2015

2
 Nursing
SUPPLY AND DEMAND
THROUGH 2020

2015
Table of Contents

Acknowledgments 1
Glossary 2
The economy will create 1.6 million job openings for nurses through 2020. 4
By 2020, the United States will face a shortfall of 193,000 nursing professionals. 5
Aging of the baby boomers, more people with health insurance, and other social and economic 7
factors have led to the pending shortages.

The demand for healthcare services, including nursing, is growing. 7

An economic recovery both increases demand for and reduces the supply of qualified nurses. 10
The end of the Great Recession will signal more nursing shortages. 12
The nursing workforce is aging. 13
Nursing has a relatively demanding job environment. 15
Government programs increase supply putting downward pressure on wages. 15
Recruitment is increasing. 16
Nursing schools lack adequate faculty, facilities, and clinical placement sites to train enough 16
students to meet the growing demand.

Changes in immigration legislation are affecting supply. 24

State analysis 26
Bibliography 38

4i
Acknowledgments

We would like to express our gratitude to the individuals and organizations that have made this report possible. First we
thank Lumina Foundation, the Bill & Melinda Gates Foundation, and the Joyce Foundation for their support of our research
over the past few years. In particular, we are grateful for the support of Jamie Merisotis, Holly Zanville, Daniel Greenstein,
Elise Miller, Matthew Muench, and Whitney Smith. We are honored to be partners in their mission of promoting
postsecondary access and completion for all Americans.

We owe special thanks to Laura Chenven, director of the Healthcare Career Advancement Program (H-CAP), for her
leadership, support, and inspiration in the production of this report. H-CAP is a national organization of major healthcare
employers and Service Employees International Union (SEIU) members supporting career advancement in healthcare.

We would also like to thank Joy Laforme, the reports designer, and Tracy Thompson and Barbara Minich, the reports
editors. Our thanks also go to our colleagues, whose support was vital to our success:

Jeff Strohl and Tamara Jayasundera, who provided superb research and editorial assistance throughout,

Andrea Porter and Ana Castanon, who provided strategic guidance in the design and production of the
report and,

Joseph Leonard and Coral Castro, who assisted with the logistics and provided overall administrative support.

Many have contributed their thoughts and feedback throughout the production of this report. That said, all errors,
omissions, and views remain the responsibility of the authors.

The views expressed in this publication are those of the authors and do not necessarily represent those of Lumina
Foundation, the Bill & Melinda Gates Foundation, or Joyce Foundation, their officers, or employees.

1
Glossary

Nursing professionals are individuals employed in nursing 5. ADN/ASN Associate degree in Nursing/Associate
professions, including registered nurses (RNs), licensed of Science in Nursing are nursing degrees that are
practical nurses (LPNs), and licensed vocational nurses completed at a community college or university. Together
(LVNs). with the NCLEX-RN exam, these degrees are the
prerequisite for applying for licensure as an RN.
CREDENTIALS
6. Diploma This is an entry-level nursing credential that,
1. DNP Doctor of Nursing Practice is a professional together with the NCLEX-RN exam, allows one to apply
doctoral degree intended to establish an individuals for licensure as an RN. The diploma is usually awarded
expertise as a clinical practitioner. The DNP prepares by hospital-based nursing programs and is slowly being
an RN to manage acute and chronic medical conditions replaced by other tertiary institutions, such as community
as a primary care provider, usually independent from a colleges and nursing schools within universities. Many
medical doctor. of the existing hospital-based programs coordinate with
nearby schools to teach classes that, together with the
2. PhD/DNS Doctor of Philosophy in Nursing or Doctor practicum/apprenticeship-based programs in hospitals,
of Nursing Science is a terminal research-focused degree are required to complete the diploma credential.
in nursing. These are academic degrees intended for
individuals who plan to be involved in teaching and OCCUPATIONS
research. The PhD/DNS is different from a DNP, which is a
clinical degree. 1. Nurse Practitioner (NP) an advanced practice
registered nurse (APRN) who usually has completed a
3. MSN Masters of Science in Nursing is a postgraduate DNP program or a set of graduate coursework and clinical
degree for RNs who have an interest in administration education beyond that of an RN (such as an MSN).
or management within the nursing field. It is also a NPs can diagnose medical conditions, order treatment,
requirement for many advanced practice registered nurse prescribe drugs, and make referrals in much the same
(APRN) specialties and in some cases is a prerequisite for way as physicians. In many states, NPs do not need to
the DNP. practice under the supervision of a physician.

4. BSN Bachelor of Science in Nursing is a four-year 2. Certified Registered Nurse Anesthetist (CRNA) an
baccalaureate degree that, together with the National advanced practice registered nurse (APRN) who usually
Council Licensure Examination-Registered Nurse (NCLEX- has completed a DNP or MSN program and is board
RN) exam, is the emerging entry-level requirement for certified in anesthesia.
RNs. Although not officially required, the BSN is highly
favored over an Associates degree in Nursing and as
an entry-level requirement for a significant number of
registered nursing opportunities.

2
Glossary Cont.

3. Certified Nurse Midwife (CNM) an advanced practice

registered nurse (APRN) who usually has completed a DNP
or MSN program and is board certified in midwifery. CNMs
specialize in the provision of care for women who are not
experiencing high-risk pregnancies.

4. Clinical Nurse Specialist an APRN who usually has

completed a DNP or MSN program in selected areas of
nursing leading to board certification as a CNS. CNSs
provide specialized care and are responsible for the
diagnosis and treatment of health, as well as the delivery of
evidence-based nursing interventions.

5. Registered Nurse (RN) a nurse who has graduated

from a nursing program and has passed the NCLEX-RN
exam. To become an RN, one must complete at least an
Associates degree (ADN/ASN) or diploma in nursing and
pass the NCLEX-RN. RNs are at the center of gravity among
the nursing professions.

6. Licensed Practical Nurse (LPN)/Licensed Vocational

Nurse (LVN) a nursing professional who cares for people
under the direction of an RN or physician. Potential LPNs/
LVNs study for one to two years at a community college or
a vocational/technical school and also pass the NCLEX-
Practical Nurse (PN) exam. No substantive difference exists
between LPNs and LVNs, except for the occupational name,
which depends on the state of practice.

3
The economy will create 1.6 million job openings for nurses through 2020.

There are close to 3.5 million nursing professionals1 Moreover, many women tend to adopt nursing as a
in the workforce today, accounting for nearly three of lifelong profession, choosing to move into and out of
every five healthcare professional and technical jobs the labor market as economic and personal conditions
in the country, or 57 percent of the 6.1 million jobs in demand. Only teachers stay in their position longer than
healthcare professional and technical occupations. nurses among female-dominated jobs. For example,
Nursing is poised to play a key role in the evolving U.S. 84 percent of teachers are still teaching 10 years out,
healthcare system, especially as reforms under the Patient while close to 75 percent of nurses are still in the nursing
Protection and Affordable Care Act, commonly called the profession after 10 years.4
Affordable Care Act (ACA) or Obamacare, continue to
be implemented.2 We project that there will be 1.6 million job openings for
nurses through 2020.
Well-developed career pathways and an expectation of Of these,
strong job growth make nursing an attractive route to
upward economic mobility. Aside from teachers, no other 700,000 will be newly created opportunities, and

profession employs as many women, both in absolute and 880,000 will be replacements for retiring baby boomer

relative terms, as nursing. Women make up 89 percent of nurses.

the nursing workforce and 85 percent of the K-12 teaching

workforce. Registered nurses (RNs) are paid relatively The projected 1.6 million job openings can be divided

high wages ($68,000), compared to other female- further into 1.2 million openings for RNs and 370,000

dominated occupations, such as high school teachers openings for LPNs/LVNs.5

($53,000) and elementary/middle school teachers

($50,000).3

1
Nursing professions include RN, which also includes the advanced practice registered nurse (APRN) specialties of certified registered nurse anesthetist (CRNA),
nurse practitioner (NP), certified nurse midwife (CNM), and clinical nurse specialist (CNS); licensed professional nurse (LPN); and licensed vocational nurse
(LVN).
2
Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, 2011.
3
Georgetown University Center for Education and the Workforce analysis of Current Population Survey (CPS), 2013. The wages presented for each occupation are
average full-time, full-year wages for prime-age (25-54) workers.
4
Georgetown University Center on Education and the Workforce, Analysis of data from National Center for Education Statistics, Baccalaureate and Beyond Longitu-

dinal Study, 2010.

5
We chose to include LPNs and LVNs in the analysis of the nursing workforce as licensed practical and vocational nurses offer important entry-level pathways to
registered nursing.

4
By 2020, the United States will face a shortfall of 193,000 nursing professionals.

Currently, the United States has the largest nursing

workforce in the world. Even considering the size of our
population, the United States has a higher-than-average
concentration of nurses. In 2011, there were 11.1 nurses
per 1,000 people in the United States, compared to an
average of 8.7 nurses per 1,000 people across the worlds
most economically developed nations.6 Norway has
the highest concentration of nurses per 1,000 people,
estimated at 19.5 in 2011, while Turkey has the lowest,
with 1.7 nurses per 1,000 people.7

Looking forward, based on the age and makeup of the

current workforce, the size of graduating nursing classes,
and nurses career decisions with regard to working in the
field and pursuing additional education, we project that
the active supply of nursing professionals will increase
steadily from the current 3.5 million nursing professionals
to 3.95 million by 2020, including over 3.2 million RNs
and 703,000 LPNs/LVNs. Yet, this substantial growth in
supply will not be enough to meet the demand for nursing
professionals, which will be around 4.14 million by 2020.
Thus, we project the nursing workforce will be facing a
shortfall of roughly 193,000 nursing professionals by 2020.
(See Projecting the Supply of Nursing Professionals, page
6, for more methodological specifics.)

So, why despite all of the growth in supply, will there still
be a shortfall of 193,000 nursing professionals by 2020?8

6
Organization for Economic Cooperation and Development, OECD Health Data 2013, 2013.
7
Organization for Economic Cooperation and Development, OECD Health Data 2013, 2013.
8
Our shortfall estimate is based on projections of nursing demand and active supply, workers who hold a job in the nursing field, in 2020. Health Resources and
Services Administration (HRSA), using a different methodology, projects a surplus of 399,000 nursing professionals by 2025. See Nursing: Methodology comparison
for more details.

5
 PROJECTING THE SUPPLY OF NURSING PROFESSIONALS

Our approach to forecasting the active supply individuals (those who are currently out of the labor
of nursing professionals in this report is similar force due to retirement or disability and worked at least
to the general approach in the Clinical Specialty one week in prior year), using the Current Population
Supply Model (CSSDM) developed by the National Survey, March supplement, 2008-2013 pooled data.
Center for Health Workforce Analysis, of the Heath
Resources and Services Administration (HRSA), in The new-entrants estimate is based on the 2013
the U.S. Department of Health and Human Services graduating classes of RNs and LPNs/LVNs, using
(HHS). To get the projected clinician supply, we National Center for Educational Statistics (NCES)
age the supply of nursing professionals forward, Integrated Postsecondary Education Data System
subtracting attrition due to mortality, disability and (IPEDS) Completions Survey data, reduced to account
retirements and adding new graduates who join the for graduates who do not enter active nursing careers
nursing workforce for each year of the projections. In (only 70 percent of licensed nursing professionals
addition, since only 70 percent of licensed nursing are employed in nursing), and, for RNs, the graduate
professionals work in nursing, we estimated the degree recipients are subtracted as they likely were
annual probability of nursing professionals changing part of the nursing workforce prior to receiving the
careers and added that to attrition. The U.S. Census graduate degree.
Bureaus and Bureau of Labor Statistics (BLS)
Current Population Survey (CPS) March supplement Since data on the age and sex of new entrants are not
data were used to derive the current supply of available in IPEDS, the average annual attrition rate for
RNs and LPNs/LVNs by age (within an age range new entrants was based on labor force participation
of 18-70) and sex. The base year for the supply rate for RNs and LPNs younger than 50 (95% for RNs
projections is 2013, the last year for which data and 91% for LPNs).
are available. However, since the data have to be
substantially subdivided (by age and sex), five years The projected supply for each year is based on the
of data 2008-2013 were pooled and averaged to projected continuing supply for that year, plus the
provide the base-year supply. cumulative number of new entrants from the previous
year. Then, in the target projection year (in this case
The age and sex-specific mortality rates are based 2020), the nursing supply is adjusted by employment
on the 2010 Actuarial Life Table from the Social status (except retired and disabled) to get active
Security Administration. The retirement and disability supply projections, which are 3.2 million for RNs and
rates are based on newly retired and disabled 702,770 for LPNs.

6
Aging of the baby boomers, more people with health insurance, and other social and
economic factors have led to the pending shortages.

A variety of occupational and social factors has inconsistent wages and wage increases have contributed
contributed to the scarcity of nurses. The growing and to many qualified nurses exiting the profession. In
aging U.S. population, increased healthcare coverage, addition, recruitment, training, and retention continue
rising disposable incomes, and changing healthcare to be significant challenges. As a result, in rural areas,
delivery models all have contributed to the steady especially in western and southwestern states, nursing
growth in demand for nursing services.9,10 Moreover, an shortages continue to be a challenge for employers
aging workforce, a demanding job environment, and and patients.

The demand for healthcare services, including nursing, is growing.

Healthcare accounts for 18 percent of the U.S. economy. Another reason for the growing demand is the
That share is expected to keep growing, albeit at a slower expansion of coverage, through both the state and
pace than it had been during the decade preceding the federal health insurance exchanges and Medicaid
Great Recession of 2008, and the expectation is that expansion in roughly half of the states under the ACA.
healthcare will reach 20 percent of the gross domestic (See box on Obamacare, for more details.) While we
product (GDP) by 2020.11 The primary reason for this still dont know the extent to which the increase in
growing demand is changing demographics. Between coverage will translate into the greater utilization of
today and 2030, more than 70 million baby boomers will services, it is safe to assume that individuals who gain
be crossing into the over-65 age group - the segment of health insurance coverage will utilize more healthcare
the population that accounts for 34 percent of all surgical services than they did when they were uninsured, and
procedures, 26 percent of all physician office visits, and therefore will contribute to the growing demand for
90 percent of all nursing home residents.12 Nursing plays healthcare.
a major role in all these services, as well as others utilized
by older adults, such as home care, hospital services,
and rehabilitation.

9
Health Resources and Services Administration, What Is Behind HRSAs Projected Supply, Demand, and Shortage of Registered Nurses?, 2004.
10
Health Resources and Services Administration, National Sample Survey of Registered Nurses (NSSRN) 1980- 2008, 2010.
11
Carnevale, et al., Healthcare, 2012.
12
Ricketts, The Healthcare Workforce, 2011: 417-430.

7
 OBAMACARE

The Affordable Care Act (ACA), popularly known as programs developed collaboratively among
Obamacare, will have a significant impact on the healthcare institutions and schools of nursing that
capacity and training of the nursing workforce in are designed to encourage mentorship and the
ways both direct and indirect. The ACA increases development of nursing specialties, as well as
financial resources to allow for greater enrollment programs to enhance the involvement of nurses
and program completion by nurses. Indirectly, the in the clinical and organizational decision-making
ACA also influences the demand for healthcare within healthcare organizations.13
services and how care is delivered, and thus the
demand for nurses. Other provisions in the ACA attempt to remedy the
shortage of nursing faculty. For example, the law
The ACA is expected to increase the number expands eligibility for the Nurse Loan Repayment
of nurses by addressing bottlenecks in nursing and Scholarship Program (NLRP), formerly limited
education through a combination of grants, loans, to nursing students, to include nursing professionals
and loan repayment programs. These include already in the workforce who, in lieu of repaying
nursing education and practice and retention grants, their student loans, commit to working for at least
which among other things are aimed at expanding two years as faculty members at accredited nursing
enrollment in BSN programs and increasing the schools. The law increases the pool of money
use of new technology, including distance learning available for federally funded student nursing
methods. Obamacare also intends to promote loans, and adds a new program that provides loan
nursing practice arrangements in non-institutional repayment of up to $10,000 for MSN graduates and
settings, such as home healthcare, as a way to $20,000 for doctoral nursing graduates who serve
improve access to primary care for underserved and as full-time faculty in accredited nursing schools
high-risk groups, such as the elderly, the homeless, for four out of six years following their graduation or
patients with Human Immunodeficiency Virus entry into the program. The legislation also increases
Infection/Acquired Immunodeficiency Syndrome funding for more hospital-based graduate nursing
(HIV/AIDS), and victims of domestic violence. education programs, as well as nurse-managed
health centers (NMHCs), which are federally funded
The retention areas covered by the grants health centers providing care to underserved
encompass career ladder programs that help populations, managed by APRNs who are affiliated
nursing students earn their degrees and nursing with an academic institution, a qualified health
professionals advance in their careers with the center, or a nonprofit.
provision of tutoring and articulation agreements
for easing credit transfer among colleges and
universities. In addition, Obamacare also funds

13
Health Resources and Services Administration, Nurse Education, Practice and Retention Grants, 2012.

8
 What all these efforts will mean in the long run is Even before the ACA, the healthcare industry
hard to predict. The laws basic purpose is to offer was moving away from in-patient hospital care
affordable health insurance to the poor and uninsured, traditionally the largest employer of nurses and
which in theory will increase overall demand for toward ambulatory and community-based care;
healthcare services. the new law is likely to bolster these trends. In the
relatively short time since Obamacare was signed
During the 2013-2014 enrollment period, over 8 million into law, nursing employment in the ambulatory care
people signed up for health insurance through the sector has grown by 23 percent, while the number
federal and state exchanges, accounting for less than of hospital-employed nurses has declined by 2
one-fifth of the more than 40 million people without percent.15 With continued pressure on hospitals to
health insurance. However, that was the first year cut costs and the growth of new delivery models,
of the program, and even with the well-publicized including medical homes, accountable care
problems with the federal and some state exchanges organizations, community health centers, nurse-
website portals, the number of sign-ups exceeded managed health centers, pharmacy clinics, episode-
early projections, in large part due to the extension of based care, remote and web-based healthcare
the deadline for signing up. In addition, Medicaid and services, and so on,16 nurses can expect this shift
Childrens Health Insurance Program (CHIP) enrollment away from hospital employment to continue.
grew by close to 5 million people, in part due to 24
states and the District of Columbia adopting the
coverage expansion enacted under the ACA to include
adults with incomes up to 133 percent of the federal
poverty level.14

14
Centers for Medicare and Medicaid Services. Medicaid & CHIP: March 2014 monthly applications, May 1, 2014.
15
Georgetown University Center for Education and the Workforce analysis of Bureau of Labor Statistics, Current Population Survey (CPS) 2010-2012 (pooled data).
16
For information on new emerging models of care promoted under the Obamacare reforms, see Carnevale, et al., Healthcare, 2012: 19.

9
An economic recovery both increases demand for and reduces the supply of
qualified nurses.

As shown in Figure 1, many qualified nurses who are Further, 15 percent of RNs who do not work in nursing
licensed to practice choose not to work in the profession. specifically identify low pay in nursing or better salaries
Nursing is a middle-of-the-road occupation in terms of elsewhere as one of the reasons for leaving nursing.18
tenure. We estimate that between 70 and 75 percent of RNs who leave nursing are most likely to work in other
nurses with a Bachelors degree remain in the profession health-related services; retail sales and services;
by mid-career compared to 85 percent of teachers, education; or pharmaceutical, biotechnology, or medical
77 percent of engineers, and 62 percent of business equipment fields.
managers. Moreover, an AMN Healthcare 2013 survey
finds that 23 percent of nurses 55 and older will retire, There is a cyclical component to the workers decisions
change career, or switch to part-time as the economy to leave nursing or to return to nursing. In tight labor
continues to improve. 17
markets, job security and relatively high wages act
as an incentive to draw qualified nurses back to the
Stressful working environments, along with long hours and profession. As the labor market starts recovering and
erratic schedules in some nursing positions, contribute more opportunities become available elsewhere, some
to many nurses moving in and out of the field based on nurses will leave the profession for jobs they find more
economic conditions and personal circumstances. Among preferable.
prime-age (25-54) RNs with an active RN license, 44
percent of those who do not work in nursing indicate that
workplace-related issues, such as burnout, scheduling,
the physical demands of the job, inadequate staffing, and
low pay relative to other opportunities contributed to their
decision to leave nursing.

17
AMN Healthcare, Inc., Healthcares 2013 Survey of Registered Nurses: Generation Gap Grows as Healthcare Transforms, 2013.
18
Georgetown University Center on Education and the Workforce analysis of Health Resources and Service Administration, National Sample Survey of
Registered Nurses, 1980-2008.

10
 Figure 1. A substantial number of licensed nurses are not working in the profession.

NUMBER OF LICENSED AND WORKING NURSING PROFESSIONALS (1987-2013):

Source: Georgetown University Center on Education and the Workforce (CEW) analysis of data from National Council of State Boards of Nursing
(NCSBN); Nursing Licensure Volume; and National Council Licensure Examination (NCLEX) Examination Statistics publication,1988-2013; and
U.S. Census Bureau, Current Population Survey (CPS) data,1987-2013.

Note: The total number of working nursing professionals includes RNs and LPNs/LVNs.

Note: For RNs with a Bachelors degree, the likelihood of remaining in the nursing field is 70 to 75 percent.19

19
Georgetown University Center for Education and the Workforce analysis of data from the American Community Survey (ACS), 2009-2012 (pooled), and the Bacca-
laureate and Beyond Longitudinal Study (B&B), 1993-2003.

11
The end of the Great Recession will signal more nursing shortages.

Many of the earlier cases supporting the existence of Over the past three years, nursing had one of the
nursing shortages preceded the Great Recession, and lowest unemployment rates of all occupations. Recent
the trends will likely reassert themselves after the recovery graduates with BSN degrees saw a 4.8 percent
reaches full employment, which is projected for 2017. For unemployment rate, while experienced BSN nurses saw
example, in a 2004-05 survey of hospital executives, 68 a 2.3 percent unemployment rate. Graduate degree
percent of chief executive officers (CEOs) and 74 percent holders in the nursing profession had unemployment
of chief nursing officers (CNOs) already perceived a very rates of 1.7 percent, on average.23
serious or somewhat serious nursing shortage affecting
their hospitals.20 As the recession cut jobs across the As the recovery trudges along, unemployment
board, weakened investment portfolios, lowered consumer rates continue to decline, and the ACA enters its
confidence, and limited access to credit, many qualified full implementation, the nursing shortage problem is
nurses delayed retirement, re-entered the workforce, expected to resurface. This is because the demand for
or switched back to nursing after previously changing nurses is expected to increase as qualified nurses exit
occupations due to economic circumstances. In addition, the labor force in better economic times. The ACA will
younger workers, enticed by the perceived job security and require a greater number of RNs, especially those with
good wages, entered the profession as quickly as slots Bachelors degrees, to provide healthcare services to
became available. millions of newly insured people. Healthcare facilities
are expected once again to demand more nurses, to
The Great Recession, therefore, to a large extent mitigated care for the newly insured patient population, and to
the impact of the nursing scarcity. In effect, the recession improve patient outcomes in line with reforms under the
increased the supply of active nurses in the workforce. 21
ACA. Reports by the Agency for Healthcare Research
and Quality (AHRQ) have linked nurse staffing levels
According to Buerhaus et al. (2009), hospital employment with key patient outcomes, including hospital-related
of RNs increased by an estimated 243,000 full-time mortality, length of stay, hospital-acquired infections,
equivalents (FTEs) in 2007 and 2008 the largest increase and unintended hospital readmissions.24,25
during any two-year period in the past four decades. Since
then, nursing employment has steadily increased to 3.5
million nursing professionals working in the field.22

20
Buerhaus, et al., Impact of the Nurse Shortage on Hospital Patient Care: Comparative Perspectives, 2007: 853-862.
21
Buerhaus, et al., The Recent Surge In Nurse Employment: Causes And Implications, 2009: w657-w668.
22
Georgetown University Center on Education and the Workforce, analysis of Current Population Survey March Supplement data, 2013. See Unicon Research
Corporation, CPS Utilities, 2014.
23
Carnevale Anthony P., and Ban Cheah. Hard Times: College Majors, Unemployment and Earnings. Washington, D.C.: Center on Education and the Workforce,
analysis of Current Population Survey March Supplement Data, 2013. http://cew.georgetown.edu/unemployment2013.
24
Kane, et al. Nurse Staffing and Quality of Patient Care, March 2007.
25
Seago, Nurse Staffing, Models of Care Delivery, and Interventions, July, 2001.
12
The nursing workforce is aging.

While today less than 14 percent of U.S. residents are

over the age of 65, by 2030, more than 20 percent are
expected to be in that age group, an increase of more
than 6 percentage points.26 The aging population will
increase the demand for nursing services and reduce
the supply of nursing professionals simultaneously. The
reduction in supply will be driven by the retirement of
baby boomer nurses. Baby boomer nurses currently
comprise more than 1.1 million nursing professionals,
constituting over a third of RNs and LPNs/LVNs.27 The
average age of an RN is now 45 and the average age of
an LPN/LVN is 43. Nursing professionals over the age of
40 now make up the majority of the workers in the field,
accounting for 62 percent of all RNs and 59 percent of
all LPNs/LVNs.

26
Ortman, et al., An Aging Nation: The Older Population in the United States, May 2014.
27
Georgetown University Center on Education and the Workforce, analysis of Current Population Survey March Supplement data, 2013. See Unicon Research
Corporation, CPS Utilities, 2014.

13
 Figure 2. Nurses 40 and older have become the majority of the workforce.

RNs BY AGE, 1980-2013:

Source: Georgetown University Center on Education and the Workforce analysis of U.S. Census Bureau, Current Population Survey (CPS) data,
1980-2013.

Percentages may not total 100 due to rounding.

14
Nursing has a relatively demanding job environment.

Staff nurses in hospitals are facing a growing number of system, with patients who once were treated in hospitals
challenges, including an aging population, resulting in now being cared for in rehabilitative, outpatient, and
sicker patients, tighter budgets, fear of punitive action for home care settings.
making an error, physical and psychological pressures of
shift work, everyday physical demands, and the challenge In addition, pressure to minimize costs has reduced
of keeping up with ever-changing technologies. These the incentive for healthcare organizations to invest in
factors, combined with infrequent or unpredictable wage RN staffing beyond the bare minimum.29,30 Insufficient
increases, have created a toxic level of stress. The trend staffing levels, long work shifts, a punitive organizational
toward shorter hospital stays and patients with more culture, and inadequate investments in the orientation
severe health conditions has increased the intensity of and training of new nurses have put stress on the
the nursing care provided in hospitals and thereby has nursing staff and have been found to be detrimental to
contributed to a more strenuous work environment for patient safety.31 Also, in some instances, the excessive
nursing professionals.28 Further, this trend has had a documentation nurses are expected to do takes time
cascading effect on nurses throughout the healthcare away from focusing on monitoring patients.

Government programs increase supply, but also put downward pressure on wages.

Government programs, created with the aim of easing for all nursing graduates are lower, including for those
the nursing shortage, have in some cases resulted in who did not receive a subsidy for their education through
unintentional consequences. Grants, scholarships, the government programs. So, while the government
tuition vouchers, and loan reimbursements, designed to programs are increasing incentives for students to go into
lower the cost of a nursing education, have also tended nursing by reducing the cost of their education, these
to depress starting wages. This is because nursing programs also potentially reduce the incentives for non-
graduates who receive subsidized education through participants. Moreover, programs often do not require
these programs are willing to, or in some cases are participants to stay in the nursing profession beyond the
required to,32 work for lower starting wages than they first two years following graduation, so they do little to
would without the subsidies. As a result, starting wages
33
address the issue of attrition among RNs.

28
Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses, 2004.
29
As part of healthcare reform implementation, including changes in payment mechanisms that reward positive patient outcomes, hospitals will have stronger
incentives to invest in their nursing workforce.
30
Fox and Abrahamson, A Critical Examination of the U.S. Nursing Shortage, October 2009, 235-244.
31
Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses, 2004.
32
Some programs require nurses to work in nursing shortage areas and/or to work for specific institutions in exchange for receiving tuition vouchers, grants, or
scholarships. This reduces competition among employers and also tends to depress starting wages, in particular in nursing shortage areas where employers feel
less pressure to increase wages due to easier access to nursing graduates through the government programs.
33
Elgie, Politics, Economics, and Nursing Shortages, 2007, 285-292.

15
Recruitment is increasing.

Recruitment has become less of a challenge in recent

years, with more young people interested in entering the
nursing profession.34 Between 1980 and 2008, the number
of applications to nursing schools increased by over
80 percent.35 While the profession still faces challenges
attracting men and racial and ethnic minorities, much
progress has been made with regard to making nursing
an attractive career choice to an increasingly diverse pool
of students.

Nursing schools lack adequate faculty, facilities, and clinical placement sites to train
enough students to meet the growing demand.

Despite the growing interest in the nursing field, BSN

programs rejected 37 percent (58,327) of qualified
applicants and Associates degree nursing programs
rejected 51 percent of qualified applicants in 2011-
2012 (Figure 3).36,37,38 The reasons for the high rejection
rates are complicated. As Carnevale et al., (2012)
point out, nursing schools lack adequate faculty and
facilities to move enough students through the pipeline
quickly enough to meet the growing demand.39

34
Buerhaus, et al., Projections of the Long-Term Growth of Registered Nurse Workforce, 2013.
35
National League for Nursing, Annual Survey of Schools of Nursing, 2007-2008, 2008.
36
The definition of qualified differs from program to program, but usually includes the completion of prerequisite coursework, a certain grade point average
(GPA), a certain SAT/ACT score, a sufficient score on the Test of Essential Academic Skills (TEAS) or similar entry exam for nursing programs, having received the
required immunizations and completed a health exam and some type of background check.
37
Fang, et al., 2011-2012 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, 2012.
38
National League for Nursing, Annual Survey of Schools of Nursing, Fall 2011, 2012.
39
Carnevale, et al., Healthcare, June 2012.

16
 Figure 3. Despite high number of applicants to nursing schools, both ADN/ASN
and BSN nursing programs fall short of meeting demand.
BACHELORS DEGREE IN NURSING (BSN) AND ASSOCIATES DEGREE IN NURSING
(ADN/ASN) PROGRAMS REJECTED QUALIFIED APPLICANTS IN 2011-2012:

Sources: Georgetown University Center for Education and the Workforce analysis of American Association of Colleges of Nursing, 2011-2012
Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing (see Fang et al., 2012); and National League for Nursing,
Annual Survey of Schools of Nursing, Fall 2011, 2012.

17
One of the contributing factors has been the move of
nursing education out of the hospitals and into colleges
and universities. When nursing education was provided
mainly through hospital-based diplomas, hospitals relied
on nursing students to provide patient care and to support
staff RNs as part of their training. Nursing students had
mentors and trainers in the form of hospital staff RNs,
and nursing faculty did not have to give up clinical
opportunities in order to take on teaching roles. With
nursing education shifting to colleges, hospitals cant rely
as much on nursing students and nursing schools have
problems finding practice facilities for their students and
with faculty recruitment.

Figure 4 illustrates the most important obstacles to the

expansion of the nursing profession, namely the lack
of enough educational facilities to accept all qualified
students and, more importantly, the lack of enough faculty
and clinical placement sites.40,41,42 The opportunity cost of
not investing in infrastructure and not providing sufficient
subsidies for teachers in nursing are sure to have
serious implications for access to care, especially for the
increasing numbers of newly insured individuals.

40
Fang, et al., 2011-2012 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, 2012.
41
National League for Nursing, Annual Survey of Schools of Nursing, Fall 2011, 2012.
42
Fang, et al., 2011-2012 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, 2012.

18
 Figure 4. The lack of facilities, the lack of faculty, and the lack of clinical
placements are the major hurdles to training more nurses.

SHARE OF PROGRAMS FACING OBSTACLES TO EXPANDING CAPACITY IN NURSING:

Source: National League for Nursing, Annual Survey of Schools of Nursing, Fall 2011, 2012.

The reasons behind the shortage of nursing faculty are who do opt for a teaching career. Other reasons include the
complex and multidimensional, but they include a lack of uncertain level of student enrollments; the relatively low pay
interest in teaching careers among nurses and nursing for academic jobs compared to other opportunities available
students who have a variety of opportunities available to nurses with graduate education; long clinical experience
both within and outside of clinical practice. Another factor required for teaching positions; early retirement, or career
is that the long clinical experience necessary to qualify changes by faculty members dissatisfied with their jobs;
to enter the academic field delays the entry of nurses and the lack of sufficient institutional funding to establish
additional faculty positions.43

43
Yordi, The Nursing Faculty Shortage: A Crisis for Health Care, 2006.
19
The inflation-adjusted average salary for an RN in an Even if academic pay levels increase, rising professional
instructor position in 2008 was only $61,055. 44,45
Although standards make a doctoral degree increasingly necessary
teaching salaries have risen since then to $88,484 for a teaching career. Yet, as of the 2011-2012 academic
for a nursing faculty member in a Bachelors degree or year, only 33 percent of all nursing faculty had doctoral
graduate program and to $72,210 for nursing educators in preparation in nursing (Figure 5).48 The result is a
instructor positions as of 2011, these pay levels were not catch-22: to produce more doctoral-level RNs, the system
as high as what RNs with a graduate education could earn needs more RNs with doctoral degrees. The problem is
in management, as a nurse practitioner (NP) or certified exacerbated by the fact that nursing faculty who have
nurse midwife (CNM), or as a certified registered nurse doctoral degrees now also educate baccalaureate and
anesthetist (CRNA). 46,47
graduate RN students, which gives them even less time to
teach students in advanced doctoral programs. Only 14
percent of nursing faculty spend time educating nursing
students in PhD and Doctor of Nursing Practice (DNP)
programs (Figure 6).49,50

44
Georgetown University Center for Education and the Workforce analysis of National Sample Survey of Registered Nurses (NSSRN) 2008 from the Health
Resources and Services Administration.
45
Georgetown University Center for Education and the Workforce analysis of the American Association of Colleges of Nursing, 2011-2012 Salaries of Instructional
and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing. (See Fang, et al., 2011-2012 Salaries of Instructional and Administrative
Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, 2012.) Instructor here refers to entry-level rank in academic faculty nursing positions,
as opposed to assistant professor, associate professor, or professor rank. By contrast, in NSSRN data, instructor refers to all RNs who identified themselves as
holding any instructor position, regardless of the rank. NSSRN data also include nursing instructors in Associates degree and diploma programs.
46
Georgetown University Center for Education and the Workforce analysis of National Sample Survey of Registered Nurses (NSSRN) 2008 from the Health
Resources and Services Administration.
47
Georgetown University Center for Education and the Workforce analysis of the American Association of Colleges of Nursing, 2011-2012 Salaries of Instructional
and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing.
48
Fang, et al., 2011-2012 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, 2012.
49
Georgetown University Center for Education and the Workforce analysis of National Sample Survey of Registered Nurses (NSSRN) 2008 from the Health
Resources and Services Administration.
50
Georgetown University Center for Education and the Workforce analysis of the American Association of Colleges of Nursing, 2011-2012 Salaries of Instructional
and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing.

20
 While the demand for more educated nurses is on the rise, the supply cannot keep up due to rising demands on
the limited number of doctoral nursing faculty.

Figure 5. Only 33 percent of nursing faculty have doctoral preparation in nursing.

SHARE OF NURSING FACULTY WITH DOCTORAL AND NONDOCTORAL PREPARATION:

Source: Georgetown University Center on Education and the Workforce analysis of American Association of Colleges of Nursing, 2011-2012
Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, 2012.

*Percentages may not total 100 due to rounding.

21
 Doctoral nurses cannot train enough new doctoral nurses and more BSN and MSN nurses at the same time. 51

Figure 6. Only 14 percent of nursing faculty spend time preparing new doctoral
nursing graduates.

LEVEL OF TEACHING FOR NURSING FACULTY:

Source: Georgetown University Center on Education and the Workforce analysis of American Association of Colleges of Nursing, 2011-2012
Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, 2012.

Percentages may not total 100 due to rounding.

The heavy workloads imposed on the limited number of and more than one-fourth of those likely to leave the nursing
doctoral nursing faculty lead to job dissatisfaction and faculty say the high workloads are one of the reasons for
departure among nursing instructors. Nearly half of all their decision.52
nursing faculty express dissatisfaction with the workload,

51
Doctoral nursing education includes research-focused PhD and DNS programs and practice-focused DNP programs.
52
Joynt and Kimball. Blowing Open the Bottleneck, May 2008.

22
Still, recent trends offer some hope. The number of RNs Even more encouraging, the number of doctoral graduates
in instructor positions grew 53 percent between 2004 in nursing has been steadily rising, from 512 in 2006 to 2,065
and 2008, the highest growth of any four-year period in 2011 (Figure 7).54
since 1980.53

Figure 7. The number of doctoral nursing graduates has been increasing steeply
since 2006.
DOCTORAL RN GRADUATES, 1992-2011:

Source: Georgetown University Center on Education and the Workforce analysis of the National Center for Education Statistics Integrated
Postsecondary Education Data System (IPEDS) Completions Survey, 1992-2011.

53
Georgetown University Center on Education and the Workforce analysis of Health Resources and Services Administration (HRSA), National Sample Survey of
Registered Nurses (NSSRN), 1980-2008.
54
Georgetown University Center on Education and the Workforce analysis of National Center for Educational Statistics (NCES), IPEDS Completions Survey, 1992
2011.
23
Changes in immigration legislation are affecting supply.

A temporary drying up of the supply of international

nurses also has put a damper on the supply of
qualified nurses. In the past, the United States relied
heavily on importing nurses from countries such as
the Philippines, which produces three times as many
nurses as it actually needs. Favorable immigration
policies made the United States a good alternative to
absorb other countries excess supply. But the number
of foreign RNs applying for work visas has contracted
by nearly a third since the beginning of the most recent
economic downturn. With the 2009 expiration of the
1999 H-1C visa program, which allowed foreign nurses
to fill shortages as determined by the U.S. Department
of Labor, the United States can no longer look to other
countries to help with shortages.

As shown in Figure 8, the supply of foreign nurses

tends to rise during periods of prosperity and to fall
during recessions. The last recession, however, was an
exception to that rule. Though the recession officially
ended in June 2009, the United States has not seen
the expected upward shift in the demand for nurses or
a rise in the demand for visas to fill nursing positions.

24
 Figure 8. The number of foreign (noncitizen) nurses in the United States has been
in decline since the beginning of the Great Recession of 2008.
FOREIGN RNS IN THE UNITED STATES:

Source: Georgetown University Center on Education and the Workforce analysis of U.S. Census Bureau, Current Population Survey (CPS) data,
1994-2012.

25
State analysis

NORTH DAKOTA TOPS THE NATION SOUTHERN STATES WILL RELY

IN THE NUMBER OF NURSES PER MORE ON NURSES THAN DOCTORS
1,000 RESIDENTS. IN THEIR HEALTHCARE MIX.
The distribution of nursing professionals substantially By 2020, nursing professionals will account for 27
varies by state, as does their role in each states percent of the healthcare workforce in the United States.
healthcare workforce. On average, there are 12 nurses But the degree to which each state will rely on nursing
per 1,000 people in the United States, but that varies professionals for the delivery of healthcare services will
from 17 nurses per 1,000 residents in North Dakota vary widely. Southern states, in particular, are expected
to eight nurses per 1,000 residents in Nevada. North to rely significantly on nursing professionals. As shown in
Dakota, Washington, D.C., and Rhode Island have the Figure 10, four of the five states that will have the highest
highest concentrations of nursing professionals, while percentage of nurses in their healthcare workforce are
California, Georgia, and Nevada have the lowest, as located in the South, including Mississippi, Alabama,
shown in Figure 9. Washington, D.C., Tennessee, and Arkansas. Utah,
New Mexico, and Arizona will have the lowest share of
nurses, and will rely more heavily on other healthcare

BY 2020, ROUGHLY ONE-FOURTH professionals. (South Dakota also will rely more on
OF ALL JOB OPENINGS IN NURSING nurses in its healthcare delivery model.)
WILL BE IN CALIFORNIA, NEW
YORK, AND TEXAS.
Large states, like California, New York, and Texas, award
the greatest number of nursing degrees. Altogether,
the three states account for 20 percent of all nursing
degrees in this country. Not surprisingly, these states
are also expected to have the largest number of job
openings for nursing professionals by 2020, 23 percent
of job openings in nursing will be in these three states.

26
 Figure 9. North Dakota, Washington, D.C., and Rhode Island have the highest
concentration of nursing professionals, while California, Georgia, and Nevada
have the lowest.
NURSES PER 1,000 RESIDENTS BY STATE:

Sources: Georgetown University Center on Education and the Workforce analysis of Carnevale, et al., Healthcare, June 2012, and Population
Distribution and Change 2000-2010. 2010 Census Briefs, C2010BR-01, 2011.

27
 Figure 10. Mississippi, South Dakota, and Alabama will have the highest share
of nursing professionals within their healthcare workforce by 2020, while Arizona,
New Mexico, and Utah will have the lowest.
SHARE OF NURSES IN DIRECT HEALTHCARE WORKFORCE BY STATE, 2020:

Source: Carnevale, et al., Healthcare, June 2012.

28
29
 Table 1. California, Texas, and New York lead the nation in the number of nursing
degrees awarded.

NURSING DEGREES BY STATE AND EDUCATION LEVEL, 2010:

ADN/ASN BSN MSN PhD/DSN DNP Doctoral Other Total

Alabama 2,060 1,700 770 10 120 0 4,660
Alaska 90 120 10 0 0 0 220
Arizona 1,910 3,350 2,180 40 0 0 7,480
Arkansas 840 710 170 10 0 0 1,730
California 7,220 4,640 1,570 50 20 0 13,500
Colorado 830 1,290 320 10 30 0 2,480
Connecticut 530 670 280 10 10 0 1,500
Delaware 250 330 130 0 0 0 710
District of Columbia 0 240 130 10 20 0 400
Florida 5,360 3,800 1,100 40 70 0 10,370
Georgia 1,530 2,050 480 20 0 0 4,080
Hawaii 160 390 50 10 0 0 610
Idaho 530 530 40 0 0 0 1,100
Illinois 2,980 2,720 790 30 0 0 6,520
Indiana 2,240 2,760 600 10 10 0 5,620
Iowa 1,390 930 230 0 0 0 2,550
Kansas 1,130 940 180 10 10 0 2,270
Kentucky 1,800 1,090 440 10 20 0 3,360
Louisiana 920 1,480 470 10 0 0 2,880
Maine 310 410 110 0 0 0 830
Maryland 1,440 1,110 440 10 50 0 3,050
Massachusetts 1,640 1,930 680 40 20 20 4,330
Michigan 2,860 2,500 510 20 30 0 5,920
Minnesota 1,940 1,380 1,370 10 30 20 4,750
Mississippi 1,350 660 150 0 0 0 2,160
Missouri 1,550 3,680 430 30 0 0 5,690
Montana 150 260 20 0 0 0 430
Nebraska 400 930 220 0 0 0 1,550
Nevada 330 460 80 10 0 0 880
New Hampshire 440 290 40 0 0 0 770

30
 Table 1 Cont. California, Texas, and New York lead the nation in the number of
nursing degrees awarded.

ADN/ASN BSN MSN PhD/DSN DNP Doctoral Other Total

New Jersey 1,890 1,410 360 40 0 0 3,700
New Mexico 680 390 90 0 0 0 1,160
New York 6,880 4,490 1,440 30 60 0 12,900
North Carolina 2,440 2,110 540 10 20 0 5,120
North Dakota 90 380 110 0 10 0 590
Ohio 4,370 3,570 980 20 90 0 9,030
Oklahoma 1,320 1,370 120 0 0 0 2,810
Oregon 590 780 50 10 0 0 1,430
Pennsylvania 2,840 4,370 1,120 30 130 20 8,510
Rhode Island 210 370 30 0 0 0 610
South Carolina 1,300 1,010 150 20 0 0 2,480
South Dakota 360 440 90 0 0 0 890
Tennessee 1,370 2,010 890 50 30 0 4,350
Texas 5,560 4,660 1,080 40 50 0 11,390
Utah 1,130 730 140 10 30 0 2,040
Vermont 210 100 40 0 0 0 350
Virginia 1,730 1,680 400 60 20 0 3,890
Washington 1,700 1,160 360 40 0 0 3,260
West Virginia 580 790 150 0 10 0 1,530
Wisconsin 1,660 1,680 350 30 30 0 3,750
Wyoming 280 140 30 0 0 0 450

Source: Carnevale, et al., Healthcare, June 2012.

31
 Table 2. The distribution of projected RN job openings through 2020 will vary
widely by state.

PROJECTED RN JOB OPENINGS BY STATE THROUGH 2020:

Alabama 26,840 Missouri 38,190

Alaska 2,930 Montana 5,050
Arizona 23,650 Nebraska 11,530
Arkansas 16,610 Nevada 8,360
California 142,940 New Hampshire 7,740
Colorado 24,150 New Jersey 39,880
Connecticut 19,640 New Mexico 8,490
Delaware 5,810 New York 91,730
District of Columbia 6,700 North Carolina 50,420
Florida 91,600 North Dakota 4,430
Georgia 45,410 Ohio 73,590
Hawaii 4,780 Oklahoma 19,580
Idaho 7,030 Oregon 16,270
Illinois 65,440 Pennsylvania 70,410
Indiana 38,100 Rhode Island 5,900
Iowa 17,700 South Carolina 23,750
Kansas 16,890 South Dakota 5,870
Kentucky 26,380 Tennessee 41,700
Louisiana 28,170 Texas 123,150
Maine 7,100 Utah 10,740
Maryland 29,200 Vermont 3,390
Massachusetts 46,350 Virginia 38,090
Michigan 48,510 Washington 31,260
Minnesota 36,280 West Virginia 10,740
Mississippi 19,020 Wisconsin 28,940
Wyoming 2,580

Source: Georgetown University Center on Education and the Workforce projections of job openings by education,
2010-2020.

32
 Table 3. The educational attainment distribution of RN jobs will vary widely
among states by 2020.

PROJECTIONS OF EMPLOMENT FOR REGISTERED NURSES BY

EDUCATION AND STATE BY 2020:

State Nursing diploma ADN/ASN BSN MSN DNP PhD/DNS Total

Alabama 1,830 23,820 21,140 3,990 950 230 51,960
Alaska 180 1,370 4,870 850 * * 7,270
Arizona 2,640 20,320 29,310 6,980 1,430 130 60,810
Arkansas 2,580 11,990 11,610 2,660 580 10 29,430
California 14,480 98,920 156,580 27,910 9,550 1,570 309,010
Colorado 3,440 13,080 24,660 5,190 2,130 60 48,560
Connecticut 3,930 11,900 17,330 4,990 1,190 * 39,340
Delaware 1,090 1,580 5,650 890 * * 9,210
District of Columbia 120 * 1,150 490 * 110 1,870
Florida 15,050 81,860 80,970 22,160 3,090 1,300 204,430
Georgia 6,600 33,050 41,170 10,740 1,230 300 93,090
Hawaii 440 3,330 7,380 1,070 * * 12,220
Idaho 480 6,860 7,100 1,390 310 * 16,140
Illinois 8,160 45,290 67,070 13,460 2,410 600 136,990
Indiana 3,370 31,050 34,940 6,850 870 220 77,300
Iowa 2,730 22,800 14,050 1,890 480 * 41,950
Kansas 1,500 14,990 14,510 3,440 470 * 34,910
Kentucky 930 22,280 22,180 4,370 850 260 50,870
Louisiana 3,360 17,080 24,820 4,650 130 680 50,720
Maine 1,720 4,290 8,630 1,210 80 * 15,930
Maryland 4,460 24,250 34,580 8,880 1,040 550 73,760
Massachusetts 7,770 25,390 49,890 15,310 2,090 450 100,900
Michigan 5,410 45,830 50,300 6,620 1,800 650 110,610
Minnesota 2,430 31,310 30,640 7,950 220 660 73,210
Mississippi 1,330 15,360 16,510 3,500 660 160 37,520
Missouri 5,080 26,180 29,440 5,460 1,370 310 67,840
Montana 560 2,410 4,980 640 * * 8,590
Nebraska 2,020 7,520 15,690 2,010 440 * 27,680
Nevada 580 5,980 11,210 2,180 860 * 20,810
New Hampshire 2,030 6,480 8,310 2,490 290 * 19,600
New Jersey 9,010 24,660 53,490 12,890 2,400 920 103,370
New Mexico 1,290 9,270 8,490 3,550 730 * 23,330
New York 18,270 66,550 100,170 26,170 6,790 810 218,760

33
 Table 3 Cont. The educational attainment distribution of RN jobs will vary
widely among states by 2020.

State Nursing diploma ADN/ASN BSN MSN DNP PhD/DNS Total

North Carolina 6,880 44,520 45,200 10,820 2,240 430 110,090
North Dakota 440 2,450 6,480 550 * * 9,920
Ohio 10,800 62,780 57,220 13,670 1,330 260 146,060
Oklahoma 2,340 15,840 16,760 3,750 860 * 39,550
Oregon 2,350 13,580 16,330 4,380 770 160 37,570
Pennsylvania 17,360 52,440 65,530 20,040 3,780 150 159,300
Rhode Island 1,010 4,590 6,990 2,230 210 * 15,030
South Carolina 3,040 21,300 22,840 6,930 900 210 55,220
South Dakota 500 5,540 7,790 550 * * 14,380
Tennessee 5,180 26,090 28,970 10,770 1,120 520 72,650
Texas 16,760 80,900 103,480 22,140 4,180 1,050 228,510
Utah 340 11,430 10,930 1,860 390 550 25,500
Vermont 670 2,680 4,000 930 * * 8,280
Virginia 6,840 26,290 32,960 11,520 2,790 650 81,050
Washington 2,120 23,270 33,090 6,280 2,300 220 67,280
West Virginia 1,730 9,910 8,910 1,890 510 * 22,950
Wisconsin 3,380 28,880 33,500 7,380 600 760 74,500
Wyoming 440 1,580 1,700 390 60 * 4,170
United States 217,050 1,191,120 1,511,500 348,910 66,480 14,940 3,350,000

Georgetown University Center on Education and the Workforce projections of employment by education, 2010-2020.

*Fewer than 10 RNs are projected to fall into this category. Current employment sample is too small for more
specific projection

34
 Table 4. In a number of large states, such as New York, California, and Wisconsin,
more than 100,000 nursing professionals are not actively working as nurses.

LICENSED NURSES VERSUS WORKING NURSES, BY STATE

(VARIOUS YEARS):

State Employed Licensed Licensed nursing State Employed Licensed Licensed nursing
nursing nursing professionals not nursing nursing professionals not
professionals professionals working in nursing professionals professionals working in nursing

AL* 44,560 62,898 18,338 MT 9,088 20,850 11,762

AK 6,271 18,096 11,825 NC 63,465 143,062 79,597
AR 37,375 51,924 14,549 ND 12,839 16,531 3,692
AZ 35,713 86,089 50,376 NE 23,133 33,396 10,263
CA 390,972 475,444 84,472 NH ** 24,219 **
CO 45,640 73,663 28,023 NJ 76,778 141,688 64,910
CT* 54,057 69,806 15,749 NM 15,746 27,954 12,208
DC 1,733 27,363 25,630 NV 26,360 31,798 5,438
DE 10,277 19,560 9,283 NY 219,080 364,200 145,120
FL 193,267 330,396 137,129 OH 171,756 247,013 75,257
GA 107,397 147,662 40,265 OK 48,231 69,469 21,238
HI 7,429 21,873 14,444 OR 26,396 54,158 27,762
IA 37,803 60,573 22,770 PA 155,810 268,556 112,746
ID 11,658 25,407 13,750 RI 10,327 19,831 9,505
IL 158,430 198,953 40,523 SC 66,362 69,989 3,627
IN 69,855 131,117 61,262 SD 15,584 18,063 2,479
KS 32,397 61,316 28,919 TN 79,041 119,690 40,649
KY 55,993 81,813 25,820 TX 248,497 353,582 105,085
LA* 43,187 81,484 38,297 UT 33,206 33,365 159
MA 56,276 142,376 86,101 VA 113,664 125,311 11,647
ME 17,131 25,558 8,427 VT 9,128 17,260 8,132
MD 79,209 87,376 8,167 WA 70,138 96,607 26,469
MI 131,587 170,525 38,938 WI 80,100 104,527 24,427
MN 78,288 115,018 36,730 WV 29,719 42,288 12,569
MS 36,548 57,326 20,778 WY 3,650 12,493 8,843
MO 82,010 116,841 34,831

*Note: Alabama, Connecticut and Louisiana did not have the 2012-2013 licensing volume data available for all nursing
professionals, so the most recent data, as reported in National Council of State Boards of Nursing (NCSBN), 2012 and
2013 Nurse Licensee Volume and NCLEX Examination Statistics, 2014, were used in the analysis.

** Data withheld due to insufficient sample size.

Source: Georgetown University Center on Education and the Workforce analysis of data from the National Council of
State Boards of Nursing (NCSBN), 2012 and 2013 Nurse Licensee Volume and NCLEX Examination Statistics, 2014; and
the U.S. Census Bureau, Current Population Survey (CPS), March Supplement, 2013.

35
 Table 5. The distribution of the healthcare workforce varies by state.

DISTRIBUTION OF HEALTHCARE WORKFORCE, BY STATE

(VARIOUS YEARS):

State Doctors Allied Healthcare Professionals Nurses Support

Alabama 10% 25% 33% 32%
Alaska 11% 31% 24% 35%
Arizona 13% 28% 24% 35%
Arkansas 11% 25% 32% 32%
California 13% 25% 26% 36%
Colorado 13% 29% 27% 31%
Connecticut 10% 26% 27% 37%
Delaware 12% 25% 32% 31%
District of Columbia 12% 28% 33% 27%
Florida 11% 26% 27% 35%
Georgia 12% 27% 29% 32%
Hawaii 16% 25% 24% 35%
Idaho 11% 26% 25% 38%
Illinois 12% 27% 28% 32%
Indiana 10% 26% 30% 33%
Iowa 9% 23% 29% 38%
Kansas 10% 26% 29% 35%
Kentucky 10% 27% 32% 31%
Louisiana 10% 23% 32% 35%
Maine 11% 26% 25% 39%
Maryland 14% 27% 26% 33%
Massachusetts 13% 29% 29% 30%
Michigan 11% 26% 25% 38%
Minnesota 11% 22% 29% 38%
Mississippi 9% 24% 34% 34%
Missouri 10% 26% 31% 33%
Montana 12% 24% 27% 37%
Nebraska 11% 25% 29% 34%
Nevada 14% 26% 25% 36%
New Hampshire 12% 28% 28% 32%
New Jersey 15% 23% 25% 37%
New Mexico 11% 26% 23% 39%

36
 Table 5 Cont. The distribution of the healthcare workforce varies by state.

State Doctors Allied Healthcare Professionals Nurses Support

New York 14% 22% 25% 40%
North Carolina 10% 24% 27% 39%
North Dakota 9% 23% 28% 40%
Ohio 10% 22% 29% 39%
Oklahoma 12% 25% 29% 34%
Oregon 14% 28% 24% 35%
Pennsylvania 10% 25% 28% 37%
Rhode Island 11% 25% 25% 39%
South Carolina 11% 26% 30% 34%
South Dakota 9% 27% 33% 30%
Tennessee 10% 27% 33% 30%
Texas 11% 25% 27% 37%
United States 12% 25% 27% 35%
Utah 12% 29% 23% 36%
Vermont 13% 30% 27% 29%
Virginia 12% 26% 28% 34%
Washington 12% 27% 27% 33%
West Virginia 10% 26% 31% 33%
Wisconsin 10% 26% 25% 38%
Wyoming 12% 28% 26% 34%

Source: Carnevale, et al., Healthcare, June 2012.

Percentages may not total 100 due to rounding.

37
Bibliography

Aiken, L.H., and Robyn Cheung. Nurse Workforce Challenges in the United States: Implications for Policy. OECD
Health Working Papers, No. 35 (2008), http://www.oecd.org/dataoecd/34/9/41431864.pdf.

Almada, P., K. Carafoli, J.B. Flattery, D.A. French, and M. McNamara. Improving the Retention Rate of Newly Graduated
Nurses. Journal for Nurses in Staff Development, 20, no. 6 (November/December 2004): 268-273.

ANM Healthcare, Inc. Healthcares 2013 Survey of Registered Nurses: Generation Gap Grows as Healthcare
Transforms. San Diego, CA: AMN Healthcare, Inc. (2013), http://www.amnhealthcare.com/industry-
research/546/1033/.

Buerhaus, Peter I., David I. Auerbach, and Douglas O. Staiger. The Recent Surge In Nurse Employment: Causes And
Implications. Health Affairs, 28, no. 4 (2009): w657-w668,
http://content.healthaffairs.org/content/28/4/w657.short.

Buerhaus, Peter I., David I. Auerbach, Douglas O. Staiger, and Ulrike Muench. Projections of the Long-Term Growth
of the Registered Nurse Workforce: A Regional Analysis. Nursing Economics, 31, no. 1 (2013): 13-17, https://
www.nursingeconomics.net/necfiles/news/JF_13_Buerhaus.pdf.

Buerhaus, Peter I., Karen Donelan, Beth T. Ulrich, Linda Norman, Catherine DesRoches, and Robert Dittus. Impact of
the Nurse Shortage on Hospital Patient Care: Comparative Perspectives. Health Affairs, 26, no. 3 (2007): 853-
862.

Bureau of Health Professions, Health Resources and Services Administration. Projected Supply, Demand, and Shortages
of Registered Nurses: 2000 2020. Washington, D.C.: U.S. Department of Health and Human Services, July
2002, http://www.ahcancal.org/research_data/staffing/Documents/Registered_Nurse_Supply_Demand.pdf.

Bureau of Labor Statistics. Registered Nurses. Occupational Outlook Handbook, 2012-13 Edition. Washington, D.C.:
U.S. Department of Labor, 2012, http://www.bls.gov/ooh/healthcare/registered-nurses.htm.

Carnevale Anthony P., and Ban Cheah. Hard Times: College Majors, Unemployment and Earnings. Washington, D.C.:
Center on Education and the Workforce, 2013, http://cew.georgetown.edu/unemployment2013.

Carnevale, Anthony P., Nicole Smith, Artem Gulish, and Bennet H. Beach. Healthcare. Washington, D.C.: Georgetown
University Center on Education and the Workforce, 2012, http://cew.georgetown.edu/healthcare/.

38
Bibliography Cont.

Center to Champion Nursing in America. Nursing Workforce Solutions for 21st Century Healthcare: Addressing
Education Capacity. Washington, D.C.: AARP and Robert Wood Johnson Foundation, February 2011. http://
campaignforaction.org/sites/default/files/Education%20Capacity%20CCNA%202%2017%20final.pdf.

Centers for Medicare and Medicaid Services. Medicaid & CHIP: March 2014 monthly applications. Washington, D.C.:
Center for Medicare and Medicaid Services, May 1, 2014, http://www.medicaid.gov/AffordableCareAct/Medicaid-
Moving-Forward-2014/Downloads/March-2014-Enrollment-Report.pdf.

Congressional Budget Office. The Budget and Economic Outlook: 2014 to 2024. Washington, D.C.: Congressional
Budget Office. February 2014, http://www.cbo.gov/publication/45010.

Elgie, Rob. Politics, Economics, and Nursing Shortages: A Critical Look at United States Government Policies. Nursing
Economic$, 25, no. 5. (2007): 285-292.

Fang, Di, Yan Li, and Geraldine D. Bednash. 2011-2012 Enrollment and Graduations in Baccalaureate and Graduate
Programs in Nursing. Washington, D.C.: American Association of Colleges of Nursing, 2012.

Fang, Di, Yan Li, and Geraldine D. Bednash. 2011-2012 Salaries of Instructional and Administrative Nursing Faculty in
Baccalaureate and Graduate Programs in Nursing. Washington, D.C.: American Association of Colleges of
Nursing, 2012.

Fox, R.L., and K. Abrahamson. A critical examination of the U.S. Nursing Shortage: Contributing Factors, Public Policy
Implications. Nursing Forum 44, no. 4 (October 2009): 235-244.

Health Resources and Services Administration. What Is Behind HRSAs Projected Supply, Demand, and Shortage of
Registered Nurses? Washington, D.C.: U.S. Department of Health and Human Services, September 2004,
http://dwd.wisconsin.gov/healthcare/pdf/behind_the_shortage.pdf.

Health Resources and Services Administration. National Sample Survey of Registered Nurses (NSSRN) 1980-2008.
Washington, D.C.: U.S. Department of Health and Human Services, 2010,
http://datawarehouse.hrsa.gov/nursingsurvey.aspx.

Health Resources and Services Administration. Nurse Education, Practice and Retention Grants. Program Number:
93.359, Washington, D.C.: Department of Health and Human Services 2012,
accessed through Catalog of Federal Domestic Assistance, https://www.cfda.gov/
index?s=program&mode=form&tab=core&id=8805382442a5b18d1478fd2ae8374410.

39
Bibliography Cont.

Hoffman, H. A Nurse Retention Program. Nursing Economic$, 7, no. 2 (1989): 94-96, 108.

Institute of Medicine (IOM). The Future of Nursing: Leading Change, Advancing Health. Washington, D.C.: The National
Academies Press, 2011.

Institute of Medicine. (IOM). Keeping Patients Safe: Transforming the Work Environment of Nurses, Washington, D.C.:
The National Academies Press, 2004.

Jones-Schenk, J. How Magnets Attract Nurses. Nursing Management, 32, no. 1 (2001): 41-42.

Joynt, Jennifer, and Bobbi Kimball. Blowing Open the Bottleneck: Designing New Approaches to Increase Nurse
Education Capacity. Washington, D.C.: Center to Champion Nursing in America, AARP, and the Robert Wood
Johnson Foundation, U.S. Department of Labor-Employment and Training Administration (ETA), May 2008,http://
championnursing.org/resources/blowing-open-bottleneck-designing-new-approaches-increase-nurse-
education-capacity.

Kane, Robert L., Tatyana Shamliyan, Christine Mueller, Sue Duval, and Timothy J. Wilt. Nurse Staffing and Quality of
Patient Care. Minneapolis, MN: Minnesota Evidence-based Practice Center, AHRQ 07-E005, March 2007,
http://www.ncbi.nlm.nih.gov/books/NBK38315/.

National Center for Education Statistics, Institute of Education Sciences. Baccalaureate and Beyond: A First Look at the
Employment Experiences and Lives of College Graduates, 4 Years On (B&B:08/12). Washington, D.C.: U.S.
Department of Education.

National Center for Educational Statistics, Institute of Education Sciences. Integrated Postsecondary Education
Data System (IPEDS) Completions Survey. 1992-2011. Washington, D.C.: U.S. Department of Education,
http://nces.ed.gov/ipeds/.

National Center for Health Workforce Analysis, Heath Resources and Services Administration (HRSA). Projecting the
Supply of Non-Primary Care Specialty and Subspecialty Clinicians: 2010-2025. Washington, D.C.: U.S.
Department of Health and Human Services (HHS), 2014.
http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/clinicalspecialties/index.html.

National Council of State Boards of Nursing (NCSBN). Nursing Licensure Volume and NCLEX Examination Statistics,
Chicago: NCSBN, Inc., 1987-2014, https://www.ncsbn.org/1236.htm.

40
Bibliography Cont.

National League for Nursing (NLN), Annual Survey of Schools of Nursing, 2007-2008, Washington, D.C.: NLN 2010,
http://www.nln.org/researchgrants/slides/viewall_0708.htm.

National League for Nursing (NLN). Annual Survey of Schools of Nursing, Fall 2011. Washington, D.C.: NLN 2012,
www.nln.org/research/slides/index.htm.

Office of Inspector General (OIG), Department of Health and Human Services. Hospital Best Practices in Nurse
Recruitment and Retention. Nursing Economic$, 7, no. 2 (1989): 98-105.

Organization for Economic Cooperation and Development (OECD). How Does the United
States Compare. OECD Health Data 2013. Washington, D.C.: OECD Publishing, 2013,
http://www.oecd.org/unitedstates/Briefing-Note-USA-2013.pdf.

Ortman, Jennifer, Victoria Velkoff, and Howard Hogan. An Aging Nation: The Older Population in the United States.
Current Population Reports P25-1140. Washington, D.C.: U.S. Census Bureau, May 2014,
http://www.census.gov/prod/2014pubs/p25-1140.pdf.

Ricketts, T.C. The Healthcare Workforce: Will It Be Ready as the Boomers Age? A Review of How We Can Know (or Not
Know) the Answer. Annual Review of Public Health 32 (2011): 417-430,
http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031210-101227
(doi: 10.1146/annurev-publhealth-031210-101227).

Seago, Jean Ann. Nurse Staffing, Models of Care Delivery, and Interventions. In Making Health Care Safer: A Critical
Analysis of Patient Safety Practices, edited by Kaveh G. Shojania, Bradford W. Duncan, Kathryn M. McDonald,
Robert M. Wachter, and Amy J. Markowitz. Rockville, MD: U.S. Department of Health and Human Services, July
2001), http://www.ncbi.nlm.nih.gov/books/NBK26966/.

Social Security Administration. Actuarial Life Table. 2010, http://www.ssa.gov/oact/STATS/table4c6.html.

United States Census Bureau. American Community Survey (ACS). 2009-2012, http://www.census.gov.

United States Census Bureau and Bureau of Labor Statistics, Current Population Survey March Supplement (Annual
Economic and Social Supplement). Washington, D.C.: United States Census Bureau and Bureau of Labor
Statistics, 1980-2013. Accessed using CPS Utilities: Documentation and Extraction Utilities for U.S. Census
Bureau Current Population Surveys, Santa Monica, CA: Unicon Corporation, 2014.

41
Bibliography Cont.

United States Census Bureau. Population Distribution and Change 2000-2010. 2010 Census Briefs, C2010BR-01.
March 2011, http://www.census.gov/prod/cen2010/briefs/c2010br-01.pdf.

Yordi, Karl. The Nursing Faculty Shortage: A Crisis for Health Care. Washington, D.C.: Association of Academic
Health Centers/Robert Wood Johnson Foundation, 2006,
http://www.rwjf.org/files/publications/other/NursingFacultyShortage071006.pdf.

42
Nursing: Supply and Demand Through 2020 can be accessed
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Center on Education and the Workforce
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