education planning grants to states upon demonstration that they have effective mechanisms in place to carry out the responsibilities outlined. This concept, embodied in recent health manpower proposals before the Congress, was successfully implemented in regard to planning for the full scope of postsecondary education in the years between 1972 and 1980 under Section 1203 of Title XII of the Federal Higher Education Act of 1965. A total of approximately $3.5 million in comprehensive planning grants was distributed across all eligible states each year. Though such planning was voluntary, eventually all but one or two states became eligible. The effects of improving the process of planning for postsecondary education are reported to have been salutary. Another possibility entertained by the committee was to require evidence of implementation of a state nurse planning program as a condition of receiving federal funding for state-sponsored nursing education activities that involve programmatic (as distinct from student) support. Private educational institutions, of course, should not be penalized in such support simply for inability to conform or for lack of state action, because their programs are often designed to meet private sector as well as interstate and national needs and should be considered on their merits. RECOMMENDATION 2 The states have primary responsibility for analysis and planning of resource allocation for generalist nursing education. Their capabilities in this effort vary greatly. Assistance should be made available from the federal government, both in funds and in technical aid.

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86 REFERENCES AND NOTES 3. 5. 6. 17. 18. Department of Health and Human Services, Health Resources Administration. Source book--Nursing p ersonnel (DHHS Pub 1 ic ation No. ~A-81-21) . Washington, D.C.: U.S. Government Printing Office, 1981, Table 1, p. 9. 2. West, M.D. Projected supply of nurses, 1990: Discussion and metholodgy. Background paper of the Institute of Medicine Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D.C., 1982. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982. 4. Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample survey of registered nurses, November, 1980 (Report 82-5, revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982. West, 11.D. Op. cit., Table 1. DHHS, ~A. Source book-nursing personnel. Op. cit., Table 1, p. 9. 7. West, M.D. Op. cit., Figure 4. 8. Ibid., Figure 5. 9. DHHS, BRA. Source book--nursing personnel. Op. cit., Table 3, p. 11. 10. Secretary of Health and Human Services. Third report to the Congress, February 17~ 1982: Nurse Training Act of 1975. Hyattsville, Md.: Health Resources Administration, 1982, Table 33, p. 168. 11. National Association for Practical Nurse Education and Service, Inc. State board of nursing survey, 1980-1981 survey. New York: National Association for Practical Nurse Education and Service, Inc., 1981. 12. Ibid., p. 6. 13. National League for Nursing. NLN nursing data book 1981, Op. cit., Table 148, p. 148. 14. American Hospital Association. Hospital statistics. Chicago, Ill.: American Hospital Association, 1972, Table 4A, p. 32. 15. American Hospital Association. Hospital statistics. Chicago, Ill.: American Hospital Association, 1981, Table 13A, p. 207. 16. Elliott, J.O., and Kearns, Jib. Analysis and planning for improved distribution of nursing personnel and services: Final report (THEN Publication No. HRA-79-16) . Washington, D.C.: U.S. Government Printing Office, 1978, p. 85. American Hospital Association. Outreach, 1980, 1~3), 1. American Hospital Association. Hospital statistics, 1981. Op. cit., Table 1, p. 4. 19. American Hospital Association. Hospital statistics, 1972. Op. cit., Table 3, p. 27.

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87 39. 20. American Hospital Association. Hospital statistics, 1981. Op. cit., Table 3, p. 13. 21. DHHS, HRA. Source book--nursing personnel. Op. cit., Table 122, p. 161. 22. Ibid., Table 123. 23. Department of Health and Human Services, Health Resources Administration. Untitled report based on unpublished data from the Bureau of Labor Statistics (Report No. 6-82), 1982, Table 1 24e Department of Health and Human Services, Health Resources Administration. Statistics on hospital personnel, from the American Hospital Association's 1980 Annual Survey of Hospitals. Paper prepared for the Interagency Conference on Nursing Statistics Exhibit at the American Nurses' Association Convention, Washington, D.C., June 1982, Table 1. 25. Ibid., Table 6. 26. Ibid., Table 4, Part 1 and Part 2. 27. Ibid., Table 7. 28. Nurse Shortage and Its Impact on Care for the Elderly: Hearing Before the Subcomm. on Health and Long-term Care of the House Select Comm. on Aging, 96th Cong. 2d Sess. 44~1980~(statement of Jack A. MacDonald). 29. American Hospital Association. Preliminary data from nursing personnel survey, 1981. Unpublished manuscript. 30. Hospital Association of Rhode Island. Final report of the HARI task force on the nursing shortage. Providence, R.I.: Hospital Association of Rhode Island, July 1981. 31. Secretary, DHB . Third report to the Congress, February 17, 1982. Op. cit. 32. National League for Nursing. NLN nursing data book 1982. In press, 1982. 33. Department of Health and Human Services, Health Resources Administration. The recurrent shortage of registered nurses: A new look at the issues (DHHS Publication NOe HRA-81-23~. Washington, D.C.: U.S. Government Printing Office, 1981. 34. Secretary, DHHS. Third report to the Congress, February 17, 1982. Op. cit., pp. 77-78; Table 32' p. 167; Table 34, p. 169. 35. Ibid., Table 33, p. 168. 36. Secretary of Health, Education, and Welfare. Second report to the Congress March 1979 (revised): Nurse Training Act of 1975 _ , , (THEN Publication No. HKA-79-45~. Washington, D.C.: U.S. Government Printing Office, 1979. 37. Ibid. 38. Deane, R.T., and Ro, K.K. Comparative analysis of four manpower nursing requirements models (NDIS Monograph No. 6, DREW Publication No. HRA-79-9~. Washington, D.C.: U.S. Government Printing Office, 1979. Doyle, T.C., Cooper, G.E., and Anderson, R.G. The impact of health system changes on the nation's requirements for registered nurses in 1985 (DHEd Publication No. EXA-78-9). Washington, De Ce U. S e Government Printing Office, 1978 e

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88 40. Secretary, DIlHS . Third report to the Congress, February 17, 1982. Op. cit., Table 33, p. 168. 41. National League for Nursing. NLN nursing data book 1982. In press, Table 55. 42. West, M.V. Op. cit., Appendix, Table K. 43. National League for Nursing. NLN nursing data book 1981. Ad. c it ., Table 119, p. 126. 44. Kearns, J.M., Cooper, M.A., and Uris, P.F. Comparision of the rationale and criteria for staffing developed by the National Panel of Expert Consultants with those developed by panels of eight states (revised February 1981~. Boulder, Colo.: Western Interstate Commission for Higher Education, 1980. 45. Ibid. 46. Lysaught, J.P. Action in affirmation: Towards an unambigous profession of nursing. New York: McGraw-Hill, 1981. 47. Roth, A., Graham, D., and Schmittling, G. 1977 national sample ~ ulation HRP-0900603~. Kansas City, Mo.: American Nurses' Association, 1979. 48. Levine, E. The registered nurse supply and nurse shortage. Background paper of the Institute of Medicine Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D.C., 1983. 49. Bauder, J. Methodologies for projecting the nation's future nurse requirements. Background paper of the Institute of Medicine Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D.C., 1983.