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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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Suggested Citation:"3 The Nursing Workforce." National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25982.
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3 The Nursing Workforce Health care delivery systems are “held together, glued together, enabled to function … by the nurses.” —Adapted from Lewis Thomas, physician, essayist, researcher The nursing workforce will be tested in a variety of ways over the next decade, including responding to an aging population that has more complex and intense medical needs, demand for more primary care ca- pacity, and the need to bridge medical and health care with the social factors that influence people’s health and well-being. To build a future workforce that effectively provides the health and health care that soci- ety needs will require a substantial increase in the numbers, types, and distribution of the nursing workforce, as well as an education system that better prepares nurses for practicing in community-based settings with diverse populations that face a variety of lived experiences. These improvements will occur more rapidly, more uniformly, and more suc- cessfully if programmatic, policy, and funding opportunities can be leveraged by health systems, governments, educators, and payers. Today in the United States, the health of far too many individuals, families, entire neighborhoods, and communities is compromised by social determinants of health (SDOH), such as food insecurity and poverty, as well as by limited access to health care services. The size, distribution, diversity, and educational preparation of the nursing workforce needed to assist in addressing these health challenges are therefore critically important. Even as the potential for nurses to help improve both SDOH and health outcomes has become clear, however, it has become increasingly apparent that a robust nursing workforce ready to meet these 59 PREPUBLICATION COPY—Uncorrected Proofs

60 THE FUTURE OF NURSING 2020–2030 challenges does not yet exist. In fact, some of the data discussed in this chapter highlight the potential for current gaps in the capacity of the nursing workforce to widen over the present decade. As described in the committee’s framework for this study (see Figure 1-1 in Chapter 1), strengthening the nursing workforce is one of the key areas that will enhance nursing’s role in addressing SDOH and improving health and health care equity. This chapter focuses on building the nursing workforce needed to respond to SDOH that affect the health care needs of individuals, communities, and soci- ety, including the pressing need to reduce health and health care inequities. The chapter begins by placing the nursing workforce in context and summarizing its current state and strengths. Next, it describes key challenges nurses will face over the current decade. Comparison of these challenges against the current state of the nursing workforce illuminates numerous gaps in the workforce that will need to be filled to meet the goal of addressing SDOH and improving health equity. After summarizing research needed to help nurses meet these challenges, the chapter ends with conclusions. The nursing workforce is composed of actively employed registered nurses (RNs), licensed practical or licensed vocational nurses (LPN/LVNs), and ad- vanced practice registered nurses (APRNs). As described in greater detail at the end of the chapter, the data and methods used to describe the nursing workforce come primarily from the 2008 and 2018 National Sample Survey of Registered Nurses (NSSRN), the U.S. Census Bureau’s yearly American Community Survey (ACS) for 2000–2018, and other sources. THE NURSING WORKFORCE IN CONTEXT The number of nurses in the United States has grown steadily over the past 100 years. The nursing workforce is the largest among all the health care profes- sions and is nearly four times the size of the physician workforce. RNs practice in a wide variety of care delivery settings, and they provide care to people living in both urban and rural areas and to vulnerable populations, including women, people of color, American Indians/Alaska Natives (AI/ANs), low-income individ- uals, individuals with disabilities, and people who are enrolled in both Medicare and Medicaid (dual eligible). The shift in nursing education from hospital-based diploma programs to degrees from colleges and universities has prepared RNs for more highly skilled roles that have expanded their reach and impact, benefiting both nurses and their employers. The emergence and growth of nurse practitioners (NPs) in the mid- 1960s, together with other advanced practice nursing roles (certified nurse mid- wives, nurse anesthetists, and clinical nurse specialists), represent a significant advancement. Nurses also benefit individuals, communities, and society through their efforts as scientists conducting clinical and health services research; as executives and entrepreneurs leading health care organizations; as members of PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 61 hospital and health system boards; as public health officers and educators; and as members of federal, state, and local governments. For decades, nurse employment has grown concurrently with increased U.S. spending on acute care, seemingly impervious to either government or mar- ket-oriented efforts aimed at constraining the overutilization of costly health care services. With unemployment rates rarely exceeding 1.5 percent, job availability has seldom been a problem for nurses (BLS, 2020a; Zhang et al., 2018). Even during economic downturns, RN employment typically has increased, some- times dramatically. Hospitals added nearly 250,000 nursing full-time equivalents (FTEs) during the Great Recession, for example, including in economically de- pressed areas of the country (Buerhaus and Auerbach, 2011). Even so, vacancies exist in some areas, including Indian Health Service areas, with uneven distribu- tion across several states, ranging from 10 to 31 percent (GAO, 2018). RNs and APRNs are among the most highly paid health professionals, mak- ing the nursing profession an economic engine for families and communities. In 2018, national RN earnings averaged $76,000, and with an estimated 3.35 million RNs working on an FTE basis in the United States, total RN earnings amounted to roughly $255 billion (not counting nonwage benefits). As a result, the value of the clinical care they deliver typically appears on the cost side rather than the revenue side of earnings statements for provider organizations. When thinking about how nurses can promote health equity, however, one should not lose sight of their contributions to the economic as well as the social and environmental fabric of the places where they live and work. The COVID-19 pandemic has illuminated the critical importance of nurses, but it also has disrupted long-standing employment patterns and threatened nurses’ financial, psychological, and physical resilience. Nurses heroically risked exposure to the coronavirus each day to care for patients and their families, sometimes with- out adequate personal protective equipment. But the pandemic also exposed nurses’ vulnerability to their clinical employers’ dependence on reimbursable services, especially elective procedures, to remain in business. With revenue from private health insurers in steep decline, many hospitals and clinics seeking quick reductions in costs have cut back on nursing through furloughs and layoffs (Gooch, 2020). This counterproductive response to the pandemic could cause long-lasting damage to the nursing profession and the health care system. This and other destabilizing effects on the nursing workforce associated with COVID-19 merit close attention. CURRENT STATE AND STRENGTHS OF THE NURSING WORKFORCE Although this chapter’s main focus is on identifying the challenges and gaps in the nursing workforce that will develop over this decade and describing ways to overcome them, the success of such actions will depend on leveraging the capacity and the many strengths of the current nursing workforce. These strengths represent opportunities to achieve and sustain a workforce of sufficient size, distribution, PREPUBLICATION COPY—Uncorrected Proofs

62 THE FUTURE OF NURSING 2020–2030 diversity, and expertise to help achieve equity in health and health care and reverse the trajectory of poor health status seen in communities across the nation. Registered Nurses Over the past 20 years, the number of people becoming RNs has increased rapidly, reaching 3.35 million FTEs in 2018 (see Table 3-1). Although the RN work- force continues to be composed largely of White women, the proportion of White RNs decreased from 79.1 percent in 2000 to 69 percent in 2018. The workforce has steadily become more diverse as the proportion of RNs who are Black/African American now approximates that of the nation’s population (12 percent), while the proportion of RNs who are Asian (9.1 percent) exceeds that of the population (6.0 percent). On the other hand, despite doubling since 2001, the proportion of Hispanic RNs in the nursing workforce (7.4 percent) is well below that of the population (18.3 percent). The proportion of men who are RNs had grown to 12.7 percent by 2018. RNs are increasingly educated at both the undergraduate and graduate levels. It is important to note that the 2011 The Future of Nursing report recommends increasing the percentage of nurses with a baccalaureate degree to 80 percent by 2020 (IOM, 2011). The number of employed RNs prepared with at least a bachelor’s degree has surpassed the number prepared with an associate’s degree. This growth has been driven, in part, by RNs completing RN-to-bachelor of science in nursing (BSN) education programs, which provide additional education needed by RNs with an associate’s degree to earn a BSN. The increase in educational attainment has been particularly strong among people of color (POC) RNs. Table 3-2 shows that na- tionally, a higher percentage of Black/African American, Hispanic, and particularly Asian RNs relative to White RNs have a BSN.1 Proportionately, more Black/African American and Asian RNs than White and Hispanic RNs have a master’s degree, or a doctor of nursing practice (DNP) or a PhD in nursing. Box 3-1 provides information on the nursing workforce educated in countries outside of the United States. Analysis of data from the American Association of Colleges of Nursing (AACN) show that between 2010 and 2017, the number of RNs who obtained a doctoral degree increased rapidly, with those obtaining a DNP far outnumbering those obtaining a PhD (see Figure 3-1). Among White RNs, the number of DNP graduates increased from 982 in 2010 to 4,138 in 2017 (an increase exceeding 3,000 percent), while the number of PhD graduates increased from 363 to 462 1  It is possible that nurses educated in other countries are more likely to have earned a bachelor’s degree, which could partially account for the higher percentage of bachelor’s-level education reported by Black/African American and Asian RNs relative to White RNs. When the committee investigated this possibility, it found no supporting evidence with regard to Black/African American nurses but a significant impact for Asian RNs. Additionally, when we examined RNs under age 40, the pattern of results persisted, as a higher proportion of Black/African American (67.3 percent), Asian (76.7 per- cent), and other (68.0 percent) RNs compared with White (65 percent) RNs had earned a bachelor’s degree in nursing, Hispanics (58 percent) being the exception. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 63 TABLE 3-1 Demographic Characteristics of Full-Time Equivalent (FTE) Registered Nurses (RNs), 2000–2018 Year Characteristics 2000 2004 2008 2018 Total FTE RNs 1,985,944 2,142,353 2,542,703 3,352,461 FTE RNs/ 7.04 7.32 8.36 10.26 population Gender Men 157,285 211,891 244,363 424,342 (7.9%) (9.9%) (9.6%) (12.7%) Women 1,828,709 1,930,462 2,298,340 2,928,119 (92.1%) (90.1%) (90.4%) (87.3%) Race White 1,571,136 1,673,073 1,906,756 2,313,002 (79.1) (78.1) (75.0) (69.0) Black/African 175,669 191,102 269,271 401,755 American (8.8%) (8.9%) (10.6%) (12.0%) Asian 128,064 161,598 211,751 305,740 (6.4%) (7.5%) (8.3%) (9.1%) Other 37,266 28,027 37,370 84,454 (1.9%) (1.3%) (1.5%) (2.5%) Hispanic 73,859 88,553 117,556 247,511 (3.7%) (4.1%) (4.6%) (7.4%) Education Associate’s 703,959 839,506 997,671 910,629 degree (37.7%) (37.4%) (38.1%) (29.3%) Bachelor’s 610,735 778,513 957,422 1,411,525 degree (32.7%) (34.7%) (36.6%) (45.4%) Master’s 202,018 296,245 361,559 644,764 degree/PhD (10.8%) (13.2%) (13.8%) (20.7%) Employment Hospital 1,307,476 1,352,356 1,606,924 2,071,034 (63%) (63.1%) (63.2%) (61.8%) Nonhospital 778,461 789,997 935,779 1,281,424 (37%) (36.9%) (36.8%) (38.2%) Age <35 895,759 486,098 584,982 980,779 (23.0%) (22.7%) (23.0%) (29.3%) 35–49 2,017,925 968,308 1,017,328 1,202,345 (51.8%) (45.2%) (40.0%) (35.9%) 50+ 980,651 687,947 940,394 1,169,337 (25.2%) (32.1%) (37.0%) (34.9%) Overall average 42.68 43.87 44.37 43.69 SOURCE: Calculations of data from the American Community Survey (IPUMS USA, 2020). PREPUBLICATION COPY—Uncorrected Proofs

64 THE FUTURE OF NURSING 2020–2030 TABLE 3-2 Number and Percentage of Nurses with Various Levels of Nursing Education by Race, 2018 Black/ African Other All Nursing Education White (%) American (%) Asian (%) Hispanic (%) (%) (%) Diploma 118,131 6,584 4,794 3,056 (5.9) (2.9) (2.8) 13,366 (4.3) (3.6) 5.3 Associate’s Degree 687,671 67,163 26,491 112,409 24,429 (34.6) (29.6) (15.6) (36.2) (29.1) 33.1 Bachelor’s Degree 968,411 119,605 117,425 155,324 49,783 (48.8) (52.07) (69.0) (49.8) (59.2) 50.8 Master’s 196,362 28,582 19,465 27,701 6,612 Degree (9.9) (12.6) (11.4) (8.9) (7.9) 10.0 Doctor of Nursing Practice (DNP) or 14,897 4,841 1,908 2,388 179 PhD (0.8) (2.1) (1.1) (0.8) (0.2) 0.9 Total 1,985,472 226,766 170,083 311,188 84,059 SOURCE: Calculations of data from the 2018 National Sample Survey of Registered Nurses. (27 percent). The proportionate growth among POC RNs was even greater. For example, the number of Black/African American RNs who obtained a DNP increased from 139 in 2010 to 826 in 2017 (a nearly 5,000 percent increase), while the number earning a PhD increased from 52 to 107 (105 percent) over this same period. Unfortunately, because RNs who have earned DNPs could not be identified in the 2018 NSSRN public use files, it is impossible to identify the sociodemographic, economic, or employment characteristics of this growing segment of the doctoral-level nursing workforce. It will be important for future NSSRNs to ensure the ability to identify RNs who have obtained a DNP so the sociodemographic, economic, and practice characteristics of this rapidly growing segment of the nursing workforce can be identified and analyzed, particularly in relation to whether and how DNPs are addressing SDOH. The average age of the RN workforce has decreased to just under 44 years as the large number of RNs belonging to the baby boom generation (estimated at 1.2 million) have retired and younger RNs have entered the workforce. RNs working in hospitals are younger (42.3) than those working in nonhospital settings (47.0) (see Table 3-1), which suggests that the large numbers of RNs retiring over this decade will likely be among those working in non–acute care settings. While many policy makers, consumers, and the media often associate RNs with working in hospitals (in fact, hospitals employ almost two-thirds of the RN workforce), what should not be overlooked is that RNs come into contact with individuals in a large number and wide array of settings. Table 3-3 shows more than 30 settings in which some RNs provide direct primary care, while others supplement the primary care workforce, provide care to rural populations, help PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 65 BOX 3-1 Internationally Educated Nurses Internationally educated nurses (IENs) are individuals who have completed nursing education outside of the United States. IENs make up 8–15 percent of the nursing workforce in the United States, with a majority coming from the Philippines (Hohn et al., 2016; HRSA, 2010). To gain employment in the United States, IENs are required to obtain employment-based (EB) visas—EB-2 visas for advanced degree nurses and EB-3 visas for associate’s or bachelor’s degree nurses. Although historically, employers typically recruited IENs during nursing shortages, this trend has changed since 2000, with greater focus on expanding the domestic nursing workforce (Auerbach et al., 2015). Data from the National Sample Survey of Registered Nurses (NSSRN) show an increase in the propor- tion of IENs between 2004 and 2008, from 3.5 percent to 5.4 percent (100,791 to 165,539 nurses) (Cho et al., 2011; HRSA, 2010). However, more recent data show decreases in the number of IENs. Data from the Organisation for Economic Co-operation and Development (OECD) demonstrate significant decreases in the annual inflow of IENs, from 24,000 in 2007 to fewer than 6,500 in 2015 (OECD, 2018). The number of first-time internationally educated candidates taking the NCLEX-RN exam decreased between 2007 and 2019, from 33,768 to 15,053 (NCSBN, 2008, 2019). Conversely, the nursing workforce has increased over time in the United States: from 2000 to 2018, the number of RNs increased from 1,985,944 to 3,352,461. The decreases in IENs can be attributed to factors that include visa retrogres- sion and the economic recession of 2007 to 2009. Visa retrogression occurs “when the number of visa applications within a particular country or category exceeds the number of available visas, causing the cutoff date to move backward in time instead of forward” (Shaffer et al., 2020, p. 30). Retrogression has major impacts on IEN recruitment. For instance, it can delay the waiting period for obtaining a visa, which sometimes exceeds a decade, and there have been times when visas have not been available. During a recession, health care employment typically does not decline since the demand for health care services is constant. Similarly, during the 2007–2009 recession, health care employment grew, with positions being filled mainly by domestic health care workers. The nursing workforce saw less turnover, and there was a decline in IEN recruitment. As the economy recov- ered, recruitment of IENs slowly increased; however, the numbers of IENs have remained significantly lower than the peak in 2007 (Masselink and Jones, 2014). improve maternal health outcomes, deliver acute and emergency care, provide health education and preventive care, coordinate patient care, and facilitate con- tinuity of care for patients and families across settings and providers. The table also shows that the average annual earnings of RNs are lowest in settings (e.g., critical access hospitals, nursing homes, inpatient and outpatient mental health facilities, public clinics, public health, school health, and home health) where RNs often interact with people facing multiple social risk factors. PREPUBLICATION COPY—Uncorrected Proofs

Number of Nursing Doctorate Graduates by 66 THE FUTURE OF NURSING 2020–2030 Race/Ethnicity Race/Ethnicity Unknown Non-U.S. Residents (International) Two or more races* White Black or African American Hispanic or Latino Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander -200 300 800 1,300 1,800 2,300 2,800 3,300 3,800 4,300 2010 PhD 2017 PhD 2010 DNP 2017 DNP FIGURE 3-1 Number of nursing doctoral graduates by race/ethnicity. NOTE: DNP = doctor of nursing practice. SOURCE: Data calculated from data from the American Association of Colleges of Nursing. TABLE 3-3 Number of Registered Nurses (RNs) by Employment Setting, Average Annual Earnings, and Age, 2018 RNs Percentage Average Older of RNs All Percentage Annual Than Age Older Than Employment Setting RNs of All RNs Earnings 50 Age 50 Hospital (not mental health) Critical access hospital  309,822 11.2 $ 77,122 120,353 38.8 Inpatient unit—not critical access hospital  755,639 27.2 72,668 210,958 27.9 Emergency department—not critical 161,603 5.8 76,577 32,708 20.2 Hospital-sponsored ambulatory care  253,347 9.1 77,826 128,015 50.5 Hospital ancillary unit  54,181 2.0 82,063 23,514 43.4 Hospital nursing home unit  13,288 0.5 72,442 7,564 56.9 Hospital administration  95,543 3.4 110,396 54,103 56.6 Other hospital setting  20,133 0.7 88,454 8,054 40.0 Other hospital setting (consultative)  49,717 1.8 85,924 34,436 69.3 Other Inpatient Setting Nursing home unit not in hospital  60,615 2.2 69,479 30,557 50.4 Rehabilitation facility/long-term care  110,554 4.0 74,832 50,160 45.4 Inpatient mental health  55,089 2.0 68,044 24,091 43.7 Correctional facility  13,775 0.5 75,769 5,028 36.5 PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 67 TABLE 3-3 Continued RNs Percentage Average Older of RNs All Percentage Annual Than Age Older Than Employment Setting RNs of All RNs Earnings 50 Age 50 Other inpatient setting 11,938 0.4 70,729 4,414 37.0 Clinic/Ambulatory Setting Nursing-managed health center  9,183 0.3 91,244 2,594 28.2 Private medical practice (clinic, physician)  138,291 5.0 72,787 58,379 42.2 Public clinic (rural health center, federally qualified health center [FQHC], Indian Health Service, tribal clinic, etc.) 33,484 1.2 69,983 14,210 42.4 School health service (K–12 or college) 65,015 2.3 57,506 36,718 56.5 Outpatient mental health/substance abuse facility  14,995 0.5 68,288 7,124 47.5 Ambulatory surgery center (freestanding) 8,807 0.3 63,668 3,062 34.8 Other clinical setting  67,182 2.4 71,599 28,773 42.8 Other Types of Settings Home health agency/service  175,212 6.3 71,277 96,400 55.0 Occupational health or employee health  11,360 0.4 77,556 8,346 73.5 Public health or community health 41,176 1.5 71,712 16,952 41.2 Government agency other than public/community health or correctional facility 41,229 1.5 81,423 23,777 57.7 Outpatient dialysis center  27,704 1.0 81,032 11,231 40.5 University or college academic department 34,698 1.2 70,857 19,178 55.3 Case management/disease management and insurance company 78,637 2.8 81,324 38,202 48.6 Call center/telenursing center  15,935 0.6 79,754 9,613 60.3 Other type of setting  12,197 0.4 89,431 7,298 59.8 Other type of setting (consultative) 38,130 1.4 92,522 21,366 56.0 All 2,778,476 100.0 76,180 1,137,176 SOURCE: Calculations based on the 2018 National Sample Survey of Registered Nurses. PREPUBLICATION COPY—Uncorrected Proofs

68 THE FUTURE OF NURSING 2020–2030 Table 3-3 also shows the percentages of RNs in each employment setting who are over the age of 50, many of whom are expected to retire by the end of the decade. Indeed, the number of employment settings in which more than 40 percent of RNs are over age 50 is striking: critical access hospitals (40 percent); outpatient dialysis centers (40.5 percent); public health/community health (41.2 percent); private physician offices (42 percent); public clinics, such as rural health centers, federally qualified health centers (FQHCs), and Indian Health Service facilities (42.4 percent); inpatient mental health facilities (43.7 percent); outpatient mental health/substance units (47.5 percent); case manage- ment/disease management (48.6 percent); nursing home units not in hospitals (50 percent); hospital-sponsored ambulatory clinics (50.5 percent); home health agencies (55 percent); school health (56.5 percent); hospital nursing home units (57 percent); call centers (60.3 percent); occupational health (73.5 percent); and other settings (>50 percent). As RNs in these settings retire, they will be replaced by more recently educated nurses who, as discussed below, may not be as prepared for taking care of medically complex patients and addressing SDOH. Fewer RNs are working in rural areas today than in the past (17 percent in 2005 versus 14.4 percent in 2018). The percentage working in rural hospitals also decreased over these same years (from 16.4 percent to 13.4 percent), as did the percentage of rural RNs working in nonhospital settings (18.0 percent to 16.0 percent). Furthermore, the decline in rural practicing RNs occurred more rapidly among younger RNs (under age 40) (from 18.1 percent to 13.7 percent) than among RNs over age 40 (from 16.4 percent to 14.9 percent). If this decrease continues, it will threaten access to care among the nation’s rural population. Given the large number of RNs working in critical access hospitals (more than 300,000) and the concern that more rural hospitals will close in the years ahead (Frakt, 2019), the number of RNs and physicians practicing in rural areas could decline further during this decade, complicating policies aimed at increasing access to care for the populations in these areas. Looking to the future, the size of the FTE RN workforce is projected to grow substantially, from 3.35 million in 2018 to 4.54 million in 2030, enough to replace all the baby boom RNs who will retire over the decade. However, this projected growth will not occur uniformly across the nation because the replacement of the large numbers of retiring RNs by younger nurses will vary by state and by region. Thus, health care delivery organizations in some regions of the country will confront more rapid retirements and slower replacements among their RN workforce relative to other regions, which could in turn result in staffing disrup- tions. Still, the estimated growth in the RN supply is encouraging and means that large, long-lasting national shortages of RNs are unlikely to be seen during the decade. At the same time, as with all projections, these estimates are based on assumptions that may not hold over the projection period and are subject to unforeseen developments, such as the economic and noneconomic effects of the COVID-19 pandemic. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 69 Licensed Practical/Vocational Nurses LPN/LVNs (for brevity, referred to here as LPNs) support RNs and APRNs in providing patient care. In 2018, an estimated 701,650 LPNs provided health care to mostly racially and ethnically diverse populations both in the community and in health care organizations. These nurses also add meaningfully to the pipeline for RN and APRN roles and, importantly, allow RNs to concentrate on caring for medically complex patients. As the U.S. population ages, LPNs are likely to become an important resource for home care, long-term care, and care for individuals with disabilities and otherwise vulnerable groups. As in the case of RNs, the majority of LPNs are White (71.4 percent), but there are proportionately more Black/African American LPNs (18.5 percent) than is the case among RNs (12 percent). Also, as with RNs, the proportion of Hispanic (7.4 percent) and male (7.7 percent) LPNs in 2017 was far below their proportion in the population. Smiley and colleagues (2018) report that newer cohorts of LPNs are younger and more likely to be racially and ethnically diverse. As of 2018, more than one-third (38 percent) of LPNs worked in nursing and residential care facilities, considerably more than in hospitals (15 percent), phy- sician offices (13 percent), and home health care facilities (12 percent). Almost one in four LPNs lived in rural areas (166,000). Because nearly one-third of LPNs are over age 55, their impending retirement over the next decade raises concern about a potential shortage of these nurses. A 2017 Health Resources and Services Administration analysis suggests that, because the demand for LPNs is growing at a slightly faster rate than the supply, a shortfall of roughly 150,000 FTE LPNs is possible by 2030. Such a shortage could mean that home care, long-term care, and care for individuals with disabilities and otherwise vulnerable groups will increasingly have to be provided by the RN workforce. Box 3-2 provides information on the impacts of COVID-19 on the nursing workforce in nursing homes. Advanced Practice Registered Nurses APRNs are nurses who hold a master’s degree, post-master’s certificate, or practice-focused DNP degree in one of four roles: NP, certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), or certified nurse midwife (CNM). As shown in Table 3-4, counting the number of APRNs is complicated because many APRNs are prepared in more than one role (e.g., they could be an NP and also a CNM or a CNS), and because a considerable number are employed in a position that is not what they were prepared for (e.g., an NP might be working as an RN rather than as an NP, or a CNM working as an NP). For consistency, this section focuses on APRNs who are employed in nursing and are working in the role for which they were prepared. Also, because of the larger numbers of APRNs practicing in the NP role relative to other advanced practice roles, this section focuses largely on NPs. PREPUBLICATION COPY—Uncorrected Proofs

70 THE FUTURE OF NURSING 2020–2030 BOX 3-2 COVID-19 and Nurse Staffing in Nursing Homes As of 2020, there were 15,417 long-term care facilities in the United States (CMS, 2020), and in 2017, these facilities housed just over 1.3 million people (Chidambaram, 2020). As of the end of May 2020, there were 95,515 cumulative confirmed cases of COVID-19 among nursing home residents in the United States and 30.2 deaths per 1,000 residents. Almost one-third (31,782) of the 103,700 people who died from COVID-19 in the United States through the end of May were residents of nursing homes (CMS, 2020). As of the end of July 2020, more than 60,000 deaths had occurred in nursing homes and long-term care facilities in the United Sates, and close to 800 staff had died (McGarry et al., 2020). A 2019 study (Geng et al., 2019) assessed nursing home staffing prior to the spread of COVID-19 using various data available from the Centers for Medicare & Medicaid Services (CMS). Among the study’s findings were the following: • Seventy-five percent of nursing homes were almost never in compliance with what CMS expected their registered nurse (RN) staffing levels to be, based on residents’ acuity. • Across staffing categories (RN, licensed practical nurse [LPN], and nurse aide), staffing levels, especially for RNs, were stable during weekdays but dropped on weekends. On average, weekend RN staffing in terms of time spent per resident was 17 minutes (42 percent) less than weekday staff- ing, LPN staffing 9 minutes (17 percent) less, and nurse aide staffing 12 minutes (9 percent) less. Larger facilities, on average, had a larger decrease in staffing time per resident during weekends. Decreases were smaller among facilities with higher five-star overall ratings and with lower shares of Medicaid residents. A 2020 study (McGarry et al., 2020) examined access to personal protective equipment (PPE), staffing, and facility characteristics associated with shortages of PPE and staffing from May through the end of July 2020. Findings included the following: • One in five nursing homes reported facing a severe shortage of PPE or staff shortage in early July 2020. Rates of both PPE shortages and staff did not meaningfully improve from May to July 2020. • PPE shortages were magnified in nursing homes with COVID-19 cases among staff or residents and those with low quality scores. •  shortages were greater in facilities with COVID-19 cases, particularly Staff among those serving a high proportion of disadvantaged patients on Medicaid and those with lower quality scores, including pre-pandemic staffing score. • Most prominent staff shortages were for nurses and nursing aides as op- posed to other providers or staff. As shown in the table below, by a wide margin, the numbers of LPNs, home and personal care aides, nursing assistants, and other support staff working in skilled nursing facilities (SNFs) far exceeded the numbers of professionals over PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 71 the 5-year period 2014–2018. There are also large proportions of Black/African American LPNs, personal care aides, and nursing assistants staffing SNFs in the United States. Nursing homes are ill prepared to manage infectious disease epidemics such as COVID-19. The burden of care falls disproportionately on the nursing staff, which too often is inadequate in numbers and insufficiently trained and protected to deal with such situations. Indeed, a recent study (Figueroa et al., 2020) of 4,254 nursing homes across eight states found that those that were high-performing with respect to nurse staffing had fewer COVID-19 cases relative to their low-performing counterparts. These findings suggest that poorly resourced nursing homes with nurse staffing shortages may be more susceptible to the spread of COVID-19 (Figueroa et al., 2020). Employment in Skilled Nursing Facilities, 2014–2018 Black or African Occupation White American Asian Hispanic Other Total Social Worker 72.9% 13.3% 3.0% 9.0% 1.9% 22,905 Occupational Therapist 77.1% 6.1% 10.9% 5.1% 0.8% 12,547 Physical Therapist 65.7% 5.8% 21.5% 5.4% 1.5% 15,911 Registered Nurse 63.8% 18.7% 9.5% 5.6% 2.4% 237,230 Licensed Vocational Nurse 54.8% 29.1% 5.5% 8.0% 2.6% 219,974 Home Health Aide 44.5% 37.2% 3.7% 11.7% 2.8% 115,582 Personal Care Aide 42.5% 30.3% 7.9% 15.7% 3.5% 71,914 Nursing Assistant 44.8% 36.8% 4.3% 10.7% 3.4% 470,183 Other Health Care Support Aides/ Assistants* 60.8% 19.9% 6.0% 10.8% 2.5% 37,726 * Includes occupational and physical therapy aides, orderlies, psychiatric aides, and medical  assistants. NOTE: Data should be interpreted as 5-year averages over the 2014–2018 period.  S  OURCE: Calculations based on the American Community Survey 2014–2018, 5-Year Public Use Micro Sample file. PREPUBLICATION COPY—Uncorrected Proofs

72 THE FUTURE OF NURSING 2020–2030 Size and Sociodemographic Characteristics The total number of APRNs increased considerably in the 10-year period be- tween the last two NSSRNs (2008 to 2018), reaching nearly 375,000 in 2018 (see Table 3-4), although APRN shortages remain in Indian Health Service areas— with vacancy rates ranging between 12 and 47 percent for NPs (GAO, 2018). By a wide margin, NPs outnumber any other APRN role, and their numbers grew more rapidly relative to other APRN roles, nearly doubling over this period. The number of APRNs working in the role of a CNS also increased. Although the total number of RNs prepared as a CRNA-only decreased, the number of CRNAs who were also prepared in another APRN role increased substantially. With regard to CNMs, difficulties associated with question wording in the 2008 and TABLE 3-4 Number of Employed Advanced Practice Registered Nurses (APRNs), 2008 and 2018 2008 2018 All APRN-Prepared Registered Nurses (RNs) Employed in Nursing Prepared in a single APRN role 205,074 347,861 Prepared in more than one APRN role 18,015 2,968 Total 223,089 373,829 Share of all APRNs prepared in more than one role 8% 7% Nurse Practitioner (NP)–Prepared RNs Employed in Nursing Prepared in the role of an NP only 125,264 258,241 Prepared as an NP and also in another APRN role 17,527 24,395 Total 142,791 282,636 Share of all NP-prepared APRNs also prepared in another APRN role 12% 9% Clinical Nurse Specialist (CNS)–Prepared RNs Employed in Nursing Prepared in the role of a CNS only 34,987 55,111 Prepared as a CNS and also in another APRN role 14,806 15,626 Total 49,793 70,737 Share of all CNS-prepared APRNs also prepared in another APRN role 30% 22% Certified Registered Nurse Anesthetist (CRNA)–Prepared RNs Employed in Nursing Prepared as a CRNA only 31,156 29,869 Prepared as a CRNA and also in another APRN role 871 7,542 Total 32,027 37,411 Share of all CRNA-prepared APRNs also prepared in another APRN role 3% 20% SOURCE: Calculations based on the 2008 and 2018 National Sample Survey of Registered Nurses. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 73 2018 NSSRNs, combined with small numbers of CNMs sampled in each survey, make estimating the numbers of CNMs problematic. Instead, using data from the American Midwifery Certification Board (AMCB), the number of AMCB-certi- fied nurse midwives in the United States increased from an estimated 11,262 in 2014 to 12,276 in 2018 (AMCB, 2019). The racial/ethnic composition of NPs has become more diverse (see Figure 3-2), though it lags behind the gains of the basic RN workforce. The proportion of Hispanic NPs increased the most between 2008 and 2018, from 3.8 percent of all NPs to 9.2 percent (an increase of 12,900). The number of Black/African American NPs also increased over this period, from just under 8,000 to nearly 13,000, while the numbers of Asian and other POC NPs increased more slowly. Similar to the basic RN workforce, NPs and CNSs have remained over- whelmingly women (in 2018, 90.3 percent and 96.7 percent, respectively). The number of male NPs increased slowly between 2008 and 2018, accounting for about 10 percent of NPs in the latter year. In contrast, the proportion of male CRNAs exceeded 40 percent in 2008 but had decreased to 32.7 percent by 2018. CNMs are predominantly female (99 percent) and White (87 percent), with only 6 percent Black or African American (AMCB, 2019). Employment Settings and Clinical Specialties Table 3-5 shows that NPs provide access to care for millions of Americans in a wide variety of settings. In 2018, more than 100,000 NPs (52 percent of all NPs) worked in different types of clinics or ambulatory settings (including nurse-managed health centers; private medical practices; school health services; 100% 90% 83.5% 80% 75.3% 70% 60% 50% 40% 30% 20% 9.2% 7.7% 10% 3.8% 6.2% 4.3% 3.8% 2.7% 3.5% 0% White Hispanic Black or African Asian Other American 2008 2018 FIGURE 3-2 Nurse practitioners by race and ethnicity, 2018. SOURCE: Calculations based on data from the 2018 National Sample Survey of Regis- tered Nurses. PREPUBLICATION COPY—Uncorrected Proofs

74 THE FUTURE OF NURSING 2020–2030 TABLE 3-5 Nurse Practitioner Employment Settings, 2018 Median Full-Time Equivalent (FTE) Annual Employment Setting Number Percentage Earnings Clinic or Ambulatory Care Settings Nurse-managed health center 1,736 0.9 $99,000 Private medical practice (e.g., clinic, physician office) 63,155 32.6 100,000 Public clinic (e.g., rural health center, federally qualified health center [FQHC], Indian Health Service [IHS]) 16,309 8.4 97,000 School health service (K–12 or college) 4,060 2.1 90,000 Outpatient mental health/substance abuse facility 5,528 2.9 110,000 Other clinic/outpatient/ambulatory care setting 9,742 5.0 106,000 Total 100,529 51.9 Other Settings Home health agency/service 4,118 2.1 $105,000 Occupational health/employee health service 1,459 0.8 106,000 Public health/community health agency 995 0.5 100,000 Government agency, other than public/community health or correctional facility 3,558 1.8 110,000 University or college academic department 2,021 1.0 91,000 Case mgmt./disease mgmt. in insurance company 970 0.5 114,000 Other setting (outpatient dialysis center, call center) 1,064 0.5 100,000 Total 14,185 7.3 105,000 Hospitals Critical access hospital (CAH) 7,971 4.1 $112,000 Inpatient unit, non-CAH 28,855 14.9 110,000 Hospital-sponsored ambulatory care 21,464 11.1 109,000 Emergency department, non-CAH 6,077 3.1 120,000 Other hospital-based setting 3,758 1.9 105,000 Total 68,125 35.2 112,000 Other Inpatient Settings Nursing home, nonhospital 2,687 1.4 $105,000 Rehabilitation facility/long-term care 3,705 1.9 105,000 Inpatient mental health/substance abuse 2,502 1.3 111,000 Correctional facility 1,567 0.8 108,000 Other inpatient setting 288 0.1 103,000 Total 10,749 5.6 SOURCE: Calculations from data in the 2018 National Sample Survey of Registered Nurses. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 75 outpatient mental health/substance abuse facilities; and public clinics, includ- ing rural health centers, FQHCs, and Indian Health Service facilities). Another 14,000 (7.3 percent of all NPs) worked in various other settings, such as home health agencies, occupational health/employee health services, and universities or colleges. Roughly 68,000 (35 percent of all NPs) worked in hospitals, ranging from critical access hospitals to inpatient units, hospital ambulatory clinics, and emergency departments. Nearly 11,000 (5.6 percent of all NPs) worked in other inpatient settings, including nursing homes, rehabilitation and long-term care facilities, and correctional facilities. With regard to annual earnings, NPs’ median earnings varied considerably by setting, ranging from a low of $90,000 for those employed in school health settings to $120,000 for those working in emergency departments in non–critical access hospitals. In 2018, a little more than half of NPs (54.7 percent or nearly 106,000) were certified as a family NP. The next largest group were NPs certified in the care of adults (33,620) and in pediatrics (21,622). The numbers of NPs certified in gerontology and psychiatric and mental health care grew the least between 2008 and 2018—9.7 percent and 5.3 percent, respectively, and in 2018 numbered only 15,921 and 10,174, respectively. Within the different settings in which they work, NPs provide a vast array of clinical specialty care. Of the nearly two dozen clinical specialties shown in Table 3-6, NPs were most likely to provide primary and ambulatory care (39.2 percent), followed by general medical surgical care (9.1 percent), psychiatric or mental health care (6.4 percent), critical care (5.9 percent), and gynecology and women’s health care (4.3 percent). The remaining 35 percent of NPs provided care in 17 other specialties, ranging from oncology (3.9 percent) to infections/ communicable diseases (0.8 percent). Care for People of Color and People with Limited English Proficiency Analysis of the 2018 NSSRN shows that a majority (70.6 percent) of NPs who reported managing a panel of patients as a primary provider said at least 25 percent of their patient panel consisted of “racial/ethnic minority groups”; one in five indicated that this was the case for 75 percent or more of their panel. Slightly more than one-quarter of NPs (25.9 percent) also reported that 25 percent or more of their patient panel had limited proficiency in English. Additionally, the vast majority of NPs indicated that to a “great or somewhat extent” (versus “very little” or “not at all”), they participated in team-based care (85.8 percent), and felt confident in their ability to practice effectively in interprofessional teams (96.1 percent) and to use health information technology effectively in their practice to manage their patient population (81.1 percent). Most NPs had observed their organization emphasizing team-based care (84 percent) and evidenced-based care (97 percent); only 60 percent reported ob- serving their organization emphasizing discharge planning to a great extent or PREPUBLICATION COPY—Uncorrected Proofs

76 THE FUTURE OF NURSING 2020–2030 TABLE 3-6 Nurse Practitioner Employment by Clinical Specialty Area, 2018 Clinical Specialty Number Percentage Primary Care 47,176 24.4 Ambulatory Care (including primary care outpatient setting, except surgical) 28,787 14.9 General Medical Surgical 17,564 9.1 Psychiatric or Mental Health (substance abuse and counseling) 12,460 6.4 Critical Care 11,462 5.9 Gynecology 8,289 4.3 Oncology 7,556 3.9 Chronic Care 7,538 3.9 Dermatology 7,337 3.8 Cardiac or Cardiovascular Care 5,224 2.7 Neurology 4,373 2.3 Home Health/Hospice 3,809 2.0 Obstetrics 3,406 1.8 Orthopedics 2,854 1.5 Gastrointestinal 2,633 1.4 Pulmonary/Respiratory 2,347 1.2 Occupational Health 2,248 1.2 Other Specialty (neonatology) 2,048 1.1 Renal/Dialysis 1,508 0.8 Infectious/Communicable Disease 1,467 0.8 Labor and Delivery 1,019 0.5 Other Specialty (including school health service, gerontology, and radiology) 12,482 6.4 Total 193,587 SOURCE: Calculations based on data from the 2018 National Sample Survey of Registered Nurses. somewhat. Refer to Chapter 7 for more detailed information on interprofessional education and training. Growth in the Size of the Nurse Practitioner Workforce The NP workforce is growing rapidly. Using data from the 2001–2016 Amer- ican Community Survey (ACS), Auerbach and colleagues (2018) project that the number of FTE NPs will more than double from 157,025 in 2016 to 396,546 in 2030 (increasing 6.8 percent annually). As discussed later, the contributions of PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 77 the growing NP workforce will be useful to overcome projections of primary care and specialty physician shortages over the decade. CHALLENGES FOR THE NURSING WORKFORCE THROUGH THE CURRENT DECADE Looking out over this decade, the nursing workforce is growing and provid- ing many different types of care in a variety of settings, giving them opportunities to understand and interact with people who face substantial social risk factors. The strengths of the nursing workforce are many, yet they will be tested by for- midable challenges that are already beginning to affect nurses and the health care systems and organizations in which they work. These challenges will arise from changes occurring throughout the broader society that are increasing the number of people who need health care; from within the nursing and larger health care workforce; and from health-related public policies and other factors that affect the size, distribution, diversity, and educational preparation of nurses. These challenges include the need to • increase the number of nurses available to meet the nation’s growing health care needs; • rightsize the clinical specialty distribution of nurses; • increase the distribution of nurses to where they are needed most; • ensure a nursing workforce that is diverse and prepared with the knowl- edge and skills to address SDOH; • overcome current and future barriers affecting workforce capacity; and • anticipate long term impacts of the COVID-19 pandemic on the nursing workforce. These challenges will unfold simultaneously over the decade, and will ex- pose shortcomings throughout the nursing workforce, widening current gaps that should be filled if nurses are to fully leverage their expertise in helping to address SDOH for individuals, communities, and society. Increasing the Number of Nurses Available to Meet the Nation’s Growing Health Care Needs In addition to growth in the overall size of the U.S. population, other fac- tors and health workforce imbalances will increase the demand for nurses, par- ticularly in areas where the RN and APRN workforce are already undersized. Salient sociodemographic factors include the aging population, increases in mental and behavioral health conditions, increases in lack of access to primary health care, persistently high maternal mortality rates, and worsening physician shortages. PREPUBLICATION COPY—Uncorrected Proofs

78 THE FUTURE OF NURSING 2020–2030 The Aging Population The aging of the U.S. population means that over this decade, increasing numbers of people will age into their 70s, 80s, 90s, and beyond. In 2030, 73.1 million people or 21 percent of the U.S. population, including all baby boomers, will be older than 65 (Vespa et al., 2020). The prevalence of multiple comorbid chronic conditions (e.g., diabetes, heart disease, obesity, cancer, disabilities, men- tal illness, Alzheimer’s disease, dementia) is high among older people and greatly increases the complexity of their care (Figueroa et al., 2019). Increases can also be expected in the number of frail older adults—those who need assistance with multiple activities of daily living, are weak and losing body mass, have multiple chronic or complex illnesses, and have an increased risk of dying within the next 2–3 years (Collard et al., 2012; Fried et al., 2001). The old-age dependency ratio (the number of people aged 65 and over per 100 people aged 20–64) in the United States will increase from 21 in 2010 to more than 35 by the end of the decade (Vespa et al., 2020). The nation’s aging population will pose extraordinary challenges for society at large and for health care delivery organizations, nurses, social workers, and families. There are wide disparities in the economic and physical welfare of older adults by gender, racial/ethnic group, and geographic location. Older women are more likely than men to live alone and are twice as likely to be poor. At age 50, Black men and women still have lower life expectancies relative to their White counterparts. Among adults aged 65 and older, POC individuals are much more likely than Whites to rely solely on Social Security for their family income. In addition to the increased risk of age-associated mental health problems and cognitive degenerative diseases, older adults living in rural areas are more likely than their counterparts living in urban areas to be poor; to experience social iso- lation; and to have significantly less access to fewer health and social resources, including mental health services (Administration on Aging, 2011). It is essential for policy makers and others to pay attention to these gender and racial/ethnic gaps and geographic trends, which could undermine progress in advancing the well-being of older Americans in the present decade. As the nation’s health care and social support systems come to terms with caring for increasing numbers of older people, increases will be seen not only in the demand for nurses but also in the intensity and types of nursing care required to care for these older adults, extending across inpatient, community-based, and home settings. The gap in the ability of nurses to respond to these needs is already deep and worrisome; according to the 2018 NSSRN, relatively few RNs work in a long-term care facility (60,000) or provide home care (91,000). Similarly, relatively few NPs work in nursing homes (in 2018, 2,700 or 1.4 percent of all employed NPs) or provide home health care services (4,100 NPs or 2.1 percent). PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 79 Increases in Mental and Behavioral Health Conditions Prior to the COVID-19 pandemic, sharp increases in suicide, substance abuse, the opioid crisis, gun violence, and severe depression among younger people were placing growing demands on the mental and behavioral health care workforce, including nurses. Yet, the rising demand for mental and behavioral health services, let alone treatment for the 44 million American adults who are estimated to have a diagnosable mental health condition, is occurring in the face of a shortage of behavioral health professionals that the Health Resources and Services Administration (HRSA, 2016) projects could worsen to a shortfall of as many as 250,000 workers by 2025. Despite current and projected shortages of mental and behavioral health workers, the regulatory policies of many states limit the capacity of existing NPs who provide psychiatric and mental health care. For example, a study by Alexan- der and Schnell (2019) assessing independent practice authority for NPs between 1990 and 2014 showed that broadening prescriptive authority was associated with improvements in self-reported mental health and decreases in mental health–re- lated mortality, including suicides. These improvements were concentrated in ar- eas underserved by psychiatrists and among populations traditionally underserved by mental health providers. According to the authors, “results demonstrate that extending prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations” (Alexander and Schnell, 2019, p. ii). Similarly, Barnett and colleagues (2019) examined the issuing to NPs and physician assistants of federal waivers for prescribing buprenorphine following passage of the 2017 Comprehensive Addiction and Recovery Act. The waiver expansions were intended to increase patients’ access to opioid use treatment, which is particularly important in rural areas underserved by physicians. The study found that between 2016 and 2019, the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent, with NPs and physician assistants accounting for more than half of this increase. Furthermore, rural counties in states that granted full scope-of-practice authority to NPs saw significantly faster growth in NPs’ buprenorphine treatment capacity compared with states with restrictive scope-of-practice regulations. “By March 2019 this pattern of growth had led to rural counties in states with full scope of practice having twice as many waivered NPs per 100,000 population, compared to those in states with restricted scope of practice (5.2 versus 2.5)” (Barnett et al., 2019, pp. 2051–2052). The COVID-19 pandemic has added new stresses for many people, partic- ularly those living in or near places with large outbreaks of the virus, increasing the need for mental and behavioral health treatment. As nurses continue to care for people with COVID-19, many will experience added stress; feelings of inad- equacy, guilt, compassion fatigue, and physical exhaustion; and uncertainty over PREPUBLICATION COPY—Uncorrected Proofs

80 THE FUTURE OF NURSING 2020–2030 their employment. Some of these nurses may leave the profession, many will need help, and too many will suffer alone (Lai et al., 2020). Increasing demand for mental and behavioral health care in the face of the decreasing capacity of mental and behavioral health care professionals implies that the nursing workforce will be relied upon to help address gaps in this care (Henderson, 2020). In addition to the capacity-reducing effect of regulations, however, the nursing workforce is unlikely to fill these gaps over the current decade because such a small percentage of RNs (3.5 percent or 78,300) provide care in psychiatric, mental health, or substance abuse settings. Similarly, small numbers of NPs work in inpatient (2,500 NPs in 2018) and outpatient (5,500) mental health/substance abuse settings. Increases in Lack of Access to Primary Health Care On the eve of the Patient Protection and Affordable Care Act’s (ACA’s) 2014 health insurance expansions, nearly 60 million people had inadequate access to primary care in the United States (Graves et al., 2016), and HRSA reported 5,900 health professional shortage areas (HPSAs). While the ACA eventually expanded insurance coverage to an estimated 20 million individuals, not all of those who gained coverage had adequate access to health care. Unfortunately, the size of the population with inadequate access to health care is rising: in March 2020, HRSA reported that the number of HPSAs nationwide had increased to 7,059, affecting 80.6 million people. The persistent lack of access to primary health care has led to recommen- dations to increase the number of nurses practicing in primary care and commu- nity-based settings (Bodenheimer and Bauer, 2016). A 2016 report of the Josiah Macy Jr. Foundation, Registered Nurses: Partners in Transforming Primary Care (Bodenheimer and Mason, 2016), emphasizes the need to overcome the limited ways in which many primary care practices currently use RNs (e.g., telephoning prescriptions to pharmacies, performing administrative duties). Instead, the re- port urges primary care practices to expand the role of RNs in providing primary care services and allow them to practice to the full extent of their education and training (e.g., by managing stable patient panels with controlled diabetes, hy- pertension, and other conditions). As discussed in Chapter 7, nursing education programs have historically emphasized preparing students for inpatient acute care and medical and surgical nursing. Consequently, too few nurses today are ade- quately prepared to practice in non–acute care settings. To address the growing need for primary care providers, educators will have to increase coursework and student clinical experiences in primary care settings, which in turn could lead to more graduates choosing careers in primary care and ambulatory and communi- ty-based settings. Fortunately, more than 160,000 NPs certified in either family health, adult health, or pediatrics provide primary care. And a large and growing body of PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 81 evidence shows that primary care NPs are more likely than their physician counterparts to practice in rural areas—areas characterized by more uninsured individuals and chronic physician shortages—and to provide care to vulnerable populations that are impacted by SDOH (Barnes et al., 2018; Buerhaus, 2018; Buerhaus et al., 2015; DesRoches et al., 2017; Xue et al., 2019). Yet, despite the growing shortage of physicians practicing primary care and growing calls from public- and private-sector organizations to expand the roles and uses of NPs, many states, hospitals, and health systems continue to restrict NPs’ scope of practice. These restrictions limit access to the high-quality primary care needed by millions of Americans. Persistently High Maternal Mortality Rates In addition to filling gaps in the delivery of mental and behavioral and pri- mary care, momentum is growing to address the increasing rates of maternal mor- bidity and mortality that are disproportionately affecting Black/African American and AI/AN women (Leonard et al., 2019; Petersen et al., 2019). As discussed in Chapter 4, these inequities can be reduced by using RNs and expanding the number of CNMs and nurses prepared to provide women’s health care to help im- prove the health status of and health care provided to pregnant women. Although perinatal RNs currently serving this population are concentrated in acute care hospitals, they could become a community resource in antenatal and postpartum maternity care. This use of RNs could be particularly effective if informed by established, evidence-based public health home visiting models. Crucial gaps in the APRN workforce need to be filled to improve maternal health. At a time when CNMs are needed more than ever, their numbers are grow- ing slowly. There were 3.745 million U.S. births in 2019 (Hamilton et al., 2020). Acute care hospitals are the site of 98 percent of U.S. births (MacDorman and Declercq, 2019), and only about 2,900 hospitals provide maternity care (AHA, 2018). If the supply of CNMs, NPs, and CNSs who specialize in perinatal care/ women’s health is not expanded (let alone maintained), millions of women will continue to be excluded from critical APRN services at a time when maternal care is increasingly complex, and improving the quality, safety, and equity of maternal care is paramount. Additionally, evidence of disparate care provided by White clinicians to Blacks, AI/ANs, and other persons of color (Altman et al., 2019; Davis, 2019; Johnson et al., 2019; McLemore et al., 2018; Serbin and Donnelly, 2016; Vedam et al., 2019; Williams et al., 2020) highlights the cru- cial need to strengthen efforts to increase the racial and ethnic diversity of the nursing workforce providing care for pregnant women. Finally, a recent study by McMichael (2020) examined all births in the United States between 1998 and 2015 (n = 69 million) and found “consistent evidence that allowing APRNs and PAs [physician assistants] to practice with more autonomy reduces the use of medically intensive procedures” (p. 880), specifically caesarean section rates, PREPUBLICATION COPY—Uncorrected Proofs

82 THE FUTURE OF NURSING 2020–2030 which place both mothers and infants at risk. This study adds new evidence of how restrictive scope-of-practice regulations (discussed further below) negatively affect maternal and child well-being. Worsening Physician Shortages A 2020 report prepared for the American Association of Medical Colleges estimates that by 2033, current physician shortages could increase, ranging be- tween 21,400 and 55,200 for primary care physicians, and between 33,700 and 86,700 for non–primary care specialty physicians (AAMC, 2020). These pro- jections, made prior to the COVID-19 pandemic, took into account decreasing hours worked by physicians, accelerating retirements, and increasing demands for medical care among aging baby boomers. Separately, HRSA projected a shortage of 24,000 primary care physicians by 2025, due mainly to population aging and overall population growth exceeding the growth in physician supply (HRSA, 2016). Current and projected shortages of primary care and specialty care phy- sicians over the next 10 years mean that both RNs and APRNs will increasingly be called upon to fill gaps in individuals’ access to care. Rightsizing the Clinical Specialty Distribution of Nurses As described above, the health and social ramifications associated with the nation’s aging population, growth in mental and behavioral health conditions, inadequate access to primary care, and unacceptably high maternal mortality rates will increasingly fall on the nursing workforce. Not only are there too few nurses and APRNs working in the settings where these populations receive care, but the number of nurses specializing in these clinical areas needs to increase. Despite the availability of many fellowship programs and the high career satisfaction reported by clinicians in geriatrics, the number of physicians enter- ing the specialty has consistently been far below the need. Currently, there are 6,671 board-certified geriatricians in the United States—1 for every 7,242 older Americans (Fried and Rowe, 2020). According to the 2018 NSSRN, fewer than 1.0 percent of RNs (0.4 percent) cited gerontology as the type of specialty care they provide in their primary employment position, and only 8.2 percent of NPs (just under 16,000) were certified in gerontology. With regard to mental and be- havioral health, despite current and projected shortages of psychiatrists, only 4.0 percent of RNs (91,750) spent most of their time providing patient care, including substance abuse treatment and counseling, in psychiatric or mental health care settings, and just 5.3 percent of NPs (10,173) were certified in psychiatric or mental health care. It is not enough merely to increase the number of RNs and APRNs during the decade ahead; rather, there is an urgent need to increase the numbers of nurses in gerontology, mental and behavioral health care, primary care, and maternal health. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 83 Increasing the Distribution of Nurses to Where They Are Needed Most A third major challenge facing the nursing workforce over this decade is to address the large portions of the U.S. population that are unable to access affordable health care because of geography, insurance status, and other circum- stances. In 2018, HRSA reported that 66 percent of HPSAs for primary care and 62 percent of those for mental health care were located in rural or partially rural areas. Because of a lack of education or transportation and competing needs, such as housing and food, individuals and families living in rural areas too often are unable to manage their health and chronic conditions. NPs and the expertise they possess have in many cases markedly expanded access to care in rural and other underserved locations, making them an important resource to help meet individual and community health care needs. As noted earlier, however, too often reimbursement policies and limitations on NPs’ scope of practice impede their effective deployment to help address these challenges. Indeed, as discussed below, state-level restrictions on the practice authority of NPs are associated with decreased access to primary care. Beyond current and growing physician shortages discussed above, particu- larly in the areas of primary care, mental health, and gerontology, the physician workforce has historically been unevenly distributed. Unfortunately, this trend is expected to worsen during this decade, with the number of physicians per 10,000 population in rural areas projected to decrease by 23 percent between 2017 and 2030 (from 12.2 to 9.4 physicians per 10,000 population) (Skinner et al., 2019). Over the same years, by contrast, the number of physicians per capita practicing in metropolitan areas will remain roughly constant at 31 per 10,000 population. The major reason for the forecast decline in rural physicians is the large number expected to retire over the decade and the need to be replaced by smaller cohorts of younger physicians. As a result, current large disparities in physician supply between rural and nonrural areas will grow over the decade, with resultant gaps in unmet needs for care falling increasingly on the nursing workforce. As noted earlier, however, fewer RNs are working in rural areas and in rural hospitals today than in the past, a decrease occurring most rapidly among younger RNs. If this trend continues, it will threaten access to care among the nation’s rural populations at a time when nurses will be counted on to fill gaps in their care. Moreover, given the large number of RNs working in critical access/rural hospitals (more than 300,000) and the number of such hospitals that could close in the years ahead, the number of nurses practicing in rural areas could decline even more during the decade, further complicating policies aimed at increasing access to care for rural populations. With respect to the NP workforce, studies show that NPs providing primary care are more likely to practice in rural areas than are physicians, and states that do not versus those that do restrict NPs’ scope of practice have a much larger supply of NPs per capita (Barnes et al., 2018; Graves et al., 2016; Xue et al., PREPUBLICATION COPY—Uncorrected Proofs

84 THE FUTURE OF NURSING 2020–2030 2019). For nurses to respond successfully to rural access problems associated with growing physician shortages and falling numbers of rural physicians pro- jected over the next 10 years, restrictive scope-of-practice provisions will need to be removed and the trend of fewer RNs working in rural areas to be reversed. Ensuring a Nursing Workforce That Is Diverse and Prepared with the Knowledge and Skills to Address Social Determinants of Health A fourth challenge facing the nursing workforce over the current decade is to ensure that nurses reflect the people and communities with whom they interact. In addition, nurses need to be prepared to address SDOH that negatively affect health and well-being. Ensuring a Diverse Workforce Over the next decade (and beyond), the U.S. population is expected to be- come more racially and ethnically diverse. Based on data reported by the U.S. Census Bureau, while the number of White individuals will increase by roughly 4 percent, the numbers of all other races will grow much more rapidly: Blacks/ African Americans and AI/ANs both by 10 percent, Hispanics by 20 percent, and Asians by 22 percent (Vespa et al., 2020). The fastest growth will be seen among people of two or more races. Box 3-3 provides information on the health dispari- ties that the AI/AN population face and the critical need for nurses to provide cul- turally competent care. Of note, data on the AI/AN population are limited. More accurate and timely collection of data on AI/AN populations living in and outside tribal lands in the United States is needed to help in determining the allocation of essential resources and services to improve health equity for these populations. On the other hand, increases in the racial diversity of the APRN workforce have not kept pace with those in the basic RN workforce. Today, most APRNs are White and female (with the exception of CRNAs, who are 30 percent male); the proportion of men who are APRNs (with the exception of CRNAs) is lower than the proportion of men in the basic RN workforce. While higher proportions of POC individuals (with the exception of Hispanics) are obtaining a master’s or PhD degree, and especially a DNP degree, APRNs have a long way to go to match RNs in achieving a more diverse workforce. At the same time, it is im- portant to keep in mind that although three-quarters of NPs are White, a strong majority provide care to people who are poor, lack insurance, are female, and are POC with complex health and social needs, and are more likely to practice in rural areas. Despite these attributes, however, the APRN workforce will need to rapidly become more diverse over the decade or it will fall further behind in reflecting the racial make-up of many of the people it serves. Chapters 7 and 9 on leadership and education, respectively, provide further information on the need for diversity in nursing. PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 85 BOX 3-3 Health Disparities Among American Indians/Alaska Natives The American Indian/Alaska Native (AI/AN) population has faced significant health inequities that have contributed to poorer health outcomes compared with non-AI/AN populations. According to the Indian Health Services (IHS), life expec- tancy for AI/AN people is 5.5 years less than life expectancy for all races in the United States (73.0 versus 78.5 years) (GAO, 2018; IHS, 2019). In addition, AI/AN populations have higher rates of mortality associated with preventable conditions, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional inju- ries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases (IHS, 2019; Leavitt et al., 2018). Specifically, AI/ANs have high rates of obesity and diabetes. In 2018, 48.1 percent of AI/AN people were obese com- pared with 31.0 percent of White people. Diabetes is the fourth leading cause of death for AI/ANs. The prevalence of diabetes among AI/ANs is almost double the percentage for Whites (15.1 versus 7.4 percent) (Carron, 2020). Historical trauma has had lasting effects on physical, mental, social, and environmental determi- nants of health for AI/AN populations (Smallwood et al., 2020). The significant health inequities that AI/ANs experience underscore the critical need for an adequate supply of nurses to address these disparities and provide culturally competent care. There are sizeable provider shortages in areas serving AI/ANs, which negatively affect their access to and quality of care (GAO, 2018). In 2017, 27 percent of positions for nurses were vacant across eight areas (Al- buquerque, Bemidji, Billings, Great Plains, Navajo, Oklahoma City, Phoenix, and Portland) in which IHS provides substantial direct health care to AI/ANs (GAO, 2018). For nurse practitioners (NPs), there was a 32 percent vacancy rate, ranging from 12 percent in Oklahoma City to 47 percent in Albuquerque (GAO, 2018). IHS has reported considerable difficulty in filling provider vacancies because of the rural location, geographic isolation, and insufficient housing that characterize AI/ ANs. It is also especially difficult to recruit and retain providers for health care fa- cilities on tribal lands. To increase the number of nurses who can provide culturally competent care to AI/AN populations, it will be important to educate nurses on culturally appropriate care specific to AI/ANs and employ strategies for recruiting and retaining these nurses that include financial incentives, professional develop- ment opportunities, and access to housing (Carron, 2020). As recommended in the 2016 report Assessing Progress on the Institute of Medicine Report The Future of Nursing, recruitment and retention of a diverse nursing workforce is a priority (NASEM, 2016). As the nation’s population be- comes more diverse, it will be important to sustain efforts to diversify the racial, ethnic, and gender composition of the nursing workforce—particularly with respect to increasing the number of Hispanics and their educational attainment. Educators can target efforts to ensure more diverse graduates and better-prepared nurses to match population and community needs by understanding the racial and ethnic characteristics of their communities, expected future trends in racial PREPUBLICATION COPY—Uncorrected Proofs

86 THE FUTURE OF NURSING 2020–2030 and ethnic diversity, and opportunities to capitalize on nurses’ ability to provide culturally and racially concordant care. Overcoming Deficits in the Knowledge and Skills Needed to Address Social Determinants of Health Nurses often treat people with multiple comorbid conditions who live in en- vironments that exacerbate social risk factors that negatively affect their health. Yet, as described earlier, many RNs and NPs perceive gaps in their preparation in areas that would help them do their jobs better—mental and behavioral health, SDOH, population health, working in underserved communities, and care for people with complex medical/social needs. Nurses working in schools, public and community health agencies, emergency rooms and urgent care settings, and long-term care settings were most likely to identify these gaps. Furthermore, both RNs and NPs who had graduated since 2010 were more likely to indicate that they would benefit from training in these areas. If RNs and NPs in both the current and future workforce are to be relied on to address social risk factors and respond effectively to the needs of complex individuals, it is critical for them to receive education and training in these areas. Overcoming Current and Future Barriers Affecting Workforce Capacity A fifth major challenge facing the nursing workforce over the current decade involves overcoming regulatory restrictions placed on nurses’ scope of practice and avoiding disruptions in care associated with the retirement of large numbers of baby boom RNs. Such restrictions limit access to care generally and to the high-quality care offered by APRNs. Those supporting these restrictions maintain that nonphysician providers are less likely to provide high-quality care because they are required to receive less training and clinical experience. However, evi- dence does not show that scope-of-practice restrictions improve quality of care (Perloff et al., 2019; Yang et al., 2020). Rather, these regulations restrict com- petition and can contribute to higher health care costs (Adams and Markowitz, 2018; Perloff et al., 2019). Scope-of-Practice Restrictions That Reduce the Productive Capacity of Registered Nurses and Nurse Practitioners Frogner and colleagues (2020) write: Ongoing payment reforms are pressing health systems to reorganize the delivery of care to achieve greater value, improve access, integrate patient care across settings, provide population health, and address social determinants of health. Many organizations are experimenting with new ways to unleash the potential of their workforce by using telehealth, various forms of digital technology and de- PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 87 veloping team- and community-based delivery models. Such approaches require flexibility to reconfigure provider roles yet states and health care organizations often place restrictions on health professionals’ scope of practice (SoP) that limit their flexibility. These restrictions are inefficient, increase costs, and decrease access to care. (p. 591) While considerable progress has been made over the past two decades in lift- ing state-level regulations restricting NPs’ scope of practice, however, 27 states still do not allow full practice authority for NPs (AANP, 2020). As of January 2021, 23 states and the District of Columbia allow full practice authority for NPs (see Figure 3-3), allowing them to prescribe medication, diagnose patients, and provide treatment without the presence of a physician. Conversely, 16 states restrict NPs’ ability to prescribe medication, requiring a physician’s authorization, while 11 states require physician oversight for all NP practice (AANP, 2020). Some states have stipulations on the kinds of medications NPs can prescribe. In Arkansas, Georgia, Louisiana, Missouri, Oklahoma, South Carolina, Texas, and FIGURE 3-3 Scope of practice for nurse practitioners by state. SOURCE: AANP, 2020. PREPUBLICATION COPY—Uncorrected Proofs

88 THE FUTURE OF NURSING 2020–2030 West Virginia, for example, NPs are prohibited from prescribing any Schedule II medications (AMA, 2017). CNMs are likewise restricted by scope-of-practice laws: they can practice independently in 27 states and the District of Columbia; a collaborative agreement with a physician is required in 19 states; and the 4 remaining states allow them to practice independently, but without the ability to prescribe medications (Georgetown University, 2019). Not permitting NPs and CNMs to practice to the full extent of their license and education decreases the types and amounts of health care services that can be provided for people who need care. As noted earlier, this artificially imposed reduction in NP and CNM capacity has significant implications for addressing the disparities in access to health care between rural and urban areas. According to the above-cited study by Graves and colleagues (2016), state-level scope-of- practice restrictions on NPs were associated with up to 40 percent fewer primary care NPs per capita in restrictive versus full-practice states, and people living in states allowing for the full practice authority of NPs had significantly greater access to primary care (63 percent) relative to those living in states that reduced (47 percent) or restricted (34 percent) NPs’ scope of practice. The harmful consequences of restricting NPs’ scope of practice become starker in light of the findings of a 2018 UnitedHealth report on primary care and NP scope-of-practice laws. According to that report, if all states were to allow NPs to practice to the full extent of their graduate education, advanced clinical training, and national certification, the number of U.S. residents living in a county with a primary care shortage would decline from 44 million to fewer than 13 mil- lion (a 70 percent reduction). Furthermore, the number of rural residents living in a county with a primary care shortage would decline from 23 million to 8 million (a 65 percent reduction). A 2020 study (Xu et al., 2021) examined the geographic locations of dual eligibles and primary care providers and found that one-third (n = 271) of the 791 counties with the highest density of dual eligibles in the United States were designated as HPSAs. These counties were more likely to be rural, located in the Southeast region of the country, and encumbered by high poverty rates and a heavy burden of chronic conditions. The investigators found that in nearly half (n = 128) of the 271 counties with both a high-density dual eligible population and a primary care physician shortage, the density of primary care NPs (PCNPs) was the highest, meaning that the distribution of PCNPs was within the highest quartile of the overall supply of PCNPs in the country. The study found that Southeastern states “impose the most restrictive scope of practice regulations that limit the capacity of NPs. Such restrictions may also increase NPs’ reluctance to locate in these states. Thus, a first step to expand access to care is to lessen the state-imposed restrictions on scope of practice for the NPs” (Xu et al., 2021). The damaging effects of scope-of-practice restrictions on access to care were recently acknowledged during the COVID-19 pandemic when several states (Florida, Kentucky, Louisiana, New Jersey, New York, Tennessee, Wisconsin, and PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 89 West Virginia) and the Centers for Medicare & Medicaid Services eased super- vision and other restrictions placed on NPs to increase the capacity of the health care workforce. It is uncertain whether these restrictions will be reinstated after the pandemic subsides (Yuanhong et al., 2020). Clearly, however, if government leaders concluded that removing restrictions on NPs was beneficial in expanding the public’s access to care during the pandemic, it would be counterproductive to reimpose those restrictions once the pandemic eases, thereby decreasing access to care. Until all APRNs are permitted to practice to the full extent of their education and training, significant and preventable gaps in access to care will continue. Millions of people who need health care will be unable to obtain needed care as readily as others who happen to live in states where NPs’ scope of practice is not restricted. For many people, delays in obtaining care lead to worsening of symptoms and disease progression, and to greater costs when care is ultimately provided. Allowing APRNs to practice to the full extent of their education and training as recommended in the 2011 The Future of Nursing report would help remediate inequities in access to health care and enable more people to enjoy the benefits of care provided by NPs and other APRNs. Disruptions in Care Delivery Associated with the Retirement of Baby Boom Registered Nurses An estimated 600,000 baby boom RNs have not yet retired and are expected to leave the workforce by 2030. The exit from the workforce by so many experi- enced RNs (about 70,000 per year) means that health care delivery organizations that depend on RNs will face a significant loss of nursing knowledge, clinical expertise, leadership, and institutional history. The number of experience-years lost from the nursing workforce is estimated to exceed 2 million each year in the current decade (Buerhaus et al., 2017). As shown earlier in Table 3-3, in 2018 well over one-third and in many cases more than half of RNs working in noninpatient settings, including many settings where nurses are vital in ensuring access to care for minority and other vulnerable populations, were over age 50. The loss of nurs- ing knowledge, clinical expertise, leadership, and institutional history associated with the retirement of baby boom RNs is likely to increase gaps in nurses’ ability to provide needed care to vulnerable populations, who often have complex clinical conditions. It is crucial for nurses who enter the workforce during this decade to be well prepared for their role in addressing SDOH and reducing health inequities. Anticipating Long-Term Impacts of the COVID-19 Pandemic on the Nursing Workforce A final challenge concerns the pandemic’s economic and noneconomic im- pacts on the nursing workforce over the immediate (next few years) and lon- PREPUBLICATION COPY—Uncorrected Proofs

90 THE FUTURE OF NURSING 2020–2030 ger-term future. The impacts are difficult to predict because of uncertainties about the length and severity of the pandemic; its effects on health care systems and other health care professions; and whether it leads to a deep or shallow economic recession, how long the recession lasts, and the speed with which the economy recovers. During the first half of 2020, health care systems reoriented their oper- ations to manage a substantial influx of COVID-19 related testing, hospital- izations, and use of postacute care. Stay-at-home orders and social distancing then led to a massive reduction in hospital admissions, surgeries, tests, diag- nostic procedures, and elective procedures. As revenues fell, hospitals took actions to decrease their costs, including furloughing nurses. Many physician offices and clinics similarly reduced their staffing. The magnitude of these short-run cost-cutting actions has varied by region and type of employer and may result in disparities in impacts by providers’ race, ethnicity, gender, and age. In the longer run, the pandemic may lead to fundamental shifts in the demand for and supply of nurses. On the demand side, there may be a sub- stantial restructuring of care delivery (e.g., toward telehealth or permanent staffing reductions in hospitals) that affects the nursing workforce. On the supply side, the pandemic may either increase or decrease entry into nursing and accelerate or slow retirement from nursing among the older members of the nursing workforce. RESEARCH NEEDS TO HELP NURSES MANAGE THESE CHALLENGES This chapter has provided information about the state of the nursing work- force, its strengths, and the many formidable challenges nurses will face in the coming years. Throughout this report, many ideas are provided for how nurses can address SDOH. What will be useful is to conduct research on how well nurses are implementing these ideas and evaluate whether the desired results are being achieved. For example, nurses are urged to become more active in com- munity-based settings, and nurse educators are urged to modify their curriculum to expand the diversity of the workforce and better prepare nurses for practicing effectively in such settings. Over the decade then, it will be important to assess whether and how effectively educators and nurses have responded to the ideas put forth in this report and determine whether and how their efforts have impacted SDOH that negatively affect health. Research is also needed in many other areas to generate information and evi- dence on what is working and fill gaps in knowledge. Box 3-4 provides questions that can be addressed through a robust research agenda. These questions were generated by experts in nursing health services research and represent their views on the most important and feasible research questions that need to be investigated to increase nurses’ ability to PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 91 • improve access to mental and behavioral health care and assess the effectiveness of interventions and services; • improve access to primary health care and the effectiveness of primary care delivery systems; • improve maternal health outcomes and the delivery of maternal health care; • improve the care provided to the nation’s aging population, particularly frail adults; and • control health care spending, reduce costs, and increase the value of nurses’ contributions to improving health and health care delivery As can be seen, these questions mirror many of the concerns about the gaps in the nursing workforce and their implications for SDOH that have been dis- cussed throughout this chapter. CONCLUSIONS The many strengths of the nursing workforce—its large and growing numbers of increasingly educated nurses; provision of basic and advanced specialty care in numerous types of acute care and community-based settings; delivery of public health, school health, and home health services; and compassion in caring for vulnerable populations in rural and undeserved locations, as well as the public’s positive perceptions of and trust in nurses, will be tested by a variety of challenges that will develop over this decade. These challenges will widen gaps in the size, distribution, diversity, and expertise of the full spectrum of the nursing workforce, gaps that will need to be addressed to help achieve health equity and reverse the trajectory of poor health status too often found in communities across the nation. Among these challenges is the growing population of older people, many of whom, particularly frail older adults, have multiple comorbid conditions that increase the complexity and intensity of the nursing care they require. Nurses at all levels will also be challenged to help expand the capacity of the primary care workforce, provide care to rural populations, improve maternal health outcomes, and deliver more health and preventive care in community-based settings. And nurses will be called on to provide mental and behavioral health care to treat growing numbers of Americans with mental health conditions and help stem increases in substance abuse, suicide, and gun violence. Projected shortages of physicians in both primary care and non–primary care specialties, combined with projections of decreasing numbers of physicians practicing in rural areas, will increase the demand for RNs and APRNs. Yet, scope-of-practice restrictions that persist in many states and within many health care organizations will reduce the capacity of the nursing workforce when and where it is most needed. Meanwhile, various health care reforms expected to evolve over the decade will require a well-prepared and engaged nursing workforce if they are to succeed. PREPUBLICATION COPY—Uncorrected Proofs

92 THE FUTURE OF NURSING 2020–2030 BOX 3-4 Agenda for Nursing Health Services Research In July 2019, a meeting of 38 individuals was convened in Bozeman, Montana, to develop a nursing health services research (NHSR) agenda for the 2020s. Experts in the fields of health services and social sciences research, survey and outcomes research, informatics, health workforce research, economics and policy, as well as physicians, and leaders in nursing education and public health, focused on identifying the key research questions that, if acted upon over the next decade, would generate evidence needed to help nurses meet the challenges of the current decade: 1.  Improve Access to Behavioral Health and the Effectiveness of Interventions and Services •  What are the emerging roles and functions of RNs and APRNs providing behavioral and mental health as health care delivery becomes increas- ingly value-based? •  What are the behavioral health competencies needed for all nurses, RNs and APRNs? •  What are the specific roles and functions of RNs and APRNs providing behavioral healthcare generally, and how do they vary by severity of behavioral health issues? •  How is team-based care affecting the delivery of behavioral health care, and what is the role of the nurse? What is the optimal configuration of teams to provide effective behavioral health care, and what role(s) do nurses play in such teams? •  How are hospitals and healthcare systems using nurses to address SDOH that negatively affect health and well-being? What is the role of nurses in addressing these SDOH? 2.  Improve Access to Primary Care and Improve the Effectiveness of Primary Care Delivery Systems •  How do we measure the value of primary care provided by nurses and measure their productivity in achieving desired primary care outcomes? •  How do APRN scope of practice (SoP) restrictions imposed by organi- zations and health systems impact access to care and effectiveness of primary care delivery systems? •  What are models of high-performing team-based primary care and how do RNs and APRNs contribute? •  How can nurse practitioners (NPs) transition into primary care practice be improved? •  What are the innovations in training RNs for careers in primary care? How can effective innovations be replicated? 3.  Improve Maternal Health Outcomes and the Delivery of Maternal Health Care •  What is the current and future capacity of the nursing workforce to provide the full spectrum of women’s health care along the reproductive life course (not just in the perinatal period)? PREPUBLICATION COPY—Uncorrected Proofs

THE NURSING WORKFORCE 93 • What are the maternal health outcomes that are directly and indirectly influenced by nurses and nursing practice? • How can evidence-based practices in maternal care be implemented consistently across care delivery settings? • Why are maternal mortality rates increasing overall in the US, and what accounts for the severe disparities in mortality rates between racial and ethnic groups? • What are the patterns and drivers of postpartum complications and deaths, and what can nurses do to address them? • What are the effects of hospital and obstetric unit closures on the deliv- ery of maternal care and on the nursing workforce skilled in delivering this care? 4. Improve Care of the Nation’s Aging Population, Including Frail Adults •  What are the roles and composition of teams caring for older people and frail adults? How do nurses contribute to team-based care serving this population? •  What are the knowledge and skills needed by nurses to work effectively with informal and unregulated care givers? •  How do other countries care for their aging populations? What can be learned from other countries in how they use nurses to provide care for older adults? What is the SOP of nurses caring for older and frail adults in other countries? •  How well educated and skilled are nurses in providing long-term care, home-based care, and care coordination? What can be done to prepare more nurses to work in non-acute settings? •  How can collaboration be improved between nurses and public health and community partners to address SDOH? 5. Help Control Healthcare Spending, Reduce Costs, and Increase the Value of Nurses’ Contribution to Health and Health Care Delivery •  What are the drivers of variation in the productivity of individual nurses and can studying individual variation identify ways to improve nurse’s contribution to value of services provided to patients and consumers? •  What are examples of successful nurse-led innovations that improve the value of health care? What are the outcomes of such innovations? What are the elements of successful innovation models? •  What are the contributions of nurses under a shared/alternative savings model of care delivery? •  What impact do nurses have on addressing the SDOH that negatively affect health and well-being? •  How are nurses contributing to or helping eliminate waste in the health care system? What are the financial, resource, ethical, and environmen- tal dimensions of waste reduction? What forms of waste are of concern to nurses and how can systems empower nurses to reduce waste? SOURCE: Excerpted from Cohen et al., 2020. PREPUBLICATION COPY—Uncorrected Proofs

94 THE FUTURE OF NURSING 2020–2030 All of these challenges will be faced by a nursing workforce that will be expanding unevenly across the nation and whose composition and capabilities will be changing as the most experienced nurses in the nation’s history retire, leading to fewer RNs practicing in rural areas and many nurses being ill pre- pared to practice in non–acute care settings. Furthermore, the number of nurses in the specialties that are most needed to serve all Americans and achieve im- proved population health are woefully lacking. While each of these challenges is uniquely consequential, it is important to recognize that the nursing workforce in the United States will confront all of these challenges simultaneously. And not to be forgotten are the unknown effects of the COVID-19 pandemic on the near- and longer-term supply of and demand for nurses. The many gaps in the capacity of the current nursing workforce will need to be overcome if the nation is to build a future workforce that can provide the health care it needs. Such a workforce would address social risk factors that negatively affect individual and overall population health and help ensure that all people can attain their highest level of well-being. Currently, there are insufficient numbers of nurses providing enough of the right types of care to the people who need health care the most, particularly in underserved locations. To overcome these deficits, substantial increases in the numbers, types, and distribution of the nursing workforce, as well as improvements in the knowledge and skills needed to address SDOH, will be needed. These improvements will occur more rapidly, more uniformly, and more successfully if programmatic, policy, and funding opportunities can be leveraged by health systems, government, educators, and payers, as well as stakeholders outside of the health care sector. Conclusion 3-1: A substantial increase in the numbers, types, and dis- tribution of members of the nursing workforce and improvements in their knowledge and skills in addressing social determinants of health are essential to filling gaps in care related to sociodemographic and population factors. These factors include the aging population, the increasing incidence of mental and behavioral health conditions, and the increasing lack of access to primary and maternal health care. Conclusion 3-2: Eliminating restrictions on the scope of practice of advanced practice registered nurses and registered nurses so they can practice to the full extent of their education and training will increase the types and amount of high-quality health care services that can be provided to those with complex health and social needs and improve both access to care and health equity. Conclusion 3-3: As the nation’s population becomes more diverse, sus- taining efforts to diversify the racial, ethnic, and gender composition of the nursing workforce will be important. PREPUBLICATION COPY—Uncorrected Proofs

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The decade ahead will test the nation’s nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

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