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Skill Shortages and Mismatches in Nursing Related Health Care Employment

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Document date: April 01, 2002
Released online: April 01, 2002

This report was prepared for the U.S. Department of Labor, Employment and Training Administration, under Contract No. K-6830-8-00-80-30, Task Order No. 8. The views expressed are those of the authors and should not be attributed to the U.S. Department of Labor or to the Urban Institute, its trustees, or its funders.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.


    Executive Summary

    1.0 Introduction

    2.0 What is a Labor Shortage?

    Other Explanations of Labor Shortages
    Using Labor Market Indicators to Measure Shortages

    3.0 The Health Care Industry and the Role of Nurses
    The Role of Nursing Staff in the Health Services Industry

    4.0 Summary of the National Picture
    Evidence of a Nurse Staffing Shortage
    Demand for Nurses
    Supply of Nurses

    5.0 Regional and Local Labor Market Evidence and Issues
    New York: Evidence of Shortages and Impacts of Earlier Cost Containment Policies
    California: Ahead of the Nation in Experiencing Shortages and in Setting Policy
    Improving Data for Regional and Local Planning

    6.0 Approaches, Recommended Solutions, and Implications
    National Legislative Efforts
    State Legislative Efforts
    Programmatic Initiatives
    Opportunities for DOL

    7.0 Conclusion


    Appendix: Labor Shortage Models
    Illustration of a Labor Shortage
    Arrow-Capron and Blank-Stigler Models

Executive Summary

Concerns about a shortage of nurses have existed for decades. Today, many providers see a shortage because of high vacancy rates and the difficulties they face in recruiting and retaining nursing staff. A number of studies at the national and state levels document providers' perceptions of a nurse staffing shortage, and recent research projects a severe shortage as the U.S. population and the nursing workforce ages.

Evidence of a current shortage is based primarily on reports by employers, and indicates that, so far, shortages are regional or local and related to certain nursing specialties. Differences in assessments of the immediacy and severity of the nursing shortage result from the variety of measures used to identify a labor shortage, data limitations, and the lack of a consensus on optimal nurse staffing in a variety of health care settings.

Projections indicate that it will be nearly ten years before demographic changes in the population and the aging of the existing workforce converge to create a severe shortage of nurses. Therefore, the country has the time and an opportunity to address the problem and avert a crisis situation. On the basis of our review of the research as well as a selection of promising practices, we believe the country needs to adopt a multi-pronged approach that addresses recruitment, retention, and training. Policies should seek to retain those already trained in the profession, attract new entrants to the labor market, and tap into the pool of workers already employed in health care that, with further training, can enter the nursing profession.

Who are nurses and where do they work?

Nursing staff—broadly defined to include registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides—play a key role in direct patient care in most major health services sectors. The three types of nursing staff (RNs, LPNs, and nurse aides) each have very different levels of responsibility, training, and compensation. Registered nurses have the most education, often have a supervisory role, and receive higher pay than other types of nursing staff. Licensed practical nurses (LPNs or licensed vocational nurses in Texas and California) provide basic bedside care under the direction of RNs or physicians, and, in nursing homes, take on additional responsibilities such as evaluating residents needs, developing care plans, and supervising the activities of nurse aides. LPNs must obtain state licensure and receive their education through one year training programs. Nurse aides have the least education, deliver much of the "hands-on" care to patients, and have average hourly wages under $9.00.

The Health Resources and Services Administration (HRSA) estimates that, in 2000, the U.S. had 2.7 million licensed, registered nurses, an increase of 62 percent since 1980. An estimated 81.7 percent of nurses or 2.2 million persons were employed in nursing in 2000. Most RNs (59 percent), are employed in hospitals, but the percentage of nurses employed in this setting has declined steadily since 1984. The average age of nurses in 2000 was 45.2 years; nursing is a female-dominated profession with men accounting for 5.4 percent of nurses in 2000.

Nursing Supply and Demand

Several factors affect the supply of nursing staff, including the shrinking labor pool for these staff, the availability of other career paths for women, the number of graduates of nursing schools, and staff's level of satisfaction with various aspects of their jobs such as workload, hours, and wages. Data from the National League for Nursing show that there was only a 10 percent increase in graduates from RN education programs between the 1975-1976 and the 1997-1998 academic years (Levine 2001). These data also show that the number of graduates in nursing programs began to decline in the 1995-1996 academic year and fell 13 percent by 1998.

Job satisfaction cannot be overlooked when considering the nursing labor supply. Nursing staffs' concerns about staffing levels and working conditions are likely to affect current nurses' commitment to remain in direct patient care. These concerns may also affect willingness to enter the nurse workforce in the future. Evidence from surveys and focus groups of nurses and former nurses, as well as early evidence of nurses' response to staffing changes, suggests a cost tradeoff between resolving the nursing shortage with higher wages and resolving the shortage by increasing nurse to patient ratios. Nurses have expressed concerns about patient load, inadequate staffing to handle the acuity of patients, inadequate time with patients, and inadequate time for required paperwork.

There are several reasons why demand for nursing is likely to increase in the future. Among them are the aging of the population, increased survival of people who are ill or have disabilities, and organizational changes in the health care industry, including the waning influence of managed care on providers' employment of nurses. Increases in the elderly population and in the number of persons with disabilities and chronic illness, and changes in the health care system will result in higher demand for all types of nursing staff in the future.

Indicators of a Nursing Shortage

Strong employment growth and greater increases in wages relative to other occupations are two indicators commonly used to identify shortage occupations. The U.S. Bureau of Labor Statistics (BLS) estimates that the rate of growth in employment of RNs from 2000-2010 will be 25.6 percent, which exceeds the projected growth in all occupations by 7.3 percent (Hecker, 2001). The rate of growth for LPNs will be 20.3 percent during this time period, while employment of aides will grow fastest of all. Nurse aide employment growth is projected to be 30.4 percent from 2000-2010.

However, "real" salaries of nurses employed full-time, taking into account changes in purchasing power of the dollar using the consumer price index, have remained relatively flat since 1992. The average annual earnings for all full-time nurses increased by 2.7 percent on an annual basis between 1996 and 2000. The actual average annual earnings for registered nurses working full-time in 2000 was $46,782. On the other hand, the New York State Department of Health's Institutional Cost Report data showed that after several years of flat or negative growth in real wages, real wages for nurses began increasing in the late 1990s, likely in response to labor shortages (Brewer and Kovner 2000).

Nursing shortages have also been identified using self-reported shortage status (as reported by hospital administrators); vacancy rate; turnover rate, adjusted number of RNs per inpatient year; and RN supply per 100,000 population. Several national studies document the difficulties involved in finding nurses, the relatively high nurse vacancy rates, and the fact that many providers and workers believe there is a nurse shortage.

Vacancy rates. According to an analysis of the 2001 American Hospital Association Workforce Survey (AHAWS), the RN vacancy rate was 11 percent, and 75 percent of the hospitals' 168,000 vacancies were for RNs (Lewin Group 2001). In addition, 75 percent of hospitals reported that they had more difficulty in recruiting nurses in 2001 than they had had in 2000.

Preliminary analysis of a 2001 survey of nursing homes conducted by the American Health Care Association (AHCA) shows that responding facilities had weighted average vacancy rates of 18.4 percent for RNs, 14.4 percent for LPNs and 11.7 percent for nurse aides (American Health Care Association 2001). The vacancy rates varied by region—for example the RN vacancy rate ranged from 16.2 percent in the West North Central region of the country to 21 percent in the Pacific region. Similar to the AHAWS, the AHCA found that the majority of responding facilities reported that recruiting nursing staff was more difficult in 2001 than it was in 2000.

State-level studies show results consistent with those at the national level:

  • The Association of Maryland Hospitals and Health Systems reported that the average hospital in the state had a nurse vacancy rate of 14.7 percent in 2000 and hospitals took, on average, 60 days to fill a nurse vacancy (U.S. GAO 2001c).
  • California had a nurse vacancy rate of 20 percent in 2000.
  • In 2001, Florida, Nevada, and Vermont reported nurse vacancy rates ranging from 7.8 to 16 percent (U.S. GAO 2001b). In Vermont, nursing homes and home health agencies in 2000 reported nurse aide vacancy rates of 16 and 8 percent, respectively.
  • A Pennsylvania study showed that in 2000, 75 percent of nursing homes and more than half of home health agencies reported staff shortages.
  • New York City, where many hospitals downsized their staffs in the 1990s in an effort to reduce expenditures, is now showing indications of a nurse shortage. In February 1999, 30 percent of hospitals in the New York City area reported taking at least three months to fill RN positions in these departments. In fall 2000, 92 percent of hospitals in New York State reported vacant RN jobs and 71 percent reported vacant LPN jobs (New York State Education Department 2001).

Turnover rates. Health care providers also report high employee turnover rates. The U.S. General Accounting Office (GAO) found a 26.2 percent annual turnover of nurses in a national survey of hospitals in 2000, a 51 percent rate for RNs and LPNs in 13 nursing home chains in 1997, and a 21 percent turnover for RNs in a 2000 national survey of home health agencies (U.S. GAO 2001c). Reported turnover rates among nurse aides are even higher, ranging from 40 to 100 percent in 12 nursing home chains in 1998. Preliminary results from the 2001 AHCA survey indicate that annualized turnover rates for responding nursing facilities were 55.5 percent for RNs, 51.5 percent for LPNs, and 76.1 percent for nurse aides (American Health Care Association 2001). These turnover rates varied markedly by region, and the methods used to calculate rates vary from study to study, but there is little doubt that turnover rates are substantial.

Some nurses are not just changing jobs within nursing, but are leaving the profession entirely. The 2000 National Sample Survey of Registered Nurses reports that, in March 2000, about 18.3 percent of nurses with current licenses (494,797 nurses) were not employed in nursing. Between 1992 and 2000, the number of RNs not employed in nursing increased about 28 percent.

Future Nurse Shortages

Several projections of the future supply of nurses suggest that the nation will be facing shortages over the next several decades. The Bureau of Labor Statistics projects that the supply of nurses will fall short of demand in 2008 and this shortfall will continue to worsen through 2020 (Levine 2001). In that year, demand for nurses is projected to exceed supply by 291,000 or 13 percent.

A model constructed by Buerhaus, Staiger, and Auerbach (2000) projects that the number of full-time RNs per capita will peak in 2007 and then will decline through 2020; the absolute number of nurses will begin declining in 2012. Based on HRSA's projections of need for nurses, the nurse workforce supply will meet requirements until 2010 but will be 20 percent below them by 2020. The aging of the workforce is projected to continue and peak at age 45.4 years in 2010. These projections assume that future cohorts will enter the nursing profession at the same rate as cohorts who were born from 1971–1975.

In California, for example, the current shortage is termed a "public health crisis" owing to a projected shortfall of 25,000 nurses by 2006 (California Strategic Planning Committee for Nursing (CSPCN) 2000).

Addressing the Nursing Shortage

The range of domestic approaches that have been implemented or proposed to address the projected nursing shortage includes both short-term and longer-term initiatives, legislative as well as program development activities, and national as well as regional or local efforts. And, the actors represent a broad range of stakeholders—nursing associations, labor unions, hospital/health industry associations, state government, federal government, higher education, and private foundations.

National Legislative Efforts. Legislative initiatives at the federal level that have been introduced or passed are aimed at easing the nation's nursing shortage by addressing education, staffing, and working conditions for nurses. The Nurse Reinvestment Act was passed in both the U.S. Senate (S. 1864) and in the House of Representatives (H.R. 3487) on December 20, 2001. The Nurse Reinvestment Act, if enacted, would amend the Public Health Service Act to direct the Secretary of Health and Human Services to make grants to support national, state, and local broadcast public service announcements promoting the nursing profession. It expands eligibility for the nursing loan repayment program and authorizes the Secretary to provide nursing scholarships in exchange for nursing services in designated health facilities. It grants preference to applicants with the greatest financial need or willingness to serve in geographic areas with nursing shortages and need. The Act also requires the Secretary to award grants to schools of nursing and/or health care facilities to develop and support outreach programs to encourage entry into the profession; encourage long-term care nursing services for the elderly as a career choice; and demonstrate models and best practices in nursing care, including retention strategies.

Many of the other national legislative efforts that were introduced to the 107th Congress aim to amend the Public Health Service Act and focus on improving nurse retention and education. Pending legislation in the Senate and House of Representatives also aims to amend other Acts, in order to address the working conditions of nurses, including prohibiting forced overtime for registered nurses, and limiting the number of mandatory overtime hours a nurse may be required to work.

State Legislative Efforts. State legislative activity has focused on five state legislative priorities identified by the American Nurses Association:

  • No Mandatory Overtime
  • Whistleblower Protection
  • Collection and Reporting of Nursing-sensitive Quality Data
  • Requiring Valid and Reliable Staffing Systems (e.g., better tools to calculate the appropriate level and mix (RN, LPN, unlicensed assistants) of nursing staff required to deliver safe, quality care)
  • Collection of Nursing Supply and Demand Data

State legislation for funding to expand enrollment in nursing schools, loan forgiveness, and grants is pending in California, Illinois, Maine, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island, and Texas.

Programmatic Initiatives

Another area of activity for addressing the nursing shortage is at the program level. A broad range of mostly local efforts are underway to tap new sources of labor, provide advancement opportunities for health care workers, and change organizational culture in order to attract and retain nurses. The examples described indicate the diverse organizational possibilities and highlight some important linkages to the workforce development system include:

Career Ladders in Long-Term Care: Extended Care Career Ladder Initiative. In Massachusetts, the Extended Care Career Ladder Initiative (ECCLI) is a $5 million program funded by the state's legislature as part of the larger Nursing Home Quality Initiative to improve nursing home care. The Commonwealth Corporation, which administers the Workforce Investment Act (WIA), oversees ECCLI. The approach of ECCLI is to establish career ladders and training and support systems for incumbent certified nursing assistant and other entry level nursing home workers. The initiative aims to increase the supply and quality of nurse aides as well as address the nursing shortage by "growing the profession from within."

Sectoral Employment Initiative: Good Faith Fund. Two organizations are focussing on health care employment under the sectoral employment initiative, a 3-year project in 10 organizations, funded by the Charles Stewart Mott Foundation. A sectoral employment initiative is a workforce development strategy aimed at helping low-skilled workers advance in the workforce and earn a decent living and at the same time creating systemic change in a targeted industry or occupation. One of these organizations, the Good Faith Fund (GFF) Careers in Health Care, works throughout the rural Arkansas delta region. GFF enrolls low-income minority women leaving welfare in a high quality, industry-driven CNA training program for 12 weeks (about three times the state's current minimum requirements) and helps the women overcome their significant barriers to training completion and job retention. In the first two years of this 3-year project GFF had enrolled 107 women—55 percent had graduated, and 97 percent of the graduates were placed in jobs.

Industry Initiatives: VHA. Through VHA, Inc. and the VHA Foundation,1 the health care industry has also initiated efforts to address the nursing shortage. VHA is a member organization of 2200 nonprofit hospitals and other health care organizations. "Tomorrow's Workforce" is an 18-month initiative that is helping hospitals redefine the work environment to promote recruitment and retention of workers. VHA's focus is on all levels and types of staff, including pharmacy, food service, and other areas as well as nursing.

In another project, with funding from the Annie E. Casey Foundation, the VHA Foundation convened a National Health Care Welfare to Work task force whose members represented nine industry leaders involved in welfare to work programs. Working with state and local providers, health systems have tapped welfare recipients and former welfare recipients as a pool of labor by developing customized programs for recruitment, training, and retention. Program outcomes, including one-year retention rates, participation in continuing education and training, and wage rates, met or exceeded welfare to work efforts of other industries. (VHA Foundation 2001).

Expanding the Pool of Nursing Candidates: District 1199C Training & Upgrading Fund. A community career ladder is in the making in Philadelphia through the auspices of the District 1199C Training and Upgrading Fund. The Training Fund operates a learning center that serves union members as well as community residents, and has used its strong linkages with health care employers and community based organizations to recruit and train entry level health care workers for skilled nursing positions. With funding from the U.S Department of Labor under the H-1B program,2 matching funds provided by three employers, and employer funds contributed to the Training and Upgrading Fund, an extensive array of preparatory classes are available free of charge. The program targets three groups who have difficulty overcoming the financial, academic, and schedule barriers to entering the nursing profession: current health care workers in entry level positions, minority populations, and immigrant groups.

Opportunities for DOL

Responses to nursing workforce issues are coming from all levels of government, from the private sector, from industry organizations, and from organizations representing health care workers. Programs supported by the U.S. Department of Labor are a critical piece in responding to the impending nursing shortage. Four areas of opportunity for DOL are: data, workforce development, training, and working conditions.

Data. The Department of Labor, through BLS, serves as the primary source for national workforce data. A closer collaboration between DOL and HRSA could enhance health care workforce planning capability. HRSA has funded four Regional Centers for Health Workforce Studies to examine geographic imbalance across five health professions disciplines: medicine, nursing, dentistry, allied health and public health. Located at the University of California at San Francisco, the University of Illinois at Chicago, the State University of New York at Albany and the University of Washington, the Centers investigate geographic distribution and related health workforce issues. The Centers work with State agencies and conduct research, including state and regional studies, and develop analytic tools that help states resolve pressing issues in health professions training. Given the importance of regional, state, and local data in analyzing labor market supply and demand, DOL could also provide technical assistance to states in their workforce planning efforts, promoting the use of consistent measures across states and agencies.

Workforce Development. Title I of the Workforce Investment Act (WIA) increases the opportunities for partnerships between government programs, employers, and education and training providers at the policy and planning level (through Workforce Investment Boards) and at the service delivery level (through One-Stop Career Centers). One-Stop Career Centers make use of technology to provide access to job listings, labor market information, resume preparation software, and information about local training programs. Adult programs under WIA had funds available to serve approximately 396,000 people in Program Year 2001. Each state maintains a workforce development web site with links to local One-Stop resources. These sites offer a wealth of information for job seekers and employers, and they are well-positioned to assist in recruiting workers for shortage occupations and facilitating the partnerships that will provide the necessary training.

Working conditions are a significant factor in nurse retention. The Department of Labor is responsible for administering and enforcing the Fair Labor Standards Act and other mandated worker protections. Consequently, DOL has the experience and the information to consider appropriate changes in legislation or in existing standards to address issues such as mandatory overtime, worker safety, and whistleblower protections. Demonstrations that evaluate the impacts of such changes on worker safety, patient care, nurse retention, and nurse recruitment will provide valuable information for decisionmakers weighing these policy changes against increases in wages and changes in hospital reimbursement levels.

Training. DOL programs are an ideal source of funding and expertise for the first steps on the ladder to professional nurse training. DOL programs are well-positioned to access non-traditional and other labor pools, including welfare recipients, low-income students, displaced workers, and youth. For example, the Job Corps offers potential for expanding existing health care training and providing a linkage to the nursing education system. Job Corps participants are between 16 and 24 years old; most come to the program without a high school diploma. There are 110 Job Corps centers across the country, serving over 60,000 new participants each year. These centers unite federal agencies, private employers, and eight national unions nationwide. For example, HCR Manor care, one of the largest providers in the long-term care industry is a Job Corps employer partner. They partner with Job Corps sites in Pennsylvania, Arizona, Florida, and Illinois. Almost all Job Corp Centers offer health-related training, including Nurse Assistant training and certification. Currently, only five Job Corps Centers offer advanced training for LPNs, usually at local community/technical colleges. The program is well suited for expanding its advanced training to individuals who have difficulty accessing or succeeding in the traditional nursing education system.

The School-to-Work Opportunities initiative and Career Academies offer additional opportunities for training youth in health occupations. In partnership with the Department of Education, DOL supports states and communities in establishing School-to-Work systems in secondary and post-secondary schools with alternative learning options for youth who have dropped out or are about to leave school. Career academies now operate in an estimated 1,500 to 2,500 high schools nationwide, located in almost every state, especially in urban areas. Organized as schools within schools, Career Academies provide a smaller learning environment, emphasize the real world relevance of school, and provide work-based experiences such as job shadowing and internships. About 20 percent of the career academies nationally have a dedicated health and human services academy theme.

Working Conditions. Working conditions are a significant factor in nurse retention.The Department of Labor is responsible for administering and enforcing the Fair Labor Standards Act and other mandated worker protections. Consequently, DOL has the experience and the information to consider appropriate changes in legislation or in existing standards to address issues such as mandatory overtime, worker safety, and whistleblower protections. Demonstrations that evaluate the impacts of such changes on worker safety, patient care, nurse retention, and nurse recruitment will provide valuable information for decisionmakers weighing these policy changes against increases in wages and changes in hospital reimbursement levels.


Based on our review of recent research and employment projections, it is clear that the nation will face a nursing shortage in the next decade, and some localities are already facing shortages.

There is no single solution to the nursing shortage. Nursing and other health personnel shortages differ from shortages in other occupations because the health industry has some unique market characteristics. The role of the government in setting Medicare reimbursement rates and other health care policies, as well as the government's role in safeguarding public health, limit the capacity of the market to adjust on its own, and cost containment pressures are an important factor in nurse staffing decisions. Government policies and expenditures, therefore, are central to addressing the shortage.

It is important to understand the varying underlying causes of the nursing shortage because the policy solutions vary. Expanding education is best suited for addressing the longer term expected increases in demand, but is less effective at addressing the short-term supply issue or distributional problems. To keep up with demographic changes, educational opportunities must be expanded to a broader population of potential students, including those who have not traditionally been trained as nurses in the past and those who may need significant remedial education and support to prepare for nursing education.

It is less costly and faster to bring a trained nurse back to the profession than to train new nurses, and improved working conditions have the potential to attract nurses back to direct patient care. Therefore, to address short-term supply and distributional problems, working conditions need to be addressed in a systematic way, with national support and visibility.

The Department of Labor can work with the Department of Health and Human Services to improve the quality and consistency of existing data, develop additional data on nursing staff beyond Registered Nurses, and provide technical assistance in the use of workforce data. Department of Labor programs are well positioned to attract new populations to nurse training and offer the first phases of training needed to prepare candidates for the professional training supported by HRSA.

1. VHA is a nationwide network of community-owned, nonprofit health care systems. VHA is a for-profit cooperative. The VHA Foundation is the nonprofit arm of VHA, Inc.

2. The H-1B Technical Skill Training Grant Program was authorized under the American Competitiveness and Workforce Investment Act of 1998 (ACWIA 1998). Grants funded under the Act have the longer term goal of raising skill levels of domestic workers to fill specialty occupations presently being filled by temporary workers admitted to the United States under the provisions of the H-1B visa. (The H-1B visa is permitted for foreign non immigrants working in high skill or specialty occupations experiencing shortages of domestic workers).

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