Table Of ContentA WHITE PAPER
ARKANSAS NURSE EDUCATOR SHORTAGE AND
ITS IMPACT ON REGISTERED NURSE WORKFORCE SHORTAGE
Submitted by:
Nurse Administrators of Nursing Education
Programs (NANEP) Task Force
Linda C. Hodges, EdD, RN, Co-Chair, University of Arkansas for Medical Sciences
Barbara G. Williams, PhD, RN, Co-Chair, University of Central Arkansas
JoAnna Christiansen, RN, East Arkansas Community College
Barbara Conrad, PhD, RN, University of Arkansas at Fayetteville
Margaret Fielding, RN, Baxter County Medical Center
Janet Graham, DNS, RN, Henderson State University
Shirlene Harris, PhD, RN, Baptist School of Nursing
Jackie Murphree, EdD, RN, Arkansas State Board of Nursing
Audrey Owens, EdD, RN, Arkansas Tech University
Ann Schlumberger, EdD, RN, University of Arkansas at Little Rock
Final Copy
May 1999
ARKANSAS NURSE EDUCATOR SHORTAGE AND
ITS IMPACT ON REGISTERED NURSE WORKFORCE SHORTAGE
I . Introduction
1. National Economic lmpact of Health Care ............................................................ 2
2 . Arkansas’ Economic Impact of Health Care ......................................................... 3
11 . Registered Nurse Workforce Shortage
1 . The Aging of the RN Workforce ........................................................................... 6
2 . Image of Nursing as a Profession .......................................................................... 8
3 . RN Working Conditions ........................................................................................ 8
4 . Low RN Salaries and Salary Compression ............................................................ 9
5 . Declining RN Student Enrollments and Graduation Rates .................................. 10
I11 . Nursing Faculty Workforce Shortage
1 . The Aging of Nursing Faculty ............................................................................. 12
2 . Availability of Prepared Faculty .......................................................................... 13
3 . Nursing Faculty Working Conditions .................................................................. 14
4 . Low Faculty Salaries ............................................................................................ 14
5 . Competing Job Opportunities .............................................................................. 15
IV . Conclusion ....................................................................................................................... 15
V . Recommendations ............................................................................................................ 18
VI . References ........................................................................................................................ 20
TABLES AND FIGURES
Tables
Table 1 : State and National Nursing Workforce and Education Data ................................ 1
Table 2: National Employment Scttings of Registercd Nurses 1980-19 96 .................................. 4
Table 3: Registered Nurses in Arkansas and Employment Settings ............................................. 6
Table 4: Employed RNs in Arkansas by Age ............................................................................... 8
Table 5: Average Entry Level Hourly Pay for Health Disciplines in Arkansas Hospitals ......... 10
Table 6: Arkansas RN Enrollment and Graduation Data. 1994- 1998 ........................................ 11
Table 7: Age of Nursing Faculty ................................................................................................ 13
Table 8: Impact of Unfilled and Lost Faculty Positions on
Student Enrollment in Arkansas ................................................................................... 14
Table 9: Average National Faculty Salaries in Selected Fields
At Public 4-Year Institutions. 1997- 1998 ..................................................................... 16
Table 10: Arkansas Nursing Faculty Salary Range and % Below $55.0 00 ................................ 17
Table 1 1 : Salaries for Arkansas Master’s-Prepared Nurses ....................................................... 17
Table 12: Comparison of Arkansas Nursing Faculty Salaries and
Beginning Salaries for Advanced Practice Nurses ..................................................... 18
Figures
Figure 1 : National BSN Shortage Projected ................................................................................. 4
Figure 2: Anticipated Changes in the Nation’s Demographics .................................................... 5
Figure 3: The Aging of the Frail Elderly ...................................................................................... 5
Figure 4: Age Distribution of U.S. Registered Nurse Population 1980-19 96 .............................. 7
Figure 5: Arkansas RN Enrollment and Graduation Data .......................................................... 11
...
111
ARKANSAS NURSE EDUCATOR SHORTAGE AND
ITS IMPACT ON REGISTEWD NURSE WORKFORCE SHORTAGE
INTRODUCTION
As early as 1996 Arkansas hospitals began to experience a shortage in registered nurses (RNs).
Since that time the shortage has grown worse, with some rural hospitals reporting up to 30% of
their budgeted registered nurse positions unfilled. In December 1998, the number of budgeted
unfilled RN positions in Pulaski County’s major hospitals was 295. This reflects a growing
national nursing shortage that has some health care institutions offering sign-on bonuses of $500
to $10,000 (American Association of Colleges of Nursing [AACN], 1999). Recruitment
strategies are less effective than in the past. Recruitment of foreign nurses from English-speaking
countries has been met with little success since countries such as England and Canada are also
experiencing a shortage of nurses. Arkansas nurse recruiters are finding that attempts to recruit
from other states are also nonproductive, since most states are experiencing similar if not worse
problems filling their budgeted positions. The factors that are contributing to the RN shortage
include: 1) increased demand for RNs; 2) the aging of RNs; 3) the image of nursing as a
desirable profession; 4) RN working conditions; 5) low salaries; 6) low enrollments and
graduation rates; and 7) a nursing faculty shortage. The anticipated shortage of RNs predicted
for the year 2000 has already arrived, while the demand for and the limited future supply of these
nurses in the coming years is daunting.
Compounding the Arkansas nursing shortage is the fact that the state has the least educated
nursing workforce of any state in the nation and one of the lowest numbers of RNs to population
ratios. As Table I presents the state is 14.4% below the nation in the number of RNs for its
citizens, has nearly twice the number of LPNs than the national average and fewer than half the
number of BSN-prepared RNs than the national average. This leaves Arkansas a smaller pool of
RNs with BSNs to assume independent roles and be available for graduate school recruitment
leading to possible faculty positions (Nursing Sample RN Survey, 1996). Arkansas is starting at
the bottom in addressing this critical crisis, with few resources to apply to the problem.
Table 1
STATE AND NATIONAL NURSING WORKFORCE AND EDUCATION DATA
State* Nation**
RNs per 100,000 population 683 798
LPN to RN ratio 1.8 to 3 1 to 3
ADN & Diploma RN to 10 to 3 10 to 7
BSN-prepared RN
* Source: Arkansas State Board of Nursing Annual Report, 1998
**Source: National Sample RN Survey, 1996
1
It is clear to meet the state’s RN workforce shortage, the RN nursing education programs must
increase their enrollment and graduation rates as quickly as possible. The ability of the state’s
RN schools to apply this long-term solution to the mounting shortage, however, is in grave
doubt. Beneath the RN workforce shortage is an even more critical problem, an unprecedented
national nursing faculty shortage that is expected to grow increasingly worse. Without an
increase in the number of nurse educators to prepare a greater number of students, the RN
nursing workforce shortage will only escalate. There are many reasons the nation and Arkansas
are experiencing a nursing faculty shortage, including: 1) the escalating retirement rate of current
nursing faculty, 2) lack of adequate numbers of prepared faculty, 3) worsening faculty work
conditions, 4) increased job opportunities in the private sector, and 5) low salaries of nursing
faculty compared to salaries of similarly prepared nurses in clinical and administrative positions,
and to those of other disciplines.
Arkansas can ill afford the staggering, negative economic impact that an inadequate supply of
RNs and nursing faculty can have on the state’s health care industry and general economy. As a
state that depends upon appropriate health care services in communities to attract and retain
industry and business, the availability of adequate numbers of prepared RNs becomes a major
factor in the state’s economic growth and stability. This is particularly true when attempting to
recruit greater numbers of retirees and industries to the state who consider access to good health
care a relocation imperative. Ensuring an adequate supply of RNs and nursing faculty in the
state must be viewed not only from the impact an inadequate supply has on the economy but also
from the nursing education and the health care perspective. Over the past five years, Health Care
State Rankings has rated the state last in the nation in terms of overall health and access to health
care. Arkansas cannot afford this downward trend, and a nursing shortage will only increase this
rate of decline. An increasingly visible level of public criticism of the system and the state will
ensue.
National Economic Impact of Health Care
In 1995, health care costs represented 13.6% of the nation’s gross domestic product (Health,
United States, 1998). In 1994, the gross domestic product by industry showed health care at
410.2 billion dollars (Bureau of Economic Analysis, 1998). According to a recent edition of
1999 Hospital Statistics, in 1997 there were 6,097 hospitals in the U.S. that boasted 1,035,390
beds (American Hospital Association, 1999). These hospitals had a total of over 245 million in-
patient days, saw over 25 million surgical procedures performed, had over 520 million outpatient
visits, and over 3.8 million births. A total of 967,404 RNs were employed in these hospitals,
approximately 10 times the number of physicians and dentists. The total payroll for the hospitals
was greater than 184.3 billion dollars, and the total gross revenue was approximately 564.5
billion dollars. When one considers the sheer impact on the economy of these hospitals using a
modest multiplier of 2.258, representing the trickle down effect of dollars from health care into
other aspects of the community, U.S. hospitals alone contribute approximately 1.27 trillion
dollars annually to the nation’s economy.
2
Arkansas’ Economic Impact of Health Care
In Arkansas, health care is one of the state’s primary industries. According to the latest figures
available in fiscal year 1995-96, Arkansas received 3.5 billion dollars from the U.S. Department
of Health and Human Services to support the state’s health care costs. To impose some degree
of reality on the way the health care industry in Arkansas affects the state’s economy, in 1995, it
was estimated that the two VA Medical Centers in Pulaski County along with Arkansas
Children’s’ Hospital contributed 160.4 million and 154 million dollars, respectively, to the
state’s economy. Indeed in Arkansas, health care is one of the largest state industries. When all
other sources of payment are factored in, the Arkansas health care industry contributes billions of
dollars to the state’s economy annually.
According to Arkansas Statistical Abslmct 1998, the average cost to hospital per stay in
Arkansas was $4,514 in 1994 compared to $6,230 in the U.S. that same year (Arkansas State
Data Center, 1998). In 1993 there were 99 hospitals in Arkansas with a total of 12,995 beds.
These hospitals reported 371,941 admissions, 2,870,076 inpatient days, 246,882 surgical
operations, over 3,478,478 outpatient visits, and over 32,432 million births. A total of 9,520
RNs were employed compared to 265 physicians and dentists. The total labor expenses were
$1,309,660 and the total expenses were $2,541,596 (5 1.5% labor expenses).
Paramount to the engine of this huge economic machine is the thousands of RNs who, in today’s
managed care environment, can financially make or break a given health care agency or hospital.
As managed care has placed hospitals and agencies in a highly competitive environment,
financial viability for the future will ultimately rest with those agencies that can produce the
highest quality of care at a reasonable price. Hospitals in the more mature managed care
environments such as California, Minnesota, and the New England region are now finding that
there is no substitute for well-prepared RNs. Indeed many hospitals that laid off senior RN staff
and clinical nurse specialists as a cost cutting strategy 3 to 4 years ago are now trying desperately
to recruit them back or hire new RNs with higher education and long years of experience. The
old adage “the only reason to be in a hospital is to receive nursing care” has never been truer
than in today’s acute care patient populations. Patients who are going to the hospital for care, but
finding a decrease in quality of care, are going to become more and more disillusioned with the
health care system. There is no substitute for a highly educated and skilled RN workforce to
ensure continued financial survival and market share in today’s health care industry.
REGISTERED NURSE WORKFORCE SHORTAGE
In 1996, the United States registered nurse population was 2,065,000. Of these RNs, 82% were
employed in nursing. The vast majority of working RNs continue to practice in hospital settings;
however, the growth rate in the number of RNs being employed in hospitals has slowed since
1992. The number of RNs employed in community-based settings such as clinics, nursing
homes, and outpatient services continues to grow at a rate faster that those in acute care settings
(Table 1). The demand for BSN nurses in all settings, however, continues to exceed the
projected supply as reported by the Division of Nursing, The 7‘” Report to Congress: Status of
Health Care Pevsonnel in the U.S., 1998 (Figure 1).
3
TABLE 2
NATIONAL EMPLOYMENT SETTINGS OF REGISTERED NURSES 1980-1996
IN THOUSANDS
Public/ Ambulatory
Date Hospital Nursing Community Care Other *
Home/ECF Health Setting
1980 800 75 125 25 50
1984 1,000 95 135 50 35
1988 1,100 75 175 100 55
1992 1,200 100 200 125 100
1996 1,240 125 375 150 175
*Includes occupational health and school health settings. From the National Sanlple RN Survey, 1996
FIGURE 1
NATIONAL BSN SHORTAGE PROJECTED
Projected Supply & Demand
BSN RNs 1990-2020
1,250
1,000
750
500
250
Source: The 7th Report to Congress, 1998
Considering the anticipated change in the nation’s population 65 years of age and older (Figure
2) as well as the aging of the frail elderly, those 85 and older, (Figure 3). It is clear that the
greatest demand for BSN graduates and RNs as predicted by the Bureau of Labor Statistics will
coincide with the rapid rise in 2010 in the proportion of the population 65 and 85 or older. These
individuals will no doubt have major chronic diseases that will demand a great deal of nursing
care and increased efforts in disease prevention. The changing demographics of older Americans
will result in sharp escalation in the demand for registered nursing services.
4
FIGURE 2
ANTICIPATED CHANGES IN THE NATION'S DEMOGRAPHICS
Average Annual Percentage Change in Population
65 Years and Older
3
2.5
&
3 2
4
u
1.5
$
0
& I
a"
0.5
0
1990 2000 2010 2020
Decade
FIGURE 3
THE AGING OF THE FRAIL ELDERLY
Number of people 85 years and older
1990 2000 2010 2020
Decade
5
In 1998, the Arkansas State Board of Nursing reported a total of 23,120 registered nurses
residing in the state. Of these, 22,3 17 were employed for a work participation rate of 96%, an
exceedingly high employment rate compared to other disciplines. Given the data collection
methods used in 1998, the type of employment of 7,119 (28%) RNs who reported “other” under
employment settings is unclear (See Table 2). These RNs could be employed outside of nursing
such as in real estate, or employed in other I~ealthc are settings not listed such as home health
care. Regardless of the place of employment, attracting the numbers of ‘at-home mom’s’ who
are RNs, but not employed, will not be a viable solution to the growing RN shortage, due to
fewer number of RNs in that age range. Unlike national employment patterns, there has been a
slight decrease (-1%) in the number of RNs employed in Arkansas hospital settings between
1994-1998. All other settings have seen dramatic increases except schools of nursing. The
demand for RNs in the state is growing at a faster rate than the supply.
TABLE 3
REGISTERED NURSES IN ARKANSAS AND EMPLOYMENT SETTING
Settings June 1994 June 1995 June 1996 June 1997 June 1998
Hospital 10,901 11,127 11 ,343 1 1,042 10,799
Nursing Home 71 1 746 816 823 84 1
School of Nursing 3 84 382 3 74 369 378
Private Duty 66 54 64 67 93
School Nurse 232 23 1 245 270 278
Occupational Health 115 137 138 137 141
Office Nurse 753 807 87 1 937 1,017
Community Nurse 1,128 1,328 1,449 1,449 1,417
Self Employed 166 183 21 1 229 234
Other 0 0 0 6,189 7,119
TOTAL 14,456 14,995 15,511 2131 2 22,317
Arkansas State Board of Nursing 1998 Data
The Aging of the RN Workforce
The age of the RN workforce, both at the national and state level, is contributing to a decrease in
the number of RNs available for full-time employment. In 1996, the National Sample RN Survey
reported the average age of the staff RN as 44.3 years of age. According to Buerhaus (1998), the
average age of RNs has been rising at a rate of one third of a year annually; therefore, in 1999
the staff RN’s average age is 45.3 years. Data show that the proportion of RNs older than 35
grew far more rapidly than the proportion of workers in the same age groups in other
professions. For example, 41 YOo f workers in other occupations were between the ages of 16 and
34, compared to only 29.7% of RNs in 1994. As nurses age, they begin to work fewer hours per
6
year, further compromising the supply of full-time equivalents in the workforce. Contributing to
the reduced RN supply is the excellent state of the nation’s economy. For the past few years the
national economy has been fueled by the lowest unemployment rates in well over a decade and
earning increases that exceeded inflation. In good times, since most nurses are women and many
are second income earners, there is less pressure to work full-time. By 2000 the largest number
of the nation’s RNs will be between 45-49 years of age when considering the annual aging rate
of one-third year (Figure 4). Given the physical demands and the level of stress in today’s acute
care setting, coupled with the excellent state of the national economy, it is expected that many of
these nurses will reduce their work hours, seek less demanding positions outside of the hospital,
and retire early.
FIGURE: 4
AGE DISTRIBUTION OF U.S.
REGISTERED NURSE BY 100,000 POPULATION 1980-1 996
500
I
450
400
350
+1 980
*
300
1984
*
250 1988
200 +1 992
150 --e- 1996
100
50
0
I I I I I I I I I I I
<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
1996 National Sample RN Survey
The age of RNs in Arkansas reflects that of the rest of the nation. Of the 22,3 17 employed, 35%
are between the ages of 40-49. Of major concern, however, is the 28% (6,281) that are over age
50, and the 1 1O /o (2,415) age 60 years plus. These two groups make up approximately 40% of
the state’s RN workforce (Table 3). With a graduation rate May 1999 of less than 1,000 and
dropping each year, a major shortfall between RNs produced and those at or near retirement age
is looming. These numbers, added to an increasing demand for RNs in the state and the
declining RN student enrollment rate, clearly illustrate a growing crisis in the availability of
well-prepared RNs to care for the state’s citizens.
7
Description:Table 9: Average National Faculty Salaries in Selected Fields. At Public 4-Year
to $10,000 (American Association of Colleges of Nursing [AACN], 1999).
