This is the accessible text file for GAO report number GAO-07-492R entitled 'Nursing Workforce: HHS Needs Methodology to Identify Facilities with a Critical Shortage of Nurses' which was released on April 30, 2007. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. April 30, 2007: The Honorable Edward M. Kennedy: Chairman: The Honorable Michael B. Enzi: Ranking Member: Committee on Health, Education, Labor and Pensions: United States Senate: The Honorable John D. Dingell: Chairman: The Honorable Joe Barton: Ranking Member: Committee on Energy and Commerce: House of Representatives: Subject: Nursing Workforce: HHS Needs Methodology to Identify Facilities with a Critical Shortage of Nurses: Registered nurses (RN) are the single largest group of health care providers in the United States, with more than 2.4 million people employed as RNs in 2004.[Footnote 1] Basic RN training may be completed through a 2-year associate's degree, a 3-year diploma, or a 4-year bachelor's degree. RNs work in a wide variety of settings, including hospitals, nursing homes, physicians' offices, and public health clinics. Reports by government agencies and others have raised concerns about nurse shortages. In 2001, we reported on an emerging shortage of RNs to fill vacant positions across a range of health care settings.[Footnote 2] The Health Resources and Services Administration (HRSA), an agency in the Department of Health and Human Services (HHS), estimated that the supply of RNs nationally fell approximately 111,000 short of demand in 2000 (5.5 percent) and projected the gap would widen in the ensuing years.[Footnote 3] A shortage of RNs, like general workforce shortages, occurs when the demand for RNs exceeds supply.[Footnote 4] The supply of RNs, or the number of RNs employed, is influenced by multiple factors, including the size of the overall labor force, the number of licensed RNs choosing to work in nursing, the number of new RNs graduating from nursing school, the capacity of nursing schools, and funding available for higher education. Demand, or the number of RNs that employers would like to hire, is also affected by multiple factors, including demographic characteristics and health status of the population, economic factors such as personal income and health insurance coverage, and characteristics of the health care system such as nurse wages and health care reimbursement rates. Having an adequate supply of RNs is important because reports have established a positive relationship between the quality of care and RN staffing levels in settings such as hospitals and nursing homes.[Footnote 5] To support the recruitment and retention of RNs in health care facilities with a critical shortage of nurses, Congress passed the Nurse Reinvestment Act of 2002 (NRA).[Footnote 6] The NRA established the Nursing Scholarship Program (NSP) to provide scholarships for individuals to attend schools of nursing.[Footnote 7] The NRA also modified an existing program, the Nursing Education Loan Repayment Program (NELRP), which was established by Congress in 1992 to help repay education loans for RNs. Under both programs, awardees must agree to work for at least 2 years in a health care facility with a critical shortage of nurses, with preference given to qualified applicants with the greatest financial need.[Footnote 8] To implement this, HRSA, which administers both programs, designates several types of facilities as having a critical shortage of nurses for the purposes of the NSP and NELRP.[Footnote 9] The Secretary of HHS is required to report annually to Congress on various aspects of the programs including the locations where award recipients are fulfilling their service obligation.[Footnote 10] The NRA directed us to conduct several studies related to the nationwide shortage of nurses.[Footnote 11] As discussed with the committees of jurisdiction, in this report we are: (1) providing information on how the number of employed RNs and the shortage of RNs has changed since 2000, both nationally and across states; and (2) describing characteristics of NELRP and NSP awardees and examining whether these programs have improved the supply of RNs in facilities with critical shortages of nurses. To determine how the employment of RNs changed since 2000 and how it varied across states, we analyzed data on RN employment from the 2000 and 2004 National Sample Survey of Registered Nurses (NSSRN). This survey has been conducted by HRSA approximately every 4 years since 1977.[Footnote 12] We also analyzed data on newly licensed RNs from the National Council of State Boards of Nursing to identify the number of potential new RNs entering the workforce each year from 2000 through 2005. To determine whether the nursing shortage has changed since 2000, we conducted interviews of experts, researchers, HRSA officials, and provider and professional associations. We also reviewed current literature and research on the RN workforce. Further, we compared HRSA's most recent state-level shortage estimates from 2000 to the growth in RN employment from 2000 to 2004;[Footnote 13] examined changes in state-level per capita RN employment from 2000 to 2004; analyzed annual Current Population Survey (CPS) data from 1999 through 2005 on RN earnings growth relative to the overall workforce;[Footnote 14] and examined trends reported by the American Hospital Association (AHA) in hospital RN vacancy rates--that is, the number of unfilled employment positions at hospitals. To describe the characteristics of NELRP and NSP awardees, we analyzed HRSA administrative data, reviewed published reports on the programs, and interviewed HRSA officials. We relied on data about the programs from fiscal year 2004 to make comparisons of the awardees to the overall RN workforce and RN student and recent graduate populations because data from 2004 were the most recent data on the RN workforce available. Data on employment location of the programs' awardees for the fiscal years 2003 through 2005 period were obtained from both published reports on the programs and HRSA officials. To examine whether these programs have improved the supply of RNs in facilities with a critical shortage of nurses we reviewed past and current program guidance, reviewed published reports on the programs, and interviewed HRSA officials and research contractors. Our review focused only on registered nurses (RN), and our results cannot be generalized to other types of nurses, such as licensed practical nurses (LPN). We also did not conduct assessments of projected shortages. We used the most recent data available, which were from 2004 for some sources and from 2005 for other sources, as we noted. We assessed the reliability of data used in our analyses and determined them to be sufficiently reliable for our purposes. We performed this work from March 2006 through March 2007 in accordance with generally accepted government auditing standards. Results in Brief: Between 2000 and 2004, the number of employed RNs in the United States grew by 10 percent, with a total of 2.4 million RNs employed in nursing in 2004. Most of the increase occurred in hospitals and ambulatory care settings, and the extent of employment growth varied widely among states. For example, among the 48 states where the number of employed RNs increased, the growth in employment ranged from 2 percent in Connecticut to 47 percent in New Hampshire. Despite evidence of growth in RN employment between 2000 and 2004, there are no data available for estimating the magnitude of changes in the shortage of RNs over this time period. Estimating changes in the RN shortage requires data on both the supply of and the demand for RNs in 2000 and 2004. Although there are data indicating that the supply or number of employed RNs increased, there are no data--either nationally or at the state level- -on RN demand in 2004, because demand estimates have not been updated since 2000. However, several indirect measures suggest that the shortage of RNs has eased since 2000. For example, RN employment growth from 2000 to 2004 was generally strongest in those states that HRSA designated as having greater shortages in 2000. In addition, between 2000 and 2004 the number of employed RNs relative to the size of the general population increased from 782 per 100,000 people in 2000 to 825 per 100,000 people in 2004--reflecting an increase in RN supply relative to one measure of demand for RNs. Finally, the rate of unfilled RN positions in hospitals declined nationally from 13 percent in 2001 to 9 percent in 2005. Recipients of NSP and NELRP awards are more likely to be from a minority group and are more likely to have received or be pursuing a 4- year bachelor's degree rather than a 2-year associate's degree when compared to the overall RN workforce. In both programs, an applicant's minority status is not used as a criterion in making awards. In 2004, 11 percent of the overall nursing workforce was minority while minorities made up 36 percent of NSP awardees and 21 percent of NELRP awardees. NSP and NELRP awardees are required to be employed in one of the types of facilities identified by HRSA as having a critical shortage of nurses. However, HRSA does not have a sound basis for determining the number of RNs needed for that facility to be considered as one experiencing a critical shortage of RNs. Consequently, we cannot identify which facilities fall into this category. Furthermore, awardees may not be serving in facilities actually experiencing a nursing shortage. HRSA is working to develop an approach for identifying facilities with critical shortages of RNs, and researchers contracted by HRSA have produced a report detailing an approach that uses available county-level data to determine facilities that could be identified as having critical shortages of RNs. This report is currently under review, so HRSA's efforts at developing an empirically- based approach for identifying facilities with critical shortages of RNs have not been completed. In order to target funding effectively for the Nursing Education Loan Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to nurses working in health care facilities with a critical shortage of nurses, we recommend that the Secretary of HHS: (1) identify the specific steps and a time frame for implementing an empirical methodology for identifying health care facilities with a critical shortage of nurses; and (2) direct the Administrator of HRSA to include a description of steps taken and progress on its time frame for implementing such methodology in HRSA's annual report to Congress on these programs. In commenting on a draft of this report, HHS provided technical comments, which we incorporated as appropriate. Background: Hospitals employ the largest share of the RN workforce with 56 percent of RNs employed in hospital settings in 2004. After hospitals, 12 percent of RNs were employed in ambulatory care, 11 percent in public or community health settings, and 6 percent in nursing homes and extended care facilities. The remaining 15 percent were employed in a variety of other settings such as nursing education and insurance companies. Although basic RN education may be completed through a 2- year associate's degree, a 3-year diploma program, or a 4-year bachelor's degree, the largest proportion of RNs has an associate's degree, with 44 percent of the current RN workforce and 61 percent of newly licensed RNs having an associate's degree.[Footnote 15] (See fig. 1.) Once they have completed their education, RNs must meet state licensing requirements and pass a national licensing examination. Figure 1: Percentage of Employed Registered Nurses by Initial Degree Type, 2004: [See PDF for image] Source: HRSA and National Council of State Boards of Nursing. Note: Data are from HRSA's 2004 National Sample Survey of Registered Nurses and the National Council of State Boards of Nursing's 2004 National Council Licensing Examination (NCLEX) statistics. [End of figure] Although numerous reports of an emerging nursing shortage have been published by researchers, provider associations, and government agencies, nurse shortages have historically been cyclical, with periods of shortage alternating with periods of equilibrium or surplus. There is often a time lag in the adjustment of RN supply to increased demand, in part due to the time it takes for a new RN to complete the educational requirements for licensure. Future demand for RNs is expected to increase dramatically as members of the baby boom generation reach their 70s, 80s and beyond--ages at which use of health care typically increases. While the population aged 65 and older is expected to double between 2000 and 2030, the number of women between 25 and 54 years of age, who have traditionally formed the core of the nurse workforce, is expected to remain relatively unchanged. The Bureau of Labor Statistics (BLS) projected that in order to accommodate growth in demand for RNs and to replace RNs leaving the workforce, 120,000 new nurses will be needed per year from 2004 through 2014. To support the recruitment and retention of RNs, the NSP and NELRP programs provide awards to nursing students or working nurses, respectively, in exchange for a minimum of 2 years service at a health care facility with a critical shortage of nurses. The NELRP provides loan repayment awards of up to 85 percent of educational loans and the NSP provides scholarship awards to individuals attending an accredited school of nursing. From fiscal years 2003 through 2005, HRSA granted 2,262 loan repayment awards totaling $51 million and 419 scholarship awards totaling $18.9 million. (See table 1.) Total funding and the number of awards granted under both programs have increased since fiscal year 2003. In fiscal year 2005, HRSA provided NELRP awards to 803 individuals, or 18 percent of applicants, with a median award of $20,925. For the NSP, HRSA provided awards to 212 individuals, or 6 percent of applicants, with a median award of $38,078. Table 1: Nursing Education Loan Repayment Program and Nursing Scholarship Program Applicants, Awards, and Funding, Fiscal Years 2003- 2005: Nursing Education Loan Repayment Program (NELRP). Applicants; 2003: 8,231; 2004: 4,873; 2005: 4,465; 2003- 2005 Total: 17,569. Awards; 2003: 602; 2004: 857; 2005: 803; 2003-2005 Total: 2,262. Total Award Funding; 2003: $14.4 million; 2004: $17.6 million; 2005: $19.0 million; 2003-2005 Total: $51.0 million. Median Award Amount; 2003: $20,911; 2004: $17,379; 2005: $20,925; 2003-2005 Total: [Empty]. Nursing Scholarship Program (NSP). Applicants; 2003: 4,408; 2004: 3,476; 2005: 3,482; 2003- 2005 Total: 11,366. Awards; 2003: 81; 2004: 126; 2005: 212; 2003-2005 Total: 419. Total Award Funding; 2003: $3.3 million; 2004: $5.9 million; 2005: $9.7 million; 2003-2005 Total: $18.9 million. Median Award Amount; 2003: $34,920; 2004: $38,387; 2005: $38,078; 2003-2005 Total: [Empty]. Source: HRSA. [End of table] Number of Employed RNs Increased since 2000, Although Gains Varied among States, and Indirect Evidence Suggests Shortage Has Eased: Between 2000 and 2004, the number of employed RNs in the United States grew by 10 percent. Most of the increase occurred in hospitals and ambulatory care settings, and the extent of employment growth varied widely among states. Despite evidence of growth in RN employment between 2000 and 2004, we are unable to estimate the magnitude of changes in the shortage of RNs over this time period. Estimating changes in the RN shortage requires data on both the supply of and the demand for RNs in 2000 and 2004. While HRSA's National Sample Survey of Registered Nurses provides data on the number of employed RNs in 2000 and 2004, HRSA's estimates of demand for RNs have not been updated since 2000. However, indirect evidence suggests that the shortage of RNs has eased since 2000. This evidence includes strong growth in RN employment in the states HRSA designated as having a shortage in 2000 and increases in the number of employed RNs relative to the size of the general population. In addition, after several years of strong relative earnings growth for RNs following reports of an emerging shortage around 2000, RN earnings have grown at a rate comparable to the overall workforce in recent years. Number of Employed RNs Increased between 2000 and 2004, and Gains Varied by Facility Type and among States: According to data from HRSA's 2000 and 2004 National Sample Survey of Registered Nurses, the number of employed RNs, either full-time or part- time, increased 10 percent between 2000 and 2004, with a total of 2.4 million RNs employed in nursing in 2004.[Footnote 16] The number of RNs employed full-time grew by 8 percent from 2000 to 2004, while those employed part-time, representing approximately 30 percent of all employed RNs in 2004, grew by 15 percent. In addition, of all licensed RNs, the percentage who were employed in nursing, either full-time or part-time, increased from 81.7 percent in 2000 to 83.2 percent in 2004; this compares to 82.7 percent in 1992 and 1996, and to rates at or below 80 percent throughout the 1980s. Nationally, between 2000 and 2004, the extent of increases in the number of RNs employed varied by facility type or setting, with the greatest gains occurring in hospitals and ambulatory care settings such as physicians' offices, clinics, and ambulatory surgical centers. (See table 2.) These settings accounted for most of the change in the number of employed RNs over the 4 years. Employment gains also occurred in teaching positions associated with nursing education, while the number of RNs employed in public and community health settings declined. Between 2000 and 2004, the number of RNs employed in long-term care facilities remained essentially unchanged. Table 2: Changes in RN Employment by Facility Type or Setting, 2000- 2004: Facility type or setting: All facility types or settings; 2000 Employment: 2,201,813; 2004 Employment: 2,421,351; Change 2000-2004: 219,538. Facility type or setting: Hospitals; 2000 Employment: 1,300,323; 2004 Employment: 1,360,847; Change 2000-2004: 60,524. Facility type or setting: Ambulatory care; 2000 Employment: 209,324; 2004 Employment: 277,774; Change 2000-2004: 68,450. Facility type or setting: Public/community health; 2000 Employment: 282,618; 2004 Employment: 259,911; Change 2000-2004: -22,707. Facility type or setting: Long-term care facility; 2000 Employment: 152,894; 2004 Employment: 153,172; Change 2000-2004: 278. Facility type or setting: School/student health; 2000 Employment: 83,269; 2004 Employment: 78,022; Change 2000-2004: -5,247. Facility type or setting: Nursing education; 2000 Employment: 46,655; 2004 Employment: 63,444; Change 2000-2004: 16,789. Facility type or setting: Occupational health; 2000 Employment: 36,395; 2004 Employment: 22,447; Change 2000-2004: -13,948. Facility type or setting: Other and unknown; 2000 Employment: 90,335; 2004 Employment: 205,736; Change 2000-2004: 115,401. Source: HRSA. Note: Data are from the 2000 and 2004 National Sample Survey of Registered Nurses. Numbers represent RNs employed both full-time and part-time. Estimated numbers may not equal totals due to rounding. [End of table] While the number of employed RNs increased nationally from 2000 to 2004, the growth varied widely among states. According to data from HRSA's 2000 and 2004 National Sample Survey of Registered Nurses, all but three states--Louisiana, Massachusetts, and Rhode Island--posted gains in RN employment between 2000 and 2004 (see enc. I). Among the 48 states where the number of employed RNs increased, the growth in employment ranged from 2 percent in Connecticut to 47 percent in New Hampshire. Growth exceeded 15 percent in 11 states, and ranged from 10 to 15 percent in 15 other states. The growth in the number of employed RNs is due in part to an increase in the number of newly licensed nursing school graduates entering the workforce.[Footnote 17] The number of newly licensed RNs available to enter the workforce, as reflected in the annual number of RNs passing the national licensing examination, grew from approximately 75,000 in 2000 to 101,000 in 2004 and 113,000 in 2005, an increase of 51 percent from 2000 to 2005 (see fig. 2).[Footnote 18] From 2000 to 2005, the number of newly licensed RNs educated in the United States increased 41 percent from 69,569 to 98,363, and the number of newly licensed RNs who were educated outside the United States grew by 182 percent from 5,231 to 14,750. Figure 2: Number of RNs Passing the National Licensing Exam, by Year, U.S.-and Foreign-Educated, 2000-2005: [See PDF for image] Source: GAO analysis of National Council of State Boards of Nursing data. [End of figure] Indirect Evidence Suggests Shortage of RNs Has Eased since 2000: Although there are data indicating that the supply of RNs--that is, the number employed--increased between 2000 and 2004, we are unable to estimate changes in the shortage of RNs over this time period. Estimating changes in the RN shortage requires data on both the supply of and the demand for RNs in 2000 and 2004. While HRSA's National Sample Survey of Registered Nurses provides data on the number of employed RNs in 2000 and 2004, HRSA's estimates of demand for RNs have not been updated since 2000.[Footnote 19] Furthermore, HRSA's estimates of RN supply and demand are at the state level and cannot provide information on whether there is a shortage within states, in rural or urban areas, or among facilities or other settings.[Footnote 20] Despite the absence of data to assess directly the magnitude of changes in the RN shortage between 2000 and 2004, indirect evidence suggests that the overall shortage of RNs has eased since 2000. This evidence consists of (1) relatively strong growth in the number of employed RNs in the states designated by HRSA as having shortages in 2000, (2) growth in the number of employed RNs relative to the size of the general population, (3) growth in the earnings of RNs that is consistent with the earnings growth for the overall U.S. workforce in recent years, and (4) reported decreases in the number of unfilled employment positions for hospital RNs. First, RN employment growth from 2000 to 2004 was generally strongest in those states that HRSA designated as having greater shortages in 2000.[Footnote 21] (See fig. 3.) HRSA estimates of RN shortages in 2000 show that 30 states were estimated to have a shortage; 9 states were estimated to have a surplus, and 12 states had no clear shortage or surplus in 2000.[Footnote 22] In the states HRSA estimated as having shortages in 2000, growth in employed RNs averaged about 14 percent from 2000 to 2004, while states that HRSA designated as having surpluses in 2000 averaged about 5-percent growth.[Footnote 23] Arizona, the state with the largest estimated shortage in 2000, had almost a 23 percent growth in RN employment from 2000 to 2004. Montana, the state with the largest estimated surplus in 2000, experienced a 3 percent growth in employment between 2000 and 2004. (See enc. II.) Figure 3: Full-time equivalent (FTE) RN Employment Growth by State, 2000-2004: [See PDF for image] Source: HRSA and GAO analysis of HRSA data. Copyright Corel Corp. All rights reserved (map). Note: RN employment based on FTEs. [End of figure] Second, between 2000 and 2004 the number of employed RNs relative to the size of the general population increased, reflecting an increase in RN supply relative to one measure of demand. According to HRSA's National Sample Survey of Registered Nurses, nationally there were 825 employed RNs per 100,000 people in 2004, compared with 782 per 100,000 in 2000 and 798 per 100,000 in 1996. Between 2000 and 2004, on a per capita basis, the number of employed RNs increased by 5.5 percent. This followed a 2 percent decline in per capita RN employment between 1996 and 2000. (See enc. III.) Changes in the per capita RN employment varied across states between 2000 and 2004. (See fig. 4.) Figure 4: Change in State Per Capita RN Employment, 2000-2004: [See PDF for image] Source: GAO analysis of HRSA data. Copyright Corel Corp. All rights reserved (map). [End of figure] Third, after several years of strong relative earnings growth for RNs following reports of an emerging shortage around 2000, RN earnings have grown at a rate comparable to the overall workforce during the most recent period from 2003 through 2005.[Footnote 24] (See fig. 5.) In a period of shortage, wage or earnings growth for RNs would be expected to exceed the earnings growth for all workers as employers raise wages to attract more RNs. Growth in RN earnings lagged behind earnings growth for all workers through most of the 1990s, and in particular in the mid-1990s period. During the 2001 through 2003 period, earnings growth for RNs averaged 4.4 percent per year while earnings for all workers grew by an average of 2.5 percent per year. During the most recent period, however, from 2003 through 2005, RN earnings rose at an average annual rate of 2.2 percent, the same as for all workers. Figure 5: Earnings Growth for Registered Nurses and All Workers, 1999- 2005: [See PDF for image] Source: GAO analysis of Bureau of Labor Statistics data. Note: Data are from the Current Population Survey (CPS) monthly household survey and represent 3-year annual averages. [End of figure] Fourth, reports of declines in the percentage of unfilled employment positions at some facilities that employ RNs are also evidence of an easing of the RN shortage because they indicate less unmet employer demand for RNs. Although no comprehensive data exist on how many of these positions go unfilled each year, some trade associations gather information on such employment vacancies from member surveys. For example, the AHA reported a national decline in the rate of unfilled RN positions in hospitals, from 13 percent in 2001 to 9 percent in 2005. The extent of the decline varied across regions of the country. For example, AHA reported that from 2001 through 2005 the greatest decline in the rate of employment vacancies occurred among hospitals in the West, where the average rate of RN vacancies fell from 15 to 9 percent. In contrast, the smallest decline occurred among hospitals in the South, where during the same time period, the average rate of RN vacancies fell from 13 to 10 percent. Characteristics of NELRP and NSP Awardees Differ from the Overall RN Workforce, and GAO Cannot Assess Programs' Effect on Nursing Supply: As a group, NSP and NELRP awardees have a higher percentage of minorities and are more likely to have received or be pursuing 4-year bachelor's degrees rather than 2-year associate's degrees than the overall RN workforce. Although NSP and NELRP awardees are required to be employed in one of the types of facilities identified by HRSA in order to meet the NRA requirement intended to address critical nursing shortages, we cannot assess whether the two programs have improved the supply of RNs in facilities with critical shortages of RNs. HRSA does not have a sound basis for identifying critical shortage facilities, and as a result, awardees of the programs may not be serving in facilities actually experiencing such shortages. HRSA is working to develop an empirically-based approach for identifying facilities with critical shortages of RNs, but these efforts have not yet been completed. NSP and NELRP Awardees Have a Higher Percentage of Minorities and Obtain Higher Degrees than Overall RN Workforce: In our comparison of minority status, we found that as a group, awardees of the NSP and NELRP have a higher percentage of minorities than the overall nursing workforce, but are similar to current nursing school students and recent graduates.[Footnote 25] (See fig. 6.) In both programs, an applicant's minority status is not used as a criterion in making awards. While minorities made up 11 percent of the overall RN workforce in 2004, they constituted 36 percent of NSP awardees, 21 percent of NELRP awardees and 26 and 22 percent of nursing school students and graduates, respectively.[Footnote 26] (See enc. IV for more detailed data on NELRP and NSP awardees.) Figure 6: Percentage of Minorities among Awardees in the NSP and NELRP, RN Students and RN Graduates, and the Overall RN Workforce, 2004: [See PDF for image] Source: HRSA and National League for Nursing (NLN). Note: Minorities include African Americans, Hispanics, American Indians, Native Hawaiians, Native Alaskans, Asians, and Pacific Islanders. NSP and NELRP awardee data are for fiscal year 2004. [End of figure] Awardees of the NSP and NELRP programs are also more likely to be pursuing or have received higher degrees than the overall RN workforce or current nursing student population. In fiscal year 2004, the percentage of NSP awardees pursuing a bachelor's degree was higher than it was among the nursing student population.[Footnote 27] While 49 percent of the nursing student population was pursuing a bachelor's or graduate degree in 2004, 70 percent of NSP awardees were pursuing this degree. (See fig. 7.) Similarly, in the NELRP, the majority of awards in fiscal year 2004 were given to applicants with bachelor's or higher degrees. This is largely due to the way in which awards are funded, with preference given to those with greatest financial need. Applicants who obtain higher level degrees (bachelor's or graduate degrees) are likely to have higher levels of debt than those with an associate's degree. Figure 7: Degree Types of NSP and NELRP Awardees Compared to Nursing School Students, Graduates, and the RN Workforce, 2004: [See PDF for image] Source: HRSA and NLN data. Note: NSP and NELRP awardee data are for fiscal year 2004. [End of figure] Other characteristics of NSP and NELRP awardees include the type of facility in which the awardees work. As of fiscal year 2005, 78 of 419 NSP awardees had completed their education and had begun their service in a critical shortage facility. Of these, 71 were serving in hospitals, 3 in Indian Health Service Health Centers, and 1 each in a home health agency, hospice, nursing home, and skilled nursing facility. As shown in table 3, the majority of NELRP awardees were completing their service requirement in disproportionate share hospitals and public health departments as of fiscal year 2005. In addition, most NELRP awardees were working in not-for-profit facilities and in facilities located in the South and West.[Footnote 28] Table 3: Work Locations of Nursing Education Loan Repayment Program Awardees, Fiscal Years 2003-2005: Total Awardees; Year: 2003: 602; Year: 2004: 857; Year: 2005: 803. Facility type; Disproportionate share hospital[A]; Year: 2003: 473; Year: 2004: 531; Year: 2005: 663. Facility type; Public health department; Year: 2003: 91; Year: 2004: 128; Year: 2005: 85. Facility type; Nursing home; Year: 2003: 38; Year: 2004: 66; Year: 2005: 32. Facility type; Federally-designated community health center; Year: 2003: 0; Year: 2004: 3; Year: 2005: 19. Facility type; Hospital; Year: 2003: 0; Year: 2004: 52; Year: 2005: 0. Facility type; Rural health clinic; Year: 2003: 0; Year: 2004: 4; Year: 2005: 4. Facility type; Indian Health Service health center; Year: 2003: 0; Year: 2004: 1; Year: 2005: 0. Facility type; Other not-for-profit health facility; Year: 2003: 0; Year: 2004: 72; Year: 2005: 0. Facility ownership status; Not-for-profit; Year: 2003: 425; Year: 2004: 411; Year: 2005: 510. Facility ownership status; For-profit; Year: 2003: 177; Year: 2004: 446; Year: 2005: 293. Region of facility[B]; Northeast; Year: 2003: 88; Year: 2004: 103; Year: 2005: 111. Region of facility[B]; Midwest; Year: 2003: 107; Year: 2004: 246; Year: 2005: 160. Region of facility[B]; South; Year: 2003: 243; Year: 2004: 270; Year: 2005: 299. Region of facility[B]; West; Year: 2003: 164; Year: 2004: 238; Year: 2005: 233. Region of facility[B]; Urban; Year: 2003: 566; Year: 2004: 770; Year: 2005: 713. Region of facility[B]; Rural; Year: 2003: 36; Year: 2004: 87; Year: 2005: 90. Source: HRSA. [A] Disproportionate share hospitals receive supplemental payments through the Medicare or Medicaid programs to subsidize the costs associated with providing care to a high proportion of low-income patients. [B] Regions consist of the following: Northeast--Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania; Midwest--Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas; South--Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, Texas; and West--Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, Hawaii. [End of table] Effect of NELRP and NSP Cannot Be Assessed Because HRSA Lacks a Sound Basis for Identifying Facilities with a Critical Shortage of RNs: We cannot assess whether the NELRP and NSP have improved the supply of RNs at facilities that actually have critical shortages of RNs because HRSA does not have a sound basis for identifying facilities with critical shortages of RNs. To meet the requirement established by NRA designed to help facilities with critical shortages, HRSA uses its list of critical shortage facility types. HRSA created the list based on the assumption that the facility types on the list target the underserved and are generally believed to be facing nursing shortages. In addition, the Secretary of HHS determined that the NELRP should emphasize serving the underserved, improving the public health infrastructure, and addressing needs at nursing homes, so the agency currently gives preference to loan repayment applicants working in disproportionate share hospitals, community health centers, rural health clinics, Indian Health Service health centers, public health departments or clinics, and nursing homes. Some awardees of the NELRP must submit a letter or other documentation from their employer that provides support that the awardee is employed at one of the critical shortage facility types. Although HRSA uses the list of facility types in making awards to NELRP and NSP applicants, HRSA does not determine the number of RNs needed for a facility to be considered as one experiencing a critical shortage of RNs. As a result, HRSA does not know the extent to which specific facilities served by NELRP and NSP awardees are actually experiencing critical nursing shortages. Therefore, we cannot assess whether the two programs have increased the supply of RNs at facilities with critical shortages. HRSA began using the current list of facility types after passage of the NRA. Prior to the NRA, the law required that preference be given to qualified applicants who agreed to work in certain health facilities located in geographic areas with a shortage of and need for nurses.[Footnote 29] To implement this, HRSA considered whether the facility was located in what was known as a nurse shortage county or in a Health Professional Shortage Area (HPSA).[Footnote 30] However, HRSA recognized limitations in both the county and the HPSA definitions. According to HRSA officials, the nurse shortage county designation was not sufficiently reflective of the entire nursing workforce because it was based only on hospital data. Similarly, according to HRSA officials, HPSAs are designed for the placement of primary care physicians, and RN work settings are both more diverse and more complex than those of physicians.[Footnote 31] As a result of these limitations to both the nurse shortage counties and HPSAs, and because the NRA deleted the requirement that preference be given to applicants serving in certain facilities located in geographic areas with a shortage of and need for nurses, HRSA discontinued the use of geographic areas in favor of using only the list of critical shortage facility types. At the same time, HRSA officials acknowledged that this new approach did not represent a scientific or empirical method for identifying actual shortage facilities and was only intended as an interim approach to meet the short-term needs of the program. HRSA has efforts underway to develop a new approach for identifying facilities experiencing critical shortages of RNs, though these efforts have not been completed. In 2004 HRSA contracted with researchers at the Center for Health Workforce Studies at the State University of New York (SUNY) at Albany to develop an empirical, data-driven method for identifying "health care facilities with a critical shortage of RNs." According to the SUNY researchers, among the contract's guiding principles were that the approach had to (1) be practical, that is, not overly burdensome on facilities or HRSA; (2) be applicable to all facility types; (3) use data that were easy to access and available over time; and (4) be easy to update. The first approach the SUNY researchers developed and tested was a facility-based model using data from North Carolina and North Dakota, two states that are recognized as having good facility-level data on RN staffing, vacancy rates, and turnover. However, the researchers found that these data were not sufficiently reliable predictors of whether a facility had an RN shortage. Also, the analysis required data that are not collected and reported by health care facilities in most states. The SUNY researchers concluded that the burden and cost of gathering facility/provider-level data from every health facility or provider in every state rendered this approach impractical. As a result, the researchers began work on an approach that could use available county- level data to determine which geographic areas could be defined as having critical shortages of RNs, so that the facilities in such areas could be identified as having critical shortages of RNs.[Footnote 32] HRSA received the final report on the results of this work from the SUNY researchers in February 2007. The report contains a recommended method for estimating the extent of nursing shortages in all counties in the United States. The advisory committee for this study recommended that before any method is adopted by HRSA it be validated in a number of states, facilities, and settings. As of March 2007, the report and its recommendations were under review, and HRSA officials said they plan to publish the results sometime in 2007. Conclusions: HRSA is in its fifth year granting awards under the Nursing Education Loan Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) since passage of the Nurse Reinvestment Act. While these two programs are aimed at encouraging graduating and employed nurses to work in facilities with a critical shortage of nurses, they may not always be achieving their intended goals. Because HRSA does not have a sound basis for identifying facilities with a critical shortage of RNs, HRSA's awardees may be working in facilities that may not be actually experiencing such shortages. HRSA received a report from its contractors that identifies available data and an approach to identify such facilities, and, as of March 2007, the report and its recommendations were under review. Because these two HRSA programs are able to support relatively few nurses, it is important that HRSA ensure that its work to develop a methodology for identifying facilities with a critical shortage of nurses is completed so that the resources of these programs can be targeted effectively to meet their intended purpose. Recommendations for Executive Action: In order to target funding effectively for the Nursing Education Loan Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to nurses working in health care facilities with a critical shortage of nurses, we recommend that the Secretary of HHS take the following steps: 1. identify the specific steps and a time frame for implementing an empirical methodology for identifying health care facilities with a critical shortage of nurses; and: 2. direct the Administrator of HRSA to include a description of steps taken and progress on its time frame for implementing such methodology in HRSA's annual report to Congress on these programs. Agency Comments: In commenting on a draft of this report, HHS provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the Secretary of HHS, the Administrator of HRSA, and other interested parties. We will also make copies available to others on request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. If you or your staff members have any questions about this report, please contact Kathleen King at (202) 512-7119 or kingk@gao.gov. Major contributors to this report are listed in enclosure V. Signed by: Kathleen King: Director, Health Care: Enclosures - 5: [End of section] Enclosure I: Change in Number of Registered Nurses (RN) Employed in Nursing, by State, 2000-2004: State: Alaska; 2000 RN employment: 4,914; 2004 RN employment: 6,777; Percent change in RN employment 2000-2004: 37.9. State: Alabama; 2000 RN employment: 34,073; 2004 RN employment: 36,538; Percent change in RN employment 2000-2004: 7.2. State: Arkansas; 2000 RN employment: 18,752; 2004 RN employment: 20,115; Percent change in RN employment 2000-2004: 7.3. State: Arizona; 2000 RN employment: 32,222; 2004 RN employment: 39,136; Percent change in RN employment 2000-2004: 21.5. State: California; 2000 RN employment: 184,329; 2004 RN employment: 211,531; Percent change in RN employment 2000-2004: 14.8. State: Colorado; 2000 RN employment: 31,695; 2004 RN employment: 34,654; Percent change in RN employment 2000-2004: 9.3. State: Connecticut; 2000 RN employment: 32,073; 2004 RN employment: 32,718; Percent change in RN employment 2000-2004: 2.0. State: Dist. of Col; 2000 RN employment: 9,583; 2004 RN employment: 11,583; Percent change in RN employment 2000-2004: 20.9. State: Delaware; 2000 RN employment: 7,337; 2004 RN employment: 8,633; Percent change in RN employment 2000-2004: 17.7. State: Florida; 2000 RN employment: 125,439; 2004 RN employment: 132,758; Percent change in RN employment 2000-2004: 5.8. State: Georgia; 2000 RN employment: 55,881; 2004 RN employment: 66,512; Percent change in RN employment 2000-2004: 19.0. State: Hawaii; 2000 RN employment: 8,518; 2004 RN employment: 9,335; Percent change in RN employment 2000-2004: 9.6. State: Idaho; 2000 RN employment: 8,230; 2004 RN employment: 8,753; Percent change in RN employment 2000-2004: 6.4. State: Illinois; 2000 RN employment: 101,660; 2004 RN employment: 113,779; Percent change in RN employment 2000-2004: 11.9. State: Indiana; 2000 RN employment: 46,244; 2004 RN employment: 54,624; Percent change in RN employment 2000-2004: 18.1. State: Iowa; 2000 RN employment: 31,020; 2004 RN employment: 32,664; Percent change in RN employment 2000-2004: 5.3. State: Kansas; 2000 RN employment: 23,779; 2004 RN employment: 24,869; Percent change in RN employment 2000-2004: 4.6. State: Kentucky; 2000 RN employment: 33,655; 2004 RN employment: 37,631; Percent change in RN employment 2000-2004: 11.8. State: Louisiana; 2000 RN employment: 37,275; 2004 RN employment: 35,369; Percent change in RN employment 2000-2004: -5.1. State: Maine; 2000 RN employment: 13,072; 2004 RN employment: 15,077; Percent change in RN employment 2000-2004: 15.3. State: Maryland; 2000 RN employment: 45,323; 2004 RN employment: 47,124; Percent change in RN employment 2000-2004: 4.0. State: Massachusetts; 2000 RN employment: 75,795; 2004 RN employment: 75,398; Percent change in RN employment 2000-2004: -0.5. State: Michigan; 2000 RN employment: 79,353; 2004 RN employment: 84,967; Percent change in RN employment 2000-2004: 7.1. State: Minnesota; 2000 RN employment: 47,102; 2004 RN employment: 51,914; Percent change in RN employment 2000-2004: 10.2. State: Mississippi; 2000 RN employment: 21,338; 2004 RN employment: 24,009; Percent change in RN employment 2000-2004: 12.5. State: Missouri; 2000 RN employment: 53,730; 2004 RN employment: 57,365; Percent change in RN employment 2000-2004: 6.8. State: Montana; 2000 RN employment: 7,327; 2004 RN employment: 7,914; Percent change in RN employment 2000-2004: 8.0. State: North Carolina; 2000 RN employment: 69,057; 2004 RN employment: 76,761; Percent change in RN employment 2000-2004: 11.2. State: North Dakota; 2000 RN employment: 7,039; 2004 RN employment: 7,484; Percent change in RN employment 2000-2004: 6.3. State: Nebraska; 2000 RN employment: 16,399; 2004 RN employment: 18,532; Percent change in RN employment 2000-2004: 13.0. State: New Hampshire; 2000 RN employment: 11,321; 2004 RN employment: 16,670; Percent change in RN employment 2000-2004: 47.2. State: New Jersey; 2000 RN employment: 67,280; 2004 RN employment: 72,980; Percent change in RN employment 2000-2004: 8.5. State: New Mexico; 2000 RN employment: 11,932; 2004 RN employment: 13,570; Percent change in RN employment 2000-2004: 13.7. State: Nevada; 2000 RN employment: 10,384; 2004 RN employment: 14,095; Percent change in RN employment 2000-2004: 35.7. State: New York; 2000 RN employment: 160,009; 2004 RN employment: 174,208; Percent change in RN employment 2000-2004: 8.9. State: Ohio; 2000 RN employment: 100,144; 2004 RN employment: 112,806; Percent change in RN employment 2000-2004: 12.6. State: Oklahoma; 2000 RN employment: 21,905; 2004 RN employment: 24,433; Percent change in RN employment 2000-2004: 11.5. State: Oregon; 2000 RN employment: 27,121; 2004 RN employment: 30,850; Percent change in RN employment 2000-2004: 13.7. State: Pennsylvania; 2000 RN employment: 123,997; 2004 RN employment: 127,013; Percent change in RN employment 2000-2004: 2.4. State: Rhode Island; 2000 RN employment: 11,542; 2004 RN employment: 11,368; Percent change in RN employment 2000-2004: -1.5. State: South Carolina; 2000 RN employment: 29,226; 2004 RN employment: 30,711; Percent change in RN employment 2000-2004: 5.1. State: South Dakota; 2000 RN employment: 8,511; 2004 RN employment: 9,278; Percent change in RN employment 2000-2004: 9.0. State: Tennessee; 2000 RN employment: 49,626; 2004 RN employment: 54,338; Percent change in RN employment 2000-2004: 9.5. State: Texas; 2000 RN employment: 126,436; 2004 RN employment: 145,336; Percent change in RN employment 2000-2004: 14.9. State: Utah; 2000 RN employment: 13,229; 2004 RN employment: 15,778; Percent change in RN employment 2000-2004: 19.3. State: Vermont; 2000 RN employment: 5,829; 2004 RN employment: 6,444; Percent change in RN employment 2000-2004: 10.6. State: Virginia; 2000 RN employment: 50,359; 2004 RN employment: 56,726; Percent change in RN employment 2000-2004: 12.6. State: Washington; 2000 RN employment: 43,482; 2004 RN employment: 48,421; Percent change in RN employment 2000-2004: 11.4. State: West Virginia; 2000 RN employment: 15,523; 2004 RN employment: 16,042; Percent change in RN employment 2000-2004: 3.3. State: Wisconsin; 2000 RN employment: 47,895; 2004 RN employment: 51,679; Percent change in RN employment 2000-2004: 7.9. State: Wyoming; 2000 RN employment: 3,849; 2004 RN employment: 4,079; Percent change in RN employment 2000-2004: 6.0. State: United States; 2000 RN employment: 2,201,813; 2004 RN employment: 2,421,351; Percent change in RN employment 2000-2004: 10.0. Source: GAO analysis of Health Resources and Services Administration (HRSA) data. Note: Data are from the 2000 and 2004 National Sample Survey of Registered Nurses, HRSA. [End of table] [End of section] Enclosure II: Change from 2000 to 2004 in Full-time equivalent (FTE) Registered Nurse (RN) Employment by Degree of State Shortage in 2000 as Estimated by the Health Resources and Services Administration (HRSA): States with a shortage in 2000. State: Arizona; Percent FTE RN shortage estimated by HRSA, 2000: -17.3; Percent change in FTE RN employment 2000-2004: 22.6. State: Tennessee; Percent FTE RN shortage estimated by HRSA, 2000: -13.4; Percent change in FTE RN employment 2000-2004: 10.3. State: New Jersey; Percent FTE RN shortage estimated by HRSA, 2000: -12.9; Percent change in FTE RN employment 2000-2004: 5.0. State: Connecticut; Percent FTE RN shortage estimated by HRSA, 2000: -12.4; Percent change in FTE RN employment 2000-2004: 1.1. State: Maine; Percent FTE RN shortage estimated by HRSA, 2000: -11.7; Percent change in FTE RN employment 2000-2004: 17.0. State: Delaware; Percent FTE RN shortage estimated by HRSA, 2000: -11.1; Percent change in FTE RN employment 2000-2004: 19.4. State: Nevada; Percent FTE RN shortage estimated by HRSA, 2000: -10.9; Percent change in FTE RN employment 2000-2004: 36.6. State: New York; Percent FTE RN shortage estimated by HRSA, 2000: -10.9; Percent change in FTE RN employment 2000-2004: 8.8. State: Colorado; Percent FTE RN shortage estimated by HRSA, 2000: -10.7; Percent change in FTE RN employment 2000-2004: 10.2. State: Massachusetts; Percent FTE RN shortage estimated by HRSA, 2000: -10.5; Percent change in FTE RN employment 2000-2004: -0.9. State: Rhode Island; Percent FTE RN shortage estimated by HRSA, 2000: -10.1; Percent change in FTE RN employment 2000-2004: -2.7. State: Virginia; Percent FTE RN shortage estimated by HRSA, 2000: -9.8; Percent change in FTE RN employment 2000-2004: 9.9. State: New Hampshire; Percent FTE RN shortage estimated by HRSA, 2000: -9.7; Percent change in FTE RN employment 2000-2004: 44.7. State: Indiana; Percent FTE RN shortage estimated by HRSA, 2000: -9.6; Percent change in FTE RN employment 2000-2004: 20.4. State: Hawaii; Percent FTE RN shortage estimated by HRSA, 2000: -9.2; Percent change in FTE RN employment 2000-2004: 6.1. State: Washington; Percent FTE RN shortage estimated by HRSA, 2000: -9.2; Percent change in FTE RN employment 2000-2004: 15.7. State: Texas; Percent FTE RN shortage estimated by HRSA, 2000: -8.9; Percent change in FTE RN employment 2000-2004: 11.3. State: Utah; Percent FTE RN shortage estimated by HRSA, 2000: -8.1; Percent change in FTE RN employment 2000-2004: 19.3. State: Missouri; Percent FTE RN shortage estimated by HRSA, 2000: -7.9; Percent change in FTE RN employment 2000-2004: 3.9. State: Arkansas; Percent FTE RN shortage estimated by HRSA, 2000: -7.7; Percent change in FTE RN employment 2000-2004: 6.8. State: California; Percent FTE RN shortage estimated by HRSA, 2000: -7.6; Percent change in FTE RN employment 2000-2004: 13.8. State: New Mexico; Percent FTE RN shortage estimated by HRSA, 2000: -7.4; Percent change in FTE RN employment 2000-2004: 14.7. State: Georgia; Percent FTE RN shortage estimated by HRSA, 2000: -6.8; Percent change in FTE RN employment 2000-2004: 18.4. State: Ohio; Percent FTE RN shortage estimated by HRSA, 2000: -5.4; Percent change in FTE RN employment 2000-2004: 11.5. State: Nebraska; Percent FTE RN shortage estimated by HRSA, 2000: -5.2; Percent change in FTE RN employment 2000-2004: 15.7. State: Pennsylvania; Percent FTE RN shortage estimated by HRSA, 2000: -4.9; Percent change in FTE RN employment 2000-2004: 2.4. State: Alaska; Percent FTE RN shortage estimated by HRSA, 2000: -4.5; Percent change in FTE RN employment 2000-2004: 36.9. State: Oregon; Percent FTE RN shortage estimated by HRSA, 2000: -3.8; Percent change in FTE RN employment 2000-2004: 13.8. State: Iowa; Percent FTE RN shortage estimated by HRSA, 2000: -3.5; Percent change in FTE RN employment 2000-2004: 6.0. State: Minnesota; Percent FTE RN shortage estimated by HRSA, 2000: -3.5; Percent change in FTE RN employment 2000-2004: 8.3. States with no clear RN shortage or surplus in 2000[A]. State: Alabama; Percent FTE RN shortage estimated by HRSA, 2000: -2.9; Percent FTE RN shortage estimated by HRSA, 2000-2004: 2.4. State: Florida; Percent FTE RN shortage estimated by HRSA, 2000: -2.8; Percent change in FTE RN employment 2000-2004: 4.2. State: Dist. of Col; Percent FTE RN shortage estimated by HRSA, 2000: -2.4; Percent change in FTE RN employment 2000-2004: 14.8. State: Maryland; Percent FTE RN shortage estimated by HRSA, 2000: -1.4; Percent change in FTE RN employment 2000-2004: 3.7. State: Michigan; Percent FTE RN shortage estimated by HRSA, 2000: -1.3; Percent change in FTE RN employment 2000-2004: 6.3. State: Vermont; Percent FTE RN shortage estimated by HRSA, 2000: -0.5; Percent change in FTE RN employment 2000-2004: 8.9. State: South Carolina; Percent FTE RN shortage estimated by HRSA, 2000: -0.4; Percent change in FTE RN employment 2000-2004: 4.0. State: Mississippi; Percent FTE RN shortage estimated by HRSA, 2000: 0.0; Percent change in FTE RN employment 2000-2004: 10.8. State: North Dakota; Percent FTE RN shortage estimated by HRSA, 2000: 0.2; Percent change in FTE RN employment 2000-2004: 10.6. State: North Carolina; Percent FTE RN shortage estimated by HRSA, 2000: 1.0; Percent change in FTE RN employment 2000-2004: 9.0. State: Illinois; Percent FTE RN shortage estimated by HRSA, 2000: 1.6; Percent change in FTE RN employment 2000-2004: 9.2. State: Wyoming; Percent FTE RN shortage estimated by HRSA, 2000: 2.0; Percent change in FTE RN employment 2000-2004: 4.7. States with a surplus in 2000. State: Oklahoma; Percent FTE RN shortage estimated by HRSA, 2000: 4.6; Percent change in FTE RN employment 2000-2004: 10.0. State: Kentucky; Percent FTE RN shortage estimated by HRSA, 2000: 5.9; Percent change in FTE RN employment 2000-2004: 11.2. State: Wisconsin; Percent FTE RN shortage estimated by HRSA, 2000: 6.2; Percent change in FTE RN employment 2000-2004: 6.4. State: South Dakota; Percent FTE RN shortage estimated by HRSA, 2000: 8.1; Percent change in FTE RN employment 2000-2004: 5.3. State: Idaho; Percent FTE RN shortage estimated by HRSA, 2000: 8.5; Percent change in FTE RN employment 2000-2004: 9.4. State: Louisiana; Percent FTE RN shortage estimated by HRSA, 2000: 9.0; Percent change in FTE RN employment 2000-2004: -6.7. State: Kansas; Percent FTE RN shortage estimated by HRSA, 2000: 9.0; Percent change in FTE RN employment 2000-2004: 0.6. State: West Virginia; Percent FTE RN shortage estimated by HRSA, 2000: 10.3; Percent change in FTE RN employment 2000-2004: 2.1. State: Montana; Percent FTE RN shortage estimated by HRSA, 2000: 14.5; Percent change in FTE RN employment 2000-2004: 3.1. State: United States; Percent FTE RN shortage estimated by HRSA, 2000: -5.5; Percent change in FTE RN employment 2000-2004: 8.9. Source: HRSA and GAO analysis of HRSA data. Notes: HRSA's shortage estimates are for 2000. GAO analysis is of data from the 2000 and 2004 National Sample Survey of Registered Nurses, HRSA. [A] Due to uncertainties in the estimation process, only states with a difference between supply and demand of greater than 3 percent were considered to have a shortage or surplus. [End of table] [End of section] Enclosure III: Change in Registered Nurse (RN) Employment per 100,000 Population, by State, 2000-2004: State: Alaska; Employed RNs per 100,000 persons: 2000: 784; Employed RNs per 100,000 persons: 2004: 1034; Percent change 2000-2004: 31.9. State: Alabama; Employed RNs per 100,000 persons: 2000: 766; Employed RNs per 100,000 persons: 2004: 807; Percent change 2000-2004: 5.4. State: Arizona; Employed RNs per 100,000 persons: 2000: 628; Employed RNs per 100,000 persons: 2004: 681; Percent change 2000-2004: 8.4. State: Arkansas; Employed RNs per 100,000 persons: 2000: 701; Employed RNs per 100,000 persons: 2004: 731; Percent change 2000-2004: 4.3. State: California; Employed RNs per 100,000 persons: 2000: 544; Employed RNs per 100,000 persons: 2004: 589; Percent change 2000-2004: 8.3. State: Colorado; Employed RNs per 100,000 persons: 2000: 737; Employed RNs per 100,000 persons: 2004: 753; Percent change 2000-2004: 2.2. State: Connecticut; Employed RNs per 100,000 persons: 2000: 942; Employed RNs per 100,000 persons: 2004: 934; Percent change 2000-2004: -0.8. State: Delaware; Employed RNs per 100,000 persons: 2000: 936; Employed RNs per 100,000 persons: 2004: 1040; Percent change 2000-2004: 11.1. State: Dist. of Col; Employed RNs per 100,000 persons: 2000: 1675; Employed RNs per 100,000 persons: 2004: 2093; Percent change 2000-2004: 25.0. State: Florida; Employed RNs per 100,000 persons: 2000: 785; Employed RNs per 100,000 persons: 2004: 763; Percent change 2000-2004: -2.8. State: Georgia; Employed RNs per 100,000 persons: 2000: 683; Employed RNs per 100,000 persons: 2004: 753; Percent change 2000-2004: 10.2. State: Hawaii; Employed RNs per 100,000 persons: 2000: 703; Employed RNs per 100,000 persons: 2004: 739; Percent change 2000-2004: 5.1. State: Idaho; Employed RNs per 100,000 persons: 2000: 636; Employed RNs per 100,000 persons: 2004: 628; Percent change 2000-2004: -1.3. State: Illinois; Employed RNs per 100,000 persons: 2000: 819; Employed RNs per 100,000 persons: 2004: 895; Percent change 2000-2004: 9.3. State: Indiana; Employed RNs per 100,000 persons: 2000: 761; Employed RNs per 100,000 persons: 2004: 876; Percent change 2000-2004: 15.1. State: Iowa; Employed RNs per 100,000 persons: 2000: 1060; Employed RNs per 100,000 persons: 2004: 1106; Percent change 2000-2004: 4.3. State: Kansas; Employed RNs per 100,000 persons: 2000: 885; Employed RNs per 100,000 persons: 2004: 909; Percent change 2000-2004: 2.7. State: Kentucky; Employed RNs per 100,000 persons: 2000: 833; Employed RNs per 100,000 persons: 2004: 908; Percent change 2000-2004: 9.0. State: Louisiana; Employed RNs per 100,000 persons: 2000: 834; Employed RNs per 100,000 persons: 2004: 783; Percent change 2000-2004: -6.1. State: Maine; Employed RNs per 100,000 persons: 2000: 1025; Employed RNs per 100,000 persons: 2004: 1145; Percent change 2000-2004: 11.7. State: Maryland; Employed RNs per 100,000 persons: 2000: 856; Employed RNs per 100,000 persons: 2004: 848; Percent change 2000-2004: -0.9. State: Massachusetts; Employed RNs per 100,000 persons: 2000: 1194; Employed RNs per 100,000 persons: 2004: 1175; Percent change 2000-2004: -1.6. State: Michigan; Employed RNs per 100,000 persons: 2000: 798; Employed RNs per 100,000 persons: 2004: 840; Percent change 2000-2004: 5.3. State: Minnesota; Employed RNs per 100,000 persons: 2000: 957; Employed RNs per 100,000 persons: 2004: 1018; Percent change 2000-2004: 6.4. State: Mississippi; Employed RNs per 100,000 persons: 2000: 750; Employed RNs per 100,000 persons: 2004: 827; Percent change 2000-2004: 10.3. State: Missouri; Employed RNs per 100,000 persons: 2000: 960; Employed RNs per 100,000 persons: 2004: 997; Percent change 2000-2004: 3.9. State: Montana; Employed RNs per 100,000 persons: 2000: 812; Employed RNs per 100,000 persons: 2004: 854; Percent change 2000-2004: 5.2. State: Nebraska; Employed RNs per 100,000 persons: 2000: 958; Employed RNs per 100,000 persons: 2004: 1061; Percent change 2000-2004: 10.8. State: Nevada; Employed RNs per 100,000 persons: 2000: 520; Employed RNs per 100,000 persons: 2004: 604; Percent change 2000-2004: 16.2. State: New Hampshire; Employed RNs per 100,000 persons: 2000: 916; Employed RNs per 100,000 persons: 2004: 1283; Percent change 2000-2004: 40.1. State: New Jersey; Employed RNs per 100,000 persons: 2000: 800; Employed RNs per 100,000 persons: 2004: 839; Percent change 2000-2004: 4.9. State: New Mexico; Employed RNs per 100,000 persons: 2000: 656; Employed RNs per 100,000 persons: 2004: 713; Percent change 2000-2004: 8.7. State: New York; Employed RNs per 100,000 persons: 2000: 843; Employed RNs per 100,000 persons: 2004: 906; Percent change 2000-2004: 7.5. State: North Carolina; Employed RNs per 100,000 persons: 2000: 858; Employed RNs per 100,000 persons: 2004: 899; Percent change 2000-2004: 4.8. State: North Dakota; Employed RNs per 100,000 persons: 2000: 1096; Employed RNs per 100,000 persons: 2004: 1180; Percent change 2000-2004: 7.7. State: Ohio; Employed RNs per 100,000 persons: 2000: 882; Employed RNs per 100,000 persons: 2004: 984; Percent change 2000-2004: 11.6. State: Oklahoma; Employed RNs per 100,000 persons: 2000: 635; Employed RNs per 100,000 persons: 2004: 693; Percent change 2000-2004: 9.1. State: Oregon; Employed RNs per 100,000 persons: 2000: 793; Employed RNs per 100,000 persons: 2004: 858; Percent change 2000-2004: 8.2. State: Pennsylvania; Employed RNs per 100,000 persons: 2000: 1010; Employed RNs per 100,000 persons: 2004: 1024; Percent change 2000-2004: 1.4. State: Rhode Island; Employed RNs per 100,000 persons: 2000: 1101; Employed RNs per 100,000 persons: 2004: 1052; Percent change 2000-2004: -4.5. State: South Carolina; Employed RNs per 100,000 persons: 2000: 728; Employed RNs per 100,000 persons: 2004: 732; Percent change 2000-2004: 0.5. State: South Dakota; Employed RNs per 100,000 persons: 2000: 1128; Employed RNs per 100,000 persons: 2004: 1204; Percent change 2000-2004: 6.7. State: Tennessee; Employed RNs per 100,000 persons: 2000: 872; Employed RNs per 100,000 persons: 2004: 921; Percent change 2000-2004: 5.6. State: Texas; Employed RNs per 100,000 persons: 2000: 606; Employed RNs per 100,000 persons: 2004: 646; Percent change 2000-2004: 6.6. State: Utah; Employed RNs per 100,000 persons: 2000: 592; Employed RNs per 100,000 persons: 2004: 660; Percent change 2000-2004: 11.5. State: Vermont; Employed RNs per 100,000 persons: 2000: 957; Employed RNs per 100,000 persons: 2004: 1037; Percent change 2000-2004: 8.4. State: Virginia; Employed RNs per 100,000 persons: 2000: 711; Employed RNs per 100,000 persons: 2004: 760; Percent change 2000-2004: 6.9. State: Washington; Employed RNs per 100,000 persons: 2000: 738; Employed RNs per 100,000 persons: 2004: 781; Percent change 2000-2004: 5.8. State: West Virginia; Employed RNs per 100,000 persons: 2000: 858; Employed RNs per 100,000 persons: 2004: 884; Percent change 2000-2004: 3.0. State: Wisconsin; Employed RNs per 100,000 persons: 2000: 893; Employed RNs per 100,000 persons: 2004: 938; Percent change 2000-2004: 5.0. State: Wyoming; Employed RNs per 100,000 persons: 2000: 780; Employed RNs per 100,000 persons: 2004: 805; Percent change 2000-2004: 3.2. State: United States; Employed RNs per 100,000 persons: 2000: 782; Employed RNs per 100,000 persons: 2004: 825; Percent change 2000-2004: 5.5. Source: Source: GAO analysis of Health Resources and Services Administration (HRSA) data. Note: Data are from the 2000 and 2004 National Sample Survey of Registered Nurses, HRSA. [End of table] [End of section] Enclosure IV: Characteristics of Nursing Education Loan Repayment Program (NELRP) and Nursing Scholarship Program (NSP) Awardees: Table 6: Race and Ethnicity of Registered Nurse (RN) Workforce, Nursing School Graduates, and NELRP Awardees, 2004: Race and ethnicity: White (non-Hispanic); 2004 RN workforce (percent): 81.2; 2004 Nursing school graduates (percent): 73.6; 2004 NELRP awardees (percent): 70.1. Race and ethnicity: Black (non-Hispanic); 2004 RN workforce (percent): 4.4; 2004 Nursing school graduates (percent): 10.4; 2004 NELRP awardees (percent): 9.7. Race and ethnicity: Asian/Pacific Islander[A]; 2004 RN workforce (percent): 3.3; 2004 Nursing school graduates (percent): 3.6; 2004 NELRP awardees (percent): 3.0. Race and ethnicity: American Indian/Alaska Native; 2004 RN workforce (percent): 0.3; 2004 Nursing school graduates (percent): 0.9; 2004 NELRP awardees (percent): 0.7. Race and ethnicity: Hispanic (any race); 2004 RN workforce (percent): 1.7; 2004 Nursing school graduates (percent): 6.0; 2004 NELRP awardees (percent): 5.7. Race and ethnicity: Other/unknown[B]; 2004 RN workforce (percent): 9.0; 2004 Nursing school graduates (percent): 5.5; 2004 NELRP awardees (percent): 10.7. Source: Health Resources and Services Administration (HRSA), National League for Nursing, and GAO analysis of HRSA administrative data. [A] Includes Native Hawaiians among the RN workforce and NELRP awardees. [B] Includes 1.5 percent identified as two or more races among the 2004 RN workforce. [End of table] Table 7: Race and Ethnicity of RN Workforce, Nursing School Students, and NSP Awardees, 2004: Race and ethnicity: White (non-Hispanic); 2004 RN workforce (percent): 81.2; 2004 Nursing school students (percent): 69.2; 2004 NSP awardees (percent): 61.9. Race and ethnicity: Black (non-Hispanic); 2004 RN workforce (percent): 4.4; 2004 Nursing school students (percent): 13.0; 2004 NSP awardees (percent): 29.4. Race and ethnicity: Asian/Pacific Islander[A]; 2004 RN workforce (percent): 3.3; 2004 Nursing school students (percent): 5.4; 2004 NSP awardees (percent): 2.4. Race and ethnicity: American Indian/Alaska Native; 2004 RN workforce (percent): 0.3; 2004 Nursing school students (percent): 0.8; 2004 NSP awardees (percent): 0.8. Race and ethnicity: Hispanic (any race); 2004 RN workforce (percent): 1.7; 2004 Nursing school students (percent): 5.7; 2004 NSP awardees (percent): 1.6. Race and ethnicity: Other/unknown[B]; 2004 RN workforce (percent): 9.0; 2004 Nursing school students (percent): 5.9; 2004 NSP awardees (percent): 4.0. Source: HRSA, National League for Nursing, and GAO analysis of HRSA administrative data. [A] Includes Native Hawaiians among the RN workforce and NSP awardees. [B] Includes 1.5 percent identified as two or more races among the 2004 RN workforce. [End of table] [End of section] Enclosure V: GAO Contact and Staff Acknowledgments: GAO Contact: Kathleen King, (202) 512-7119 or kingk@gao.gov: Acknowledgments: In addition to the contact names above, Linda T. Kohn, Assistant Director; Eric Anderson, Krister Friday, Romonda McKinney, Dae Park, Ollie Richie, and Jessica C. Smith made key contributions to this report. (290529): FOOTNOTES [1] This includes RNs employed both full-time and part-time. Data for 2004 were the most recent available on the overall RN workforce. [2] GAO, Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors, GAO-01-944 (Washington, D.C.: July 10, 2001). [3] HRSA Bureau of Health Professions, Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 (Rockville, Md., 2002). [4] For a recent study of labor shortages, the Department of Labor defined a shortage as "a market disequilibrium between supply and demand in which the quantity of workers demanded exceeds the supply available and willing to work at a particular wage and working conditions at a particular place and point in time." See The Urban Institute, Skill Shortages and Mismatches in Nursing Related Health Care Employment (Washington, D.C., April 2002). [5] See J. Needleman et al., Nurse Staffing and Patient Outcomes in Hospitals, Final Report for HRSA, Contract No. 230-99-0021, Harvard School of Public Health (Boston, Mass., 2001). See also M.W. Stanton and M.K. Rutherford, Hospital Nurse Staffing and Quality of Care, Agency for Healthcare Research and Quality (Rockville, Md., 2004). [6] Pub. L. No. 107-205, 116 Stat. 813 (2002). [7] In this report, we consider any RN training program, including 2- year, 3-year, and 4-year programs, to be a school of nursing. [8] According to program guidance, for the NELRP, applicants with the "greatest financial need" are those with nursing educational loans 40 percent or greater than their annualized salary. For the NSP, applicants with the greatest financial need were defined as those who had zero expected family contribution on their federal financial aid application. NSP awardees begin to fulfill their service obligation after graduation from nursing school. Because NELRP awardees have already completed nursing school, they begin to fulfill their obligation upon receipt of the award. [9] For the NSP, the facility types are: (1) Indian Health Service health center; (2) rural health clinic; (3) Native Hawaiian health center; (4) nursing home; (5) home health agency; (6) federally- designated migrant health center; (7) hospice program; (8) federally- designated community health center; (9) state or local public health department including a clinic within the department; (10) federally- designated health care for the homeless health center; (11) skilled nursing facility; (12) federally-qualified look-alike health center (a migrant, community, or health care for the homeless health center meeting federal Public Health Service grant requirements but not currently receiving such funds); and (13) ambulatory surgical center; and (14) hospital. The NELRP includes these facility types but separates hospitals into three subtypes: federal hospital; disproportionate share hospital (a hospital that receives supplemental payments through the Medicare or Medicaid programs to subsidize the costs of caring for a high proportion of low-income patients); and nonfederal, nondisproportionate share hospital. [10] HRSA has prepared and provided these reports on behalf of the department. [11] Pub. L. No. 107-205, § 204, 116 Stat. 811, 818-19. [12] This survey was first conducted in 1977, again in 1980, and every 4 years thereafter. The most recent survey was conducted in 2004. [13] In this report, we use the term "state" to refer to the 50 states and the District of Columbia. [14] The Current Population Survey is a monthly survey of households conducted by the Bureau of the Census for the Bureau of Labor Statistics (BLS). [15] RNs may also obtain graduate nursing degrees that may qualify them to teach in a university setting or work as a nurse practitioner or as other advanced nursing specialists. [16] This represents a sizable increase compared to the previous 4 years when RN employment grew by about 4 percent from 1996 to 2000. [17] To be licensed as an RN in a state, a nurse must graduate from an approved nursing program and pass a national licensing exam developed by the National Council of State Boards of Nursing. [18] We use the number of nurses passing the national RN licensing exam to approximate the number of newly licensed RNs. Some states may impose additional requirements prior to issuing a license. [19] HRSA has a contract to update its model for estimating demand, but the update is not expected to be available until 2008. [20] In our 2001 report, we noted that available national data were not adequate to describe the nature and extent of nurse shortages across states or provider types. [21] See HRSA Bureau of Health Professions, Projected Supply. [22] Due to uncertainties in the estimation process, only states with a difference between supply and demand of greater than 3 percent were considered to have a shortage or surplus. [23] Because HRSA calculated state RN shortage estimates based on full- time equivalents (FTE), we calculated state-level RN employment change in terms of FTEs for this comparison. An FTE is the percentage of time a staff member works, represented as a decimal. A full-time person is 1.00, a half-time person is .50 and a quarter-time person is .25. [24] According to labor economists, in a condition of shortage, where demand exceeds the supply of workers, labor market data will generally show strong employment and wage growth for an occupation relative to the workforce overall. See C. Veneri, "Can occupational labor shortages be identified using available data?" Monthly Labor Review, March 1999. [25] Because the NELRP provides awards to RNs with student loan debt, we use nursing school graduates as the closest comparison group for NELRP awardees. Similarly, because the NSP provides awards to individuals entering nursing school, we use nursing school students as the best comparison for NSP awardees. [26] While race and ethnicity are not criteria for awards for the NSP or NELRP, the Institute of Medicine and the National Advisory Council on Nurse Education and Practice (NACNEP), an advisory body for HRSA on nurse workforce issues, have identified the need to increase racial and ethnic diversity among RNs and other health professionals. [27] While the educational degree type is not a criterion for NSP awards, the NACNEP and the American Association of Colleges of Nursing have called for increasing the proportion of bachelor's-prepared RNs in the workforce. As of 2004, 53 percent of the RN workforce held a bachelor's or higher degree. [28] HRSA established preference categories to target certain facility types on the list. For example, priority for NELRP awards in fiscal year 2005 was given to RNs working in disproportionate share hospitals, nursing homes, state or local public health departments, federally- designated community health centers, federally-designated migrant health centers, or rural health clinics. [29] These facilities included an Indian Health Service health center, native Hawaiian health center, public hospital, migrant health center, community health center, rural health clinic, or public or nonprofit private health facility determined by the Secretary to have a critical shortage of nurses. The law also required preference be given to qualified applicants with the greatest financial need. [30] The nurse shortage county designation was developed using AHA hospital survey data. It was based on the number of full-time equivalent nursing staff relative to the average daily census among hospitals in a county. HRSA designates HPSAs based on the ratio of the number of primary care physicians relative to the population, among other factors. A HPSA can be a distinct geographic area such as a county, a specific population group within an area, or a specific health care facility. [31] HPSAs are used by HRSA for primary care physicians. See GAO, Health Professional Shortage Areas: Problems Remain with Primary Care Shortage Area Designation System, GAO-07-84 (Washington, D.C.: Oct. 24, 2006). [32] In contrast to the facility-based methodology initially developed by the SUNY researchers, this approach considered other sources of data, including the decennial Census, the American Community Survey, the National Sample Survey of Registered Nurses, and the Area Resource File. GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. Obtaining Copies of GAO Reports and Testimony: The fastest and easiest way to obtain copies of GAO documents at no cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts newly released reports, testimony, and correspondence on its Web site. To have GAO e-mail you a list of newly posted products every afternoon, go to www.gao.gov and select "Subscribe to Updates." Order by Mail or Phone: The first copy of each printed report is free. Additional copies are $2 each. A check or money order should be made out to the Superintendent of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more copies mailed to a single address are discounted 25 percent. Orders should be sent to: U.S. Government Accountability Office 441 G Street NW, Room LM Washington, D.C. 20548: To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202) 512-6061: To Report Fraud, Waste, and Abuse in Federal Programs: Contact: Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov Automated answering system: (800) 424-5454 or (202) 512-7470: Congressional Relations: Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S. Government Accountability Office, 441 G Street NW, Room 7125 Washington, D.C. 20548: Public Affairs: Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, D.C. 20548: