I.  THE NURSING PIPELINE

The supply of the nursing workforce is the sum of nurses in the pipeline—including students enrolled in nursing programs in the United States and abroad—and current nurses in the workforce. The current supply of nurses is not meeting today’s demand, and the gap is expected to worsen in the years to come.  To bolster the supply to meet current and future demand, policymakers, health care employers and educators are adopting various strategies, with most efforts focusing on the difficult task of expanding the capacity of nursing programs to admit sufficient numbers of nursing students.  This chapter examines the nursing education pipeline and determines the extent to which the five focus States are prepared to meet tomorrow’s demand.

Demand Projections

The demand for registered nurses across the country will outpace supply through 2020, the BHPr predicts. ^[1]   A 7 percent shortfall nationally of Registered Nurses (RNs) in 2005 is expected to jump to nearly 30 percent by 2020, translating into a shortage of more than 800,000 nurses nationally (figure 1).  Among the factors driving demand are a rapidly growing population—with much of the growth occurring in the elderly population—and medical advances that increase the need for nurses. ^[2]

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This National nursing shortage is affecting certain States and localities more than others.  Figure 2 shows that 30 States experienced shortages of RNs in 2000, including each of the five States studied in this report: California, Georgia, Indiana, Texas and Utah.  By 2020, the States with shortages are expected to increase to 44. ^[3]  

Figure 2.  States With Projected Shortages, 2000 and 2020

2000                                                          2020

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Source: Bureau of Health Professions, Health Resources and Services Administration, 2002.

The extent of the shortage varies by State.  Four of the focus States for this report are expected to fare worse than the nation by 2020.  As shown in table 1, California and Georgia—facing the most severe shortage by 2020—face a 40 percent shortage or more, and Indiana and Utah could experience shortages of at least 30 percent. Although Texas is somewhat better off than the nation as a whole, shortages there are nonetheless expected to reach 26 percent by 2020.  In short, what is already a problem is worsening at an alarming pace and, if not monitored, the five States studied face serious shortfalls in the years to come.

Table 1.  Projected Shortages, 2000-2020

Source: Health Resources and Services Administration, Bureau of Health Professions, 2002.

The demand for nurses is increasing for a number of reasons. Among them is a rapidly aging population.  As the baby boom generation ages, it will demand that more health care services be provided by more health care professionals.  During the next 25 years, the over-age-65 population will increase at five times the rate of those under age 65.  

At the same time that demand is intensifying, the supply of nurses is decreasing because today’s nurses also are growing older, and there are not enough new nursing school graduates to replace those who will soon retire.

Despite the dire forecasts, there are some positive signs.  After years of downward trends in enrollments and graduations—the number of graduates from all three types of RN programs declined by 31 percent between 1995 and 2000 ^[4] —schools across the country are reporting upward trends in the number of students and graduates.  Enrollments in entry-level baccalaureate programs were up by 11 percent in 2004 over the previous year, according to the American Association of Colleges of Nursing (AACN), marking the fourth consecutive year of growth since 2001 (figure 3). 

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Moreover, the National League for Nursing (NLN) reports that admissions and graduations for all three types of nursing programs—diploma, associate and baccalaureate programs—were up by about 6 percent between 2002 and 2003. 

Although these are impressive gains, a lack of institutional capacity is jeopardizing continued growth.  In 2004, nursing programs reportedly turned away 26,000 qualified applicants.  This trend, coupled with the slower enrollment growth in 2004 (see figure 3), suggest that “…some nursing programs have reached the limit on how far they can expand.” ^[5]  

In short, a serious lack of institutional capacity is limiting how many new nurses will emerge from the pipeline.  It is no surprise, then, that addressing this problem is a key concern for policymakers, nursing educators and the health care industry.  The following section describes the educational pipeline in general and for the five States studied in this report.

Educational Pipeline

The nursing pipeline refers to the process of educating nurses—which takes between two and five years—and takes into account the number of students applying to, enrolling in and graduating from nursing programs.  In addition to U.S.-educated nurses, the pipeline of future nurses also includes nurses educated abroad.  The pipeline is comprised of various steps (summarized below), each of which is a target of various policy measures designed to expand the size of each group.

• Applications. The pipeline begins with the applicants who apply to nursing programs.  The benefits of a large applicant pool are obvious.  For one, it allows nursing programs to admit more students—a critical element, in light of the growing need for more nursing graduates.  Second, a larger pool gives programs the ability to select those candidates who are academically prepared for the rigors of nursing education and who respond to the State’s specific needs, such as greater diversity or geographic distribution throughout the State.
• Admissions. Programs often turn away qualified candidates, particularly when the applicant pool is large and the program’s capacity is limited.  In response, strategies focus on expanding program capacity, primarily by increasing the faculty workforce.
• Enrollment.  Not all students who are admitted to nursing programs enroll; therefore, the enrollment numbers typically are lower than admissions.  To offset this, many programs over-admit students.
• Graduates.  The number of students enrolled in a program may drop due to expected attrition for academic or personal reasons.  Strategies focus on supporting students so they achieve academically and remain able to manage other responsibilities. 
• Licensure. Taking the licensing exam is the final step in becoming a nurse.  Schools have adopted various strategies to improve the percentage of students who pass these exams.

Policymakers and health care employers focus on expanding the pipeline because it is one way to increase the supply of nurses to meet demand.  Expanding the pipeline typically involves increasing the available labor pool, increasing diversity within that pool—nursing personnel remain predominately white and female—and reducing turnover or departure from the field by nurses who already are in the workforce. ^[6]

Path to Nursing

There are various ways to become a nurse.  The following are descriptions of the educational requirements for licensed practical nursing and registered nursing.

Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) care for the sick, injured, convalescent and disabled under the supervision of a physician or registered nurse. LPNs “…provide basic bedside care, may give injections or medications, change dressings, evaluate patient needs, implement care plans, and supervise nursing assistants.” ^[7]

Professional or Registered Nurses (RNs) have obtained the initial professional license of registered nurse. RNs “…interpret and respond to patient symptoms, reactions, and progress” and plan or direct care accordingly in a variety of settings, including specialized areas such as intensive care, obstetrics and public health. “They teach patients and families about proper health care, assist in patient rehabilitation, and provide emotional support to promote recovery. RNs use a broad knowledge base to administer treatments and make decisions about patients.” ^[8]

Structure of Nursing Education

Educational Program Leading to Licensure as a Practical Nurse (LPN). After completing a 1 year educational program, practical nurse program graduates are eligible to sit for the National Council of State Boards of Nursing Licensure Exam for Practical Nurses, also known as the NCLEX-PN exam. Approximately 1,152 State-approved LPN programs were offered in 2000 in the United States. ^[9]

Educational Programs Leading to Initial Professional Licensure (RN).  Students can prepare to become RNs in three ways.

• Diploma nursing programs are 2-3 year hospital-based programs that prepare students to deliver direct patient care in hospital settings. Some of these programs are affiliated with community and technical colleges. Diploma programs declined in number from 256 in 1985 to 76 in 2002. ^[10] These programs accounted for 5 percent of all RN programs in 2003, according to the NLN.
• Associate degree in nursing programs are 2-3 year programs, typically offered in community and technical colleges, that prepare students to provide direct patient care in a variety of settings. After a period of growth—between 1985 and 1995 the number of these programs increased by 13 percent—associate degree programs declined in number. In 2003, there were 846 such programs, down by 11 from 2002. ^[11]  Associate degree programs account for 59 percent of all RN programs, and about the same proportion—60 percent of all RN students—are admitted annually into such programs.
• Bachelor’s degree in nursing – entry level programs are 4 year programs that prepare students to practice in all health-care settings. The generic or entry-level baccalaureate program admits students who have no previous nursing education and awards a baccalaureate nursing degree upon completion.  According to the AACN, 566 schools offered generic, or entry-level, baccalaureate degrees in 2003. ^[12] These programs account for about 36 percent of all RN programs, and roughly the same percentage of students are admitted into them annually.
• Accelerated programs for non-nursing college graduates admit students who hold baccalaureate degrees in other disciplines but have no previous nursing education and award graduates a baccalaureate nursing degree. These fast-track programs typically take 12 to 18 months of full-time, year-round study. In 2004, 136 accelerated baccalaureate nursing programs were available in 37 States and the District of Columbia.  According to the AACN, 50 new accelerated baccalaureate programs currently are in the planning stages. ^[13]

Educational Programs Leading to Advanced Professional Licensure (RN)

• Bachelor’s degree in nursing – non-entry-level programs admit RNs with associate degrees or diplomas in nursing and award a baccalaureate nursing degree.  In 2004, there were 611 of these programs, also called RN completion or RN-to-Baccalaureate programs. ^[14]  

Advanced Education

• Master’s degree in nursing programs prepare students for education, management and advanced practice roles.  Practicing nurses who wishes to become advanced practice nurses or desire more advanced nurse education in a clinical specialty may choose to enroll in a master of science in nursing (MSN) program with a specialization in their chosen area of interest (e.g., family nurse practitioner, acute care clinical specialist) or a track in the chosen function (e.g., educator, health policy, ethics, administrator). Most of these students already will have earned their BSN degree, and a majority will already be licensed to practice nursing. In 2003, 400 institutions in the United States and its territories offered master’s degrees in nursing. ^[15]
• Accelerated master’s programs are available for individuals who have completed baccalaureate or other graduate degrees in fields other than nursing.  These programs include 12 months of intensive nursing education, after which the student is eligible to sit for the NCLEX-RN. Upon passage of the exam, the student then continues with the master’s portion of the program to complete the chosen specialization.  Thirty-seven institutions offer accelerated master’s programs in the United States and its territories, and programs at another 18 institutions are in the planning stages. ^[16]
• Doctoral degrees in Nursing (i.e., Ph.D., DNS, DNSc) represent the terminal degree in the field.  In 2003, 88 institutions offered doctoral degrees in nursing. ^[17]  In most large public universities and academic health centers, nursing faculty must hold a doctoral degree to teach in master’s and doctoral programs. This cadre of faculty are most often engaged in nursing research and the advancement of nursing sciences.

National and Five-State Trends in the Nursing Pipeline

Significant increases in the number of interested and qualified nursing program applicants suggest that interest in nursing is growing—likely due to a number of factors, including effective recruitment strategies, increased financial incentives for potential nurses and nursing instructors, improved work conditions and relatively sluggish job growth in other fields. 

Applications to nursing programs are on the rise nationally and in the five focus States, in many cases outpacing the capacity of nursing programs to accept all qualified candidates.  As a result, nursing programs are turning away qualified applicants or placing them on a waiting list. 

Applications for generic and RN-to-Baccalaureate programs were increasing in each of the five States, with every State but California reporting gains of 20 percent or higher (figure 4).

As in the nation as a whole, schools in the five focus States are turning away qualified applicants, as shown in figure 5.  Schools in California and Utah turned away more than 40 percent of qualified applicants to associate degree programs in 2002, and Georgia schools rejected 54 percent of qualified LPN applicants.

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Nursing programs from the five States reported that they could not accept more qualified applicants in 2002 because the programs lacked sufficient faculty and admission seats were filled.

Following years of downward trends, enrollments now are on the upswing nationally, as well as in the five States studied here.  As shown in figure 6, enrollment in generic or entry-level baccalaureate programs increased by 30 percent nationally between 1999 and 2003—from 62,821 in 1999 to 80,629 in 2003.

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As shown in figure 7, the number of students in master’s degree programs increased by 10 percent between 2001 and 2003, after a decline in the two previous years.

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Enrollment in doctoral programs, as shown in figure 8, increased by 14 percent—from 2,797 in 1999 to 3,198 in 2003.

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The National League for Nursing also reports an increase in enrollment between 2002 and 2003 in associate degree and diploma programs. Enrollment in associate degree programs jumped 9 percent—from 117,192 to 127,709—while enrollment in diploma programs saw a 14 percent increase—from 9,767 to 11,153. ^[18]

At the State level, nursing programs are reporting enrollment gains as well.  Figure 9 compares enrollments at two points in time. Enrollment between 1999 and 2000 in entry-level RN programs increased slightly in California, Georgia and Texas, while it dropped in Indiana and Utah.  Three years later, however, all five States reported one-year enrollment increases (from 2002 to 2003) in entry-level baccalaureate programs.  Georgia schools reported the largest annual enrollment increase, nearly 18 percent.  In short, enrollment trends are changing course in the five focus States. 

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Moreover, with a few exceptions, States reported continued enrollment gains for every degree type between 2002 and 2003.  As shown in Figure 10, doctoral programs reported a significant annual increase in enrollments in Texas and Utah—at 25 percent and 62 percent, respectively.  Enrollment in entry-level baccalaureate programs increased in all five States, ranging from an 18 percent jump in Georgia to a modest gain of 1.7 percent in California.  Enrollment in master’s degree programs was higher in 2003 than the previous year in every State except California, with gains of up to 20 percent in Indiana.

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In the United States, about 4 of every 10 graduates from nursing programs have received a baccalaureate degree, and nearly 6 in 10 received an associate degree (with just 3 percent having earned a diploma degree.)  As shown in figure 11, California and Utah have the highest proportion of graduates with associate degrees, at 74 and 71 percent, respectively.  The other three States have more BSN graduates as a percentage of all graduates in 2003 than the nation as a whole.

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Following a 6 year decline in graduations from entry-level baccalaureate programs, nursing programs began reporting an upward trend in the number of graduates in 2001.  As shown in figure 12, between 2001 and 2003, the number of generic baccalaureate graduates increased slightly, while graduations from master’s degree programs remained relatively stable from previous years, but overall were slightly lower than in 1999. 

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Graduations from entry-level baccalaureate programs continued to increase after 2003.  The AACN reported that graduations from entry-level baccalaureate nursing programs were up significantly in 2004: more than 27,000 new graduates were ready to join the workforce, a 14 percent increase from 2003.  These new data move graduation levels for generic baccalaureate programs above 1999 levels. ^[19]  

The number of graduates from entry-level baccalaureate programs in the five States also is on the rise, although modestly in some regions.  (The most recent graduation data that allows for comparison across the country examines regional rather than State graduation data.) 

As shown in figure 13, every region in the country graduated more entry-level baccalaureate students in 2003 than in 2002.  In the midwest region, where Indiana is located, there was a one-year increase of nearly 9 percent, while more modest gains of 2 percent occurred in the southern region (which includes Georgia and Texas). ^[20]

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In contrast, graduations from master’s and doctoral degree programs were down in almost every region.  The number of graduates from master’s degree programs dropped by almost 3 percent in the western region (which includes California and Utah).  The only region to see gains in master’s degree graduations was the midwest, which experienced a slight 1 year gain of 1 percent.  Significantly fewer doctoral graduations occurred in 2003 than in the previous year—ranging from a 4 percent drop in the west to a 12 percent drop in the midwest. 

Graduation rates are likely to increase as the larger classes of students enrolled in master’s and doctoral degree programs move through the pipeline; however, the flat or downward trend in graduations from these programs suggests that short-term relief to the growing crisis in the faculty workforce is yet to be attained. 

Passing the nurse licensure exam is the final step in the licensure process; therefore, the number of individuals who pass the registered and practical nurse licensure exams is a good indicator of how many new nurses are entering the profession, according to the National Council of State Boards of Nursing (NCSBN).

• RN Exam-Takers. The number of people who took the National Council Licensure Examination for RNs (NCLEX-RN) in 2004 was up by 15 percent from 2003.  In 2004, 121,006 RN candidates took the exam; in the same 9 month period in 2003, 105,410 RN candidates took the exam. The pass rate in 2004 was 73 percent; therefore, more than 88,000 new RNs were available for employment in 2004.
• PN Exam-Takers. Almost 4,000 more licensed practical nurse candidates took the National Council Licensure Examination for Practical Nurses (NCLEX-PN) in 2004 than in 2003, an increase of about 8 percent. In 2003, 43,563 LPN candidates took the exam, while 47,401 took it 1 year later. With a pass rate of 80 percent, about 38,000 new licensed practical nurses were available for employment in 2004.

A key concern for States is how to increase the pass rates on the NCLEX exams.  For example, after a steady decline in the pass rate for the NCLEX-RN exam, the California Board of Registered Nursing set up a task force in 2000 to identify factors that improve the pass rates for first-time takers and to make recommendations for achieving higher overall pass rates.  The task force surveyed nursing education administrators, who cited the following factors that adversely affect scores: English fluency, interval of time between graduation and test-taking, and number of hours the student works. ^[21]

Student Demographic Statistics

In addition to building a large enough nursing supply, policymakers and others also are seeking policies that will increase diversity, so that the nursing workforce more closely resembles the overall population. 

According to the National Advisory Council on Nurse Education and Practice (NACNEP), advisors to the HHS Secretary and Congress, “…a culturally diverse workforce is essential to meeting the health care needs of the Nation’s population.” ^[22]  Not only is the entire U.S. population becoming more diverse, but minority populations have higher rates of certain diseases, lower rates of successful treatment, and are more likely to reside in areas where shortages exist of health care providers.  Moreover, diversity in the health care workforce has been found to improve health care quality and outcomes, particularly among people of color.

Nationally, nursing students and graduates at all levels were more diverse in 2003 than in 1993, according to data compiled by the AACN. As shown in figure 14, minority students comprised nearly 25 percent of baccalaureate nursing programs in 2002, up from 17 percent in 1993. Nationally, schools reported increases in minority enrollment for master’s degree and doctoral programs as well—with master’s programs reporting a near doubling of minority enrollment, from 11 percent in 1993 to 21 percent in 2003.

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The five focus States also are achieving more diversity among nursing students and graduates.  This growing diversity among nursing students may be a result of strategies aimed at reducing barriers, such as financial assistance, loan repayment, tutoring, mentoring and creative approaches by nursing schools to recruit and retain students from diverse backgrounds ^[23]  Each of the five reported having a greater proportion of non-white enrollees in generic RN baccalaureate programs in 2001 than in 1997. ^[24]  In Texas, for example, the percentage of white enrollees dropped from 64 percent to 59 percent; at the same time, the proportion of Hispanic enrollees increased from 14 percent to 21 percent.

Graduates from RN-to-Baccalaureate programs were proportionately more diverse in 2001 than in 1997 in all five States. The percentage of African-American graduates doubled in Indiana and Texas, while the percentage of Hispanic graduates nearly doubled in California.

At the master’s level, the proportion of non-white graduates increased in every State but Indiana, which reported no change.  In Texas, the proportion of African-American graduates increased from 3 percent to 6 percent, and in Utah, the proportion of Hispanic graduates tripled from 2 percent to 6 percent.  The graduating classes from doctoral programs in three States—California, Georgia and Indiana—were more diverse in 2001 than in 1997. The percentage of African-American graduates increased from 14 percent to 25 percent in Georgia; Hispanic graduates increased from 7 percent to 11 percent in California; and Asian or Pacific Islander graduates increased by 14 percent in Indiana.

Nursing Faculty Trends

National and State economic conditions and demographic shifts influence necessary nursing pipeline expansion.  A significant constraint is the faculty shortage: without enough educators, programs are forced to turn away qualified and interested candidates.  This becomes a vicious cycle, as lack of faculty squeezes programs’ ability to enroll more students, resulting in fewer students who can pursue nursing education, thus curtailing the opportunity to expand the pipeline in the future. 

The faculty shortage has several causes.  For one, the teaching workforce reflects the demographic changes in the population at large: teachers are becoming older and closer to retirement.  Second, there is a lack of younger teachers.  As shown in figure 15, the median age of faculty in all five States increased by two to three years between 1997 and 2002.

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According to the National League for Nursing, the top reason faculty left in 2002 was retirement (36 percent), followed by those who “wanted a career change.”  Other reasons included relocation, health problems and termination. ^[25]

Furthermore, nursing instructors typically earn less and have less salary growth potential than their colleagues who hold clinical jobs.  Nurses can earn more in clinical practice with a master’s degree than in a faculty position that may require a doctoral degree. ^[26] Starting salaries for new graduates may exceed salaries of faculty who have both advanced degrees and experience.  

In addition to relatively low salaries, the demand for lengthy and costly education can deter nursing students.  According to the NLN, completing a doctorate degree (from the start of the doctorate program) takes 8.3 years in nursing, versus 6.8 years in other fields. ^[27]   Because of the lengthy process involved to become an educator, increasing the faculty workforce takes time.  A master’s degree is the minimum requirement for teaching in community college programs and clinical teaching in undergraduate programs. 

Unfortunately, near-term help may not be available.  In a 2002 survey, the Southern Regional Education Board (SREB) found that just 8 percent of the 2,837 graduates in their 16-State region were prepared as nurse educators. According to the NLN, trends in master’s program enrollments do not portend an increase in the number of nurse educators.  In 2003, 24,838 students were enrolled in master’s programs, a drop of nearly 20 percent from 1993.   Moreover, the number enrolled in educator tracks dropped from 3,301 in 1993 to 1,366 in 2003.  Although the number of graduates remained relatively stable between 1993 and 2003 (at 7,926 and 7,516, respectively), the number of graduates from educator tracks dropped from 755 in 1993 to 247 in 2003.

Current Workforce Supply

In addition to the prospective nurses in the educational pipeline, the total supply of nurses also is comprised of nurses who already are in the workforce.  Although this report focuses on nursing education, a discussion of nursing supply would be incomplete if it failed to address those nurses who already work in the field.  After downward trends between 1995 and 2000—when there was a 31 percent decrease in the number of graduates and half of all States saw a drop in their RN-to-population ratios—the supply of nurses now is increasing.  Among the ranks of the nursing workforce, more nurses are working full-time and more are employed in nursing (rather than other fields).  In 2000, there were 2.7 million licensed RNs in the United States, according to the National Center for Health Workforce Analysis (NCHWA) at the HRSA, BHPr.

Supply of Nurses

One measure of how well the nursing workforce is meeting demand is the number of employed nurses per 100,000 individuals. Although use of this number alone has limitations—States with more elderly residents may require more services and resources than other States that have more young or healthy residents, for example—it provides an overview of the availability of nurses among the State’s overall population.

As shown in table 2, certain States already were facing significant shortfalls in 2000.  Of the five focus States, all but Indiana were “red States” in 2000, meaning they were more than 10 percent below the National average of RNs per capita.  In California, there were 544 RNs per 100,000 people—the second lowest in the nation behind Nevada—and significantly below the U.S. average of 782. ^[28]  

Table 2.  RNs per Capita by State