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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
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.
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
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).
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
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
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 ~ .~
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).
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).
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.
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.
62 0 200 400 600 800 1 000 Washington DC New Hampshire Massachusetts Vermont Rhode Island Connecticut Arizona M innesota Pennsylvania Delaware Colorado New York Maine North Dakota Nebraska Washington Illinois Oregon Iowa Florida South Dakota O trio Kansas Hawaii U.S average New Jersey Wisconsin Maryland Missouri North Carolina Michigan Nevada Wyoming Alaska Virginia I nd ia no West Virginia California Ida ho Georgia Montana New Mexico Tennessee South Carolina Kentucky Utah Texas Ok lahoma Alabama Louisiana M ississippi Arkansas 0 200 400 600 RNs r I LPNs l 800 1 000 FIGURE 7 Employed registered nurses and licensed practical nurses (FTE) per 100, 000 population, by state, 1977.
63 nurses per 100,000 population. At the other extreme, there were four states in which the ratio was less than 500 per 100,000. If distribution within individual states is taken into account, the ranges are even wider. Future Supply and Demand There is a considerable history of successive undertakings sponsored by the DHHS to estimate future supply and future needs for nurses with projection models that use baseline data available from periodic sample surveys and inventories of educational and employment settings, together with trend data on employment in hospitals, nursing homes, and other settings. Any such projections can, at best, be considered not as firm forecasts but as tools with which to examine the possible effects of alternative assumptions about policies and practices. These forecasts are updated periodically as newer baseline data become available. The Third Report to Congress submitted by the Secretary of Health and Human Services on February 17, 1982, presented the latest departmental supply and demand projections.31 They were made to the year 2000, based principally on data from the 1977 National Sample Survey of Registered Nurses. Congress asked the Institute of Medicine to consider the future supply of nurses and the future need for nurses under the present health care delivery system, as well as under some alternative possibilities. These include increased use of ambulatory care facilities and the enactment of legislation for national health insurance. Because market demand and perceptions of need for RNs and LPNs alike are highly localized and tend to become lost or homogenized in national level projections, modeling at the national level can provide only very general guidance for basic nurse manpower planning. We present our estimates with considerable caution and offer them as illustrations of likely future trends under certain stated assumptions. These estimates depict only the mathematical results - derived after making adjustments in certain observed trends, on the basis of assumptions about changes in factors relevant to nursing. The estimates are for the year 1990; the committee took the position that the many uncertainties in the shape of the future health care systems would invalidate projections for a longer term. In formulating its estimates of future demand and supply, the committee has drawn on the valuable work done by DHHS in developing nurse manpower projection methodologies. It has also been able to make use of data from the National Sample Survey of Registered Nurses, November 1980, which became available in July 1982, and various other materials that were not available to the DHHS analysts who prepared the department's Third Report to Congress. This has made it possible for purpose of this study to develop updated national estimates of both the future supply and the demand for RNs. For LPNs, however, no significant new data are available; the study simply presents the estimates of LPN supply contained in the Third Report to Congress, which were based on 1974 survey material.
64 The Future Supply of Nurses DHHS Projections for RNs The recent DHHS projections of nurse supply, because they reflected expected net increase in supply from 1977 in what subsequently proved to be an especially dynamic growth period, underestimated the actual 1980 supply, particularly as to the extent to which nurses increase their labor force participation. Nonetheless, for the most part, over time the DHHS supply projections have earned a deserved reputation for utility. Appendix 5 compares the DHHS Third Report projections for 1990 with those contained in this paper. Study Projections for RNs The supply of active* RNs at the end of 1990 will be determined by the number in the profession, the number of new entrants into the profession (including foreign graduates, a significant element in a few states), and labor force participation rates. Decrements from deaths are taken into account. The number of new entrants will be affected by the availability of educational opportunity (both as to location, capacity, and enrollment policy of schools), the costs of education, the level of public and private support given to the financing of nursing education, the relative attractiveness of nursing as a career in teems of job satisfaction and economic incentives, and immigration laws and regulations that influence inflows of foreign graduates. Labor force participation is influenced by general conditions in the nation's economy, compensation rates, and a host of other factors (Chapter VII). The study developed three alternative projections of this supply--low, intermediate, and high--using the 1980 data that reveal the sharp increase in labor force participation that took place between 1977 and 1980:+ · The intermediate projection (normative) assumes that the labor force participation of RNs will continue the rise of recent years, although at a somewhat slower rate. It assumes also that financial resources for nursing education will not diminish appreciably and that new entrants to nursing schools will continue to come from a wide age distribution. In view of the declining numbers of young people, however, which reflect the low birth rates of the early 1960s, it is assumed that the total number of graduates from the basic programs *Active is defined here as the number who would be employed if it is assigned that conditions of opportunity, work, financing, etc. are comparable to those in 1980. +Methodology for the study's supply projections is described in detail in West, M. D. Projected supply of registered nurses, 1990: Discussion and methodology (see Reference 2 for complete citation).
65 preparing for ON licensure will drop from 74,900 in 1981 to 70,000 in 1990.* Under the assumptions of this projection, the number of active KNs would rise from some 1,273,000 at the end of 1980 to 1,710,000 by the end of 1990. · The low projection assumes that the rate of labor force participation will not rise above the 1980 level and that the number of graduates will drop to 10 percent below that of the intermediate level, so that the number of graduates will slide to 63,000 in 1990. Such effects might result from continued economic recession reflected in reduced ability to pay for nurse education. Under this projection, there would be 1,643,000 active RNs by the end of 1990. · The high projection assumes that the increasing number of older women entering basic RN programs will push the number graduating to 76,900 in 1990, and labor force participation will rise at the same rate as in the intermediate projection. Under the high projection there would be 1,728,000 active KNs at the end of 1990. For the purposes of comparing alternative projections of supply, these three projections are shown in Figure 8 as trend lines for FTE and in Table 11, both as totals and as FTE RNs. As can be seen, the TABLE 11 Supply of Active Registered Nurses, Total and FTE, 1980, and Study Projections for 1982 and 1990 November 1980 1, 27 2, 900 December 31, 1982 1, 360, 000 December 31, 1990 High Intermediate Low 1,728,000 1, 7 10, 000 1, 643, 000 SOURCE: See Ap pend ix 5 . Registered Nurses Employed FTEs 1,057,300 1, 130, 000 1,451,000 1,436,000 1, 379, 000 *The intermediate projection assumes that annual graduates of baccalaureate and associate degree programs will hold at close to their present levels, with a continuation of the long-term downward trend in hospital diploma graduates as those programs move to join with educational institutions for the joint use of educational and clinical facilities, and to make transitions to degree-granting programs. In 1990, under these assumptions, graduates of basic programs would total 70,000, including 37,600 with associate degrees, 8,500 with diplomas, and 23,900 with baccalaureate degrees. Reports on the number of fall 1981 admissions to these programs indicate that to the average degree programs diploma and bacclaureate admissions are holding close _ _ s to associate 32 of the years 1978-1980, while admission are up by 5 percent above that average.
66 FIGURE 8 Supply of active registered nurses (FTE), 1970-1980, with study projections to 1990. cn o ~ 1,400 A lL <I: - LLJ 111 ~ 800 J LL ~ 600 UJ cc A 400 111 a: lL ~ 200 LL 1,600 1,200 1 ,000 High I r Termed it' ~Low~ /' . _ _ 1970 1980 1990 END OF YEAR study projects a continued steep rise in the nation's RN supply to 1990, even under its most conservative projection. The prospect is that all parts of the nation will share in the increase in nurse supply but that marked state and regional differences will persist. The validity of these projections will depend primarily on the accuracy of the assumptions as to future graduation levels of the educational programs that prepare RNs. The study projections are made at a time of economic recession, and at a time in which both the government and the private sector are increasingly concerned with overall costs and methods of payment for health services as well as with the rising costs of education. The effects of future changes in demand, expressed in willingness to employ nurses and adjustments in their salary levels, might well be translated into unforeseen changes in output. A recent DENS report on the phenomenon of recurrent shortages of KNs describes the lag between changes in compensation rates and the rates of entrants to nursing and postulates that changes in nurse graduations cause cycles of boom and bust.33 The relatively short length of nurse education programs, however, allows a more rapid response to increased or decreased demands in local labor markets than is possible in most of the other health professions.
67 Licensed Practical Nurses In view of the paucity of current data, it is hazardous to make new projections of the future supply of LPNs. DHHS has projected that the rate of graduation of LPNs will continue to decline, reaching a level of 30,000 to 35,000 by 1990.34 This output, however, will still more than offset expected losses by retirement and death, so that the 1990 supply of active LPNs is projected by DHHS to be between 661,000 and 667,000, or same 100,000 larger than its estimates of the 1980 supply.35 In relation to population, the change would be from an estimated 249 per 100,000 in 1980 to 274 LPHs per 100,000 in 1990, representing an increase of 10 percent on a per capita basis. The Future Demands for Nurses DUES Projections for RNs A variety of approaches have been developed to estimate the overall future demand or need for KNs. An extensive review of these was presented in the 1977 Second Report to Congress from DHHS.36 Some of these approaches are discussed in Appendix 5, and further detail is given in a background paper of this report.* DHHS has also published several analyses of results and methodologies of its various projections.37~38~39 In the 1982 Third Report to Congress, DHHS focused on two refinements of earlier approaches--a projection model based on historical trends in effective demand for KNs, and a model based on criteria that represented professional judgments of staffing needs. Because the former was originally developed by Vector Research, Inc., it is sometimes referred to as the "Vector model," but hereinafter we shall refer to it as "the historical trend-based demand model." The second model, based on criteria established by the Western Interstate Commission on Higher Education, is generally called the 'NICHE model." We shall refer to it as the "judgment-of-need model." The historical trend-based demand model assumes that future demands for services rest on the base of actual experience and, thus, will strongly reflect past patterns of utilization and past trends in the delivery of health care. Some of the projection components of this model are based on trends in the provision of services and the uti lizat ion of RNs per unit of service in spec if ic kinds of work settings--hospitals, nursing homes, etc. Others are based on trends of employed nurses per unit of population. No distinction is made in this model as to the type of RN educational preparation. Its projections extend to the year 2000. *For detail, see Bauder, J. Methodologies for projecting the nation's future nurse requirements (see Reference 49 for complete citation).
68 The judgment-of-need model is eased on assumptions made by panels of KNs and others concerned with the numbers and kinds of nursing service personnel needed to achieve desired health care goals. It incorporates professional judgments regarding desirable changes in the future delivery of health care services as well as in numbers and educational preparation of the nurses (both KN and LPN) required to provide such services. This method--developed for state and national estimating purposes--calls for panels of experts to use judgment to develop criteria for staffing ratios by educational level and in a wider variety of specific work settings than does the historical trend-based model. Two sets of criteria are used: "lower bound'' criteria to be met by the target year of the state planning effort, and "upper bound" criteria to be met progressively. The national WICHE projections go to 1990. The 1982 Third Report to Congress presents the latest DHHS projections of nursing requirements under both approaches. The historical trend-based demand model used the 1977 sample survey of RNs as a base and projected increases in utilization of nurses based on observed trends between 1972 and 1977, with some adjustments based on analytical considerations. The judgment-of-need model reflected modified WICHE assumptions and criteria, updated in November 1980. The DHHS historical trend-based demand model projected a need for 1,245,400 FTE RNs in 1990. In contrast, the judgment-of-need model projected a lower bound need of 1,784,000 FTE RNs in 1990--43 percent more than the historical trend-based demand approach. The comparison in Table 12 shows the magnitude and the difference in estimates obtained from the two approaches according to work setting.* The large differences between the two projections arise from the WICHE panel's judgments as to the need for a far greater number of RNs in nursing homes and in community health services. The former setting accounts for about 377,000 and the latter for about 139,000 of the differences. The judgment-of-need level of staffing in these two settings could be met only through dramatic increases in the supply of RNs, with a major transfer of functions from LPNs to RNs. For all settings combined, the estimated 1990 need for LPNs is 331,000--a level markedly below both the present and projected supply estimates. The projections of the two models for numbers of nurses employed in hospitals are comparatively close, as are those for physicians' offices; the judgment-of-need reduced projections for nursing education appear primarily to be caused by technical peculiarities of the two projection processes. The judgment-of-need model, unlike the historical trend-based demand model, also projected the number of RNs needed according to levels of educational preparation. Those results are summarized and their implications discussed later in this chapter. *The upper bound criteria produced a requirement of 2,440,200 FTE RNs for 1990, but this extreme estimate is not considered in our study report or in the supporting background papers.
69 TABLE 12 Department of Health and Human Services Projections of Requirements for Registered Nurses (FTE), Two Models, January 1990 Historical Trend- Judgment-of-Need Based Demand Model Model (WICHE), Work Setting (Vector) Lower Bound Difference TOTAL--RN 1, 245, 4001, 784, 400539 ~ 000 Hospital 899, 920935, 70035, 780 Nursing home 93, 330469, 900376, 570 Community health 101, 100240, 500139,400 Physicians' office 71,89066,700-5,190 Nurs ing education 47,10037,000-10,100 Other 32,02033,7001, 680 TOTAL--LPN Not projected331,000- Hospital -100,800 Nursing home -208,000 Community health -2,000 Physicians' office -20,000 SOURCE: Secretary, DHB . Third report to the Congress, February 17, 1982: Nurse Training Act of 1975, 1982, pp. 174 and 176 (see Reference 10 for complete citation). Study Projections for RNs The committee reviewed the approaches, assumptions, and problems involved in using the historical trend-based demand model compared with the judgment-of-need model. We recognized the value of both approaches. However, we found the historical trend-based demand approach more consistent with our view that future economic demands for nurses are strongly indicated by experienced trends in actual utilization. Also, this model enabled the committee to make estimates of national demand under alternative assumptions as to future patterns of health service financing and delivery. Accordingly, the committee requested the DHHS to produce certain projections, using this model.* The availability in mid-1982 of data from the November 1980 National Sample Survey of Registered Nurses made it possible for the committee to update certain base information in the DHB historical *The committee is grateful for the assistance of DHHS staff in determining the feasibility of making several adjustments in the model and for producing new calculations for the three alternative estimates discussed below. In providing these services, however, the DHHS staff assumed no responsibility for the assumptions and specifications that the study committee developed.
70 trend-based demand model so as to reflect recent changes in AN staffing. However, we still faced limitations of existing data, including the lack of new 1980 U.S. Census population projections. Other limitations were encountered in timing, resources, and model design. More important, changes in the nation's economic situation during the 1980s; whatever they may turn out to be, may further influence in unanticipated ways both the supply of and the demand for nurses. The estimates presented below, therefore, do not prognosticate; they serve only to illustrate by general orders of magnitude changes that might occur in the use of nurse manpower during this decade. Responding to the specific provisions of the congressional charge for this study, the committee considered the potential effects of the enactment of a national health insurance program (Illustration 1) and of increased use of ambulatory care facilities (Illustration 3~. In addition, we felt it would be useful to test the potential impact on RN demand of a hypothesis that present patterns of service will continue, but under assumptions of stringent cost containment (Illustration 2~. In our illustrations, however, the committee did not venture assumptions as to the effects of possible restructuring of RN roles in the health services delivery system. We assume that restructuring of many types of positions in a variety of settings will occur, but we believe that in view of the evolutionary nature of this process and the lack of national consensus on staffing mix (by educational preparation), the potential restructuring phenomenon does not lend itself to national projection at this time. The assumptions used in the study's illustrative estimates are outlined below, and the operation of the model is discussed in Appendix 5 in some detail. Illustration l: Estimated Demand for RNs in 1990 Under National Health Insurance The congressional charge asked that need for nurses be considered under the health care delivery system "as it may be changed by the enactment of legislation for national health insurance." The study's considerations included the facts that (1) there is no consensus as to a version of national health insurance legislation that might be enacted, (2) current public consideration of Medicaid issues does not permit solid assumptions as to ultimate coverage and services under Medicaid, or as to its absorption into a national health insurance program, and (3) the level of resources and breadth of coverage for newly covered (now uninsured) populations in a national plan cannot be predicted. Nor is it clear what changes might occur in the details of the Medicare program. Moreover, assumptions would have to have been made as to date of enactment, phasing, and the question of whether a general overlay of catastrophic insurance for the entire population would be included. Faced with these many uncertainties, the committee simply adopted a set of high health service utilization requirements to illustrate the demand that might be experienced in the initial years of national health insurance. This estimate also can serve to illustrate what
71 demand might be during the balance of this decade in the absence of national health insurance, if one were to assume that cost containment programs will not be very effective in reducing hospitalization and resulting manpower requirements before the end of the decade. Essentially~this estimate assumes a continuation of the demand trends of the past decade; however, a higher base for community health nurse projections was employed. Under these assumptions the demand for FTE RNs would rise to 1.47 million by the end of 1990. Illustration 2: Estimated Demand for RNs in 1990 Under Cost Containment Measures An intermediate or normative estimate (not specifically called for by the congressional charge but offered by the committee to illustrate a likely set of assumptions) depicts the possible effect on demand for RNs if stringent cost containment policies at federal and state levels were to become progressively effective over the balance of the decade. The assumptions are that governmental budget imbalances and continuing increases in hospital costs, as well as the continuation of an appreciable rate of inflation in overall health care costs, will cause Medicare and Medicaid (federal and state) to exert increasing pressures on inpatient utilization by means of the capping of appropriated funds. Further limitations on payment are envisioned, such as movement toward prospective rate setting and per capita payment arrangements for groups of sponsored "public patients." Some extension of these trends is also assumed for the private sector. Under these assumptions the demand for FTE KNs would rise to 1.35 million by the end of 1990. Illustration 3: Estimated Demand for RNs in 1990 Under Increased Use of Ambulatory Care Facilities The other major alternative the committee was asked to consider was a health system modified by increased use of ambulatory care facilities. For purposes of this estimate, we assumed a substantial expansion of health maintenance organizations (HMOs) by the end of the 1980s, accompanied by an increasingly competitive climate among groups of physicians and providers. We also assumed a cost containment climate in which public and private payers increasingly will question the inappropriate use of intensive care units and of inpatient services when outpatient surgery or ambulatory care could be appropriate. For the technicalities of modeling, a surrogate assumption was made that, by the end of 1990, 30 percent of the United States population will receive services from HMO s or from some other pattern of service provision that similarly promotes ambulatory care. For this population, the model assumed sharp reductions in the volume of inpatient hospital services characteristic of membership in traditional HMOs (prepaid group practice plans). In addition to an adjustment in the model to reflect a higher base for community health nurse employment projections, the independent assumption was made that ~, .. -
72 TABLE 13 Study~s Illustrations of Projected Demand for Registered Nurses, Total and FTE, 1990, tender Three Sets of Assumptions Date and Projections - Registered Nurses Total FTE November 1980 (actual supply of employed RNs) December 1990 (pro j ected demand) Illustration 1--National health insurance Illustration 2--llospital cost containment Illustration 3--Increased ambulatory care 1,272,900 1,057,300 1,773,000 1,472,000 1,623,000 1,348,000 1,563,000 1,298,000 SOURCE: Appendix 5, Table 18. there would be a doubling in the per capita rate for home care visits for the entire population. under these assumptions, the demand for FTI; Ens would rise to 1.3 million by the end of 1990. When these three sets of assumptions were applied to the November 1980 estimate of employed RNs-~hich represented the effective demand at that time--a demand was projected at the end of 1990 that ranges between 1.30 million and 1.47 million full-time equivalent RNs (Table 13~. The slope of the resulting trend lines is portrayed in Figure 9. It is assumed that in 1990, as in 1980, nurses working part FIGURE 9 Demand for registered nurses (FTE) 1970-1980 (actual) with three illustrative study projections to 1990. ,,, 1 600 C5 o 5: - a LL J > 31 000 UJ LL J J 1600 cn LL cr) cc A 400 LL ~200 cn Lo cc 1 400 1 200 800 l l l ustration 1 1 1 -/ 111 ustrati on 2 _~ / /~// /~/: , ~ Illustration 3 z - 7 1= 1970 1980 1990 END OF YEAR
73 time will make up almost a third of the KN labor force. If this proved to be the case, the demand expressed as numbers of individual active RNs would range between 1.56 million and 1.77 millions There are no linear relationships in these estimates between changes in patient utilization of different services and nurse employment, because different service settings have varying rates of RN utilization per service and because of other reasons inherent in the model's construction. The study's projections of FTE RN demand are shown by selected work settings in Table 14. Almost all the TABLE 14 Study's Illustrations of Projected Demand for Registered Nurses (FTE) in Selected Practice Settings, December 1990, Under Three Sets of Assumptions Illustration Illustration Illustration Practice Settings I II III Hospital (total) 1,024,000 Short-term hospital inpatient 799,700 ICU (212,700) Non-ICU inpatient (569,800) Nursing administration (17,200) Outpatient 111,400 Other hospital 113,000 906,000 844,000 688,100 653,000 169,500) (169,500) 501,300) (466,600) (17,200) (17,200) 104,400 77,900 ll3,000 113,000 Nursing home100,000100,000 100,000 Community health123,000123,000 123,000 Home care30,00030,000 62,000 Physicians' office64,00064,000 22, coca HMO-type organizations10,00010,000 32,000 Nursing education57,00052,000 50,000 Private duty and other63,00063,000 63,000 TOTAL1,472,0001,348,000 1,298,000 NOTE: Detail may not add to totals because of rounding. fThe sharp drop in nurse requirements in physicians' offices under Illustration III can be discounted; it appears to be only partially attributable to a shift in patient utilization due to increased HMO services. It may also be due, in part, to the fact that the existing model was not designed to acca~odate such large increases in assumed HMO enrollments which cause correspondingly large decreases in non-HMO physicians' offices. The resulting nurse requirements for this practice site may reflect the manner in which model components interact. SOURCE: Appendix 5, Table 18.
74 differences among the three illustrations are accounted for by their varying assumptions as to future trends in hospital ICU and non-ICU inpatient services and by the added assumed impact on both hospital inpatient and outpatient demand of high HMO enrollment in Illustration III. Licensed Practical Nurses There is little current information on which to base projections of the future supply of and demand for LPNs. The 1990 supply of employed LPNs was projected by DHHS at 662,000 to 667,000.40 The study's illustrations of RN demand presented above generally make no assumptions as to future demand for LPNs but also carry no implications as to diminishing need. Comparison of the Study's Projections for Supply of and Demand for Registered Nurses In the future the demand for RNs can be expected to continue to increase with technological advances in health care delivery, population growth, and aging at rates that will depend somewhat on the organization and financing of health care delivery. At the same time, the supply also can be expected to increase, assuming continued financial support for nurse education to assure the reasonably steady rates of graduation described earlier and depending on a continuing high rate of labor force participation. The three supply projections for RNs made by the committee for the end of 1990 all fall within the wider range of estimates for 1990 demand (Table 15 and Figure 10~. This suggests, as far as can be estimated today, that in terms of national RN supply and demand, a reasonable degree of equilibrium will continue. However, because the assumptions for high supply and high demand estimates on the one hand and for low supply and low demand on the other operate on totally different sets of variables, no conclusion should be drawn that a probable concurrence of all low or all high factors in both supply and demand can be assured. The juxtaposition of the two low trend lines, thus, is not to suggest a probable oversupply of nurses; it simply shows order-of-magnitude relationships. TABLE 15 Summary of the Study's Alternative Projections of the Supply of and Demand for Registered Nurses (FTE), December 1990 Projection Demand Supply High Middle Low 1,451,000 1,472,000 1,436,000 1,348,000 1,379,000 1,298,000 SOURCE: Summary of Tables 11 and 13.
1 600 1 400 o - - c~ as LL J <1: > 1.200 1, 000 Lo LL - 800 600 z LL LL 400 200- _ 75 it' / ~1 ,, An/ 1 _, ~ - 1970 1980 1990 END OF YEAR Range of Projections UP Y Demand - FIGURE 10 Comparison of the projected supply of and demand for registered nurses (FTE), 1980-1990, under alternative study assumptions. The Need for Continued Monitoring The committee recognizes that however reasonable the foregoing estimates may be in the light of 1982 conditions, new circumstances could render them inappropriate to both national and state needs in 1990 or even earlier. Unforeseeable changes certainly will occur in the responsibilities and activities of nurses, in the economy, in the spending priorities that legislators, educators, and individuals establish, in alternative career opportunities available for women, and in the ability of the health care system to prevent, to arrest, or to cure disease and disability. Some of the forces that could operate to influence the extent, nature, and distribution of the future RN and LPN supply, either positively or negatively, are discussed in detail in succeeding chapters of this report. ~ Given the likelihood of change, nurse education planning, like any other education planning, should rely on a continuing monitoring of the needs of the population as well as conditions in the profession and in health services so as to guide appropriate allocation of nurse education resources. Much of this monitoring should be conducted at
76 the state level. It should encompass the predicted market demand for nurses in various settings of care by geographic regions and subregions, the predicted numbers and distribution of educational output as well as of total future supply, and consideration of unmet needs of special populations. Conclusion As this report is being written, in the midst of a prolonged economic recession, the extent to which hospitals, nursing homes, and other major nurse employers will choose to adjust the numbers and mix of their RN staffs is uncertain. In many geographical areas, past shortages in clinical settings now seem to have been greatly reduced. Improvements in the general economy could reverse some of these situations. However, as of the fall of 1982, on the basis of all evidence we have been able to marshal!, the committee concludes that there is no national aggregate shortage of generalist RNs or of LPNs. Rather, we have identified shortages that occur unevenly throughout the nation in different geographic areas, in different health care settings and institutions, within institutions, and in specialty nursing. These and other kinds of shortages are explored at length in succeeding chapters of the report. Their resolution will depend both on the operation of market forces and on concerted actions to be taken by all parties--federal, state and private sector--to facilitate the operation of these forces. After reviewing alternative sets of factors that might influence supply and demand by 1990, the committee concludes that, although hospitals and others are likely to want to employ greater numbers of RNs and LPNs throughout the decade, additions to the aggregate supply of generalist nurses are likely to keep pace. No exact equilibrium can be assured. Nevertheless, no critical imbalance in basic nurse supply seems imminent. Continued monitoring of supply and demand is required to detect imbalances that may develop and to guide future nurse education planning. RE COMMENDATION 1 No specific federal support is needed to increase the overall supply of registered nurses, because estimates indicate that the aggregate supply and demand for generalist nurses will be in reasonable balance during this decade. However, federal, state, and private actions are recommended throughout this report to alleviate particular kinds of shortages and maldistributions of nurse supply.
77 Supply of Registered Nurses Educated in the Three Types of Generalist Programs Although shortages are usually perceived in terms of aggregate supply, they also are frequently viewed by nurse educators and by some employers in terms of shortages or surpluses of RNs specifically prepared in one or more of the three different types of basic nurse education programs--diploma, associate degree (AD), and baccalaureate in nursing. In order to provide information that may be useful as background to more particularized analyses of nursing supply, the committee disaggregated its estimate of future national RN supply according to educational preparation. As of 1980, of the overall supply of approximately 1.27 million employed kNs, 20 percent had an associate degree as highest level of educational attainment, 51 percent had a diploma, and 29 percent had a baccalaureate or higher degree. This total of employed RNs, as noted earlier in Table 11, is projected by the study to grow to between 1,643,000 (low projection) and 1,728,000 (high projection) by the end of 1990. Within the study's intermediate projection total of 1,710,000 employed RNs, the number ~ - ~ higher degrees will have increased about 36 percent of total (Table 16~.* _ of nurses with baccalaureate or ~ bv about 257.000 and will make up *The present supply and projected increases in nurses with master's and doctoral degrees are discussed in Chapter V. TABLE 16 The Supply of Employed Registered Nurses, 1980 and Projected to 1990, by Highest Educational Preparation (Study's Intermediate Projection) Highest Educational - 1980 1990 Intermediate Projectionb ~. Preparation Number Percent Number Percent Diploma 645,500 50.7 614,000 35.9 Associate 256,200 20.2 475,000 27.8 Baccalaureate or higher 364,400 28.6 621,000 36.3 Unknown 6,800 0.5 - - TOTAL 1,272,900 100.0 1,710,000 100.0 aSVURCE: DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses ? November, 1980, Table 3, p. 11 (see Reference 4 for complete citation). bSOUXCE: West, M.D. Projected_supply of registered nurses, 1990: Discussion and methodology, Table 16 (see Reference 2 for complete citation).
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).
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
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
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
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
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.
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.
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
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.
