Joint Statement from the Tri-Council for Nursing on
Recent Registered Nurse Supply and Demand Projections
American Association of Colleges of Nursing
(AACN)
American Nurses Association (ANA)
American Organization of Nurse Executives
(AONE)
National League for Nursing (NLN)
The downturn in the U.S. economy has had an impact on every
employment sector and has led to an easing of the nursing shortage in
many parts of the country. Workforce analysts, including Dr. Peter
Buerhaus, Director of the Center for Interdisciplinary Health Workforce
Studies at the Institute for Medicine and Public Health at Vanderbilt
University Medical Center, have documented this shift in registered
nursing (RN) employment. However, these authorities have also raised
concerns about slowing the production of RNs given the projected demand
for nursing services, particularly in light of healthcare reform.
(See Dr. Buerhaus’ perspective on the outlook for registered
nurses in the U.S. on page 4.)
On June 9, 2010, Minnesota Public Radio produced a story titled
“What’s the right number of nurses?” that looked at
the job market in Minnesota for new nurses and noted the impact of the
recession on the number of readily available RN positions. This piece
included projections from Economic Modeling Specialists, Inc. (EMSI)
indicating that local schools were producing more nurses than the state
needed to fill current vacancies. Soon after, EMSI posted on its blog a
state-by-state analysis of the number of RNs being produced and the
number of job openings to provide a national snapshot of supply and
demand. The company indicated that RNs were being overproduced in all
states except Nevada and Alaska. EMSI
conveyed in its analysis that using data reported by schools to the
Department of Education through the Integrated Postsecondary Education
Data System (IPEDS) to determine RN supply has serious limitations.
Following a review of the EMSI analysis, the Tri-Council has the
following concerns:
The IPEDS data used to determine supply includes graduates for every
type of nursing program, including Licensed Practical Nurse (LPN), RN to
baccalaureate, master's, doctoral, and certificate programs. These
graduates are not new RNs and should not be included in the supply
total. In the company's analysis of where RN graduates are being
produced, they point to Excelsior College, the University of Phoenix, and Chamberlain
College as the "top
producers of registered nurses." Though the majority of graduates from
Excelsior’s associate degree program may indeed be new nurses,
only a small percentage (3-4%) of new RNs graduated from the University
of Phoenix and Chamberlain College in 2009.
The EMSI supply data counts graduates from pre-nursing,
health/medical preparatory programs, and health services/allied health
programs. These should not be included in the RN category. Schools also
misreported more than 2,000 LPN graduates or “completers”
under the Nursing/Registered Nurse category in IPEDS, which is inflating
the numbers.
Basing the supply of new nurses on the number of new RNs who passed
the national licensing examination for registered nurses, the
NCLEX-RN©, may be a closer approximation to the number
of nurses actually entering the workforce each year (NCSBN, 2010). Only
nursing program graduates who pass this exam may legally practice in the
US as an RN. In 2009, 147,812 graduates passed the NCLEX. This
supply figure is almost 43,000 less than the supply figure used by EMSI
(190,615).
The EMSI analysis focused only on new nurses entering the workforce
and did not consider those who leave. Data from the latest National
Sample Survey of Registered Nurses (HRSA, 2010) indicate that nearly
73,000 RNs leave the profession annually due to retirement,
child-rearing, returning to school, career change, death, or for other
reasons. EMSI’s sole focus on growth in the number of new RNs
belies the true challenge of maintaining and expanding the population of
working RNs to meet the growing demands for nursing services.
On the IPEDS Website, the 2008-2009 data on degree completions is
considered “early release” data, and there is a disclaimer
posted stating that "early release files are provided for institutional
level analysis only, and should not be used for national, state, or
other aggregate estimates." Nonetheless, 2008-2009 IPEDS data were used
in this analysis without noting this limitation.
EMSI uses a proprietary database to identify demand projections that
pulls from many different sources. Consequently, the Tri-Council cannot
determine exactly how these numbers were derived.
Many organizations and individuals have contacted EMSI about this
workforce analysis, and company representatives have been very
responsive in explaining their approach and validating concerns about
the limitations of using IPEDS data and the likelihood of
over-estimating new RNs in the supply estimates. Even so, nursing
programs are encouraged to work closely with their state workforce
officials, boards of nursing, employers, and other stakeholders to
ensure that current and future demands for RNs are met at the local
level and that an adequate number of nurses with the right skill mix is
produced to meet the population’s healthcare needs.
Given the fluctuations in the economy, no one can accurately project
how long the nation will take to recover and exactly when old workforce
patterns may re-emerge. In the short term, the changing characteristics
of employment options for new nurses is causing frustration to many new
graduates who expected a different occupational outlook from what
currently exists in many places. However, we know that the Baby
Boomers are entering their retirement years and their demand for care is
escalating, the nursing workforce is aging rapidly, and healthcare
reform will soon provide subsidies for 32 million citizens to more fully
utilize the healthcare system. At the same time, we know that health
care was the only sector of the economy to maintain steady growth since
the recession was first identified in December 2007 and that the Bureau
of Labor Statistics has identified Registered Nursing as the top
profession in terms of projected growth through 2018.
Further, the latest findings from the 2008 National Sample Survey of
Registered Nurses (HRSA, 2010) points to the first wave of projected
retirements from the nursing workforce. Even though 444,668 nurses
received their license to practice from 2004 through 2008, the U.S.
nursing workforce only grew by 153,806 RNs during this timeframe
providing the first clear indication of the large scale retirements
which the aging nursing profession has begun and will continue to
experience. Given the demographics of the nursing workforce, this
pattern is expected to continue over the next decade.
In light of these realities, the Tri-Council is very concerned that
diminishing the pipeline of future nurses may put the health of many
Americans at risk, particularly those from rural and underserved
communities, and leave our healthcare delivery system unprepared to meet
the demand for essential nursing services.
Practicing nurses and those new to the profession are strongly
encouraged to see the current trend in RN entry-level employment as an
opportunity to move their career to the next level. Nurses with advanced
education are needed now to serve in a variety of roles as faculty,
scientists, primary care providers, specialists, and top administrators.
In a consensus policy statement on the Educational Advancement of
Registered Nurses released in May 2010, the
Tri-Council stated that:
“There are currently too few nurses choosing to advance their
education. First is a need for education advancement to the
baccalaureate level then to the graduate level to meet the urgent need
for Advanced Practice Registered Nurses (APRNs) and nurse
educators. Current healthcare reform initiatives call for a
nursing workforce that integrates evidence-based clinical knowledge and
research with effective communication and leadership skills. These
competencies require increased education at all levels. At this tipping
point for the nursing profession, action is needed now to put in place
strategies to build a stronger nursing workforce.”
The Tri-Council organizations agree that a more highly educated
nursing profession is no longer a preferred future; it is a necessary
future in order to meet the nursing needs of the nation and to deliver
effective and safe care.
References
Health Resources and Services Administration [HRSA]. (2010). Initial
findings: 2008 National Sample Survey of Registered Nurses. Download at
http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings2008.pdf.
National Council of State Board of Nursing [NCSBN]. (2010). 2009
number of candidates taking NCLEX examination and percent passing, by
type of candidate. Download at https://www.ncsbn.org/Table_of_Pass_Rates_2009.pdf.
The Tri-Council is an alliance of four autonomous nursing
organizations each focused on leadership for education, practice and
research. While each organization has its own constituent
membership and unique mission, they are united by common values and
convene regularly for the purpose of dialogue and consensus building, to
provide stewardship within the profession of nursing. These
organizations represent nurses in practice, nurse executives and nursing
educators. The Tri‑Council’s diverse interests encompass the
nursing work environment, health care legislation and policy, quality of
health care, nursing education, practice, research and leadership across
all segments of the health delivery system.
Dr. Peter Buerhaus’ perspective on the short- and long-term
outlook for registered nurses in the US:
Both the near and long-term outlooks for the stability and growth of
the nursing workforce are dominated by the aging of RNs and by
uncertainty over key economic factors. In the near-term (next
couple of years) we can expect that, until there is a strong jobs
recovery, most hospitals and other employers will continue to find that
they can employ all the RNs they want at prevailing wages. To some
observers, this situation might understandably suggest that it would be
wise to decrease the production of new nurses and thereby avoid
enlarging what might already be an excess supply of RNs. The
danger of this strategy is, of course, that once the jobs recovery
begins and RNs’ spouses return to work, many currently employed
RNs could leave the workforce. Because hospital employment of RNs
over the age of 50 increased by more than 100,000 in 2007 and 2008, the
exit could be swift and deep as many of these RNs seek to resume (or
begin) their retirement once their spouses’ rejoin the labor
market. And just as fast as the current great recession unfolded,
we could find ourselves facing yet another nursing shortage. Because of
the uncertainty about how soon a jobs recovery will unfold, uncertainty
over whether it will be a slow or fast jobs recovery, and because of
uncertainty over how fast and intensely RNs will respond to the eventual
jobs recovery, slowing the production of nurses is not without
significant near-term risk.
The risk grows even more consequential when shifting the time horizon
out over the longer-term. Over the next 15 years, it is reasonable
to assume that demand for RNs will grow considerably due to a number of
factors, including (but not limited to): the increasing size of
the population; the expansion of health insurance coverage to tens of
millions of currently uninsured Americans via the enactment of health
reform; the changing age composition of the population marked primarily
by the estimated 80 million baby boomers, the first of whom reach 65
years of age in 2011 (those over the age of 65 consume much more
healthcare services compared to those under 65); advances in technology;
and the expected shortage of physicians that will shift more work onto
nurses. How much demand will grow is uncertain, but there is
little doubt that it will outpace the growth of the size of the nursing
workforce. Currently, nearly 900,000 RNs (out of an estimated 2.6
million working RNs) are over the age of 50, and large numbers of these
RNs are expected to retire in the years ahead (independent of the pace
and intensity of a jobs recovery). Thus, the long-term task before the
profession is twofold: replace these aging baby boom RNs, and
beyond that, increase the total supply of RNs to meet the increasing
demand.
Given the magnitude of these long-term challenges, it is important to
resist the short-term urge to curtail the production of RNs. If nursing
education capacity is decreased now, the ability to respond to the
longer term, yet more predictable challenges will be hampered, as well
as responding to the unpredictable near-term challenges should a strong
and swift jobs recovery develop. Meeting both short-and long-term
challenges is vital for the healthcare system, the health of society,
and for the advancement of the nursing profession over the next two
decades. The costs of failing to meet these challenges must be
weighed against the benefits of reducing the current capacity of nursing
education programs. Rather than decrease education capacity and
output of new nurses and become caught up with the distraction that such
a policy could ignite, now is the time to intensify the search for novel
and effective ways to engage new graduates into the nursing profession
so that we will be ready to respond successfully for both near- and
longer-term challenges.
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