MARYLAND’S NURSING SHORTAGE: A WORKFORCE CRISIS

Barbara R. Heller, Ed.D., R.N., F.A.A.N. Del Sweeney, Ph.D.

The Nursing Workforce Project March 2003

Center for Health Workforce Development University of Maryland 515 West Lombard Street, Suite 479

Baltimore, Maryland 21201

CENTER FOR HEALTH WORKFORCE DEVELOPMENT UNIVERSITY OF MARYLAND
Mission The core mission of the Center for Health Workforce Development, which was founded in 2002, is to assist health care professionals, educators, the health care industry, and public policy makers in anticipating and effectively responding to the challenges of recruiting, educating, managing, and retaining an evolving health workforce in order to promote the safety, quality, and accessibility of health care in an era of cost containment. Strategic Initiatives • Document shortage areas and other major health workforce challenges in Maryland and the region by conducting and reporting research related to workforce recruitment, retention, distribution, and utilization; In partnership with the health care industry and government agencies, develop interventions aimed at resolving workforce and workplace issues; Strengthen and institutionalize interdisciplinary education, community-based learning, and regional cooperation among educational institutions; Help inform and shape public policy as it relates to health workforce development; Develop innovative strategies to promote health professions careers and increase the diversity of the workforce.

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Executive Director Barbara R. Heller, Ed.D., R.N., F.A.A.N., is Executive Director, Center for Health Workforce Development, and Rauschenbach Distinguished Professor of Nursing. Dr. Heller served as dean of the University of Maryland School of Nursing, 1990-2002. She is a national leader in health workforce policy and education and envisions the Center as a dynamic resource that is quick to respond to the challenges facing all health care professions. For further information, please contact the Center at 410-706-1146.

PREFACE
The Nursing Workforce Project was undertaken to gain a better understanding of the causes, extent, and impact of the nursing shortage in Maryland and to help inform and shape public policy as it relates to the future development of the nursing workforce. This report provides compelling evidence that the current nursing shortage differs quantitatively and qualitatively from those of the past and that, while some progress has been made in addressing the shortage from a recruitment and retention perspective, the underlying problems contributing to the shortage remain unresolved. The recommendations are a call to action to the many stakeholders that share concern about this issue—nurses, academic institutions, the health care industry, professional associations, government agencies, legislators, philanthropic organizations, and consumers—for collaborative efforts to seek innovative solutions to this public health crisis. We are indebted to the Aaron Straus and Lillie Straus Foundation, Inc., for providing funding for the project and also to Carefirst BlueCross Blueshield, MedStar Health, the Governor’s Workforce Investment Board, the Maryland Board of Nursing, and the University of Maryland School of Nursing for their additional support. The authors would like to thank the many individuals who contributed to this report, especially Ms. Jan Rivitz, Executive Director of the Aaron Straus and Lillie Straus Foundation, Inc., for her prescience in originally commissioning the research and to Marla Oros, M.S., R.N., Associate Dean for Clinical and External Affairs, University of Maryland School of Nursing, for assisting in the initial conceptualization and development of the project. We also wish to thank Donna M. Dorsey, M.S., R.N., Executive Director, Maryland Board of Nursing, for providing access to Board of Nursing databases, for her critical review of the manuscript, and for sharing her extensive knowledge of current nursing issues. Scott E. McBride, M.S., M.P.A., of Hollander Cohen & McBride conducted and analyzed the focus groups and other interviews. Donna Kenly, M.B.A., also of Hollander Cohen & McBride, assisted in collecting and analyzing demographic and salary data. Anirban Basu, M.A., formerly Executive Director of RESI Research and Consulting, Towson University, developed the methodology and the projections of supply and demand for registered nurses in Maryland; Hal Cohen, Ph.D., former Executive Director of the Maryland Health Services Cost Review Commission, assisted in interpreting financial data and critically reviewed the draft report. Edward O’Neill, Ph.D., M.P.A., Director, Center for the Health Professions, University of California, San Francisco, helped to develop the methodologies employed in this study. Lesley A. Perry, Ph.D., R.N., Senior Associate Dean, School of Nursing, University of Medicine and Dentistry of New Jersey, provided assistance in the early management of the project and contributed to the chapter

on nursing education. Michele M. Molesworth, Database Administrator, Maryland Board of Nursing, furnished demographic and education data collected by the Board of Nursing. Many people gave of their time to provide information relevant to this study. We wish especially to thank Mr. Calvin Pierson, President, Association of Maryland Hospitals and Health Systems; Clare E. Hastings, Ph.D., R.N., Chief, Nursing and Patient Care Services, and Carol A. Romano, Ph.D., R.N., Deputy Chief, Department of Clinical Research Informatics, both of the Warren Magnuson Clinical Center, National Institutes of Health; Judy Reitz, Sc.D., R.N., Executive Vice President and Chief Operating Officer, and Lisa Rowen, M.S., R.N., Director of Nursing, Surgery, both of the Johns Hopkins Hospital; and Karen Drenkard, M.S.N, R.N., C.N.A.A., Chief Nurse Executive, Inova Health System. Finally, we wish to thank the members of the Advisory Board of the Center for Health Workforce Development for their ongoing support of the Center and their insights into health workforce issues; and the University of Maryland Office of Academic Affairs and faculty and staff of the School of Nursing for their assistance. We deeply appreciate the advice of all of those individuals who discussed nursing shortage issues with us. The views expressed in this report, however, are solely those of the authors. B.R.H. D.S.

TABLE OF CONTENTS
Preface 4 Table of Contents...............................................................................................................................6 Executive Summary.......................................................................................................................vii

   Characteristics of the Nursing Shortage in Maryland                                             ......................................  vii      Supply and Demand Projections                                                                            .....................................................................  viii      Causes of the Shortage in Maryland                                                                      ...............................................................  viii      Impact of the Nursing Shortage on Access, Quality, Safety, and Cost                     ...............  x      Recommendations                                                                                                    .............................................................................................  xi      Conclusions                                                                                                             ......................................................................................................  xv  
1. Purpose and Methodology .............................................................................................................1

  A. Purpose of the Study                                                                                            ......................................................................................  1     B. Methodology and Data Sources                                                                            .....................................................................  2     C. A National Problem                                                                                              ........................................................................................  3     D. The Impact of a Nursing Shortage                                                                       ................................................................  10     E. Recent National and State Initiatives                                                                   ............................................................  13     F. Initiatives in Maryland                                                                                         ..................................................................................  15  
2. Supply and Demand Analysis of the ...........................................................................................19 Nursing Market in Maryland ..........................................................................................................19

  A. Demand Analysis                                                                                                 ..........................................................................................  19     B. Supply Analysis                                                                                                   ............................................................................................  23     C. Projections                                                                                                           ....................................................................................................  25     D. Conclusions                                                                                                         ..................................................................................................  26  
3. The Maryland Nurse Workforce...................................................................................................29 29

  A. Demographics                                                                                                      ...............................................................................................  29     B. Employment Settings of Nurses                                                                          ...................................................................  36     C. Salaries                                                                                                                 ..........................................................................................................  41     D. Vacancy and Turnover Rates                                                                               ........................................................................  43  
4. Workplace Issues..........................................................................................................................46

  A. Sources of Satisfaction                                                                                        ................................................................................  47     B. Sources of Dissatisfaction                                                                                   ............................................................................  49     C. Recent Changes in the Workplace                                                                       ................................................................  67  
5. Nursing Education in Maryland ..................................................................................................68

  A. Types of Nursing Education Programs                                                                .........................................................  68     B. Trends in Enrollments and Graduations                                                              .......................................................  72     C. Trends in Nursing Education                                                                               .......................................................................  75  
6. Conclusions and Recommendations.............................................................................................82

  A. Conclusions                                                                                                         ..................................................................................................  82     B. Recommendations                                                                                               ........................................................................................  85     C. Need for Further Research                                                                                   ............................................................................  92  
References 94

Appendix A 100 Center for Health Workforce Development..................................................................................100 Advisory Committee.....................................................................................................................100 Appendix B 102 Detailed Projection Methodology and Calculations......................................................................102

   Demand­Side Methodology                                                                                  ...........................................................................  102      Supply­Side Methodology                                                                                     ..............................................................................  105  
109 109 Appendix C 112 Maryland’s Hospital All-Payer System and the Nursing Shortage...............................................112

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EXECUTIVE SUMMARY
Maryland, like many other states, is facing a nursing workforce crisis that is quantitatively and qualitatively different from past shortages. The current shortage in Maryland is estimated at 3,000 nurses—more than 2,000 in hospitals alone. This report presents the findings of a research study, the Nursing Workforce Project, conducted by the University of Maryland Center for Health Workforce Development, which investigated the current and projected nursing shortage in Maryland. The Project was funded by a grant from the Aaron Straus and Lillie Straus Foundation, Inc., with additional support from CareFirst BlueCross BlueShield, MedStar Health, the Governor’s Workforce Investment Board, the Maryland Board of Nursing, and the University of Maryland School of Nursing. In the face of a rapidly changing health care delivery system and the pressures of a gathering workforce crisis, the Nursing Workforce Project focuses on the demand, supply, distribution, and utilization of the nursing workforce. The purpose of this study was to characterize the nursing workforce in Maryland, to document the nature and extent of the current shortage by identifying its quantitative and qualitative indicators, to project the supply and demand for nurses in Maryland through 2012, to investigate the nursing practice and education issues that have contributed to the shortage, and to make recommendations to mitigate the projected future shortages of nurses and to help inform and shape state and national policy as it relates to the development of the nursing workforce. This research is intended to link directly to such potential public policy shifts as:  Initiation of coordinated statewide long-term planning for nursing workforce recruitment, education, retention, distribution, and utilization; Development of innovative approaches to promoting nursing and increasing the capacity of nursing education programs; Stimulation of public-private partnerships to develop strategies aimed at resolving workforce and workplace issues.

CHARACTERISTICS OF THE NURSING SHORTAGE IN MARYLAND
• Maryland has a current shortage of more than 3,000 registered nurses. Over 2,000 RNs are needed in hospitals alone according to the Association of Maryland Hospitals and Health Systems. Although the proportion of full-time nurses working in hospitals has continued to decline, from 56% in 1997 to 53% in 2001, the actual number of RNs working in vii

hospitals in Maryland increased by 3.4% because of an increase in admissions, the greater acuity level of patients, and increasingly complex technology. In the past two years, the utilization of agency (temporary) nurses in hospitals has increased sharply. In 2001, hospitals utilized 1,386 FTE agency nurses. This number rose by 37% to 1,898 FTE in 2002. • The vacancy rate for RNs in Maryland hospitals was 15.6% in 2001, higher than the national average of 13%. The rate for licensed practical nurses (LPNs) in Maryland hospitals was 12.9%. Turnover rates for RNs also have increased in Maryland hospitals, rising from 8.3% in 1996 to 14.5% in 2001. Vacancy rates in nursing homes are even higher. According to the American Health Care Association, the estimated vacancy rate in Maryland is 23.1% for staff RNs (366 positions) and 16.9% for LPNs (431 positions). Turnover rates are 57.4% for staff RNs and 55.9% for LPNs.

SUPPLY AND DEMAND PROJECTIONS
The current shortage of registered nurses in Maryland is projected to worsen significantly over the next decade. The shortage has arisen from a confluence of factors affecting both the supply of nurses and the demand for health care services. • • The demand for registered nurses in the year 2012 is projected to increase to 62,333 nurses. The supply of registered nurses in Maryland is projected to increase by 7%, from an average of 49,010 for 1999-2001 to 52,587 in 2004, and then to decrease by 14%, to 45,217 in 2012. The number of registered nurses in 2012 is expected to be nearly 3,800 fewer than in 1999-2001. The estimates made for the Nursing Workforce Project forecast a shortage of more than 17,000 registered nurses by 2012 if actions to increase the supply of new nurses and improve the retention of currently employed nurses are not effective.

CAUSES OF THE SHORTAGE IN MARYLAND
The nursing shortage in Maryland has several causes: • The primary factor underlying the increased demand for nurses during the period from 2002 to 2012 is the projected increase of 16% (or 100,000 people) in the number of persons aged 65 and older in Maryland. Since older people utilize health care services and facilities more intensively than younger people do, more health care professionals will be needed, particularly nurses. Changes in the

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organization of health care delivery, especially managed care policies and increasingly sophisticated technology, have also had a significant effect on the demand for nurses. Hospital stays are shorter, and patients are older and sicker, requiring much more intensive care and monitoring. Because hospitalized patients are discharged earlier, many need more skilled nursing care in long term care settings and rehabilitation facilities or in home care, which increases the demand for nurses in those settings as well. Procedures that used to be performed in hospitals are increasingly being performed on an outpatient basis, thus requiring more specialized nursing services in ambulatory clinics, surgicenters, and the home. • Nurses are aging along with the general population. The median age of nurses in Maryland in 2001 was 45. Many nurses retire before their mid-60s, often in their 50s, because of the physical demands of nursing work. Twenty-two percent (22%) of nurses in Maryland are 53 years of age or older, and therefore large numbers can be expected to retire in the next ten years. The replacement of these nurses will increase the demand for labor well beyond that resulting from the growth in the number of new positions. Minorities and men are not well represented among Maryland’s RNs. Although minorities constitute 26% of RNs in Maryland, recruitment does not draw proportionately from their representation in the general Maryland population, which is 36%. Men account for only 5% of RNs in Maryland. Among LPNs, the percentages of minorities and men are higher: 50% come from minority ethnic/racial backgrounds, and 11% are men. Many nurses are leaving the profession because of dissatisfaction with working conditions. Nurses say that changes in the way nursing is structured, especially in hospitals, make it difficult for them to experience the rewards of caring for patients in the way they had expected. They report that the relentless pace of work leads to stress and burnout. The dominant issue raised by Maryland nurses was their perception that they were often unable to provide quality care because they could not spend enough time with patients. An inadequate number of auxiliary and support staff has exacerbated the problem. Other issues raised by nurses were related to shift work, and the volume of paperwork and documentation that they are required to complete. Many RNs say that they are not respected or viewed as professionals and are not given the autonomy of practice that they expected. Many believe they have little input into decisions that affect their work. Salaries and benefits have been an issue related both to recruitment and retention of nurses and to increasing hospital costs. Although the average nominal wages of RNs in the United States increased by 24% between 1992 and 2000, average real (inflation-adjusted) wages of nurses were flat. While compensation and bonuses for newly hired nurses have increased markedly, salary compression is an issue for nurses who have been employed for longer periods. The nursing shortage is driving up wages, creating an even more competitive labor market and increasing the cost of care. ix

Fewer students are graduating from Maryland colleges and universities with degrees in nursing. The number of graduates with associate degrees in nursing fell by 29.8%, from a high of 982 graduates in 1994 to 689 in 2001. The number of graduates with a baccalaureate degree in nursing declined by 17.9%, from 885 graduates in 1998 to 727 in 2001. After declining steadily since 1993-1994, nursing enrollments at community colleges and universities increased for the first time in 2001. However, the number of new nursing graduates in Maryland can be expected to continue to decrease until the students who are now in the educational pipeline graduate. Nursing education programs in Maryland have limited capacity to expand enrollments. The Maryland Board of Nursing estimates that about 20% of qualified applicants to nursing education programs in 2000-2001 were not admitted. Growing faculty shortages and an inadequate number of clinical placement sites are reported to be contributing factors in limiting the number of students admitted. Nursing is viewed unfavorably by young people making decisions about a career. High school and college students do not consider nursing a viable career option. Women have a wider array of career choices than they had 30 years ago. Many young people have a perception of nursing as drudgery, with women performing difficult tasks and receiving salaries that are not commensurate with the level of job responsibility. The educational requirements for nursing are not well understood, and professional nursing education is often confused with vocational programs. The views of young people have been negatively influenced by television and movie portrayals of nurses. Young men view nursing as “not a manly thing to do.”

IMPACT OF THE NURSING SHORTAGE ON ACCESS, QUALITY, SAFETY, AND COST
A review of national studies confirms that the nursing shortage has significantly impacted access to health care services, the quality and safety of patient care, and the costs of health care delivery, especially in hospitals. • A survey of 693 acute care hospitals conducted for the Association of Nurse Executives found that for hospitals with vacancy rates at or above the national average, 51% reported emergency department overcrowding, 23% had restricted admissions, and 25% had closed beds. Of these hospitals, 60% reported higher costs to deliver care. A study by the Voluntary Hospitals of America found that hospitals with a high staff turnover, of 20% or more, had an increase in costs of 36% compared with hospitals with lower staff turnover. Maryland hospitals paid staff nurses an average of $34 per hour in 2001; agency nurses, however, cost $55 per hour, a differential of about 60%. According to the Association of Maryland Hospitals and Health Systems, Maryland hospitals spent

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more than $144 million on agency nurses in FY 2001 and $107 million in the first half of FY 2002. Of the $144 million in FY 2001, $19.4 million represents the additional cost of substituting agency nurses for staff nurses. • An increasing body of evidence has demonstrated that RN staffing levels have a significant effect on patient outcomes and that the shortage of nurses in American hospitals is putting patients’ lives in danger. A study of Pennsylvania hospitals found that for each additional surgical patient above four patients per nurse, there was a 7% increase in the likelihood of dying within 30 days of admission. In a large-scale study of nurse staffing and patient outcomes in a sample of hospitals in 11 states conducted for the U.S. Health Resources and Services Administration (HRSA), higher RN staffing levels were associated with a 3-12% reduction in the rates of several adverse patient outcomes. Nursing homes also have been severely affected. An Institute of Medicine report (2000) noted that “Current [nurse] staffing levels in some facilities are not sufficient to meet the minimum needs of residents for provision of quality of care, quality of life, and rehabilitation.”

RECOMMENDATIONS
While some progress has been made in addressing the nursing shortage in Maryland from a recruitment and retention perspective, more concerted efforts are required. The following recommendations are derived from the findings of the Nursing Workforce Project. Many of the recommendations are applicable also to other health professions experiencing shortages. 1. Launch an Aggressive Statewide Effort to Build the Educational Pipeline A. Develop more effective strategies to increase student enrollments in existing RN and LPN programs and recruit a more diverse student population: (1) Increase outreach to youth through partnerships with K-16 education, with particular attention to middle school students. (2) Enhance recruitment efforts to reach out to underrepresented minorities and men. (3) Target second degree/second career students by streamlining nursing curricula to offer accelerated entry-level BSN programs of 12-15 months. (4) Reduce financial barriers to nursing education by increasing scholarships and other financial aid.

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(5) Support career ladders in nursing by developing sustainable career pathways for paraprofessionals. (6) Develop a coordinated statewide media and marketing campaign to improve the public image of nursing as a profession and to promote nursing as a career of choice. B. Expand the capacity of nursing education programs to meet the projected statewide demand for nurses: (1) Coordinate statewide planning for increasing student admissions, enrollments, and graduations. (2) Provide additional resources to promote the expansion of existing nursing education programs. (3) Increase the supply of nursing faculty through fast-track preparation, the use of non-nurses in selected subject areas, and more joint appointments between health care and educational institutions. (4) Increase the use of pre-clinical simulation technologies and laboratories to augment capacity and reduce instructional costs. (5) Increase the accessibility and flexibility of educational programs and offerings through distance learning technologies and alternative scheduling and outreach options. (6) Develop curricula that reflect changes in demographics and in the organization of health care delivery. (7) Strengthen strategic alliances with international partners to enhance the education and training of foreign nurse graduates coming to American markets. 2. Reinvent Nursing to Improve the Productivity and Retention of Nurses A. Redesign nursing work with meaningful input from nurses at all levels in the organization: (1) Establish nursing workloads based on the degree of complexity of patient needs and nurse qualifications and competencies. (2) Use new information systems technologies to improve the quality and safety of patient care and to streamline reporting and documentation.

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(3) Develop work processes that incorporate ergonomic principles to provide a safe practice environment for nurses. (4) Develop more realistic and satisfying roles to accommodate older workers such as serving as mentors to new nurses and as in-house consultants. (5) Increase clerical and patient care support staff and improve training to assist nurses with patient care; consider utilizing a corps of volunteers like the Americorps Program as an auxiliary workforce. B. Improve salary and benefit packages: (1) Review salaries to ensure that compensation strategies reflect differences in education, experience, and competencies, and that salary compression is addressed. (2) Ensure that benefit packages including educational and retirement benefits meet nurses’ needs. C. Facilitate the transition of new graduates to the workplace to enhance retention and to better prepare them for the realities of the work world: (1) Encourage partnerships between academic and health care institutions to provide a seamless transition to the workplace. (2) Develop mentoring, internship/externship, and residency programs for new graduates. D. Foster changes in the culture of health care organizations to increase respect, visibility and recognition of nurses: (1) Implement and reward collaborative and multidisciplinary team approaches to accomplishing work. (2) Empower nurses to participate in decisions regarding organizational and clinical matters. (3) Encourage continuing education and professional training and take educational attainments into account as a basis for differentiated practice and compensation. (4) Develop the competencies and effectiveness of front-line managers and strengthen executive-level nursing leadership.

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3. Support Research and Evaluation to Improve Decision-Making, Encourage Innovation, and Inform Public Policy A. Develop a standardized, statewide approach to and structures for collecting educational and workforce data, and analyzing and interpreting trends for planning purposes, decision support, and resource allocation. B. Design, develop, and evaluate demonstration projects of new professional practice and innovative care delivery models. C. Disseminate research and identify best practices and exemplars through consensus conferences and meetings of statewide/regional nursing groups. D. Continue the Nurse Support Program of the HSCRC based on an evaluation of funded program outcomes. E. Establish the University of Maryland Center for Health Workforce Development as a clearinghouse for information on the nursing workforce.

CONCLUSIONS
Although enrollments in nursing education programs have begun to rise since 2001, and health care facilities are developing initiatives to increase retention, the forecasts of a growing nursing shortage made as part of this study indicate that there will be a protracted and even more serious shortage of nurses in Maryland over the next ten to twenty years. While nursing represents the single largest health care occupation, the entire health workforce is critical to the ability to deliver safe and high quality health care in Maryland. Effective health policies intended to expand access, improve quality, and contain costs must be based on accurate, up-to-date information and on analyses of the supply, distribution, training, and utilization of the health workforce. The current and projected shortages in nursing and other sectors of the health workforce could ultimately threaten the viability of the health care industry, with significant economic implications for the state. High vacancy and turnover rates in the health care industry and an educational system that is not currently producing enough professionals and skilled workers to meet employers’ needs also will result in an erosion in the quality and safety of health care services. A shortage of nurses has been shown not only to limit access to health care services, but also to diminish the quality of care and to endanger patients, putting them at risk for increased illness, disability, and even death. Nursing shortages may be seen a symptom of a much larger problem: an overburdened health care delivery system that has undergone a sea change over the past two decades, and a dissatisfied, overstressed workforce. Taken together, these should be viewed as

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warning signs of even greater problems in the future if decisive action is not taken now. Many states have become involved in addressing shortages of nurses and other health professionals not only because of their role in the financing and regulation of health and education, but also in response to general concerns about safety, quality, access, and cost. Although the health care industry and the education sector have attempted to address these shortages, their actions alone cannot reverse this trend. State government also must provide leadership in addressing the shortages. A lack of attention to these issues will mean continued shortfalls in the health workforce. More focused and aggressive approaches will help to close the gap. The assessment of nursing and other health workforce needs and the development of systems to address those needs must not be viewed as a one-time fix but as a long-term undertaking that will require sustained attention. The state and the nation’s changing demographics will continue to put even greater strains on the health care delivery system. While enrollments in some nursing and health professions programs are beginning to increase, perhaps as a result of the recent downturn in the U.S. economy, the underlying problems contributing to the shortages remain unresolved. All stakeholders—nurses, academic institutions, the health care industry, professional associations, government agencies, legislators, philanthropic organizations, and consumers—must attempt to find solutions to these problems by stimulating new partnerships, implementing innovative strategies, and reaching across organizational and institutional lines as well as state and international borders. Nursing and health workforce issues are a complex challenge that will remain on the state’s policy agenda for some time to come.

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1.PURPOSE AND METHODOLOGY
There are three major issues. Nurses aren’t coming in. They’re not staying in. And those who are there aren’t happy. —Georges C. Benjamin, M.D., Maryland Secretary of Health and Mental Hygiene Testimony before the U.S. Senate Committee on Aging, February 13, 2001

A. PURPOSE OF THE STUDY
This report is the result of a research study, The Nursing Workforce Project, conducted by the University of Maryland Center for Health Workforce Development. The Project was funded by a grant from the Aaron Straus and Lillie Straus Foundation, Inc., with additional support from CareFirst BlueCross BlueShield, MedStar Health, the Governor’s Workforce Investment Board, the Maryland Board of Nursing, and the University of Maryland School of Nursing. The Center for Health Workforce Development, which was established in 2002, is dedicated to understanding and analyzing workforce dynamics and trends, and translating this knowledge into policy and programs to develop the health workforce. The core mission of the Center is to assist health care professionals, educators, the health care industry, and public policy makers in anticipating and meeting the challenges of recruiting, educating, managing, and retaining an evolving health workforce, thereby promoting the safety, quality, and accessibility of health care in an era of cost containment. In the face of a rapidly changing health care delivery system and the pressures of a gathering workforce crisis, the Nursing Workforce Project focuses on the demand, supply, education, distribution, and utilization of the nursing workforce. The purpose of the study was to characterize the nursing workforce in Maryland; to document the nature and extent of the current shortage by identifying its quantitative and qualitative indicators; to project the supply and demand for nurses in Maryland through 2012; to investigate the nursing practice and education issues that have contributed to the shortage; and to make recommendations to mitigate projected future shortages and to inform and help shape state and national policy as it relates to the development of the nursing workforce.

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This research is intended to link directly to such potential public policy shifts as: • • • Initiation of coordinated statewide long-term planning for nursing workforce recruitment, education, retention, distribution, and utilization; Development of innovative approaches to promoting nursing and increasing the capacity of nursing education programs; Stimulation of public-private partnerships to develop strategies aimed at resolving workforce and workplace issues.

This chapter presents the methodology employed in the study and an analysis of the nursing shortage from a national perspective and the experience of other states. A supply and demand analysis of the nursing labor market, and workforce projections in Maryland through 2012 are given in Chapter 2. An analysis of Maryland’s nursing workforce is presented in Chapter 3. Workplace issues identified by Maryland nurses are discussed in Chapter 4, and a review of nursing education programs and recruitment issues is found in Chapter 5. Conclusions and recommendations for action are provided in Chapter 6.

B. METHODOLOGY AND DATA SOURCES
A number of quantitative and qualitative research methodologies were utilized in this study. Published national and state studies on the nursing shortage were reviewed to provide a context for understanding the nursing shortage in Maryland. Financial and demographic databases were analyzed, and focus groups were conducted to obtain information on the nature, scope, and causes of the shortage. Nursing and health care administrators were interviewed to help interpret the findings. Recommendations to mitigate the nursing shortage were derived from these analyses. The Advisory Committee for the Center on Health Workforce Development reviewed the progress of the project, and members provided guidance and feedback on the findings and recommendations. A list of the members of the Advisory Committee is given in Appendix A. Various national organizations have published analyses of the nursing shortage and made recommendations for addressing the problem, including the American Hospital Association (AHA Commission on Workforce for Hospitals and Health Systems, 2001), the Joint Commission on Accreditation of Healthcare Organizations (2002), the Institute of Medicine (2001) and numerous nursing organizations such as the American Nurses Association (2002) and the TriCouncil for Nursing (2001). Reports of the nursing shortage in other states prepared by special task forces and commissions provided a context for the analyses presented in this study. Suggested strategies to increase the supply of nursing graduates and to increase retention among employed nurses were reviewed to determine their applicability in Maryland. Demographic and statistical data on nurses in Maryland was obtained from the Maryland Board of Nursing (MBON), the Association of Maryland Hospitals and Health Systems 2

(MHA), and the Maryland Health Services Cost Review Commission (HSCRC). The National Sample Survey of Registered Nurses (NSSRN, 2002) was used for national comparisons. Data on nursing education programs in Maryland was obtained from the Maryland Board of Nursing and the Maryland Higher Education Commission (MHEC). The Center for Health Workforce Development contracted with RESI Research and Consulting, Towson University, to investigate the current and prospective registered nurse labor market in Maryland. Their analysis and projections of supply and demand utilized Maryland-specific data. Rather than applying the methodology designed by the Health Resources and Services Administration (HRSA) for all fifty states, a methodology was developed specifically for this study, generating results that are most closely aligned with specific demographic and economic factors and trends in Maryland. More detailed information about the methodology is given in Chapter 2 and in Appendix B. An important component of the Nursing Workforce Project was the identification of workplace issues of concern to Maryland nurses. Through focus groups conducted for this study by Hollander Cohen & McBride in June 2002, nurses’ views about their jobs and about the nursing profession were elicited. Additional information about workplace issues was derived from the Workplace Survey 2001, a project of the Workplace Issues Subcommittee of the Maryland Commission on the Crisis in Nursing, which surveyed a large sample of nurses in Maryland. In addition, interviews were conducted with nursing executives and other health care leaders in Maryland to validate issues raised in the focus groups and to elicit suggestions about best practices in recruitment and retention. Edward O’Neil, Ph.D., M.P.A., Director, Center for the Health Professions, and Professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco, helped to develop the methodologies employed in this study. Hal Cohen, Ph.D., President, Hal Cohen, Inc. and Executive Director of the Maryland Health Services Cost Review Commission from 1972 to 1987, assisted in obtaining and interpreting financial data and prepared the discussion of the Maryland hospital all-payer system and the nursing shortage given in Appendix C.

C. A NATIONAL PROBLEM
The current shortage of nurses in the United States has been documented in a number of recent reports by national organizations and state commissions and task forces and in a multitude of newspaper articles and television broadcasts. Although there have been cyclical nursing shortages over the past century, the present shortage is generally acknowledged to be quantitatively and qualitatively different from past shortages. It is projected to be a long-term structural shortage that will worsen over the next 20 years unless concerted efforts to recruit, educate, and retain nurses are made by hospitals and other health care organizations, professional nursing associations, educational institutions, and government agencies.

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1. EXTENT OF THE SHORTAGE In 2000, an estimated 2.7 million persons held registered nurse (RN) licenses, and 2.2 million RNs were employed in nursing in the United States. The number of employed nurses has increased by 73% since 1980, but the rate of increase between 1996 and 2000 (an average of 1.3% per year) was the slowest since 1980 (NSSRN, 2000). The current shortage of registered nurses is estimated at more than 125,000 nurses (HRSA, 2002). In 2001, 82% of 1,092 hospitals surveyed by the American Hospital Association (2001) reported difficulty in recruiting registered nurses. The average vacancy rate was 13%, and one in seven hospitals reported more than 20% of RN positions vacant. The RN vacancy rate had increased since 1999 in 60% of those hospitals. Maryland’s vacancy rate is higher than the national average—15.6% in 2001 (MHA, 2002). Vacancy rates in nursing homes are even higher than in hospitals. In 2001, the vacancy rate for staff RNs in U.S. nursing facilities was 18.5%; for licensed practical nurses (LPNs), it was 14.6%. Annualized turnover rates in these facilities were 56.2% for staff RNs and 53.6% for LPNs (American Health Care Association, 2002). The number of states with a shortage of nurses is expected to grow from 30 states in 2000 to 44 states in 2020, at which time there will be about 808,000 fewer nurses than needed (HRSA, 2002). According to projections made by the U.S. Bureau of Labor Statistics (2001), more than one million new and replacement nurses will be needed by 2010. The National Center for Health Workforce Analysis estimates that the shortage of registered nurses will increase slowly until 2010, when it will reach 12%. At that time the shortage is projected to accelerate and reach 20% by 2015. If the trend continues, the shortage will grow to 29%, or 3 out of 10 positions by 2020. The shortfall in 2020 will result from a projected increase in demand of 40% compared with only a 6% growth in the nurse population (HRSA, 2002). To cope with these shortages, hospitals and other health care institutions have increasingly used a variety of strategies to ensure sufficient staffing, including mandatory overtime, on-call, and reassignment (“floating”) of nursing staff. To recruit additional nurses, hospitals are using temporary and traveling nurses, recruiting overseas, and paying signing bonuses as well as offering other hiring incentives. In a survey of acute care hospitals conducted for the American Organization of Nurse Executives, 54% of responding hospitals reported using non-permanent RN staff (agency or traveling nurses) (AONE, 2002). In another survey, 41% of hospitals reported paying signing bonuses to nurses in 2001 (American Hospital Association, 2001). 2. AGING OF THE POPULATION The nursing shortage is projected to intensify over the next decade as baby boomers age and a large percentage of the current workforce retires. The most significant factor in the projected increased demand for nursing services is the aging of the U.S. population as a whole. The “baby boom” generation will begin to turn 65 in 2011, and by 2030 it is

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projected that one in five persons will be age 65 or older, or 20% of the population (Federal Interagency Forum on Aging Related Statistics, 2000). Older people, on average, require considerably more health care services than younger persons, which affects not only hospitals but also other sectors of the health care industry. Hospitalized patients on average are older and sicker, requiring much more intensive care and monitoring. Because they are discharged earlier, many patients need more skilled nursing care in long term care settings and rehabilitation facilities or in home care, which increases the demand for nurses in those settings. Procedures that used to be performed on an in-patient basis are increasingly being performed on an outpatient basis, thus requiring more specialized nursing services in ambulatory clinics, surgicenters, and the home. The characteristics of patients in nursing homes also have changed; patients not only are more acutely ill on average than before, but also frequently present with cognitive impairments and behavioral problems. Nursing homes and extended care facilities are expected to furnish more specialized care for these patients (Salsberg, 2002). 3. STRUCTURAL CHANGES IN HEALTH CARE DELIVERY The causes of the widespread shortage of nurses are complex. The far-reaching changes in health care delivery over the past decade are a significant factor. Hospital restructuring during the 1990s encompassed such major changes as mergers and closing of facilities. In addition, hospital operations were “re-engineered” to increase productivity and cut costs. In a survey of general hospitals in urban areas conducted in 1996, 57% of hospital CEOs reported that their institutions had undergone restructuring. The types of organizational changes were similar across the country: personnel reduction through attrition, crosstraining of personnel to take on tasks outside their usual scope of work, reduced percentages of RNs on patient units, reassignment of support functions to patient units, and redistribution of patients (Aiken et al., 2000). In many cases, these restructuring initiatives affected nursing roles, workload, and authority within the organization (Norrish and Rundell, 2001). As a consequence of these changes, hospital patients now have shorter stays than in the 1980s and are seen at “the most acute, nurse-intensive part of their illness trajectory” (Fagin, 2001). Such patients require more intensive and specialized nursing care (Aiken et al., 2000). The ratio of RNs per bed actually increased 53% between 1983 and 1994 as the number of hospital beds shrank. There were, however, declines in the ratios of LPNs and aides per bed, an indication that hospitals were changing the skill mix of the nursing staff in favor of RNs rather than increasing total staffing (Buerhaus and Staiger, 1996). In fact, the number of nursing positions in hospitals increased by 8% between 1999 and 2001 (American Hospital Association, 2001). 4. FEWER NURSING GRADUATES On the supply side of the equation, the number of new nursing graduates entering the profession has been declining for several years. According to the National Council of

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State Boards of Nursing, the number of first-time, U.S.-educated nursing school graduates who took the NCLEX-RN licensure examination decreased by 28.7% between 1995 and 2001 (cited in AACN, 2002c). The decline in the number of new registered nurses reflects decreasing graduations in nursing programs between 1995 and 2000. In 2000, associate degree graduations totaled 32,023, a decrease of 45% since 1995, when they totaled 58,749. In the same period graduations from hospital-based diploma programs declined from 7,049 to 2,168 (69%) as hospitals closed their schools. Graduations decreased also in entry-level baccalaureate programs, although not quite as steeply, by 27%, from 31,254 to 22,681. The number of students enrolled in baccalaureate programs is reported to have increased by 3.7% in 2001 and by 8% in 2002, but the number of baccalaureate graduates is expected to continue to decline until the larger number of students now in the educational pipeline graduate (AACN, 2002b, 2002d). The principal causes of the decrease in the number of new nurses include students’ perceptions of nursing as an undesirable profession, the availability of alternative careers for women, the lack of success in recruiting sufficient numbers of men and greater numbers from ethnic and racial minority groups, and the growing shortage of nursing faculty, which has limited the capacity of nursing programs to increase enrollments. a. Alternative Careers for Women Through at least the first six decades of the twentieth century, career opportunities were relatively limited for women, and a large proportion of young women entered professions traditionally designated as suitable for women: teaching, social work, librarianship, and nursing. Beginning in the 1960s and 1970s, schools of medicine, law, and business began admitting significantly larger numbers of women. Women began to make gains in scientific and engineering fields as well. The propensity of women born after World War II to choose nursing as a career was studied by Staiger and colleagues. Their results show that the number of RNs in the cohort born in the early 1970s and entering nursing in the 1990s was 30-40% smaller than that of the number in the cohort born in the 1950s who entered nursing in the 1970s. Data on probable career choice from annual surveys of college freshmen indicated a rise in interest in nursing in 1992, but that proved to be temporary, and recent surveys do not show a renewed interest. In the 1999 freshman college survey, 5% of women and less than 0.05% of men identified nursing as being among their top career choices. The authors conclude that “it appears unlikely that women will ever again enter nursing careers at the rate seen in the boom years of the 1970s” (Staiger, Auerbach, and Buerhaus, 2000). A study of children’s attitudes showed similar results. In a series of focus groups with students in grades 2 through 10, children in all grades indicated an almost universal lack of interest in nursing as a career, despite widespread exposure to nursing care (cited in Bednash, 2001).

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b. Limited Numbers of Men and Minorities Entering Nursing Men currently constitute 5.4% of RNs, up from 2.7% in 1980 (NSSRN, 2000). Although increasing rapidly, the number of men in nursing is still small. It has been suggested that if men entered nursing at the same rate that women do now, the problem of RN shortages would be solved (Buerhaus, Staiger, and Auerbach, 2000c). One study found, however, that men with nursing degrees are leaving direct nursing positions for other jobs at a higher rate than women are (Sochalski, 2002). Minorities represent an important potential source of new nurses and, in fact, accounted for the largest percentage increase in the number of RNs between 1996 and 2000. Minority RNs increased by 35% while non-minority nurses increased only 2%. However, in 2000, minorities were still underrepresented in nursing, at 12% of the total RN population (NSSRN, 2000). c. Limitations on Capacity of Nursing Programs In 2000-2001, baccalaureate and graduate nursing programs turned away 5,834 qualified students because of a reported shortage of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. More than one-third of the schools identified faculty shortages as a reason for not accepting all qualified students (AACN, 2001). In Maryland, nursing education programs reported turning away 558 qualified students from registered nursing programs in 1999-2000, and 685 qualified students in 2000-2001. A second factor limiting enrollments is reported to be the shortage of clinical placements for students. The restructuring of hospitals and the shortage of registered nurses has meant that fewer nurses are available to precept students. Current state budget crises will certainly have an impact on whether nursing education programs can be expanded. 5. AGING OF THE RN WORKFORCE The US. workforce is aging. RNs, however, are aging at a rate more than twice that of all other occupations (Staiger, Auerbach, and Buerhaus, 2000). The average age of nurses increased from 40.3 years in 1980 to 45.2 years in 2000. In 1980, 52.9% of nurses were under 40 years of age; in 2000 only 31.7% were under 40 (NSSRN, 2000). Since the largest cohorts of nurses were born in the 1950s and early 1960s, a significant proportion of nurses can be expected to retire in the next decade, just as the baby boomers begin to turn 65 (Buerhaus, Staiger, and Auerbach, 2000a). Nursing faculty as a group are even older than the general population of nurses: 70% of baccalaureate nursing faculty are 50 years of age or older (Berlin and Sechrist, 2002). One of the distinctive characteristics of the nursing profession is the relatively late entry of graduates into the workforce. The average age at which nurses completed an associate degree program increased from 27.1 years of age for those who graduated in 1984 or earlier to 33.2 years for those who graduated in 1995 or later. For baccalaureate graduates, the average age increased from 23.5 to 27.5 years over the same period (NSSRN, 2000).

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Many nurses retire before their mid-60s, often in their 50s, because of the physical demands of nursing work. The result of the relatively late entry of nurses into the workforce and their relatively early retirement is that nurses have shorter careers than many other professionals. 6. WORKPLACE ISSUES Exacerbating the problem of the declining number of new nursing graduates is the fact that experienced nurses are leaving the workforce in significant numbers not only because of retirements but also as a result of dissatisfaction with their work. Working conditions have emerged as an important reason for nurses leaving their jobs or the profession altogether. Nurses report that the relentless pace of work leads to stress and burnout. As a report by the American Hospital Association noted: “Even if enrollment in education programs for health professional and support personnel increases, the hospital workforce shortage will not diminish if new graduates continue to rapidly leave the hospital setting” (AHA Commission on Workforce for Hospitals and Health Systems, 2002). Many nurses appear to be dissatisfied with their work. A study of turnover and vacancy rates in acute care hospitals conducted for the Association of Nurse Executives (2002) reported that 20% of nurses leaving the surveyed hospitals cited “job dissatisfaction” as a reason. A number of recent surveys and focus group sessions with employed nurses have elicited very similar statements about the way nurses view their profession, their working environment, and the nursing shortage. a. Workload and Staffing According to a national study, 89% of RNs believe that there is a nursing shortage in their local area (Hart, 2001). The most frequent and serious concern of nurses, particularly in hospitals, is that staffing shortages have impacted their ability to meet patient needs. About two-thirds of nurses reported inadequate staffing levels to handle the number of patients in a shift or the level of acute care required by most patients, and inadequate time to spend with patients. Other concerns were inadequate time to complete paperwork (60%), the physical demands of the job (55%), and inadequate time for breaks (51%) (Hart, 2001). Over half of the hospitals surveyed in another study reported that nurses believe it is more difficult to provide quality care as a result of the workforce shortage. Both nurses and hospitals report increased patient complaints or decreased patient satisfaction because of the shortages (American Hospital Association, 2001). In North Carolina, about half of the staff nurses employed in hospitals said that short staffing impaired their ability to meet patients’ needs; more than half of all RN and LPN staff nurses in long term care settings said that their ability to deliver care had been compromised. The study found that “staff nurses’ perceptions of the frequency with which short staffing affects their ability to meet their patient’s needs is a consistent predictor of job satisfaction,” even when patient load is taken into account (North Carolina Center for Nursing, 2002). A similar finding emerged from a study of

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Pennsylvania hospitals. Nurses in hospitals with high patient-to-nurse ratios were almost twice as likely to be dissatisfied with their jobs as nurses in hospitals with low ratios (Aiken et al., 2002). Mandatory overtime has been a frequent complaint of nurses. Nurses often feel that they cannot refuse an assignment to work extra hours or “float” to another nursing unit. Nurses in Oregon were especially concerned about their ability to give quality care under these conditions (Northwest Health Foundation, 2001). Staffing problems have been exacerbated in recent years as the numbers of support staff have been reduced. Nurses report being frequently responsible for non-nursing tasks, many clerical and administrative, which reduces the time available for patient care. Other concerns expressed by nurses include risks to health and safety, the burden of paperwork, a perceived lack of a role in decision making, and lack of advancement opportunities. Many of these issues were raised by Maryland nurses, both in the focus groups conducted as part of this study and in the Workplace Survey conducted for the Maryland Commission on the Crisis in Nursing (see Chapter 4). b. Salaries In surveys of nurses and in the Maryland focus groups, a recurring theme was that salaries are not commensurate with the responsibilities of the job and are not differentiated by education or experience. Nursing salaries, until the large increases of the past two years, were a source of complaint. Nurses’ salaries nationally showed large real (inflation-adjusted) increases between 1980 and 1992, but were relatively stagnant between 1992 and 2000 (NSSRN, 2000). In addition, while staff RNs in U.S. hospitals earned an average of $43,476 in 2000, staff RNs in nursing homes/extended care facilities earned an average of $38,237 and those in ambulatory care an average of $36,521 (NSSRN, 2000). Nurses’ salaries, while competitive at the time of hire, frequently reach their maximum level after just a few years. In recent years, there has been no significant differential between salaries of associate degree nurses and baccalaureate nurses. In interviews, nurses say that there is no financial reward for additional education, experience, or responsibilities. Differentials occur primarily for nurses who have a master’s degree, with advanced practice certifications, such as nurse practitioners, nurse anesthetists, and clinical nurse specialists. Nurses express resentment about signing bonuses given to new hires and the higher rate of pay for agency or traveling nurses (Northwest Health Foundation, 2001).

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c. Satisfaction with Nursing as a Career The majority of nurses in surveys say that they are satisfied with their choice of nursing as a career; however, they express reservations about their current job. In one national study, 63% of nurses said that the overall situation facing nurses where they work has been getting worse. Forty-nine percent (49%) said that if they were younger and just starting out they would pursue a different career (Hart, 2001). In addition, nurses who are dissatisfied, frequently advise their children and friends not to pursue nursing as a career. In a North Carolina survey, while only about half of the RNs and LPNs were satisfied with their work environments, two-thirds were satisfied with their choice of nursing as a career. However, only about one-half of those satisfied with nursing as a career said they would encourage others to become a nurse (North Carolina Center for Nursing, 2002).

D. THE IMPACT OF A NURSING SHORTAGE
Recent national reports have attempted to quantify the nursing shortage and explain the serious threat this problem poses to health care delivery and the negative effects on patient outcomes. Information about the impact of the nursing shortage comes from several recent surveys and research studies, which confirm nurses’ reports that the quality of patient care and hospital operations overall have suffered as a result of the shortage. A survey conducted for the American Hospital Association (2001) found that 38% of hospitals reported emergency department overcrowding, and 25% had diverted emergency patients. Twenty-three percent (23%) reported a reduced number of staffed beds. Nineteen percent (19%) reported increased waiting times for surgery, and 10% had canceled surgeries. The survey of acute care hospitals conducted for the Association of Nurse Executives (2002) reported that for those hospitals with a nursing vacancy rate at or above the national rate, 51% reported emergency department overcrowding, 23% had restricted admissions, and 25% had closed beds. Of these hospitals, 54% reported using agency or traveling nurses, and 60% reported higher costs to deliver care. Other health care sectors have been affected as well. For example, home health agencies in Connecticut reported that, because of short staffing, home health agencies in the state have had to refuse new admissions. In New York State, 93% of home health agencies could not find enough staff to fill vacancies (Home care nursing shortage must be reversed, 2001). 1. IMPACT ON PATIENT CARE An increasing body of evidence has demonstrated the effect of RN staffing on patient outcomes. The Joint Commission on Accreditation of Healthcare Organizations (2002) found that “[nurse] staffing levels have been a factor in 24% of the 1609 sentinel events —unanticipated events that result in death, injury or permanent loss of function—that have been reported…as of March 2002. Other identified contributing factors such as patient assessment, caregiver orientation and training, communication and staff competency implicate nursing problems as well.” In the most recent of a series of articles on the effects of RN staffing, Aiken and colleagues have shown that in hospitals with

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patient-nurse ratios higher than 4 to 1, for each additional surgical patient per nurse, there was a 7% increase in the likelihood of dying within 30 days of admissions and a 7% increase in the likelihood of failure-to-rescue (Aiken et al., 2002). A study conducted by the American Nurses Association (1997) showed that higher nurse staffing per acuity-adjusted day was strongly related to shorter hospital stays and that indicators for preventable conditions (pressure ulcers, pneumonia, postoperative infections, and urinary tract infections) were inversely related to the RN share of nursing staffing and, to a lesser extent, to total nurse staffing per acuity-adjusted day. In a largescale study of nurse staffing and patient outcomes in a sample of hospitals in 11 states, “strong and consistent relationships” were found between nurse staffing and five outcomes in medical patients: urinary tract infections, pneumonia, length of stay, upper gastrointestinal bleeding, and shock. Higher RN staffing was associated with a 3-12% reduction in the rates of these patient outcomes. The association between staffing and patient outcomes was stronger for RN staffing than for a total staffing mix that included LPNs and aides as well as RNs (Needleman et al., 2001). The Voluntary Hospitals of America (2002) found that in hospitals with turnover rates higher than 22%, the severityadjusted average length of stay was 1.2 days higher than in hospitals with the lowest turnover rates. Staffing in nursing homes also has come under increased scrutiny. The Institute of Medicine (IOM) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (Wunderlich et al., 1996) concluded that “the preponderance of evidence, from a number of studies using different types of quality measures, shows a positive relationship between nursing staff levels and quality of nursing home care, which in turn indicates a strong need to increase the overall level of nursing staff in nursing homes.” The IOM Committee recommended that the federal government require a 24-hour presence of RNs in nursing facilities to replace the current 8-hour standard. An IOM report published in 2000 noted that “current staffing levels in some facilities are not sufficient to meet the minimum needs of residents for provision of quality of care, quality of life, and rehabilitation. Research provides abundant evidence of quality-of-care problems in some nursing homes, and such problems are related in part to inadequate staffing levels.” The report reaffirmed the recommendation of a 24-hour RN presence (Institute of Medicine, 2000). A more recent study on minimum nurse staffing ratios in nursing homes, conducted for the Centers for Medicare and Medicaid Services (2002), found that the benefits of increased nurse aide staffing obtained up to 2.4 hours per resident day for hospital transfer short-stay quality measures and 2.8 hours for long-stay quality measures; for licensed nurses, those thresholds occurred at 1.15 hours for the hospital transfer shortstay quality measures and 1.3 hours for long-stay quality measures. The report concluded that “implementation of these thresholds as minimum requirements would find 52 percent of all nursing homes failing to meet all of these standards and 97 percent failing to meet one or more.”

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2. IMPACT ON HEALTH CARE COSTS Most of the information about the impact of the nursing shortage on health care costs is derived from hospital surveys. Across the country, hospitals report that the nursing shortage has significantly increased the cost of operations. Hospitals have attempted to cover their staffing needs in a number of ways. Many facilities are now paying signing bonuses often ranging from $1,000 to $5,000. In 2001, 41% of hospitals reported this practice, up from 19% in 1999. In addition, over half of U.S. hospitals reported using agency or traveling nurses, who generally receive more than 20% above the payments made to staff nurses (American Hospital Association, 2001). The Association of Maryland Hospitals & Health Systems (2003) reported that Maryland hospitals spent more than $144 million on agency nurses in FY 2001, and $107 million in the first half of FY 2002. Of the $144 million in FY 2001, $19.4 million represents the additional cost of substituting agency nurses for staff nurses. In Pennsylvania, hospitals reported spending more than $65 million in FY 2001 on agency staff, an average of $766,171 for each hospital. Other salary and benefit adjustments for the same hospitals totaled over $38 million, or an average of $618,206 for each hospital (Hospital & Healthsystem Association of Pennsylvania, 2002). Florida hospitals spent a total of $159 million to cover vacant positions in 2001, including overtime, on-call, contract/traveling nurses, and temporary staffing agencies, and an average of $226,000 per hospital for nurse recruitment (Florida Hospital Association, 2002). High turnover and vacancy rates are driving up industry costs. The costs associated with filling each vacancy are estimated differently depending on whether only recruiting costs are included or whether premium pay for overtime and the use of agency nurses during the vacancy as well as training new nurses are accounted for. The Voluntary Hospitals of America (2002) estimated that it costs a nurse’s annual salary to fill a vacant nursing position. Assuming a $46,000 salary for a medical/surgical nurse, a hospital that employs 600 nurses and experiences a 20% vacancy rate could spend an average of $5.5 million per year to fill vacancies. In 2001, 82% of hospitals reported that the effort required to recruit RNs had increased since 1999 and that recruitment costs for salaries, benefits, overtime pay, agency fees, and bonuses had risen significantly (American Hospital Association, 2001). The magnitude of these costs can be seen in hospitals with a staff turnover rate of 20% or more, which had an increase in costs of 36% compared with hospitals with lower staff turnover (Voluntary Hospitals of America, 2002). In California, where inpatient hospital costs are rising faster than the national average, the Blue Cross and Blue Shield Association reported that the nursing shortage, together with the rapid adoption of advanced technology, is the main driver of higher costs. “Each 1percent increase in nursing shortage leads to a 1-percent increase in hospital per-capita expenditures…. California’s severe nursing shortage directly correlates to our hospital cost crisis” (Dr. Joel Hay, University of Southern California, quoted in Blue Cross and Blue Shield Association, 2002).

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E. RECENT NATIONAL AND STATE INITIATIVES
A number of steps have been taken, both at the federal and the state levels, to deal with the nursing shortage. The federal Nurse Reinvestment Act was signed into law in August 2002. It authorizes scholarships and loan repayments for nursing students who agree to a service commitment. The law also authorizes public service announcements to promote nursing as a career, loan cancellations for nursing faculty, grants for geriatric nurse education, and grants to encourage nursing best practices. In February 2003, the Conference Report on the FY 2003 Appropriations Bill provided $113.5 million for nurse training programs, including $20 million for the Loan Repayment and Scholarship Program. Scholarships for nursing students are to be awarded in exchange for service as a nurse for at least two years at a health care facility with a critical shortage of nurses. The loan repayment program is to be directed to high priority urban and rural areas with severe nursing shortages. Funding also was also appropriated to establish the Nurse Faculty Loan Program and Comprehensive Geriatric Education ($3 million each). In order to reduce barriers and facilitate nurse practice across state lines, the National Council of State Boards of Nursing developed the Nurse Licensure Compact. Nineteen states have passed the compact thus far. Maryland was the third state to pass legislation adopting the Nurse Licensure Compact (1999) and the first state to implement the compact. A nurse licensed in Maryland whose primary residence is in Maryland may practice nursing in any other Compact state without obtaining a license to practice in that state. As long as the nurse maintains the primary residence in a Compact state, the nurse is granted the privilege to practice in any other compact state. The Compact eliminates the time it takes for a nurse to be licensed in another state while at the same time ensuring public protection. Nurses can move more quickly into the workplace, and the need for multiple licenses is eliminated. The Compact also reduced the risk of practicing nursing without a license when a nurse crosses state lines via the use of technology. (Nurse Licensure Compact Administrators, 2002). During the past few years, most states have introduced legislation to address various aspects of the nursing shortage in their state. Legislators in many states have introduced bills to provide additional scholarships for nursing students and assistance to nursing education programs. Other measures have been proposed concerning nurse workforce planning, nurse staffing, quality indicators of nursing care, mandatory overtime, and whistleblower protection. The following summary is based largely on reports by the American Nurses Association Government Affairs Division (2002) and the National Conference of State Legislatures (2002). 1. WORKFORCE PLANNING The North Carolina Center for Nursing was the first research center on the nurse workforce established by law (1991). In 2002, legislation on the nursing workforce was enacted in ten states; similar legislation had been passed in eight states in earlier years. Most of these states, including Maryland (in 2000), established a special commission or workforce to examine the nursing shortage and to make recommendations for increasing

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the number of nurses. In Maine, South Dakota, and Oklahoma, nursing workforce centers were created. Earlier legislation in Florida and Texas set up centers for nursing which included as part of their mission the development of a statewide plan for the nursing workforce. 2. ASSISTANCE TO NURSING EDUCATION PROGRAMS In 2002, 29 states introduced legislation dealing with the nursing shortage, and 12 states enacted measures providing incentives for nursing education programs. Eight states passed similar legislation in 2001. Many of these laws created scholarships for nursing students and loan assistance repayment programs for nurses who agree to accept employment in a defined type of health care facility for a specified period of time. Some laws provided funds to schools of nursing to expand enrollments; others have provided support for graduate programs to increase the number of advanced practice nurses and nursing faculty. 3. NURSE STAFFING PLANS AND RATIOS The imposition of nurse staffing ratios is perhaps the most controversial approach to dealing with quality of care issues that have become more urgent as a result of the nursing shortage. In 1999, California became the first state to mandate specific nursepatient ratios for in-patient units in acute care hospitals. The ratios, which are to be phased in beginning July 2003, range from a minimum of one licensed nurse per patient in operating rooms to one nurse per eight infants in newborn nurseries. The ratios for medical-surgical (the largest proportion of beds) and rehabilitation units are one nurse per six patients initially, and then one nurse per five patients after 12-18 months. The majority of hospitals in California already comply with some or all of the proposed ratios, and the costs to implement them would average about $217,000 per hospital per year, or 1.7% of current nursing wages (Coffman, Seago, and Spetz, 2002). Unionized nurses and some other nurses support mandated ratios; hospital administrators, including many nurse administrators, and some professional nursing associations have expressed opposition. Critics of ratios suggest two dangers: first, that minimum ratios might be interpreted as maximum required staffing, and, second, that hospitals, by diverting resources to personnel, might reduce investment in medical technology and facilities, which may have a greater potential to improve patient safety and ease demands on nurses. It has been further conjectured that hospitals might also further reduce the level of support staff, particularly in those areas where nurses could pick up the tasks (Coffman, Seago, and Spetz, 2002). Another approach to ensuring adequate nurse staffing levels, proposed by the American Nurses Association, would require individual hospitals to develop and implement staffing plans based on the complexity of patients’ needs including the severity of illness, the experience of the nursing staff, and the available technology and support staff. Legislation enacted prior to 2002 in Oregon, Kentucky, and Virginia, and regulations adopted in Nevada, required hospitals to develop a staffing methodology. In 2002, although 17 states introduced legislation on nurse staffing, only Florida enacted

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legislation in this area. In Florida, minimum staffing standards for a subacute pediatric center were established as a pilot program. In a report on Patient Safety in Maryland, the Maryland Health Care Commission reviewed the literature on nursing staff ratios and declined to endorse mandatory ratios for hospitals. Instead, it recommended that outcomes in states that do mandate ratios be monitored and that “consideration should also be given to the appropriateness of ratios given the level of patient’s acuity and whether the ratios apply to actual bedside time” (Maryland Health Care Commission, 2002). 4. NURSING QUALITY INDICATORS Legislation introduced in several states to publicly disclose nurse staffing levels and patient outcomes failed everywhere except in Connecticut. In Connecticut, the Department of Health is required to collect data on the clinical performance of health care facilities. Texas, through regulations, requires hospitals to develop nurse staffing systems and nursing quality indicators to measure patient outcomes. 5. MANDATORY OVERTIME As discussed earlier, mandatory overtime is one of the most common complaints that nurses have about their jobs. The practice appears to have become more frequent as a result of staffing shortages. Twenty-one states introduced legislation in 2002 related to mandatory overtime, and laws prohibiting or regulating the practice were enacted in five states including Maryland. The other four were Minnesota, New Jersey, Texas, and Washington. Three states—California, Maine, and Oregon—had passed similar laws in prior years. 6. WHISTLEBLOWER PROTECTION Whistleblower laws protect nurses against retaliatory action by employers when nurses report problems related to the quality of patient care. Maryland enacted such legislation in 2002, as did New York and Florida (related only to Medicaid fraud). These states joined Oregon and West Virginia, which had passed such legislation earlier.

F. INITIATIVES IN MARYLAND
1. MARYLAND COMMISSION ON THE CRISIS IN NURSING The Maryland Commission on the Crisis in Nursing was established by legislation passed in 2000 (Senate Bill 311 and House Bill 363). The Commission, whose term is five years, is chaired by the Secretary of Health and Mental Hygiene. The 53 members are broadly representative of nursing and other groups including nursing education, the health care industry, legislators, and the public. The charge to the Commission was to convene a Crisis in Nursing Summit to identify issues involved in the nursing shortages in the state,

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to study a number of issues regarding the extent and implications of the nursing shortage and to make “recommendations on, and facilitate implementation of strategies to reverse the growing shortage of qualified nursing personnel in the state.” Subcommittees were specified for nursing education, recruitment of nurses, and retention of nursing personnel. The Commission in 2002 received an additional charge to identify “a technology driven point of care application…[to] maximize nursing productivity and increase the quality of patient care; and improve the work environment infrastructure in health care facilities.” The Commission sponsored a Workplace Survey of Maryland nurses in 2001, which provides useful information about nurses’ perceptions of their jobs. The Commission also supported bills introduced into the 2001 session to increase scholarship support for nursing students and supported other bills in 2002 which prohibited mandatory overtime for nurses and provided whistleblower protection (Maryland Commission on Nursing, 2002; Guterl, 2002) 2. FINANCIAL AID The General Assembly in the 2001 session passed three bills related to scholarships under the Economic Development Student Assistance Grants program. The first raised the maximum tuition and fees awards to $3,000 per year and the maximum total award to $12,000 (House Bill 547). Students whose program includes a mandatory summer session are eligible for up to $4,500 per year. The second bill (Senate Bill 618) raised the amount that recipients of a nursing scholarship under the Economic Development Student Assistance Grant could receive in the form of an additional grant for living costs, based on financial need, to $3,000 per year. The additional grant entails a service obligation, after graduation, of employment in a nursing shortage area in an eligible organization. The third bill allowed recipients of Economic Development Students Assistance Grants nursing scholarships to receive scholarships under the Legislative Scholarship Program and the Distinguished Scholar Program (Senate Bill 96). A fourth bill (House Bill 753), to make nursing students who do not meet the criteria for the Hope Scholarships eligible for those scholarships in return for a service obligation of working as a nurse in Maryland was defeated in committee. 3. NURSE SUPPORT PROGRAM In 2001, the Health Services Cost Review Commission (HSCRC), with payer support, reestablished the Nurse Support Program (NSP) dedicated to nurse workforce recruitment and retention activities that support cost containment and contribute to access to patient care. The financing comes from 0.1% of hospital revenues, which totals about $7 million per year. Those dollars have been added to hospital rates based upon successful proposals to recruit and retain nurses. In August 2002, hospitals filed their first annual project reports. Evaluation data on the effectiveness of the funded programs has not yet been disseminated. For a more detailed discussion of HSCRC funding, see Appendix C.

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4. MANDATORY OVERTIME On May 6, 2002, Governor Glendening signed into law Senate Bill 537 prohibiting mandatory overtime for nurses except in special circumstances. The law specifies that an employer may not require RNs or LPNs to work more than their regularly scheduled hours according to a predetermined work schedule except, for example, in an emergency situation that could not be reasonably anticipated or if a nurse has critical skills and expertise that are required for the work. 5. WHISTLEBLOWER PROTECTION In the 2002 legislative session, the General Assembly passed House Bill 329, which provides protection against retaliatory actions to health care workers who disclose an activity, policy, or practice of an employer that violates law or regulation and poses an substantial and specific danger to public health or safety. 6. OTHER INITIATIVES A number of other initiatives related to the recruitment and retention of nurses have been established or are being planned by health care institutions, nursing education programs, local governments in Maryland, and the Association of Maryland Hospitals and Health Systems. A compilation of these initiatives would be very useful, but was beyond the scope of this study. A consensus conference, “Seeking Solutions to the Nursing Shortage,” sponsored by the Center for Health Workforce Development, has been scheduled for June 6, 2003 to identify exemplars of best practices in recruitment and retention. The remainder of this report deals with the characteristics of the nursing shortage in Maryland. While the situation in Maryland is similar to that of other states, there are some important differences. These will be highlighted in the chapters on the nurse labor market, the Maryland nurse workforce, workplace issues, and nursing education and recruitment issues.

17

18

2.SUPPLY AND DEMAND ANALYSIS OF THE NURSING MARKET IN MARYLAND
The analysis of the nursing market can be separated into two constituent parts. The first part is an analysis of the future demand for registered nurses (RNs) based on Maryland’s evolving demographics. The second part is a projection of the registered nursing supply based on numerous factors, including the current demographic profile of the state’s nurses and licensing data. Taken together, these two analyses are used to determine whether and to what extent RN shortages will prevail in Maryland through 2012. There are already reported labor/skills shortages in numerous health-related occupations in Maryland and throughout the United States, including registered nurses. These current shortages would be troubling enough given the centrality of health to human well being, but both demographic factors and recent educational statistics make the issue all the more critical. The former suggests that demand for health care services, including those provided by RNs, will be on the rise. The latter hints that the supply of RNs may be insufficient to deal with prospective demand. The Center for Health Workforce Development contracted with RESI Research and Consulting to investigate the current and prospective status of the registered nurse (RN) labor market in Maryland. The scope of the study was to analyze the current and future demand for RNs in Maryland as well as studying supply factors. Although supply and demand projections for Maryland have been included in national studies of the nursing shortage (HRSA, 2002), the present study differs in its utilization of Maryland-specific data including the prevailing Maryland RN vacancy rate and detailed demographic data from the Maryland Board of Nursing. Moreover, rather than applying a methodology developed for all fifty states, a methodology was developed specifically for this study, generating results that are most closely aligned with idiosyncratic Maryland demographic and economic factors.

A. DEMAND ANALYSIS
1. DEMOGRAPHICS Numerous factors are driving the demand for registered nurses (RNs) both nationally and in Maryland. Not surprisingly, the most salient factors relate to demographics, namely the size of the general population and the age composition. According to the 2000 Census, persons 65 years or older numbered 35 million in 2000 nationally, reflecting a 12% increase since 1990. The number of individuals currently aged 45-64 who will attain the age of 65 or older over the next two decades increased by

19

34% over the past decade, setting the stage for a sharp increase in demand for health care services (U.S. Administration on Aging, 2001). This trend has been emerging for decades. Since 1900, the percentage of Americans 65 or older has more than tripled (from 4.1% in 1900 to 12.4% in 2000), and the number has increased elevenfold (from 3.1 million to 35.0 million). In addition, the older population itself is getting older. In 2000, the 65-74 age group (18.4 million) was eight times larger than in 1900, the 75-84 group (12.4 million) was 16 times larger, and the 85 and older group (4.2 million) was 34 times larger (U.S. Administration on Aging, 2001a). According to national estimates, the “baby boom” generation will begin to turn 65 in 2011, and by 2030 it is projected that one in five persons will be age 65 or older. By 2030, there will be about 70 million older persons, more than twice their number in 2000. People 65 and older represented 12.4% of the population in the year 2000 but are expected to grow to be 20% of the population by 2030 (Federal Interagency Forum on Aging Related Statistics, 2000). In Maryland, projections show that the population aged 65 and older will grow 16% between 2002 and 2012, resulting in over 100,000 additional people in this demographic group (U.S. Administration on Aging, 1998). Obviously, the growth in the number of elderly persons is a reflection of positive developments, including advances in science and medicine and a growing emphasis on healthy lifestyles. The impact of these positive developments shows up more evidently in life expectancy calculations. In 2000, persons reaching age 65 had an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males), and a child born in 2000 could expect to live 76.9 years, about 29 years longer than a child born in 1900 (U.S. Administration on Aging, 2001a). This in turn leads to a higher percentage of the total population aged 65 and older, which translates into higher demand for RNs. 2. INTENSITY OF UTILIZATION The focus on aging is required in this analysis because of the intense utilization of medical facilities and personnel that the older population requires. For example, most elderly persons have at least one chronic condition and many have multiple conditions. The most frequently occurring conditions per 100 elderly in 1996 were arthritis (49), hypertension (36), hearing impairments (30), heart disease (27), cataracts (17), orthopedic impairments (18), sinusitis (12), and diabetes (10). Moreover, the elderly had about four times the number of days of hospitalization (1.6 days) as did the under-65 age population (0.4 days) in 1999. The average length of a hospital stay was 6.0 days for older people, compared with 4.1 days for people under 65. Finally, older persons averaged more medical contacts with doctors in 1999 than did persons of all ages (6.8 contacts vs. 3.5 contacts) (U.S. Administration on Aging, 2001b).

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3. DEMAND-SIDE METHODOLOGY To determine the demand for RNs in Maryland, a variety of data were used, including the size of the current and prospective population, changing composition by age, and RN vacancies currently prevailing in Maryland. On the basis of data from the Maryland Board of Nursing and U.S. Census population data for Maryland, the per capita number of active RNs was calculated for both the overall population and the population aged 65 and over. The average number of RN vacancies was then calculated for the period 1999 through 2001. To eliminate the double counting of agency nurses included in the staffing vacancies, the average number of agency nurses employed from 2001 to 2002 was subtracted (Association of Maryland Hospitals and Health Systems, 2002).
Historic and Projected Demand for RNs in Maryland, 1999-2012

Year 1999-2001* 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Projected Demand 53,985 54,784 55,227 55,669 56,111 57,000 57,889 58,777 59,666 60,555 61,444 62,333

*Historic data: three-year average

The RN per capita ratio was applied to the projected population for the state to determine the estimated demand for RNs over the period 2002 through 2012. The RN demand was then estimated based on the total projected population as well as the projected population of the 65 and over cohort. An equation was then constructed to link the two discrete impacts of population size and age together. To create a starting point for 2002 (the first-year forecast), current demand was adjusted by the average number of RN job vacancies (based on RN vacancies at Maryland hospitals) and the utilization of agency nurses for the period 1999 through 2001. One of the central issues of the methodology utilized here is whether this vacancy rate is applicable to the entire RN profession in Maryland, since the vacancy rate figure characterizes the situation only in hospitals and not among other types of health providers. In Maryland, 53% of all RNs work in a hospital setting; the corresponding national figure is 59% (NSSRN, 2000).

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In summary, the increase in nursing demand reflected in the projections is driven by two factors: the increase in Maryland’s population and the changing age demographics of that population. 4. FACTORS THAT COULD DIMINISH RN DEMAND A number of emerging factors could serve to diminish demand for RN services. For instance, the ongoing soft economy, the lack of job creation, and higher health insurance premiums resulted in an additional 1.4 million people losing their health insurance coverage nationwide in 2001 according to Census Bureau figures. The total number of uninsured in 2001 reached 41.2 million, or 14.6% of the population. Despite the increase in uninsured people last year, 2001 figures are still down from the record 44.3 million that were uninsured in 1998. Surprisingly, families with incomes above $75,000 made up nearly 58% of the increase in the uninsured, even though they make up only 30% of the population. Experts explain that this income group is most likely to have coverage and, therefore, during times of job cutbacks or recession, the group most likely to lose it. Indeed, the number of people covered by insurance through their employers declined 1% last year, although that was partially offset by an increase of 0.6% among those covered by government health programs. Although the health sector is less sensitive to economic downturns than other sectors, an increase in the number of uninsured people could lower the demand for health care workers generally. The National Academy of Sciences reported that people without insurance are less likely to seek health care when needed (National Academy of Sciences, 2001).1 Although most health care providers in the United States provide some level of uncompensated care for the uninsured, available resources are currently being strained by rising health care costs. In addition, rising unemployment might lead some employers to reduce their health insurance costs by restricting benefits, requiring employees to cover a greater share of costs, or eliminating health insurance benefits altogether. These factors present uncertainty regarding the future demand for RNs. It should be noted, however, that the proportion of insured Americans will begin to rise, all things being equal, as a greater share of Americans begin to qualify for Medicare. Another factor not included in the demand side of the model is the prospect for the greater utilization of LPNs (licensed practical nurses). To the extent that LPNs could be used in greater numbers, aggregate demand for RNs in Maryland would be suppressed. There are a number of arguments suggesting that this consideration is not particularly forceful. First, there are identifiable differences in RN and LPN tasks. LPNs provide health care under the supervision of other licensed health professionals (primarily RNs)

1

Federal and state policymakers recognized the potential loss of health insurance coverage caused by the economic slowdown in the context of the economic stimulus bill.

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in structured settings.2 In the typical high stakes health setting, substitution potential may be limited. The fact that LPNs require only a one-year state-approved practical nursing program and successful completion of the NCLEX-PN examination, while RNs require an associate degree plus passage of the NCLEX-RN examination suggests further limitations in the scope of services that LPNs can provide. Second, the LPN population has not grown significantly, because of retirements and the large number who return to school to obtain an RN. In fact, there is already a shortage of LPNs in Maryland. According to the Association of Maryland Hospitals & Health Systems Hospital Personnel Survey 2001, the LPN vacancy rate in Maryland hospitals climbed to 12.9% in 2001. 5. FACTORS THAT WOULD TEND TO INFLATE RN DEMAND There are factors that could lead to an increase in RN demand. The uninsured often end up in emergency rooms. U.S. hospitals reported that in 2000 alone, they absorbed almost $22 billion in the costs of treating patients without coverage (Commonwealth Fund, 2001). Furthermore, hospital emergency departments or outpatient departments serve as the regular source of care for one out of every six uninsured patients (National Academy of Sciences, 2001). Costs for outpatient hospital services in Maryland increased by 18% in 2001 (Maryland Health Care Commission, 2003). Another issue is the fact that the minority population in Maryland is increasing by 1.67% annually (Maryland State Data Center, 2002), which also affects outpatient hospital services. According to the U.S. Agency for Health Care Policy and Research (2000), African Americans and Hispanic Americans are far more likely to rely on hospitals or clinics for their usual source of care than are white Americans (16% and 13%, respectively, vs. 8%). This will trigger the need for more RNs in hospitals, which will exert upward pressure on the existing RN vacancy rate among Maryland hospitals.

B. SUPPLY ANALYSIS
1. DWINDLING SUPPLY The dwindling supply of RNs both nationally and in Maryland has been well documented. There has been a decline in the number of new nursing graduates. In Maryland, licenses issued to new nursing graduates in the state of Maryland dropped by more than 300 in 2001, which represents more than 10% of new RNs entering the field (data supplied by the Maryland Board of Nursing). This decline reflects the national situation (see Chapter 1). During the period 1995-2000, there was a 41% decline in the number of nursing graduates in the United States. BSN graduates declined by 27%, associate degree graduates by 45%, and diploma graduates by 69% (National League for Nursing, 2002). The decrease in associate degree graduates is particularly significant
2

It should be noted that the U.S. hospital RN to LPN ratio is 8 to 1, while the ratio in Maryland hospitals is 20 to 1.

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since they account for 60% of new nurses entering the profession (American Association of Community Colleges, 2002). In addition, the supply of RNs is affected by the number of nurses retiring or leaving the profession for other reasons, increasingly because of dissatisfaction with working conditions, and by the capacity of nursing schools to increase enrollments. These subjects will be discussed in the following chapters of this report. 2. SUPPLY-SIDE METHODOLOGY To determine the supply of RNs in Maryland, the number of new RN licensees in Maryland from 1998 to 2001 was identified from Maryland Board of Nursing data. These new licensees include both examination and endorsement licensees, therefore taking into account both new graduates and RNs moving into the state. These figures were then used to determine the average number of new entrants into the RN labor pool. The next step was to identify the trend in new graduates (associate degree, hospital diploma and baccalaureate) to determine the growth rate of new entrants into the RN labor pool (American Association of Colleges of Nursing, 2002d). A negative 10 percent (-10%) annual growth rate (baseline scenario) was calculated from data obtained from the National League for Nursing.3 Using this rate as the baseline growth, a 0% annual growth rate (lower bound) and a −20% annual growth rate (upper bound) were assumed in order to provide reasonable parameters around the baseline rate of growth. In fact, national data suggests that the –20% annual growth rate may itself be a rather conservative/optimistic one. For example, the National Council of State Boards of Nursing reported a 28.7% decrease in RN graduates taking the NCLEX-RN examination from 1995 through 2001 (cited in American Association of Colleges of Nursing, 2002d). It should be noted that the extent to which these parameters become relevant is a function largely of actions that can be taken over the next decade. A lack of attention to these issues will mean continued shortfalls in nursing capacity. More focused and aggressive approaches will help to close the gap. These three growth rates were applied over a ten-year period (2002-2012) to the average number of new licensees to determine the number of new entrants per year. The next step was to identify the percentage breakdown of new entrants by age category from 1998 to 2001 from Maryland Board of Nursing data. This percentage was applied to total new entrants by year, thus yielding the number of new entrants in each age category for each year in the model. Labor force participation rates (LFPRs) by age were determined, and average LFPRs were utilized when age categories did not match precisely. The Maryland Board of Nursing provided the number of active nurses by age category for 1998-2001. The actual

3

Based on unpublished data from the National League for Nursing (2002), RN graduates experienced a 41% decrease in diploma, ADN, and BSN graduates over a 5-year period. This decline translates into a -10% decrease when calculated on an annual basis.

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labor pool available (though not all RNs were active) was calculated by applying the LFPRs to the number of active nurses by age category. Several assumptions were employed in creating the model used to predict RN supply in Maryland. In projecting active RNs by age category for the years 2002-2012, an equal share of RN population across each age category was assumed (i.e., 10% of total number in age category per year). The growth of the RN population was then projected based on the addition of new entrants per year per age category + 10% of previous year’s PREVIOUS age category + 90% of previous year’s SAME age category, and multiplied by the LFPR appropriate to the age category, and so on.

C. PROJECTIONS
As discussed above, the RN supply projections were based on three scenarios: 1. Upper Bound, or Optimistic Scenario: a 0% annual growth rate in new licensees in order to provide a conservative parameter of growth; 2. Middle Bound, or Baseline Scenario: a –10% annual growth rate in new licensees based on RN graduate data; 3. Lower Bound or Pessimistic Scenario: a –20% annual growth rate in new licensees to provide a reasonable worst case parameter of growth. Based on these three scenarios, the RN supply was estimated over the decade 2002-2012. According to the baseline scenario, the supply is projected to increase by a total of 7% until 2004 and then decrease through 2012 by a total of 14%. As of 2000, there were 876 RNs per 100,000 population (the corresponding national figure is 782) (NSSRN, 2000). By 2010, it is estimated there will be 836 RNs per 100,000 population in Maryland, a decline of 4.6% from the 2000 figure. When one considers the fact that the composition of the state population will be shifting, the results become somewhat more stark. As of 2000, there were 7,881 RNs per 100,000 population aged 65 and over. By 2010, this figure is projected to drop to 6,965 RNs per 100,000, a decline of 11.6%.

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Projected Supply of RNs in Maryland Year 1999-2001* 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Upper Bound/ Optimistic 49,010 51,975 53,236 54,459 55,646 56,797 57,915 56,627 55,311 53,971 52,611 51,236 Middle Bound/ Baseline 49,010 51,735 52,345 52,587 52,527 52,220 51,711 50,444 49,158 47,855 46,540 45,217 Lower Bound/ Pessimistic 49,010 51,501 51,605 51,235 50,553 49,663 48,633 47,380 46,110 44,828 43,537 42,242

*Historic data: three-year average

D. CONCLUSIONS
Based on forecasts of supply and demand, it is estimated that a shortage of RNs exceeding 17,000 will occur by 2012. The optimistic scenario shows RN shortages approaching 11,000 by 2012. The pessimistic scenario shows shortages climbing past 20,000 by the end of the forecast horizon. These forecasts are shown in the charts that follow.

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Demand Optimistic Supply Shortage Baseline Supply Shortage

19992001* 53,985 49,010 -4,975 49,010 -4,975

2002 54,784 51,975 -2,809 51,735 -3,049

2003 55,227 53,236 -1,990 52,345 -2,882 51,605 -3,622

2004 55,669 54,459 -1,210 52,587 -3,082 51,235 -4,434

2005 56,111 55,646 -466 52,527 -3,584 50,553 -5,558

2006 57,000 56,797 -203 52,220 -4,780 49,663 -7,337

2007 57,889 57,915 26 51,711 -6,178

2008 58,777 56,627 -2,150

2009 59,666 55,311 -4,355

2010 60,555 53,971 -6,584

2011

2012

61,444 62,333 52,611 51,236 -8,832 -11,097

50,444 49,158 47,855 46,540 45,217 -8,333 -10,508 -12,700 -14,904 -17,116

Pessimistic Supply 49,010 51,501 Shortage -4,975 -3,283 *Historic data: three-year average.

48,633 47,380 46,110 44,828 43,537 42,242 -9,256 -11,397 -13,556 -15,727 -17,907 -20,091

Optimistic Supply
65,000

60,000

Shortage: -11 ,097

55,000 Demand Supply 50,000

45,000

40,000 Demand Supply

2002 54,784 51 ,975

2003 55,227 53,236

2004 55,669 54,459

2005 56,1 1 1 55,646

2006 57,000 56,797

2007 57,889 57,915

2008 58,777 56,627

2009 59,666 55,31 1

2010 60,555 53,971

2011 61 ,444 52,61 1

2012 62,333 51,236

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Baseline Supply
65,000

60,000 Shortage: -17,1 6 1 55,000 Demand Supply 50,000

45,000

40,000 Demand Supply

2002 54,784 51 ,735

2003 55,227 52,345

2004 55,669 52,587

2005 56,1 11 52,527

2006 57,000 52,220

2007 57,889 51,71 1

2008 58,777 50,444

2009 59,666 49,1 58

2010 60,555 47,855

2011 61 ,444 46,540

201 2 62,333 45,21 7

Pessimistic Supply
65,000

60,000

Shortage: 55,000 -20,091 Demand Supply 50,000

45,000

40,000 Demand Supply

2002 54,784 51 ,501

2003 55,227 51 ,605

2004 55,669 51,235

2005 56,1 1 1 50,553

2006 57,000 49,663

2007 57,889 48,633

2008 58,777 47,380

2009 59,666 46,1 0 1

2010 60,555 44,828

2011 61 ,444 43,537

2012 62,333 42,242

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3.THE MARYLAND NURSE WORKFORCE
As the market analysis in Chapter 2 has shown, Maryland currently has a nursing shortage and this shortage is projected to worsen significantly by 2012. In this chapter, current demographic characteristics of Maryland nurses and their distribution by workplace setting are presented. Trends in nurses’ salaries and vacancy rates in health care institutions also are discussed. Data was obtained from the Maryland Board of Nursing (MBON), the Association of Maryland Hospitals and Health Systems (MHA), the American Health Care Association, and the Maryland Health Services Cost Review Commission (HSCRC). Comparisons between Maryland and the United States as a whole were obtained from the 2000 National Sample Survey of Registered Nurses (NSSRN, 2000).

A. DEMOGRAPHICS
1. SUPPLY OF NURSES In 2001, there were 49,566 active licensed registered nurses in Maryland. The number of active registered nurses has fluctuated over the past five years. The total increase since 1997 has been 4%, an average of about 1% per year. The national RN population grew slightly more, an average of 1.3% each year between 1996 and 2000, which was less than average increases in prior years of 2-3% (NSSRN, 2000). Fewer new entrants into the nursing workforce and larger losses as a result of retirement or other reasons accounted for the decline in the rate of growth.

Active Registered Nurses in Maryland, 1997-2001
47,737 47,860 45,525 46,675 49,566

1997 Data source: MBON, 1997-2001

1998

1999 Year

2000

2001

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The number of licensed practical nurses living in Maryland also has fluctuated over the past five years. In 2001, the number of active LPNs was 8,823, 4% more than the 1997 total of 8,468.
Active Licensed Practical Nurses in Maryland 1997-2001
8,468 8,229 8,823 7,895 7,945

1997

1998

1999 Year

2000

2001

Data source: MBON, 1997-2001

Nurses with active licenses are not necessarily employed in nursing. Nationally, more than 18% of licensed RNs are not currently employed in nursing (NSRRN, 2000). Based on the 2000 National Sample Survey of Registered Nurses, Maryland was estimated to have 856 employed RNs per 100,000 people, an increase from 842 in 1996 and 778 in 1992. Using Maryland data, however, a more accurate figure has been calculated for 2000—876 employed RNs per 100,000 Maryland residents. As noted in Chapter 2, this number is projected to fall to 836 by the year 2010. A comparison of RNs per 100,000 residents is shown below for the Mid-Atlantic and neighboring states.
Registered Nurses Employed per 100,000 Population

1,010 843 800 876 936 711 858

New York

New Jersey Pennsylvania

Maryland

Delaw are

Virginia

West Virginia

Data source for Maryland: MBON, 2000

Data source for other states: NSSRN, 2000

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2. AGING TREND OF THE NURSE WORKFORCE Over half (56%) of Maryland’s RNs are 43 years of age or older, with the largest proportion (18%) between the ages of 43 and 47. The median age of RNs in 2001 was 45 (44.7). Only about one in ten RNs holds an active license after the age of 58. The proportion of LPNs per age category is almost identical to that of RNs. LPNs between 43 and 47 years of age constitute the largest proportion (16%), and the median age in 2001 also was 45 (44.8).
Maryland Nurse Distribution by Age, 2001
18% 13% 12% 10% 9% 5% 5% 2% 3% 16% 15% 16% 16% 15% 11% 11% 7% 7% 4% 1% 3%

RN LPN

* 18-22 23-27 28-32 33-37 38-42 43-47 Age 48-52 53-57 58-62 63-67

68+

Data source: MBON, 2001

* Less than 1%

The “graying” of the RN workforce is a trend in Maryland as it is in the rest of the nation. Between 1997 and 2001, the proportion of RNs 48 years of age or older increased from 33% to 38%, while the proportion of RNs less than age 48 decreased from 67% to 62%. Nationally, the average age of nurses increased from 40.3 years in 1980 to 45.2 years in 2000. In 1980, 52.9% of U.S. registered nurses were under 40 years of age; in 2000 that proportion declined to 31.7% (NSSRN, 2000).

Age Distribution of Maryland RNs, 1997-2001
Year 1999 6% 25% 35% 24% 9% 1%

Age 18-27 28-37 38-47 48-57 58-67 68+

1997 6% 25% 36% 23% 9% 1%

1998 4% 23% 36% 26% 10% 1%

2000 8% 24% 35% 24% 8% 1%

2001 6% 22% 34% 27% 10% 1%

Data source: MBON, 1997-2001

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Similar to aging trends among RNs, the proportion of LPNs 48 years of age or older increased from 36% to 40% between 1997 and 2001, while the proportion of LPNs less than age 48 decreased from 64% to 60%. The age distribution of LPNs in Maryland over the period 1997-2001 is given below.

Age Distribution of Maryland LPNs, 1997-2001
Year 1999 7% 24% 31% 24% 11% 2%

Age 18-27 28-37 38-47 48-57 58-67 68+

1997 9% 23% 32% 24% 10% 2%

1998 6% 22% 31% 25% 12% 3%

2000 9% 24% 32% 23% 10% 2%

2001 7% 22% 31% 25% 12% 3%

Data source: MBON, 1997-2001

Fewer younger nurses are entering the field than in prior years. In 1980, a quarter of RNs were less than 30 years old. By 2001, less than 10% of RNs were less than 30 (NSSRN, 2000). The median age of new Maryland RNs in 2001 was 33.6. New RNs are defined as those who have obtained a license within the past year. Consistent with national trends, the median age of new RNs in Maryland has increased as more people have made the decision to become a nurse as a career change or after raising a family.

Age Distribution of New Maryland RNs, 1998-2001
Year 1999 33% 37% 22% 7% 1% 0%

Age 18-27 28-37 38-47 48-57 58-67 68+

1998 27% 41% 24% 7% 1% 0%

2000 37% 35% 20% 7% 1% 0%

2001 30% 36% 22% 10% 2% 0%

Data source: MBON, 1998-2001

The age distribution of nurses by work setting is not available for Maryland. Nationally, however, hospital nurses had the youngest average age at 41.8 years in 2000 (NSSRN, 2000). Nearly three-fourths of all employed nurses under the age of 30 worked in 32

hospitals. Less than half of the nurses who were 50 years of age or older were employed in hospitals. The average age was 45.3 years for nurses in nursing homes/extended care, 44.3 years in ambulatory care, and 46.8 years in school health services (NSSRN, 2000). 3. RACIAL/ETHNIC DIVERSITY Three-quarters of Maryland’s RNs are Caucasian (74%). Just over one-quarter (26%) of the current RN workforce consists of minority nurses, including African American, Asian, Hispanic, and other ethnic groups. The ethnic diversity of the Maryland RN workforce is not representative of the ethnic diversity in Maryland. In 2000, Maryland’s population was composed of Caucasian (64%), African American (28%), Asian (4%), Hispanic (4%) and other (less than 1%) ethnic groups (U.S. Census Bureau, 2000). A higher proportion of the LPN population in Maryland (50%) is composed of minorities (MHA, 2002).
Racial/Ethnic M ix of M aryland, 2000
Other < 1% Hispanic 4% Asian 4% African American 28% Data source: U.S. Census Bureau, 2000 Caucasian 64%

Racial/Ethnic M ix of M aryland RNs, 2001
Other 5% Hispanic 1% Asian 5% African American 15% Data source: MBON, 2001 Caucasian 74%

Between 1997 and 2001, the proportion of Caucasian RNs decreased from 80% to 74%, and the proportion of minority nurses increased from 20% to 26%. Although Maryland’s proportion of minority RNs is still not representative of its total population, the proportion is much higher than it is nationally. In 2000, minority nurses accounted for 12% of the national RN workforce. The number of minority nurses nationally, however, grew at a much faster rate (about 35%) between 1996 and 2000 than did that of nonminority nurses (about 2%) (NSSRN, 2000), thus highlighting the importance of minority populations as a recruitment pool.
Racial/Ethnic Mix of Maryland RNs, 1997-2001
Year 1999 78% 14% 5% 1% 2%

Race Caucasian African American Asian Hispanic Other

1997 80% 13% 4% 1% 2%

1998 79% 13% 4% * 3%

2000 76% 14% 5% 1% 4%

2001 74% 15% 5% 1% 5%

* Less than 1% Data source: MBON, 1997-2001

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4. GENDER Men account for a very small proportion of Gender Mix of Maryland RNs, 2001 Maryland RNs. In 2001, only 5% of RNs were male, and this proportion has remained constant since 1997. The proportion of male RNs in Maryland in Male RNs 5% 2000 was similar to the national proportion (5.4%) (NSSRN, 2000). However, the rate Female of growth in the male nurse population has RNs far exceeded that of the female nurse 95% population. Between 1997 and 2001, the female RN population in Maryland grew only by 3% compared with a 30% growth Data source: MBON, 2001 in the male nurse population. However, even a small percentage change in the number of female nurses translates into a large actual number of nurses. Among LPNs in Maryland, males constitute 11%. A pattern that has become evident recently is that male registered nurses appear to be dropping out of nursing at a higher rate than female RNs. A study based on the National Sample Survey of Registered Nurses found that among registered nurses not currently working in a nursing position, 56% of male RNs were employed in other positions compared with 26% of female RNs. Of even greater concern, among new nursing graduates, 7.5% of men and 4.1% of women were employed in non-nursing positions (Sochalski, 2002). 5. MARITAL STATUS As of 2001, two-thirds of RNs were married. One-fifth (19%) of registered nurses were single and 10% were divorced. Only 5% were separated or widowed. The proportion of married RNs in Maryland was lower than the national proportion of married RNs (72%) in 2000. Only 10% of RNs nationwide were single (NSSRN, 2000).
Marital Status of Maryland RNs, 2001
Widow ed 2% Divorced 10% Married 66%

Separated 3%

Single 19%

Data source: MBON, 2001

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6.

BASIC AND HIGHEST EDUCATION LEVELS

The basic educational level of Maryland RNs represents the nursing degree that nurses had when they entered the nurse BSN, 33% workforce. Nurses increasingly MS/Doctorate, report a baccalaureate degree as 1% their basic education degree. The percentage of nurses with a Unknown, diploma has continued to 9% decrease because of the closing Associate, Other, 1% of diploma programs and the 29% retirement of older nurses, who were more likely to have been Diploma, prepared in hospital-based Data source: MBON, 2001 27% programs. In 2001, 33% of nurses reported that they had a BSN when they entered the nurse workforce, 29% had an associate degree, and 27% had a diploma. Only 1% had a master’s or doctoral degree.
Basic Education of Maryland RNs, 2001

The changes in basic education can be seen on a national scale. Between 1980 and 2000, nurses who reported that their basic education had been obtained in a diploma program decreased from 60% to 30%. At the same time, nurses whose basic education was in an associate degree program increased from 19% to 40%, and those with a basic nursing education at the baccalaureate level increased from 17% to 29%. Between 1996 and 2000, however, the number of RNs graduating from baccalaureate programs grew at a faster rate than those graduating from associate degree programs (NSSRN, 2000). Many nurses obtain additional education after their basic nursing education. As of 2001, 42% of Maryland nurses reported that their highest level of education was a baccalaureate degree in nursing. Thirteen percent (13%) reported a master’s or doctoral degree in nursing or another field. One-fifth each claimed that their highest level of education was a diploma (20%) or an associate degree (18%). Nationally, in 2000, 33% of RNs reported their highest degree as a baccalaureate degree, 10% a master’s or doctoral degree, 19% a diploma, and
Highest Education of Maryland RNs, 2001

MS/Doctorate, 13% Unknow n, 2% Other, 5% Diploma, 20%

BSN, 42%

Associate, 18%

Data source: MBON, 2001

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37% an associate degree (NSSRN, 2000). Maryland’s nurses on average, therefore, have more years of education than the national nurse population.

B. EMPLOYMENT SETTINGS OF NURSES
There are significant regional differences in the concentrations of RNs in Maryland. The regions used for reporting by the Maryland Department of Health and Mental Hygiene are the Western Region, Central Region, Suburban Region, Southern Region, and Eastern Region. Over half (59%) of RNs practice in the Central Region, including 26% who work in Baltimore City. One-quarter of RNs (24%) are employed in the Suburban Region. Far fewer practice in the Eastern (7%), Western (7%), and Southern (3%) Regions.

The large proportion of RNs practicing in Baltimore City is accounted for by the concentration of hospitals with specialty units such as the hospitals of the John Hopkins Medical Institutions and the University of Maryland Medical System. Hospitals continue to be the dominant employer of Primary Employment Settings of RNs RNs in Maryland, with 53% of fulltime employed RNs licensed in Long Term/Extended Maryland working in this sector. Care The second largest employer (13% 9% A mbulatory Care of full-time employed nurses) is 1% 1 community health/school health. Eleven percent (11%) of RNs are Community employed in ambulatory care. Long Health/School Hospital Health term/extended care accounts for 9% 53% 1 3% of RNs. Fewer than 15% of RNs Nursing work in other employment settings Education including nursing education, 4%
Data source: M BON, 2001

Other 8%

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Temporary A gency 2%

temporary agencies, insurance agencies, military, and private duty nursing. More detailed information about the distribution of nurses in these settings is given in the following sections. The distribution of licensed practical nurses in the same employment settings is different from that of RNs. The primary employer for full-time working LPNs is long term/extended care. In 2001, nearly two-fifths of LPNs (38%) worked in these settings. Only one-quarter (24%) worked in hospitals, and 13% were employed in ambulatory care. Ten percent (10%) worked in community health or school health, and 15% worked in nursing education, temporary agencies, or other employment settings. 1. HOSPITALS More than half of Maryland’s full-time nurses work in hospitals, although the proportion has continued to decline from 56% in 1997 to 53% in 2001. The actual number of RNs working in hospitals in Maryland, however, increased by 3.4%. This is consistent with the national trend. Although the proportion of nurses working in hospitals has declined, the number of nurses employed by hospitals has grown as a result of increased admissions, the greater acuity level of patients, and increasingly complex technology. In the same period, the utilization of agency nurses in hospitals increased sharply. Although data was not collected on the number of agency nurses employed in Maryland hospitals between 1998 and 2000, it is believed to have been minimal (personal communication from MHA). In 2001, however, Maryland hospitals utilized 1,386 FTE agency nurses. This number rose to 1,898 FTE in 2002, an increase of 37%.
Primary Employment Settings of LPNs
Other 1 0% Hospital 24%

Temporary Agency 3% Nursing Education 2% Community Health/School Health 1 0%

A mbulatory Care 1 3%
Data source: M BON, 2001

Long Term/Extended Care 38%

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Number of FTE RNs Working in Hospitals, FY 1998-2002

14,191

14,783

14,265

14,397

14,677

1,386 1998 1999 2000 Year Staff RN 2001

1,898

2002

Agency RN data not available before 2001. Data source: MHA, 1998-2002.

Agency RN

The proportion of full-time employed LPNs working in hospitals has declined steadily since 1997. In 2001, one-quarter of full-time LPNs (24%) were employed in hospitals, down from nearly one-third (31%) in 1997. The number of LPN positions increased between 2000 and 2002, but at a lower rate than RN positions (4.3%).
Percentage of Full-Time Nurses Working in Hospitals, 1997-2001
56%

55%

56%

55%

53%

31%

29%

28%

27%

24%

1997

1998

1999 Year

2000

2001

Data source: MBON, 1997-2001

RN

LPN

The decline in the proportion of nurses working in hospitals is a national trend. After a peak in 1984, when 68% of RNs worked in hospitals, the percentage of hospital-based RNs declined steadily to 59% in 2000 (NSSRN, 2000). Since the total number of number of RNs employed in hospitals has increased, the decrease in the percentage of nurses employed in hospitals is the result of a growth in nurse employment in other health care sectors.

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2. COMMUNITY HEALTH/SCHOOL HEALTH Thirteen percent (13%) of RNs and 10% of LPNs reported working in community health/school health in Maryland. Settings include school systems, home health, community health, industry, and school-based clinics. Since 1997, there has been a slight upward trend in the proportion of full-time LPNs who work in community health/school health. The proportion of full-time RNs working in these settings has about remained the same.
Full-Time Nurses Working in Community Health

13% 8%

13% 9%

13% 9%

12% 9%

13% 10%

1997

1998

1999 Year

2000

2001

Data source: MBON, 1997-2001

RN

LPN

3. AMBULATORY CARE One-tenth of RNs (11%) and slightly more LPNs (13%) work in ambulatory care in Maryland. Settings include ambulatory care centers, offices, private practice, physician practice, addiction treatment centers, and HMOs. Over the past five years, the proportion of full-time nurses in this sector, both RNs and LPNs, has remained about the same.

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Full-Time Nurses Working in Ambulatory Care

12% 10% 10%

13% 10%

13% 10%

12%

13% 11%

1997

1998

1999 Year

2000

2001 RN LPN

Data source: MBON, 1997-2001

4. LONG TERM /EXTENDED CARE Nearly one-tenth of RNs (9%) and nearly two-fifths of LPNs (38%) work in long term or extended care facilities. The settings include nursing homes, rehabilitation centers, hospices, and assisted living facilities. LPNs provide the largest proportion of professional nursing care in these facilities, and since 1998 the percentage of full-time LPNs working in these settings has increased (from 36% to 39%). The proportion of fulltime RNs working in these settings has remained about the same.
Full-Time Nurses Working in Long Term/Extended Care
36% 33% 35% 37% 38%

10%

9%

8%

9%

9%

1997

1998

1999 Year

2000

2001 RN LPN

Data source: MBON, 1997-2001

5. TEMPORARY AGENCIES Hospitals and other facilities use temporary agencies to fill some of their vacancies. Of the nurses who reported working part-time (part-time data available since 2000 only), roughly one-tenth of RNs and one in seven LPNs work for a temporary agency. A very small but consistent proportion of LPNs (3%) and RNs (2%) work full-time for temporary agencies. 40

Nurses Working in Temporary Agencies*
20% 16% 15% 10% 10% 5% 1% 0% 3% 1% 3% 3% 3% 8% 3% 14%

2%

2%

2%

1997

1998

1999 Year

2000
FT RN FT LPN

2001
PT RN PT LPN

* Part time data not available prior to 2000 Data source: MBON, 1997-2001

C. SALARIES
1. RN SALARIES The types of data available permitted an analysis of salaries, turnover rates, and vacancy rates primarily of nurses working in hospitals. Over the past decade, the average base salary of an FTE RN (40 hours a week for 52 weeks a year) working in Maryland hospitals has increased by 55%, from $35,440 in 1991 to $55,060 in 2002. The base salary does not include other wages earned through Salary and Cost of FTE RNs in Hospitals overtime, shift premiums, 80000 71 ,680 and on-call premiums.
70000 60000
61 ,580

Between 1991 and 2000, the average base salary grew by 50000 55,060 1% to 3% annually until 40000 2000, when there was a 5% increase. In 2001 salaries 30000 1 991 1 992 1 993 1 994 1 995 1 996 1 997 1 998 1 999 2000 2001 2002 began climbing at a rate of Year 9% annually. In 1991, the Data source: HSCRC Annual average base salary and Wage and Salary Survey RN Base Salary RN Salary RN Cost additional wages earned through overtime and other premiums was $39,650, which increased to $61,580 by 2002. The cost of a hospital RN, which includes salary and fringe benefits, increased from an average of $44,990 in 1991 to $71,680 in 2002.

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However, on the basis of national data, it can be seen that average real (inflationadjusted) salaries of registered nurses were flat between 1992 and 2000. According to the National Sample Survey of Registered Nurses, actual or nominal annual salaries increased 24%, from $37,738 in 1992 to $46,782 in 2000. Using 1980 as the base year, real salaries increased by only 0.8%, from $23,166 in 1992 to $23,369 in 2000 (NSSRN, 2000). The costs for agency nurses are much higher than those for staff nurses. Maryland hospitals paid staff nurses an average of $31.88 per hour in 2000 and $34.45 per hour in 2001, while agency nurses cost $50.65 per hour in 2000 and $55.12 in 2001, a differential of about 60% (MHA, 2002). 2. LPN SALARIES Over the past decade, the average base salary of an FTE LPN (40 hours a week for 52 weeks a year) working in Maryland hospitals has increased by 56%. Base salary growth ranged from 1% to 3% annually until 2000, when salary increases began climbing at a rate of 7% annually. In 1991, the average base salary for a hospital-based LPN was $23,410. By 2002, the average base salary had increased to $36,620. In 1991, base salary plus additional wages averaged $26,910, which increased to $40,950 by 2002. The average cost incurred by a hospital to employ an LPN, including fringe benefits, was $31,430 in 1991 and nearly $50,000 by 2002.
Salary and Cost of FTE LPNs in Hospitals Although Maryland data is 60000 not available for other 49,230 50000 health care sectors, 40,950 findings from the National 40000 Sample Survey of 30000 36,620 Registered Nurses for 2000 show that staff RNs 20000 in hospitals have higher 1 0000 average annual earnings 1 991 1 992 1 993 1 994 1 995 1 996 1 997 1 998 1 999 2000 2001 2002 ($43,476) than staff RNs Year in all other sectors. For Data source: HSCRC Annual Wage and Salary Survey LP N Base Salary LP N Salary LP N Cost example, full-time staff RNs in nursing homes/ extended care facilities had average earnings of $38,237, and nurses in ambulatory care settings, $36,521 (NSSRN, 2002).

While compensation for newly hired nurses has been increasing steeply, the wages of nurses who have been working longer have increased only slowly. An analysis of the NSSRN data showed that wages of hospital staff nurses who graduated 20 years earlier and did not pursue additional education or promotion were only 10% higher than wages paid to nurses who had graduated only 10 years earlier (Sochalski, 2002).

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D. VACANCY AND TURNOVER RATES
The national vacancy rate for RNs working in hospitals in 2001 was 13%. The Maryland vacancy rate was even higher at 15.6% and has been rising since 1997, according to the Hospital Personnel Survey conducted by the Association of Maryland Hospitals and Health Systems. The vacancy rate, which was 12.5% in 1989, declined to 6.1% in 1992 and even further to a low of 3.3% in 1997. Since then the vacancy rate has climbed steeply. The 15.6% vacancy rate in 2001 is the equivalent of over 2,000 RN positions needed in Maryland hospitals. In 2001, the vacancy rate for LPNs in Maryland hospitals was 12.9%. It should be noted that hospitals also have high vacancy rates for other health care professionals such as radiation therapy technologists (21.1%), nuclear medicine technologists (18.0%), and respiratory therapists (13.6%).
RN Vacancy Rates in Hospitals, 1996-2001*
13.9% 11.0% 7.6% 3.8% 5.5% 15.6%

3.3%

1994

1995

1996

1997 Year

1999

2000

2001

Data source: MHA Hospital Personnel Survey 2001

*No survey conducted in 1998

Vacancy rates in Maryland vary by location and type of facility. Some rural areas are experiencing considerably higher than average vacancy rates not only in hospitals but in nursing homes and home health agencies (Community Foundation of the Eastern Shore, 2002). Turnover rates also have increased. Between 1996 and 2001, the turnover rate in Maryland hospitals rose from 8.3% to 14.5%. In 2000, Maryland hospitals required 60 days on average to fill an RN vacancy, an increase from 41 days in 1997 (MHA). Vacancy and turnover rates in nursing homes are even higher than in hospitals. The estimated national vacancy rate in nursing homes in 2001 was 18.5% for staff RNs and 14.6% for LPNs. The estimated vacancy rates in Maryland (on the basis of a sample survey) were higher than the national average: 23.1% for staff RNs (or 366 positions) and 16.9% for LPNs (or 431 positions). The national annualized turnover rates in nursing homes in 2001 were 56.2% for staff RNs and 53.6% for LPNs. Rates in Maryland’s nursing homes were estimated at 57.4% for staff RNs and 55.9% for LPNs (American Health Care Association, 2002). Furthermore, nursing homes are at a disadvantage in recruiting nursing personnel since the wages and benefits tend to be less than in hospitals (Decker, Dollard, and Kraditor, 2001). Three-quarters of nursing homes reported that it

43

has become more difficult than a year ago to recruit staff RNs and LPNs (American Health Care Association, 2002).

44

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4.WORKPLACE ISSUES
The more understaffed hospitals are, the more demoralized nurses become, the fewer recruits join their ranks, the worse nursing shortages grow, and the more understaffed hospitals become. —Abigail Zuger, M.D., Prescription, Quite Simply, Was a Nurse, New York Times, November 19, 2002 Workplace issues have emerged as an important reason why nurses are leaving their jobs or leaving the nursing profession entirely. This chapter deals with nurses’ perceptions about their jobs and conditions in the workplace. Most of the information was obtained from focus groups conducted with Maryland nurses in June 2002. Six focus group sessions were conducted with 65 full-time registered nurses from all regions of the state. One group each consisted of nurses in Western Maryland and on the Eastern Shore. Two groups each represented nurses in the Baltimore area and the Washington suburbs. To participate in the focus groups, nurses had to have at least two years of experience, be a direct care nurse, be a permanent employee (non-agency), and work at least 30 hours per week. About half of the participants worked in hospitals, and half worked in public health, psychiatric nursing, school nursing, home care, prisons, hospices, research, and private practice, reflecting the distribution of practice settings in the state. Different educational levels were represented, including nurses with associate degrees, baccalaureate degrees, and master’s degrees. Several participants were nurse practitioners. Nearly 80% of those recruited agreed to participate in the discussions. The information from the focus groups was supplemented by a comparison with the results of the Workplace Survey conducted in 2001 for the Maryland Commission on the Crisis in Nursing. The Workplace Survey targeted RNs and LPNs licensed in Maryland who worked full-time in a hospital, long term care facility, or home health agency or hospice in Maryland. There were 1,531 returned surveys for a 52% response rate. Seventy-one percent (71%) of the respondents were over 45 years of age, and 67% had more than 20 years’ experience in nursing. The following sections discuss the workplace issues that emerged from the focus groups and the Workplace Survey. The nurses who participated in the focus groups are referred to as the “focus group participants,” and the Workplace Survey 2001 respondents as the “survey respondents.”

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A. SOURCES OF SATISFACTION
1. REASONS FOR BECOMING A NURSE Many focus group participants held the nursing profession in high regard and felt it was very valuable, rewarding, and challenging. A number of nurses said that that nursing was something they had always wanted to do, even as a child. For others it was a particular experience, such as a hospital visit or caring for a sick relative, that made them choose nursing as a profession. It’s just something that I’ve always wanted to do from the time I was very little. I was always the type that hauled home the animals, you know, the bird with the broken wing and the cat with the broken foot or leg. I was bent on saving everybody. It was just natural. [Western Maryland] I was 6 years old and I went to the hospital with my father. It was just so amazing watching all these people take care of sick people. I just felt that I wanted to be a nurse right then. I liked the idea of taking care of people, helping people, taking care of people in pain, helping them deal with these situations. I like a lot of hands on. [Baltimore] Some focus group participants said they were attracted to the field because of appealing marketing, the easy availability of jobs, and low-cost subsidized education. For others, it represented an attractive and reliable second income with the flexibility in scheduling they felt they needed to raise a family. Newer nurses were attracted by the variety of options available in nursing and opportunities for educational advancement. A small number had considered a medical or veterinary degree and then decided on nursing. Older female nurses said they felt that they had had few options (nursing, teaching, social work) when they chose a career. They had been advised to pursue a career in the event a husband could not provide for them. Most participants had been in their late 20s or 30s when they chose nursing as a second career. Many said they had been discouraged from going into nursing by other nurses, family members, and guidance counselors who told them that they did not have the right personality type to be a nurse or that their career would peak early and their earning capacity would not be comparable to other professions. Many participants felt that discussing their own motivations to become a nurse and the motivations of other nurses helped them to better understand some of their dissatisfaction with the profession. In some cases, what they had heard about a career in nursing had not been realistic. Changes in the field had made it difficult for them to experience the rewards of helping others in the way they had expected. They noted that it was important for prospective nursing students to have a realistic picture of the role of the nurse.

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2. REWARDS OF NURSING Focus group participants found many rewards in the nursing profession. Consistently, participants mentioned that the satisfactions of nursing included helping other people to get well (or die with dignity), flexibility in scheduling, easy availability of jobs, doing something important, having better than average pay, and being part of a professional group. Many enjoyed the intellectual challenges of working with patients and their families. They spoke of having a common bond through language and technical knowledge in the health care field. Some mentioned the ability to follow a patient through the process of getting better, getting to know the family, and feeling appreciated by patients and their families. This was seen as one of the benefits of working in nursing homes, since patients have longer stays than hospital patients. While dissatisfied with many aspects of the field of nursing, most nurses had gravitated to an area of health care that they preferred. Nearly all had held a number of nursing positions, often in different departments, until they found the area they liked. For many, this meant leaving hospitals with required overtime, changing shifts, and other causes for dissatisfaction. I like the challenge. It’s always different… I especially like it in research. You get involved in what we want to do now, how do we do it … and how do we make it work for the patient. How do we teach them what they need to know to be successful in following the program? [Washington area] [I like] the independence, the ability to use my intellect, the interaction with the clients and their families, and the interaction with other members of the health care team. [Washington area] I get my rewards from [the patients]. I work mostly with the geriatric population. Some of them are disabled. They are medical-assistance recipients, so it’s a low socio-economic group. The disabilities they have and their determination is incredible…. It’s just amazing how positive they are in such difficult times. I learn a lot from them. [Eastern Shore] I work with the terminally ill…. You treat more than just the patient, you know, you treat the whole family. People always think it’s so depressing dealing with cancer day in and day out, but you just get so many pats on the back from the family and thank you’s and appreciation from them that it makes it definitely worth it. Some don’t do as well as others, but others do well, go on, and live full lives. It kind of balances the ones that don’t make it. [Eastern Shore] I would encourage someone to go into nursing because it’s an exciting field. You do interesting work. You’re making an impact. You don’t have to stay doing the same thing all the time. As you develop and as your needs change, you can

48

change your area within your zone and you can go at your own pace. If you can only afford to go to an associate degree program at first, you can start there, or you can go to a bachelor’s program first. It has so much flexibility and it’s so interesting and rewarding. [Washington area]

B. SOURCES OF DISSATISFACTION
Nurses in the focus groups identified a number of “dissatisfiers” about their current work environment. The comments of the focus group participants are corroborated by the results of the Workplace Survey, which involved more than 1500 nurses. Survey respondents cited many reasons why they were dissatisfied with their current position or place of employment. An overview of the key workplace issues can be derived from the Workplace Survey. The dominant issue that emerged from the survey was nurses’ feelings about their ability to provide quality care. Half of the survey respondents felt that the inability to give quality care was an issue in their work setting; more than half of those thought the issue was critical enough to make them consider leaving their current job, while one-third would consider leaving the nursing profession altogether. Other issues that would make more than one-third of respondents consider leaving their jobs were mandatory overtime, other scheduling issues, mandatory on-call, reassignment and associated compensation, and the quantity of staffing. Of those identifying mandatory overtime and reassignment as critical issues, approximately one in five said that those issues would warrant leaving the profession. The percentage of nurses who reported the issue as present in their workplace is given in the following table together with the percentages of nurses who felt the issue was significant enough to make them consider either leaving their job or leaving the nursing profession.

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Factors/Issues Most Associated with Desire to Leave Current Job or the Nursing Profession
% Identifying Presence of Issue in Workplace 51% 37% 37% 32% 37% 21% 57% 62% 52% 29% 52% 65% 7% 62% 36% 44% 25% 56% Seriousness of Issue % Respondents % Respondents Who Would Who Would Would Leave Job Leave Nursing 54% 45% 44% 43% 41% 41% 34% 29% 27% 27% 26% 25% 25% 20% 20% 19% 19% 15% 32% 22% 17% 16% 19% 18% 18% 12% 10% 11% 13% 9% 8% 7% 11% 7% 9% 6%

Factor/Issue Inability to give quality care Mandatory extra hours/overtime Scheduling issues Mandatory on-call Reassignment Compensation for reassignment Quantity of staffing Relationships with administration Inadequate support services Compensation for on-call Staffing skill mix Relationships with management Lack of employer-sponsored adult care Inadequate supplies/equipment Compensation for experience Unavailability of clinical ladder Compensation for attained education Relationships with subordinates

Note: Percentages are based on the number of nurses responding that the particular factor is an issue in their workplace as the denominator. The numerator is based on the number of nurses responding that the issue would make them consider leaving their job or leaving nursing. Source: Adapted from Workplace Survey 2001.

The issues identified by survey respondents as reasons to consider leaving the nursing profession are shown, by work setting, in the table below. Respondents employed in hospital, long term care, and home health/hospice settings shared similar views about the factors that would lead them to consider leaving their current job. The most pervasive issues were scheduling, reassignment, mandatory extra hours, on-call, administrative relationships, and quantity of staffing. Among the respondents who would consider leaving the nursing profession, the factor that would most impact their decision is their perceived inability to provide quality care. This was the case across employment settings. Mandatory extra hours, reassignment, compensation for reassignment, and mandatory on-call were the issues highlighted by hospital-based respondents. More nurses in long term care facilities expressed concern about the quantity of staffing than did those in hospitals and home health/hospices. Scheduling issues were a greater concern among long term care and home health/hospice nurses than among nurses in hospitals and other facilities.

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Reasons for Leaving Nursing by Setting
Factor/Issue Inability to give quality care Mandatory extra hours/overtime Reassignment Compensation for reassignment Mandatory on-call Quantity of staffing Relationships with administration Scheduling issues Staffing skill mix Inadequate support services Compensation for experience Compensation for on-call Relationships with management Support services Compensation for attained education Inadequate supplies/equipment Professional independence Relationships with others/physicians Breaks Lack of employer-sponsored adult care Unavailability of clinical ladder Access of clinical ladder Compensation for extra hours Employer-sponsored child care Relationships with subordinates Relationships with peers Relationships with patients Scheduling issues-flexibility Scheduling issues-self scheduling Hospital 33% 22% 19% 18% 16% 15% 14% 13% 11% 11% 10% 8% 8% 8% 7% 7% 7% 7% 6% 6% 6% 5% 5% 5% 4% 4% 4% 3% 2% Long term Care 33% 23% 19% 20% 17% 26% 12% 21% 19% 13% 13% 17% 10% 9% 15% 9% 8% 5% 5% 16% 11% 9% 10% 14% 10% 5% 3% 4% 6% Home Health/ Hospice 33% 18% 13% 11% 13% 12% 6% 21% 6% 3% 6% 7% 6% 3% 2% 2% 6% 6% 3% 0% 3% 4% 9% 0% 2% 2% 1% 4% 3% Other 26% 19% 21% 14% 15% 16% 13% 18% 11% 8% 14% 13% 10% 7% 11% 5% 10% 8% 2% 0% 11% 14% 13% 0% 7% 5% 4% 8% 7%

Note: Percentages are based on the number of nurses responding that the factor is an issue in their workplace as the denominator. The numerator is based on the number of nurses responding that the issue would make them consider leaving nursing. Source: Adapted from Workplace Survey 2001.

As one focus group participant commented: If you want to retain them, you have to give these nurses an equitable salary. You have to have good benefits. You have to make the working conditions attractive because we don’t have to stay in nursing…. There are lots of jobs and other training out there, so we have to make it attractive. [Baltimore]

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1. STAFFING ISSUES Like the survey respondents, the focus group participants identified many issues of concern, especially those related to working in hospitals and long term care facilities. Focus group participants felt that the most critical nursing shortages were occurring in hospitals and that as a result the hospital environment tended to “burn out” nurses. Nurses in rural areas said that they felt even greater stress because they had fewer employment options. The main staffing issues that emerged from the discussions were the level of staffing and the impact on patient care, scheduling, temporary reassignment, and time required for documentation. a. RN Staffing and Ability to Give Quality Care The impact of the shortage of nurses is reflected in staffing levels, nurse-patient ratios, and the level of care provided. As discussed in Chapter 1, recent studies have increasingly demonstrated that inadequate nurse staffing levels are correlated with increases in a number of adverse patient outcomes and with nurses’ dissatisfaction with their jobs. These views were shared by Maryland nurses who participated in the focus groups and in the Maryland Workforce Survey. The Workforce Survey found that, among 774 respondents (51% of the total respondents) who said that the quality of care was an issue at their place of employment, 54% of those would consider leaving their job and 32% would consider leaving the nursing profession because of it. According to these respondents, over half (55%) felt that the quantity of RNs and LPNs on staff was adequate, but 45% said that staffing was sometimes, rarely or never adequate. Findings were similar with regard to the adequacy of proportions of RNs, LPNs, assistants, and ancillary staff. Of the 877 survey respondents (57%) who claimed that the quantity of staffing was a workplace issue, 34% would consider leaving their job and 18% would consider leaving nursing. Long term care nurses (26%) were more likely to leave nursing for this reason than hospital (15%) or home health nurses (12%). The focus group participants also said that they were concerned about their ability to deliver adequate care to patients. They felt that staffing models in hospitals were often outdated or impractical. They noted that managed care policies pressured hospitals to release patients sooner. Nurses expressed concern that they didn’t get to know the patients well because they were discharged quickly. The patients who remained, and those who returned soon after having been released, had more serious illnesses and required greater care. The participants suggested that staffing models should be developed to recognize different staffing needs by department and severity of illness. Nurses said that they often had to deal with 10 to 15 patients at a time, leaving little time for normal personal needs such as lunch or restroom breaks. In addition, participants expressed concern that most nurses in hospitals were older and would not be able to keep up the pace required in bedside nursing. I think to retain the nurses we need to recognize that there is a nursing shortage, and not overload the nurses that are there. I think if you continue to overload them, then you are going to burn them out. [Baltimore]

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I think my biggest frustration is trying to get management to understand what the real workload is…. The number of patients [doesn’t] reflect at all what the workload is [Washington area] I don’t think they have ever come up with a staffing model that really measures truly what is done in patient care. It doesn’t measure the things behind the desk. It doesn’t measure the multiple phone calls you make to make sure things happen. It only measures that period of time that you’re in there doing hands on and that is such a small percentage many times. It’s the other things that are done and that’s never measured accurately. [Washington area] They all want to look at history…. “Five years ago, you could take care of 15, why can’t you do that now?” You didn’t have the degree of illness, [patients] are much sicker. [Eastern Shore] Even the kids in school are sicker. There’s 850 kids in middle school and the health needs just boggle my mind. They don’t have a nurse practitioner, they have a health tech…. They did not have all those needs all those years back. [Eastern Shore]. Several focus group participants reported that the lack of staff made it nearly impossible for nurses to take sick days, vacation, training, or even breaks while they were working. If no one was available to cover when their shift was over, they were asked to stay until someone could relieve them. Many nurses believed their life outside of the hospital was not taken into consideration. We are told, “No, you can’t have lunch today. We don’t have anybody to relieve you. You can’t go home.” If you did that in businesses, businesses would just fold. But we stay there. We don’t get any more pay or any more benefits or anything. We go with maybe taking 15 minutes, having maybe one or two… bathroom breaks. [Baltimore] It got so bad that I thought I was going to have a nervous breakdown. It was that bad. They don’t think that you have a life outside of the hospital. I have children at home that I have to get to. I just said that’s it, two weeks notice, and I found a job somewhere else. [Western Maryland] b. Lack of Support Personnel The skills and number of other types of nursing personnel and support staff were a major cause of dissatisfaction. In the Workplace Survey, of the 795 survey respondents who said that skill mix was a factor that would impact their decision to leave their job or nursing, one-quarter (26%) would leave their job and 13% would leave nursing. Among those who said they would leave nursing, long term care nurses (19%) appeared to be more impacted by skill-mix issues than hospital (11%), or home health/hospice (6%) nurses.

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Problems created by the shortage of nurses are exacerbated by inadequate numbers of support/auxiliary staff. Some focus group participants commented that when the practice model of having one nurse responsible for the primary care of a patient was implemented, support staff were eliminated to allow the nurse the personal fulfillment of serving all of the patient’s needs. However, when the primary care model was found impractical due to the nursing shortage and cost-cutting, more patients were added to the nurse’s load without rehiring the support staff. These nurses said that they did not understand why managers hired traveling and agency nurses instead of hiring support staff at lower cost, which would free staff nurses to give better care to the patients. Some nurses had ambivalent views about support staff. While they said that more support staff were needed, they expressed concern about the competency and supervision of support personnel. I like my job a lot. There’s always something new. Every day is different. The most frustrating part of my job is when I have to do things other than my job. When you are spending your time doing someone else’s job, your own work is going unfinished or you are trying to do both at the same time. [Washington area] In the nursing home, when there are not enough aides you’re going to be getting water, you’re going to be taking inventory, you will be out of the role we initially signed on for and into what nursing has become because of the shortage. [Washington area] One of the reasons why I would never go back to the floor is because they don’t give the time to do what needs to be done for a patient, and it is this constant running and doing what I call menial tasks. If dietary doesn’t put out the meal trays, nursing gets them. If something spills on the floors and housekeeping doesn’t get it, nursing does it. [Baltimore] A lot of times you may have enough ancillary help, but they’re not doing the right jobs. They’ve got people like techs to do simple things like blood pressure and some of them you can’t trust to do those things. So you have to repeat their job. [Baltimore] c. Working Shifts, Holidays, and Weekends In Maryland, over half of the respondents to the Workplace Survey worked a traditional schedule of five 8-hour shifts in hospital, long term care, hospice, or home health settings in Maryland. The other 45% worked non-traditional schedules. Over one-quarter (27%) of respondents rotated shifts. Nearly three-quarters of respondents (71%) stated that their preferences were considered in scheduling. However, seniority and physical limitations were not often considered. Three-quarters (73%) of the 1,026 respondents with more than twenty years of experience claimed that seniority was not considered in scheduling. Of the 541 respondents who reported a physical limitation, over 60% stated that their physical limitations were not taken into account in scheduling or assignment changes.

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Of the 574 respondents who claimed that scheduling was an issue at their workplace, 44% said that they would consider leaving their job, and 17% said that they would consider leaving the nursing profession. Long term care nurses (21%) and home health nurses (21%) were more likely to say that they would leave nursing because of scheduling than were hospital nurses (13%). Many participants in the focus groups said that working shifts and having to work on holidays and weekends were major drawbacks of nursing. Many nurses had worked shifts in the past, but complained of feeling burned out after doing it for a long time. They also said that working shifts was difficult on their families, although flexibility in the schedule was a major reason cited by many for entering the nursing profession. Nurses commented that hospitals didn’t pay much more for shift work, and they thought longer gaps between shifts were needed. The nursing shortage made shift work even more difficult because a nurse might be scheduled to work several different shifts in a week or regularly be oncall. Many nurses said that not having to work shifts was one of the reasons that they enjoyed their current position. I think it’s pretty obvious why many people leave their job—the shift work. You have no life and are expected to act like that’s normal and just cope with it. Everybody was happy with their jobs, but they left because of that, so you [lost] really good nurses with lots of experience because they wanted a family life and job. [Eastern Shore] When I worked in the hospital setting, I had two younger children and it seemed like I had to work every other weekend, or you had to rotate shifts, or every other holiday…. That was why I left the hospital setting and what turned me on to this job was not particularly the place or the people, but the hours—no weekends, no holidays, it was day shift. [Baltimore] Being a young mother, the home health field is good for me. You know, not working an 8 or 12 hour shift. I don’t have to work weekends or holidays. It is very flexible. I can take the appointments as I need them. I don’t see myself ever leaving this particular field, at least while my children are young. [Baltimore] d. Mandatory Overtime Mandatory extra hours/overtime, or hours required in addition to routinely scheduled hours, was another important source of dissatisfaction. In order to deal with unexpected situations and, increasingly, with the shortage of nurses, hospitals and other health care institutions have had to resort to mandatory extra hours/overtime as well as greater use of other strategies to cover patient units such as reassignment and on-call. The extent of unhappiness about this issue can be seen in the Workplace Survey, where 87% of the respondents reported that they had had to work extra hours in the past year. Of the 567 survey respondents (37%) who claimed that mandatory extra hours contributed to their dissatisfaction with nursing, 45% said they would consider a new job and 22% would consider leaving nursing. Among those considering leaving nursing, mandatory extra

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hours was one of the top three factors for hospital (22%), long term care (23%) and home health (18%) nurses. Legislation in Maryland prohibiting mandatory overtime for RNs and LPNs, except under special circumstances, was passed by the General Assembly and signed into law in May 2002. If adhered to, the law should help remove one of the major issues that nurses are concerned about. The focus group sessions were held after the law was signed, and it is perhaps for this reason that it was not addressed as an issue by the participants. e. On-Call On-call is a practice that has been used to staff units that have nursing shortages and to ensure adequate staff as the number of patients in units fluctuates. A nurse on-call is on standby and must come to work if called. One-third (35%) of the survey respondents stated that being on-call is part of their job responsibilities. Among respondents on-call, half said it was a routine part of their job (55%). Others said they were on-call nonroutinely when there is an unexpected staff absence (31%) or when there is an unexpected number of patients or level of patient acuity (20%). Of the 493 survey respondents who claimed that mandatory on-call contributed to their dissatisfaction with nursing, 43% would consider a new job and 16% would consider leaving nursing. Among those considering leaving nursing, mandatory extra hours was one of the top three reasons for hospital (22%), long term care (23%), and home health (18%) nurses. A few focus group participants said that being on-call interfered with their family life and made their life stressful. Some nurses had taken other jobs in nursing that did not require being on-call. I left my job in the recovery room because of being on call. I worked in recovery for 18 years. My husband had died and my son was home alone and I’m taking call. It wasn’t fair to him and it wasn’t fair to me. I never saw him. A surgery position became available and at that time you didn’t take call. Now, we’re back to taking call and I don’t like it. [Eastern Shore] I am taking call every week. Every third week I have to have my family on hold because when I leave that job and I go home and if my beeper goes off I have to be ready to run back out that door no matter what. Whether we’re at a ballgame, whether we’re at the swimming pool, whether I’m in the market, I have to go. You know it’s stressful, because you don’t go home and relax because you know you’re on-call. [Western Maryland] f. Temporary Reassignment Nurses are sometimes reassigned on a temporary basis to work in a location that is different from their normal one (“floating”). Problems may arise when nurses are unfamiliar with the unit or do not feel they have the required competencies to perform the work in that location. Just over half of the survey respondents said that they had been reassigned, including 3% who said they were reassigned very often, 7% often, 22%

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sometimes, and 21% rarely. Of those respondents who were reassigned, nearly threequarters (71%) said they felt competent to work in the new area, and half said they received an orientation to the new unit. Of the 573 survey respondents who said that reassignment had contributed to their dissatisfaction with nursing, 41% would consider a new job and 19% would consider leaving nursing. Among those considering leaving nursing, reassignment was one of the top three reasons for hospital (19%) nurses. Onefifth (19%) of long term care nurses placed this reason in the top ten as did 13% of home health nurses. Some nurses in the focus groups said that reassignments were due to staff shortages. A few participants said that being assigned in a different area was difficult because they were not familiar with the equipment, procedures, or paperwork. A couple of participants found it difficult commuting between two campuses that had recently been merged. There are not enough people to cover the shift in some instances. If a nurse is sick, we have to cover that area. The nurse is on vacation, we have to cover that area…. I think everybody has their little niche, but suddenly you’re diversified. You have to be a jack of all trades and as I get older, I’m a master of none. I don’t like that insecurity. I feel inadequate because I don’t know what I’m doing 100% of the time. [Eastern Shore] The women in the profession are asked to have expertise in 20 different fields. I did the OR thing at one hospital for a while and then I had to drive up the street to another hospital. You get to the point where you’re not good at anything you’re doing. [Eastern Shore] I was pulled out of the unit that I worked in and put on a strange floor…I didn’t know the layout of the floor. I didn’t know where anything was, and I was expected to do charts that night on twenty some patients. I told them no, I would not do it. I’d be a staff nurse and take a full team of patients, but I would not take the responsibility to chart…. I took a stand and I didn’t compromise my integrity of taking proper care of these patients. [Eastern Shore] Nothing puts me in a bad mood like them telling me I’m going to the other campus because no matter how much they worked on this, things are not the same. The equipment’s different, procedures are different, and paperwork is different. We can take care of the patient, but it’s all the other things we have to go through. [Western Maryland] g. Documentation The growing amount of time required for documentation has become a significant workforce issue. Required documentation has increased as a result of reimbursement procedures established by Medicare, Medicaid, and insurance carriers; increasing regulatory requirements; and concerns about legal liability. The time needed for documentation exacerbates the problem of short staffing, resulting in even less time to

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spend with patients. In some cases, nurses have to stay beyond the end of their shift to complete paperwork. In the Workplace Survey, nearly two-fifths (38%) of the respondents reported that they spent more than 50% of their shift doing paperwork. Over two-thirds (67%) felt that paperwork sometimes, often, or very often kept them from spending as much time with patients as needed. Over two-thirds (69%) said that paperwork sometimes, often, or very often resulted in their working beyond scheduled work hours. The focus group participants noted that the amount of paperwork and charting has increased significantly. Hospital nurses spend a good portion of their time entering information into a computer. Those in non-hospital environments, particularly long term care and home health, were more likely to complain about the length of time it took to complete the paperwork, and many attributed this to regulatory requirements. Most nurses in the focus groups thought that the extensive amount of information gathered was not used and that the required forms and charting had been designed by non-clinical personnel, without feedback from direct care nurses. Even school nurses commented that the number of children needing prescribed medications had grown, which increased the related paperwork. However, one participant reported positively about the forms used in her facility, because nurses were involved in the design of the forms. There is a 20-25 page document when you admit a patient asking all kinds of information. They even created special positions like admissions nurses that would only do all the OASIS paperwork. [Baltimore] We are losing a lot of home health nurses because they're just going back to the hospital…. The bottom line in a lot of those decisions is the paperwork—it's horrendous. [Washington area] In long term care, a big problem is the paperwork and the regulations. In the last two years, our ability to be at the bedside, to be with the resident has decreased …. The paperwork is astronomical. The nurses in long term care now are not doing care. They are doing paperwork. [Baltimore] With outpatient procedures, it takes longer to do the paperwork than to do the procedure. It’s unbelievable. [Eastern Shore] Our paperwork is great…. Whenever we need a new form, we design it ourselves. We all have input, so ours is all very simplified. I can do paperwork in five minutes, so I get to spend time with patients instead of doing paperwork. [Baltimore]

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2. COMPENSATION AND BENEFITS a. Salary and Job Position Differentiation When asked to rate satisfaction with compensation, half of the survey respondents said they were satisfied with their compensation, including 13% who were very satisfied and 37% who were somewhat satisfied. Half of the respondents were dissatisfied, including one-third (31%) who were somewhat dissatisfied, and one-fifth who were very dissatisfied. Participants in the focus groups thought that their salaries were not commensurate with the level of responsibility they had. In addition, the ceilings for nursing salaries and the lack of raises made it difficult to attract new nurses to the field. Some participants said that there was inadequate differentiation of compensation and job responsibility based on the level of education a nurse had. They commented that nurses with associate degrees had the same duties as nurses who had baccalaureate degrees. These nurses felt that the effort to obtain a baccalaureate or master’s degree was not worth the small increment in salary. Some participants said that higher level positions offered more authority, but little difference in salary. At the age of 50 I am making what I consider a very good salary. But it shouldn’t have taken a nursing shortage to get me a $10,000 raise this year. It shouldn’t have taken 30 years of practice. I think there is an art to knowing what your patient needs and wants. I don’t think everybody has that ability, and it shouldn’t have taken 30 years in nursing to get where I have gotten. [Baltimore] Increased salaries paid to new hires and sign-on bonuses have created resentment. A few participants in the focus groups believed that new nurses were treated better than nurses already on staff. Some said that new nurses were paid nearly as much as, and sometimes more than, experienced nurses, and many times the new nurses were not required to work the less desirable shifts and be on-call. Other participants said that experienced nurses were less willing to help newer nurses because of perceived inequities, and some believed that new nurses had not been trained to be team players. In terms of retention, I think job satisfaction is the key to that, and job satisfaction can be defined as how much money you are making, what your workload is, what kind of environment you’re working in. Too many people say that there is no way they would go into nursing; it just doesn’t pay enough. [Baltimore] I believe also that the money is an issue. You have to make it enticing. Low paid nursing isn’t going to pay all the bills all the time. So they have to give retention bonuses, perhaps sign-on bonuses, increased salary [Baltimore]. b. Benefits Respondents to the Workplace Survey were asked to rate their satisfaction with selected benefits. Respondents were most satisfied with leave (holidays, vacation, and sick days),

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cost of insurance, continuing education, and extra-hour compensation benefits. Threequarters of respondents were satisfied with leave, including 31% who were very satisfied and 42% who were somewhat satisfied. Nearly two-thirds of respondents were “very satisfied” or “somewhat satisfied” with the cost of insurance, continuing education, and compensation for extra hours. Respondents were least satisfied with on-call compensation, bonuses, and retirement health benefits. Over three-quarters (80%) of respondents were not satisfied with or did not receive compensation for being on-call. Over two-thirds of respondents were not satisfied with or did not receive retirement health benefits (67%) or bonuses (69%).
Satisfaction with Selected Benefits
Benefit Leave Cost of Insurance Continuing Education Compensation for Extra Hours Insurance Tuition Bonus Retirement Health Benefits Compensation for On-Call Very Somewhat Not Satisfied Satisfied Satisfied 31% 42% 18% 25% 36% 24% 24% 37% 20% 22% 17% 23% 12% 9% 6% 38% 40% 31% 20% 23% 14% 22% 27% 19% 30% 31% 24% Don't Have 8% 15% 19% 17% 17% 28% 39% 36% 56%

Source: Adapted from Workplace Survey, 2001.

Most focus group participants received benefits; however, they considered that the benefits they did get were poor, and they viewed the lack of benefits as another way in which they were not considered professionals. The focus group participants raised concerns about leave, retirement plans, and continuing education, and tuition reimbursement. With regard to leave, many nurses were unsure about the amount of vacation and sick time they had. They said that they could not always use vacation time when they wanted to, because of the staffing shortages. Although they had sick leave, participants felt they were strongly encouraged to come to work when they were sick. Some mentioned being reprimanded for using sick leave. Several participants noted that having several occurrences of sick leave could result in a demerit placed in a nurse’s file plus the threat of suspension. Participants from the Eastern Shore spoke positively about “pal time,” in which any unused sick time can be accumulated as leave for other purposes. If sick leave is not used by the end of the year, nurses are paid for it. You’re written up if you’re out more than three days and you have to have a doctor’s note even if it’s the flu. Now you’re a health professional, you know you have the flu, the doctor can’t do anything for you. You have to go to the doctor

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and ask him for a slip saying that you actually were, in fact, sick. But you still get an occurrence against you and if you have more than a certain number of occurrences within a time frame, you get a written warning. [Baltimore] I like our “pal time”…. Everybody gets two weeks’ vacation and then they accrue the sick time that they never can take. They lump it all together. I’m never sick so I get all of that in my leave time. [Eastern Shore] Many participants expressed concern about retirement. They said that salary opportunities encouraged them to change positions, but that their retirement plans did not vest for periods of between five and eleven years. Most participants said that they would receive no health insurance benefits after retirement. School nurses in Baltimore appear to fare better under teachers’ benefit plans. [Nurses] tend to go from one organization to another, changing jobs, and they can’t combine their benefits. [Washington area] I see the way nursing is treated; it’s not treated as a career. Nobody in administration expects a nurse to retire from nursing into a pension, so our pensions tend to be pretty lax. My place of work doesn’t match contributions to retirement funds. They keep saying they will, but it’s been ten years and they haven’t. We won’t get health care when we retire. [Baltimore] I think [to retain nurses] they need to improve benefits, and I’m not necessarily talking about money. I’m talking about…child care. I’m talking about the education many people can’t get. [Washington area] 3. EDUCATION AND TRAINING PROGRAMS A controversy over the associate degree versus the baccalaureate degree has existed within the nursing profession for more than 50 years. Either degree qualifies nursing graduates to sit for the NCLEX-RN examination, and most hospitals and long term care institutions accept either degree for entry-level staff positions. In general, public health positions and, increasingly, supervisory positions require a baccalaureate degree. Those who wish to become advanced practice nurses (nurse practitioners or other clinical specialists at the master’s degree level) must have first completed a baccalaureate degree. There is some evidence now that RNs with a baccalaureate degree, whether as their only degree or obtained after the associate degree, tend to stay in the workforce longer—on average three more years than do nurses with only an associate degree (Sochalski, 2002). Most participants in the focus groups said that there was little differentiation between associate degree and baccalaureate nurses in terms of work and pay. However, associate degree nurses said they felt they were being pressured to continue their education. Some associate degree nurses said that they did not have the time to pursue a degree because they had families or were very close to retirement. A few baccalaureate nurses said that

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they did not feel more qualified or competent than associate degree nurses and did not think that it had been worthwhile to pursue the baccalaureate degree. Nurses also spoke about the importance of orientation programs for entry-level nurses. Some suggested that there should be a six-month orientation program for new nurses as had been the case in the past. Another suggestion was to give new nurses a nurse mentor. I just think the whole education issue has to be addressed in nursing. I’m not saying there’s not a role for two-year nursing, but they have to differentiate…. If we’re not going to do anything different with a two-year or four-year or master’s [degree], then why get one? I did it intrinsically for myself, but basically I’m doing the same thing that someone with two years or four years [of education does]. Are there two-year lawyers? [Washington area] There’s no way to better yourself from your initial education to go into a better position in the hospital…. They want me to go back to school to have the job that I’ve been doing for the last ten years. [Baltimore] I graduated [from a four-year program] …. I worked in long term care to begin with, and then I went to a med-surg floor…. One guy’s IV came unattached. He was bleeding. Thank God there was another nurse there. I had no experience and it was terrifying. [Baltimore] I had the orientation and that was wonderful. You did learn and then when you felt more comfortable, you eased your way up and did more and more. At the end of the orientation period, you felt confident Now they don’t do that anymore. [Western Maryland] Hospitals are keenly aware of the importance of education, both to upgrade nursing skills and as a recruitment tool. Health care institutions, in response to the shortage, are increasing their educational benefits for employees and for their families. For example, Johns Hopkins Hospital has expanded tuition reimbursement programs for employees and also for their dependents. A number of hospitals have student loan repayment programs. While education benefits were available to most focus group participants, many nurses said that they could not find the time to take courses. They were unable to take time off because of understaffing. Some nurses reported that they could seldom take even required training courses during the normal work day. We have x amount of dollars in our budget strictly for education, but nobody can use it because you can’t get the time off. [Baltimore] They have these competencies we have to do yearly on the computer. Nobody has time to get to the computer to do the competencies, but it’s a requirement that you do them or you can’t get a raise. [Baltimore]

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It makes you scared about the people that you’re working with because some of these people haven’t taken a class in the last 25 years. [Eastern Shore] My place of work actually has two…scholarships. They paid for my books and tuition reimbursement. I had to apply for that and I got it two years in a row. I was amazed. They also give a small amount of money every year if we are certified in our field. Then they also give money every year for education. [Baltimore] We have a new thing at the hospital. It’s an endowment fund and it is to fund education and that is a recruitment piece. I think it’s very positive; however, if they cut the educational budget, it’s not going to be there very long. It is a very sad thing and that actually is why I went to school now for my master’s …. It didn’t cost me any money out of my pocket, so for me that was a very positive benefit. [Eastern Shore] 4. PROFESSIONAL PRACTICE AND AUTONOMY Nurses in the focus groups frequently expressed appreciation for environments that were team-oriented. Some nurses spoke about formal teams of nurses, physicians, and other health care professionals who work together to serve patient needs. The Institute of Medicine report, To Err is Human (1999), has recommended the use of teams as a way of helping to prevent medical errors. Health care teams have a fairly flat organizational structure, where team members meet and discuss individual patient care. The team respects each member’s area of expertise. The nurses participating in these teams felt that this was a positive environment although cost-cutting and greater management control had sometimes changed this approach. Participants also mentioned the primary care model of nursing, which assigns a single nurse to follow a patient through the cycle of care. It was seen as a positive approach although increasingly unrealistic in understaffed hospitals. I work with a great team of people…. We all look out for each other. For a very long time, we operated without a manager…. We divided the manager’s duties between us. We took turns going to the management meetings. I took on the payroll and hiring and firing, another person took on the budget and another took on the handling of the liaison with the docs. We all just stepped in and nobody had to say a word. One of us could take a sick day and somebody else would pick up the drop for them. [Baltimore] We’ve been a professional practice model for eight years. We are a self-governing unit. We take that seriously…. We’ve got two professional practice models in the general operating room. They run in a very slick fashion. We get our cases done on time. We’re reasonably well-organized—about as well-organized as the docs will let us be. [Baltimore]

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I do home care for a hospice in Baltimore. I like the fact that we are very respected by the physicians we work with and the management staff. We are pretty independent. We are respected for what we say. It is a team approach and everybody has equal say. Everybody’s input has merit. [Baltimore] I work in oncology and we work together as a team. We communicate to each other. We are sort of on the same level as a hospice. I like working with the patients. They care for you as a person not just as a nurse. It is a family kind of feeling. In a hospital, you only see them for a day or two and then you don’t see them again. I like the consistency, too. [Baltimore] I kind of like the independence. In the recovery room, we have a standing set of orders, so you don’t have to be running to the doctors all the time. We can arrange stations and decide what patients can go…. Then, if it’s something we can’t handle we talk to the doctor…. But, there’s still that critical care involved in the recovery room. [Western Maryland] Many nurses, however, expressed the opinion that they were not viewed as professionals and were not given the autonomy of practice they expected. Traditionally, nurses saw themselves as self-sacrificing and subservient to physicians. Some characterized themselves as “indentured servants” or blue collar workers. Traditional leadership roles were seen to be held by men, who gave orders to women to do whatever what was needed to assist them. Nurses could be called by first names, while men were always “Mister” or “Doctor.” The focus group participants believed that many of the older nurses allowed this kind of behavior to continue. Many focus group participants expressed the view that doctors were viewed as generating revenue, while nurses were seen as a cost center. Whenever cuts were needed, nursing was viewed as the first area to be targeted. An emphasis on patient satisfaction surveys created additional pressure, because nurses believed they had little input into decisions that impacted patient care. Some participants said that the bottom line was profit and not good patient care. Right now there is a big shortage of us, so they want to bring new people in …. They don’t want to retain us because we cost too much. We’re maxed out at our pay scale and they know that they can get young people in, but it’s a blue-collar job…. We’re just treated like workers and that’s all we are. We’re someone to fill a slot and here’s a paycheck. [Baltimore] Management doesn’t trust us to do what we can do and so they take that control away. I think that’s where you get all the frustration with nursing…. They think they’re appeasing you by giving you more money or vacations, but they’re not. Give us control of our practice and what we do well and let us do it. [Baltimore] One of the biggest problems in nursing is the hospitals do not look at us as money generators. They look at physicians as money generators and they will do

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anything to make a doctor happy. One of the ways we receive patients is that previous patients spread the word about us, and therefore we get more patients as a result. I really think hospitals need to look at us as money generators because… each one of the things that each person does helps to recruit patients. I don’t think many organizations that we work for look at that. If they did, then I think they would treat people in our profession a lot better. [Baltimore] 5. HOSTILE WORK ENVIRONMENT Many nurses, including the focus group participants in Maryland, complain about abusive treatment by physicians and patients. In a nationwide survey of employed nurses, 28% reported episodes of violence in the workplace in the prior year, and about one in five nurses reported sexual harassment or a hostile work environment related to physicians (19%) or other staff (19%) (NurseWeek/AONE, 2002). That nurse-physician relations remain problematic in some hospitals is evidenced by a recent JCAHO report, which cites a Voluntary Hospitals of America study that finds it is a small minority of physicians who behave badly towards nurses. The JCAHO report notes that “the impact of abusive incidents can have grave consequences for patients as well. The abuse breeds intimidation, and may consequently inhibit nurses from communicating with physicians even when the communication may be vital to the quality and safety of care.” A number of institutions are adopting “zero-tolerance” policies for abusive behaviors by health care practitioners (JCAHO, 2002). Relationships with physicians were seen as a problem by some focus group participants; however, in other situations, nurses said that they were respected by physicians and worked as a team. Many focus group participants believed that some doctors were arrogant and condescending to nurses, but that conditions were improving because younger nurses did not accept this behavior. Even some older nurses were taking a stand against it. Male participants agreed that they were treated better by physicians and by patients than were female nurses. I’m very fortunate to work in an environment now where [verbal abuse] has become substantially less tolerated and when it does happen, I have some recourse…. At least I get to write it down and tell somebody. [Washington area] [Male nurse:] Personally , I know I’m treated differently because if I stand up for myself the docs won’t dismiss me. [Baltimore] The younger nurses that are coming into the field now are not as tolerant of the abuse, the disrespect, the long hours, and the mandatory overtime. They say, “I’m not going to deal with this; I don’t have to.” They’ll leave the field; they’ll leave the hospital. We should have done that. [Washington area] I think respect…[in] the way nurses are treated would be a big thing [Washington area].

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6. RELATIONSHIPS WITH SUPERVISORS Maryland nurses, both in the focus groups and in the Workplace Survey, were positive about their immediate supervisors. They were more reserved, however, about the ability of nurse managers to be effective advocates for their staff. Two-thirds of the survey respondents thought that their supervisor was competent and had adequate skills for the position. More than half, however, felt that their supervisor did not receive the kind of backing from the organization’s administration to enable them to support and respond to nurses’ concerns related to staffing and scheduling. Almost all of the focus group participants said that raising concerns on the job was not effective. They noted that many managers were not experienced in the area they were managing. These managers were said to have unrealistic expectations of what nurses could handle, and they could not help with patients when needed. Some participants mentioned that even when the manager was a nurse, the manager might still expect too much because upper management was actually giving the orders. On the other hand, a number of participants said that when a nurse manager was a “team player,” it had a positive effect on the working environment. If you do get a manager who has been a nurse, she may not have been specialized in that particular area. If they’re not specialized in that area, they really don’t know [it]. [Baltimore] I think it’s pretty sad when a supervisor cannot take care of patients and at my hospital that’s typical. If you’re going to be in charge, be the night supervisor, you should be able to take care of patients if you would actually need to, but they can’t. I would like for them to do some rotation, so if the worst case scenario came they wouldn’t say, “Well, I’m here, but I don’t know how to do it. [Eastern Shore] My direct boss has been fantastic. Anything you want to do, she’s very proactive, but she’s such a rarity. In 30 years of nursing, I’ve had two like her. I mean the rest of my bosses have been people who should have never been in management, because they were people who were really good at the bedside, but they didn’t have whatever management skills that one needs. [Washington area] Focus group participants in more rural areas reported that it was difficult to bring up personal concerns in the workplace. They said they were expected to raise only concerns that dealt with patient care. Examples of issues they found difficult to discuss with management included lack of backup staff, having to work when sick, poorly trained new employees, inequities of assignments and income, and scheduling. Nurses felt that they raised personal concerns at their own risk. Nurses who were able to make decisions and voice their opinions in their work appeared to enjoy their jobs more than others. However, in some facilities, nurses felt that only lip service was being paid to their complaints. 66

If I don’t like something, I can go directly to my clinical manager’s office…and she isn’t waiting to ding me on an evaluation because I’ve made an observation or because I have an opinion on something. My opinion is worth something and that is really important. [Baltimore] It has changed our language in that we now talk about system issues. I really see a difference in how people respond to it and much more willingness to use it. [Washington area] We did this survey and I actually got a chance to stand up and say, “Well, we really don’t know how well we’re doing. We’re not doing a good job training our new people.” Now it’s like a new idea. [Washington area] To retain nurses, listen to the staff and find out what their needs are and respond. [Baltimore] Wouldn’t it make you feel differently if management said, “Okay, here’s something we’ve got to work on,” and they make it part of their job and actually come up with a resolution to a problem? [Western Maryland]

C. RECENT CHANGES IN THE WORKPLACE
The focus group participants noted some positive and negative changes over the past two years, and mentioned several institutions in Maryland where positive change has occurred. Some participants noted increased efforts to pay attention to the needs of nurses. Interdisciplinary team models and self governance have met with success. Some hospitals have conducted surveys of nurses and held internal focus groups to discuss nursing issues. Some participants noted as positive developments retention bonuses, recent raises, and advertising that mentioned the role of nurses. Negative changes noted were additional paperwork, the increasing severity of the nursing shortage, increased cost-cutting as a result of managed care, and hospital mergers that placed additional responsibilities on nurses. A new focus on improving customer service was viewed as a change with both positive and negative aspects. Nurses said that it had improved relationships among employees in different departments of the hospital so that they communicated better and provided support to one another. A negative aspect mentioned by some participants is that nurses felt pressured to improve customer service to patients at a time when they were already stressed by their current responsibilities and situations.

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5.NURSING EDUCATION IN MARYLAND
With about 2,300 full-time jobs open in Maryland hospitals, even if every one of the 800 to 1,000 nursing students expected to graduate in the state this year were hired, hospitals would still be short-staffed. —The Washington Post, p. A17, May 14, 2002 The supply of new nurses in the state comes primarily from graduates of nursing education programs in Maryland. This chapter describes Maryland’s nursing education programs, examines patterns in enrollments and graduations, considers recruitment issues related to the image of nursing, especially among young people, and summarizes trends in nursing education.

A. TYPES OF NURSING EDUCATION PROGRAMS
1. REGISTERED NURSING PROGRAMS (RN) Three types of nursing programs lead to eligibility for the RN license: associate degree (ADN), baccalaureate (BSN), and hospital-based diploma programs. Hospital-based programs, historically the largest supplier of nurses, have closed in Maryland although many current nurses hold a hospital diploma as their basic preparation. Baccalaureate programs also enroll students who already have an RN license but want to advance to a baccalaureate degree (RN to BSN). a. Associate Degree Programs Associate degree nursing programs (ADN) were developed in the early 1950s in order to increase the supply of nurses by establishing a new technical level of nursing. ADN graduates from approved nursing programs are eligible to take the RN licensure examination (NCLEX-RN). Graduates are prepared to function as caregivers in a variety of settings and to work with other professional nurses and members of the health care team in planning and implementing comprehensive health care (Maryland Board of Nursing, 2001). Fourteen of Maryland’s community colleges offer ADN programs in nursing. The ADN program is designed to be completed in two academic years by a full-time student, although many programs require five semesters or one or more summer sessions to complete the requirements. The number of graduates per year varies among these institutions, with about half producing fewer than 40 graduates. Prince George’s Community College, Anne Arundel Community College, and the Community Colleges of

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Baltimore County produce on average between 90 and 100 graduates per year. All of the colleges admit part-time students. Half of the programs offer evening nursing courses, and two offer nursing courses on the weekend, to accommodate working students. b. Baccalaureate Programs Eight colleges and universities in Maryland offer the basic, or traditional, entry-level BSN program (Bowie State University, Columbia Union College, Coppin State College, Johns Hopkins University, Salisbury University, Towson University, University of Maryland Baltimore, and Villa Julie College). These programs are designed to be completed in four academic years. Graduates are awarded either a bachelor of science in nursing degree (BSN) or a bachelor of science degree (BS) with a major in nursing. Upon completion of the program, graduates are eligible to take the NCLEX-RN examination. The baccalaureate programs prepare the graduate to provide care to individuals, families, and communities in wellness and illness settings that provide comprehensive health services. Baccalaureate nurses are prepared to assume positions of leadership and professional responsibility in a variety of practice settings. Programs consist of a combination of general education and science courses, with an upper division concentration on nursing theory and clinical practice (Maryland Board of Nursing, 2001). All of the baccalaureate programs except those at Johns Hopkins University and Towson University offer courses in the evening. All accept part-time students. c. RN to BSN Programs The institutions that offer baccalaureate programs also offer programs for registered nurses prepared in associate degree or hospital-based programs. The College of Notre Dame of Maryland offers only the RN to BSN program. Students in the RN to BSN program often attend school part-time since most continue to work as nurses while they pursue their degree. According to the Maryland statewide articulation model, graduates of associate degree nursing programs can transfer 30 nursing credits and 30-36 general education credits to participating colleges offering baccalaureate nursing programs in the state so long as they enroll within seven years of graduation and have graduated from an accredited program. Students are then required to take up to an additional 64 credits, in general education, science, and nursing. A second option is an examination option, which validates 30 nursing credits and may transfer up to 60 additional general education and science credits. For RNs who completed their nursing education more than seven years before their baccalaureate admission, 60 credits can be accepted after the completion of three transition courses. d. Advanced Education Programs Maryland’s educational institutions offer accredited graduate programs in nursing at the master’s and doctoral levels and also post-master’s certificate programs. These programs prepare students for careers as advanced practice nurses, nursing administrators, researchers, and nursing faculty.

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At the master’s level, the largest programs, at the University of Maryland and the Johns Hopkins University, offer an array of specialties that prepare advanced practice nurses, including nurse practitioners, certified nurse midwives, and clinical nurse specialists. The fourth type of advanced practice specialty, the nurse anesthetist program, is not offered in Maryland. The University of Maryland Baltimore, among its 20 specialties, offers eight nurse practitioner programs, a nurse midwifery program, programs in informatics, administration, and environmental health, and M.S. or Ph.D. programs combined with an M.B.A. in cooperation with other University of Maryland institutions. Johns Hopkins University has an acute care and three primary care nurse practitioner programs, clinical health specialties in forensic nursing and health systems management as well as a community health nurse specialty. In addition, joint master’s degree programs in nursing and public health or business administration are offered. Johns Hopkins University and the University of Maryland offer the two doctoral programs in the state. Coppin State College, Bowie State University, and Salisbury University offer the family nurse practitioner program. In addition, Bowie State University offers a community/public health clinical specialty, and Salisbury University offers programs that prepare nursing service administrators and home health nursing clinical specialists. 2. PRACTICAL NURSING PROGRAMS (LPN) There are twelve approved practical nursing programs in Maryland. Eleven programs are offered by community colleges; there is also a two-year high school program. Upon completion of these programs, graduates are eligible to take the practical nursing licensure examination (NCLEX-PN). The LPN program prepares the graduate to function as a direct caregiver in a team relationship with other licensed health professionals (primarily RNs) in structured settings such as hospitals, nursing homes, and chronic care facilities. The program places an emphasis on clinical practice skills and generally requires a full year of education, including a summer session (Maryland Board of Nursing, 2001). In a number of community colleges, LPN students and RN students take the same curriculum for the first year. LPN students take a summer option to complete their program and are then eligible to take the NCLEX-PN examination. These students, after licensure, may apply for the second year of the RN program to obtain their associate degree. Under a statewide articulation plan, graduates have the opportunity to transfer, within five years of graduation, some or all of their credits to any Maryland associate degree program. Upon completion of the associate degree program, they are eligible to take the NCLEX-RN examination. LPN programs have been producing fewer than 170 graduates per year, a total that has not fluctuated significantly in the past ten years. Many programs have fewer than 20 graduates each year. The largest programs are at Wor-Wic Community College and Prince George’s Community College. Effective September 2001, applicants for LPN licensure who graduated from a registered nursing education program approved by the Maryland

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Board of Nursing, or from a program that the Board finds substantially equivalent to approved registered nurse programs, may also take the NCLEX-PN and become licensed as an LPN. 3. FINANCIAL AID The importance of financial aid for nursing students was documented in a survey of students conducted by Maryland Colleagues in Caring in 2000. Over 40% of the students surveyed reported that tuition support and support from significant others affected to a great extent their ability to begin or continue their program. More than 60% said that balancing school, work, and family obligations affected to a significant extent their ability to begin or continue their program, and 50% reported that it was necessary to reduce their number of work hours in order to pursue their education (Maryland Colleagues in Caring, 2001). a. Aid to Students A variety of types of financial aid are available from state agencies and from health care institutions. In addition to the types of scholarships for which students are broadly eligible, the Maryland Higher Education Commission administers scholarship programs that are either designated specifically for nurses or are limited to the health professions. The State Nursing Scholarship and Living Expenses Grant Program makes awards for tuition and fees up to $3,000 and a stipend of up to $3,000 per year. Recipients must enroll for at least 6 credits of nursing per semester and serve as a full-time nurse in Maryland after graduation, for one year for each year of the scholarship in a licensed hospital, public health agency, nursing home, home health agency, or adult day care facility. While this program is of benefit to many students, according to the Maryland Board of Nursing more than 200 eligible applicants were not funded in 2001 (personal communication, 2003). Ten percent of the funds are reserved for nurses pursuing advanced degrees. In addition, through the Health Personnel Shortage Incentive Grant Program, out-of-state students pursuing a nursing degree can pay tuition at Maryland colleges and universities at the in-state student rate, in return for agreeing to practice nursing in an approved facility in the state after graduation. The Graduate and Professional School Scholarship, which is designed for full-time students in the health, human services, and law professions, has a stipend which was raised in 2001 from a maximum of $1,000 per year to a maximum of $5,000 per year. In addition, a statewide loan assistance repayment program (LARP) has been established that includes nurses employed in shortage areas as defined by the Department of Health and Mental Hygiene. In 2002, 51 awards were made. Eligible nurses must be employed either in state or local government or in the nonprofit sector. A number of hospitals have established nurse externship programs, which provide parttime jobs for student nurses and provide tuition assistance in return for students’ agreeing to accept employment with the institution upon graduation. Some hospitals offer tuition reimbursement programs to non-nursing employees, including technicians and nursing aides, who wish to pursue first degrees in nursing.

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The Clinical Scholars Program, developed by the University of Maryland School of Nursing, with funding of $1 million as of 2002, established partnerships with hospitals in Baltimore, Montgomery County, and Washington, DC. The program provides tuition assistance for nursing students in their final year of the baccalaureate program; students take a capstone clinical emphasis course at one of the participating hospitals and then agree to accept employment for one year in that hospital after graduation. Similar programs have recently been established by other nursing education programs. BD Diagnostic Systems and the Association of Maryland Hospitals & Health Systems established the BD-MHA Hospital Scholars Program in 2002 to support Maryland residents who are preparing for careers in health care professions. Of the ten hospital employees who received scholarships of $2,500, four of the recipients are pursuing BSN degrees and two are pursuing ADN degrees. b. Aid to Institutions The Health Personnel Shortage Incentive Grant Program provides funding to Maryland educational institutions based on the increased number of graduates eligible for licensure, certification, or registration in certain health occupations experiencing shortages. The allocation formula for funding to the institution is $1,500 for each eligible student. In FY 2002, eligible programs included nursing, physical and occupational therapy, medical technology, radiology, health care and health information technology, physician assistant, dental, pharmacy, and family practice. The total amount awarded to all institutions was $338,747. Grant funding was used by the institutions to recruit students and market programs. Schools also invested in computer equipment and clinical laboratory enhancements and held professional development workshops for faculty.

B. TRENDS IN ENROLLMENTS AND GRADUATIONS
Enrollment and graduation data from the Maryland Higher Education Commission (MHEC) and the Maryland Board of Nursing were compared for purposes of this study. The data was not found to be comparable because of differences in reporting criteria, especially for enrollment data. In addition, between 1997 and 2001, the Board of Nursing collected data on admissions rather than on enrollments. For these reasons, specific enrollment data is not reported here. The MHEC graduation data shows only slight differences from the Board of Nursing data and has been used here for the analysis of graduation trends. Data on first-time takers of the NCLEX-RN and NCLEX-PN examinations, compiled by the Board of Nursing, is reported as an additional source of information.

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1. RN PROGRAMS a. Enrollments The available enrollment data cannot be reliably used at this point except to indicate broad trends. It is clear that enrollments in both associate and baccalaureate degree programs in Maryland increased substantially during the period from the late 1980s through 1993-1994 and then declined through the year 2000 (especially in associate degree programs), turning up again only in 2001. This is consistent with national trends, as described in Chapter 1. b. Graduations For the analysis of the number of graduations from Maryland nursing education programs, MHEC reports of degrees awarded were used (MHEC, 2002). The number of associate degree graduates in Maryland rose overall between 1988 and 2001 by 7.2%, from 643 to 689 graduates. This number masks considerable changes: an increase of 52.7% from 1988 to 1994, to a high of 982 graduates, and then a decline of 29.8% by 2001 to 689 graduates (approximately the level in 1990).
Number of Associate Degree Graduations, 1988-2001
737 839 903 982 909 882 843 841 768 791

643

557

660

689

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Data source: MHEC, 1988-2001

Year

The number of baccalaureate graduates has not declined as steeply as the number of associate degree graduates. The number of baccalaureate graduates in Maryland (including RN to BSN students) grew by 27.3% between 1988 and 2001. The number increased by 55.0% between 1988 and 1998, to a high of 885, and then decreased by 17.9%, to 727 in 2001 (approximately the level in 1994). The number of nursing graduates in Maryland can be expected to continue to decline each year until the larger number of students who enrolled in 2001, and are currently in the educational pipeline, graduate.

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Number of Baccalaureate Degree Graduations, 1988-2001
705 784 836 883 885 831 795 727

571

544

508

470

583

668

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Data source: MHEC, 1988-2001

Year

These trends are also evident in the number of graduates of Maryland nursing programs who took the NCLEX-RN examination for the first time. The number of associate degree graduates taking the NCLEX-RN examination decreased by 13% between 1993 and 2002, but dropped more steeply, by 29%, between 1995 and 2002. The number of baccalaureate graduates taking the examination for the first time increased by 2% between 1993 and 2002, but decreased by 16% between 1995 and 2002. The total number of new graduates of Maryland nursing programs taking the NCLEX-RN licensure examination for the first time between 1995 and 2002 (including graduates from hospitalbased programs up to the year 2000) fell by 29%, or 504 graduates.
Graduates of Maryland RN Programs Taking the NCLEX-RN for the First Time
1043 854 854 579 332 590 884 587 847 624 763 563 682 704 580 569 746 498

1993

1994

1995

1997

1998

1999

2000

2001

2002 Baccalaureate

Data not available for 1996. Data source: MBON, 1993-2002

Year

Associate

These numbers are similar to national trends. The number of first-time U.S.-educated associate degree graduates who took the NCLEX-RN decreased by 28.2% between 1995 and 2001; the number of baccalaureate graduates decreased by 20.4% (National Council of State Boards of Nursing cited in AACN, 2002c).

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2. LPN PROGRAMS Trends in LPN programs are difficult to determine because some colleges have a separate practical nursing program while others issue an LPN certificate as part of their associate degree RN programs. All but one of the high school programs were phased out in favor of programs in community colleges. The trend in LPN programs can be seen in the results of the NCLEX-PN examination. Data is available for first-time test takers in Maryland from 1997 through 2002. The number of practical nursing program graduates taking the NCLEX-PN examination declined by 29%, from 446 in 1997 to 319 in 2002.
Graduates of Maryland LPN Programs Taking the NCLEX-PN for the First Time
446 370 322 318 307 319

1997 Data source: MBON, 1997-2002

1998

1999 Year

2000

2001

2002

The decline in the total number of students graduating from Maryland nursing education programs means a decrease in the number of new nurses likely to practice in Maryland. The increase in enrollments that began in Fall 2001, while signaling a shift in enrollment trends, is still insufficient to meet the projected demand over the next ten years.

C. TRENDS IN NURSING EDUCATION
Nursing schools in Maryland and across the country are struggling to find creative ways to expand student capacity despite such challenges as funding cuts, inadequate facilities, competition for students, an insufficient number of clinical placements, and a growing shortage of nursing faculty. While nursing schools are stepping up efforts by recruiting new populations into nursing, increasing the use of clinical simulation laboratories, developing alternative types of clinical placements, and increasing access through distance learning programs, it is clear that to meet the growing demand for nurses, new approaches to recruitment, curricula, and program organization and delivery must be adopted. 1. IMAGE OF NURSING In March 2001, the University of Maryland School of Nursing held a number of focus groups to elicit perceptions about nursing as a career in order to market its programs more effectively. High school and college students participated as well as current nursing students and practicing nurses. One focus group consisted entirely of male nurses and

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nursing students. The discussions revealed that there are considerable obstacles to recruiting more students into nursing programs. The high school and college students who participated in the focus groups did not think of nursing as a viable career option. They viewed nurses as having a subordinate role to physicians in hospitals and thought that people chose nursing as a career because they did not have the commitment to become a physician. These students had a perception of nursing as drudgery, with women performing difficult tasks and receiving salaries that were not commensurate with the level of responsibility. Their views have been negatively influenced by television and movie portrayals of nurses (University of Maryland School of Nursing, 2001). In the words of one of the nurse participants in the focus groups conducted for the present study (2002): I think that in terms of what nursing needs to do in order to attract people to the profession is that we have to correct the image of nursing ..... People that aren’t nurses need to understand how important nurses are for them in the event that they are ill [and] how much we can impact health care in the future. a. Nursing as Women’s Work Women currently constitute 95% of the nursing population. Replenishing the supply of nurses has traditionally meant recruiting women. However, women now have an array of career options, a situation very different from that of the first six decades of the twentieth century, when a large proportion of young women went into careers designated as suitable for women—teaching, social work, librarianship, and nursing. Beginning in the 1960s and 1970s, professional schools of medicine, law, and business began admitting significantly larger numbers of women, and women began to make gains in scientific and engineering fields as well. Men currently constitute 5.4% of RNs, up from 2.7% in 1980 (NSSRN, 2000). Although increasing rapidly, the number of men in nursing is still small. It has been suggested that if men entered nursing at the same rate that women do now, the problem of RN shortages would be solved (Buerhaus et al., 2000c). However, men are leaving direct nursing for other jobs in nursing or other careers at a higher rate than women, or not even entering nursing after they receive their nursing degrees (Sochalski, 2002). Male high school and college students in the University of Maryland focus groups (2001) viewed nursing as “not a manly thing to do” and were concerned that others would make fun of such a choice. Even young women in the focus groups agreed that men would have to be strong to put up with the gender stereotypes. Some of the male nursing students in the focus groups had entered nursing because they were not admitted to medical school or had decided that they did not want to invest the time involved in a medical education. Others had been unsuccessful in seeking admission to a physician assistant program. Male students had been influenced by other nurses, but said that an even greater influence

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had been physicians and physician assistants. Like female nurses, male nursing students and nurses had been attracted to nursing because of the diversity of specialty options, the opportunity for advancement, and the experience of working with people and making a difference in their lives. Male nursing students and nurses in the focus groups thought that nursing had greater advancement opportunities for men than for women, an opinion supported by female nurses. Many male nurses had advanced to more technical roles that the public might not perceive as typical nursing positions. Both male and female nursing students and practicing nurses thought that the nursing profession would be elevated as more men entered the field. Salaries would rise and greater respect would be accorded to nurses as the public began to view nursing as an important career (University of Maryland School of Nursing, 2001). b. Nursing as a Profession Many high school and college students in the focus groups did not understand the educational requirements for nursing and often confused RN education with vocational programs. They seemed unaware of the range of career options in nursing and the income potential. During the focus group sessions, however, when high school students were presented with the variety of potential nursing specialties and work settings, they viewed nursing somewhat more positively. Nurses have always been a primary source of student referrals into nursing, whether students encounter them as family members, friends, or professional caregivers. In the past, the children of nurses frequently chose nursing as a profession. This appears to be changing as a result of nurses’ dissatisfaction in the workplace and because of the alternative career options available to women. Many nurses, unhappy with their own positions, are reluctant to recommend nursing as a career to members of their family and friends. In a North Carolina study, while two-thirds of the RNs and LPNs surveyed were satisfied with their choice of nursing as a career, only about one-half would encourage others to become a nurse (North Carolina Center for Nursing, 2002). Many nurses in the 2002 focus group sessions conducted for the Nursing Workforce Project were willing to recommend nursing as a profession and had suggestions for recruiting students. Besides recommending improvements in nursing salaries, benefits, and working conditions, they urged targeting high school students and making them aware of the importance of nursing and the varied opportunities in the profession. I think you have to recruit younger. I think you have to look at the high school population, and if you want more nurses to come into the profession you have to make it appealing… Not just girls, boys too, who are in high school, and say this is a worthwhile profession to get into…. [It’s] not that the hospital isn’t important, because it is, but there’s tons of different opportunities…. And they don’t really market that to high schoolers.

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The greatest challenge for nursing schools is recruiting college-bound youth into nursing careers. A nationwide attempt to improve the image of nursing and increase interest in nursing careers can be seen in Johnson & Johnson’s $20 million multiyear Campaign for Nursing’s Future, launched in 2001 in collaboration with professional nursing organizations. This is a multimedia initiative to promote careers in nursing, which includes television advertisements, a recruitment video, a website, and brochures mailed to schools across the country. In Maryland, the Recruitment Committee of the Maryland Commission on the Crisis of Nursing has developed a toolkit of information to help parents, teachers, and community organizations promote health careers and has developed a website together with the Association of Maryland Hospitals and Health Systems (www.marylandhealthcareers.org). 2. EXPANDING DIVERSITY AND RECRUITING NEW POPULATIONS INTO NURSING Since nurses from minority racial/ethnic backgrounds represent the fastest growing segment of the nursing population, recruitment of students from minority and other underrepresented populations is an important way to increase enrollments. Both shortterm and long-term strategies are being used to promote nursing as a career choice among these groups through programs targeted at middle and high school students in urban areas, environments that promote cultural awareness, and programs that provide faculty mentoring and other types of assistance for nursing students. Diversity also includes generational diversity, attracting older students who may be considering a new career in nursing. Until recently, career changers and second-degree students (students with a baccalaureate degree in another field) were a virtually untapped market. Given the current economic climate, accelerated degree programs are quickly gaining momentum nationwide. A recent report by the American Association of Colleges of Nursing suggests that second-degree students bring “new dimensions to nursing and a rich history of prior learning” (AACN, 2002c). Employers value graduates of accelerated programs for their multidimensional skill sets and their years of academic study and work experience. These older, generally high achieving students appear to be more highly motivated and therefore may be more likely to pursue advanced degrees in nursing. A number of nursing schools in Maryland now offer an accelerated option leading to the BSN in programs ranging from 13.5 months to three semesters. Students obtain the same number of clinical hours as students in traditional programs through a combination of prerequisite offerings and summer and other “bridge” programs. Some institutions also offer accelerated RN to BSN programs and accelerated programs leading to a master’s degree. 3. CLINICAL SIMULATION AND ALTERNATIVE CLINICAL EXPERIENCES To help overcome the shortage of clinical training sites and nurse preceptors, nursing programs are relying more on technology-based simulated clinical and pre-clinical practice experiences. Such training, often organized in self-paced instructional modules, allows students to master basic and advanced psychomotor skills through simulated, hands-on learning experiences, thereby reducing the number of faculty needed for

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supervision. An additional benefit of simulation technology is that clinical learning and evaluation have been shifted to a safer learning environment, but with comparable technological sophistication. Universal Patient Simulators (Sim Man) represent the latest intelligent manikins on which students can safely perform procedures and receive feedback. Another trend in simulation education is the use of standardized patients: human actors trained to role-play individuals who have specific health conditions. Human patient simulators are a sophisticated method of clinical education and are expected to become a standard component of nursing education in the future. To offer students additional clinical experiences and to provide service to the community, schools of nursing have established nurse-managed primary care clinics in which students can obtain clinical practice experiences. Such operations expose students to a wide array of clinical experiences. Both Coppin State College and the University of Maryland offer nurse-managed clinical experiences on their campuses. At Coppin, the clinic serves as the student health center as well as providing services to the neighboring community. At the University of Maryland, an ambulatory pediatric clinic is operated in cooperation with the Schools of Medicine, Pharmacy, and Social Work. The University of Maryland also operates the Governor’s Wellmobile Program, with a fleet of five vehicles, that provides nurse practitioner services across the state and links patients with health care providers in their locality. At the five Lillian Wald Community Health sites, Johns Hopkins University nursing faculty and students provide patient care services in Baltimore. The University of Maryland also operates a community-based health center, Open Gates, in southwest Baltimore, where faculty and students provide health services to an underserved urban population. 4. USING TECHNOLOGY TO INCREASE ACCESS TO NURSING EDUCATION Some of Maryland’s nursing education programs are investing more heavily in technology to accommodate students who work or reside in educationally underserved geographic regions of the state. Such technology includes an increasing number of interactive web-based courses. Distance learning technologies, including audio/video simulcast, permit programs to be offered at remote locations with a combination of homebased and on-site faculty. The University of Maryland offers the RN to BSN degree also as a web-based program, with local arrangements made for clinical course components. 5. FACULTY SHORTAGES A study conducted in 2001 by the Council on Collegiate Education for Nursing of the Southern Regional Educational Board (SREB, 2002) found that the 491 institutions in the 16 SREB states (including Maryland) and the District of Columbia reported more than 425 unfilled faculty positions; 86 institutions reported that they did not have enough faculty to staff their undergraduate and graduate programs. Twenty-five percent (25%) of baccalaureate programs reported that they could not accept more students, and more than two-fifths (43%) of associate degree programs that said they had no more capacity.

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In Maryland, the Board of Nursing estimates that about 20% of qualified students (a total of 733) applying to baccalaureate, associate degree, and practical nursing programs in 2000-2001 were not admitted because of the stated inability of nursing programs to accept additional students. Of the 14 associate degree programs, eight had caps on admissions, as did six of the baccalaureate programs, two of the RN to BSN programs, and most of the LPN programs. Nursing faculty have some unique characteristics when compared with faculty in other disciplines. First, the requirement of a doctoral degree for nursing faculty was established relatively late. In 1978, only 15% of faculty in nursing schools held a doctoral degree. Although the proportion of faculty holding doctoral degrees grew to 50%, there has been no further increase in this percentage in the past five years (AACN, 2002d). The number of students in the United States graduating with doctoral degrees in nursing has essentially been flat for five years, with 409 students receiving degrees in 2001 (AACN, 2002b). Maryland has two doctoral programs in nursing, at Johns Hopkins University and the University of Maryland Baltimore. These programs awarded 17 doctorates in 2001; the number has varied between 13 and 19 per year since 1996. Graduate students in nursing take much longer to receive their degrees than do students in other fields. The mean number of years enrolled in a doctoral program was 8.3 years for nursing graduates nationally compared with 6.8 years for all doctoral recipients. Median elapsed time between entry into a graduate program (master’s) to completion of the doctorate in nursing was 15.9 years, almost twice as long as in other fields (8.5 years) (Berlin and Sechrist, 2002). Nursing faculty, like other faculty, are increasing in average age, but in nursing, where doctoral study is undertaken later than in many other fields, the average age of assistant professors in baccalaureate and graduate programs is high and is increasing (from 45 years of age in 1996 to 50.4 years in 2001) (AACN, 2000d). In 1993, 50.7% of faculty were 50 years of age and over; in 2001, that proportion was 70.3% (Berlin and Sechrist, 2002). Nursing faculty retire at 62.5 years of age on average, and therefore occupy a faculty role for only 15-20 years, a shorter average time than in other disciplines (Hinshaw, 2001; Berlin and Sechrist, 2002). By the end of 2006, 784 nurse educators in the southern states, including Maryland, are expected to retire (SREB, 2002). Nurses with doctorates have many choices besides academic positions; they can serve as chief nursing officers, clinical researchers, and directors of corporate quality assurance and research programs. Often these positions are more highly paid than faculty positions, and nursing programs are hard-pressed to pay competitive salaries to retain faculty. The Council on Collegiate Education for Nursing, Southern Regional Education Board, reported on the post-resignation status of 223 former nursing faculty members. Of those whose status was known, 40% had remained in teaching, but more than half had taken a clinical (40%) or private practice (14%) position, and 5% had left nursing (SREB, 2001). Of the U.S. doctoral graduates in nursing who received degrees in 1998 and 1999, 25% reported that they had taken jobs other than in schools of nursing (Berlin and Sechrist, 2002).

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Across the country, schools of nursing are attempting to expand the pool of faculty through such measures as joint appointments with health care institutions; improved marketing, financial incentives and scholarships; accelerated educational programs; and new approaches to retaining senior faculty (AACN, 2002c; Hinshaw, 2001). To contain costs, more collaborative arrangements and joint appointments could be established between health care and academic institutions to share the limited pool of clinicians/faculty with advanced degrees in nursing.

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6.CONCLUSIONS AND RECOMMENDATIONS
A. CONCLUSIONS
Maryland is facing a nursing workforce crisis that is quantitatively and qualitatively different from past shortages. The shortage has arisen from a confluence of factors affecting both the supply of nurses and the demand for health care services. The current estimated shortage of 3,000 nurses in Maryland is projected to worsen significantly over the next decade. The demand for nurses in Maryland, in 2012, is projected to grow to 62,333 nurses. The supply of nurses is projected to increase by 7%, from an average of 49,010 for 1999-2001 to 52,587 in 2004, and then to decrease by 14% to 45,217 in 2012. The number of nurses in 2012, therefore, is expected to be nearly 3,800 fewer than in 1999-2001. The estimates made for the Nursing Workforce Project forecast a shortage of more than 17,000 nurses by 2012 if actions to increase the supply of new nurses and improve the retention of currently employed nurses are not effective. Fueling this increased demand over the period 2002-2012 is the projected increase of 16% (or 100,000 people) in the number of persons aged 65 and older. Since older people utilize health care services and facilities more intensively than younger people do, more health care professionals will be needed, most notably nurses. Changes in the organization of health care delivery, particularly managed care policies and increasingly sophisticated technology, also have had a significant effect on the demand for nurses. Hospital stays are shorter, and patients are older and sicker, requiring much more intensive care and monitoring. Because hospitalized patients are discharged earlier, many need more skilled nursing care in long term care settings and rehabilitation facilities or in home care, which increases the demand for nurses in those settings. Procedures that used to be performed in hospitals are increasingly being performed on an outpatient basis, thus requiring more specialized nursing services in ambulatory clinics, surgicenters, and the home. The projected decline in the supply of nurses in Maryland has several causes. Nurses are aging along with the general population. The median age of nurses in Maryland in 2001 was 45. Many nurses retire before their mid-60s, often in their 50s, because of the physical demands of nursing work. Twenty-two percent (22%) of nurses in Maryland are 53 years of age or older, and therefore large numbers can be expected to retire in the next ten years. The replacement of these nurses will increase the demand for labor well beyond that resulting from the growth in the number of new positions. In addition, many nurses are leaving the profession because of dissatisfaction with their working conditions. Although focus group participants in this study held the nursing profession in high regard and considered it a very valuable, rewarding, and challenging occupation, many said that changes in the way nursing is structured, especially in hospitals, made it difficult for them to experience the rewards of caring for patients in the way they had expected. Nurses report that the relentless pace of work leads to stress and

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burnout. The dominant issue raised in both the focus groups conducted for the Nursing Workforce Project and the Workplace Survey conducted for the Maryland Commission on the Crisis in Nursing was nurses’ perceptions that they were often unable to provide quality care because they could not spend enough time with patients. An inadequate number of auxiliary and support staff has exacerbated the problem. Other issues were related to shift work and the volume of paperwork and documentation that nurses are required to complete. Professional issues were another concern: many RNs said that they felt they were not respected or viewed as professionals and were not given the autonomy of practice that they had expected. Many believed they had little input into decisions that affected their work. Nurses who responded to the Workplace Survey indicated that some of these issues would lead them to consider changing their job or leaving nursing altogether. In response to the shortage, hospitals and other health care facilities have pursued competitive strategies to recruit and retain nurses by offering substantial salary increases and bonuses for new hires, more flexible scheduling, by recruiting overseas, and utilizing expensive agency nurses to supplement staffing. These are short-term strategies. The 37% increase in the use of agency nurses in Maryland hospitals between 2001 and 2002 (over 500 additional nurses) is a measure of the magnitude and cost of the problem. To help meet the increasing demand for nurses, long-term strategies must be adopted and a much greater investment made in the retention of currently employed nurses. The diminishing supply of new nurses also is at the heart of the problem. At current enrollment levels, the demand for nurses will continue to exceed the supply. Fewer students have been graduating from Maryland colleges and universities with degrees in nursing. The number of graduates with associate degrees in nursing fell by 29.8%, from a high of 982 graduates in 1994 to 689 in 2001. The number of graduates with a baccalaureate degree in nursing has declined by 17.9%, from 885 graduates in 1998 to 727 in 2001. After declining steadily since 1993-1994, nursing enrollments at community colleges and universities increased for the first time in 2001. However, the number of nursing graduates in Maryland can be expected to continue to decrease until the students who are now in the educational pipeline graduate. The Maryland Board of Nursing estimates that about 20% of qualified applicants to nursing programs in 2000-2001 were not admitted because of the stated inability of nursing programs to accept additional students. This represents 346 applicants to basic baccalaureate programs, 323 applicants to associate degree programs, and 58 applicants to practical nursing programs. A number of programs have capped admissions. According to regional and national reports, growing faculty shortages and an inadequate number of clinical placement sites are contributing factors in limiting the number of students admitted to nursing programs. A key aspect of the supply problem is the fact that nursing is viewed unfavorably by young people making decisions about a career. High school and college students in focus groups conducted by the University of Maryland School of Nursing in 2001 did not consider nursing a viable career option. These students had a perception of nursing as

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drudgery, with women performing difficult tasks and receiving salaries that were not commensurate with the level of job responsibility. Many students did not understand the educational requirements for nursing and often confused professional nursing education with vocational programs. Their views have been negatively influenced by television and movie portrayals of nurses. Male high school and college students in the focus groups viewed nursing as “not a manly thing to do.” Nursing represents the single largest health care occupation and is the backbone of the health workforce, which is critical to the ability to deliver safe and high quality health care in Maryland. Furthermore, labor costs are the major driver of health care expenditures. The current and projected shortages in nursing and other sectors of the health workforce could ultimately threaten the viability of the health care industry, with significant economic implications for the state. High vacancy and turnover rates in health care facilities and an educational system that is not currently producing enough professionals and skilled workers to meet employers’ needs will also result in an erosion in the quality and safety of health care services. A shortage of nurses has been shown not only to limit access to health care services but also to diminish the quality of care and to endanger patients, putting them at risk for increased illness, disability, and even death. The shortages are a symptom of a much larger problem: an increasingly overburdened health care delivery system that has undergone a sea change over the past two decades, and a dissatisfied, overstressed workforce. Taken together, these should be viewed as warning signs of even greater problems in the future if decisive action is not taken now. Many states have become involved in addressing shortages of nurses and other health professionals, not only because of their role in the financing and regulation of health and education, but also in response to general concerns about access, safety, quality, and cost. Although the health care industry and the education sector have attempted to address these shortages, their actions alone cannot reverse this trend. Leadership by state government also is needed. A lack of attention to these issues will mean continued shortfalls in the nursing workforce. More focused and aggressive approaches are required to help close the gap between the demand for health care services and the projected supply of nurses. The assessment of nursing and other health workforce needs and the development of systems to address these needs must not be viewed as a one-time fix but as a long-term undertaking that will require sustained attention and investment. The state and the nation’s changing demographics will continue to put greater strains on the health care delivery system. While the slight increase in nursing school enrollments in 2001 represents a shift from the decline over the previous six years, the number of students in the educational pipeline is still insufficient to meet the projected demand over the next ten to twenty years. Over that period even greater shortages are likely than have been seen in the past because the underlying problems contributing to the shortage remain unresolved. It is possible that the recent enrollment increases may be a result of the downturn in the national economy. Another factor, the potential need for additional nurses in disaster preparedness as a result of September 11, is yet to be explored. Key stakeholders including, nurses, academic institutions, the health care industry,

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professional associations, government agencies, legislators, philanthropic organizations, and consumers, must attempt to find solutions to these problems by stimulating new partnerships, implementing innovative strategies, and reaching across organizational and institutional lines, and even state and international borders to address the nursing and health workforce shortage. Inherent in the ability to mitigate the nursing shortage is a better public understanding of the ramifications of the shortage and the political will for action.

B. RECOMMENDATIONS
While some progress has been made in addressing the nursing shortage in Maryland from a recruitment and retention perspective, more concerted efforts are required. The following recommendations are derived from the findings of the Nursing Workforce Project. Many of the recommendations also are applicable to other health professions experiencing workforce shortages. 1. LAUNCH AN AGGRESSIVE STATEWIDE EFFORT TO BUILD THE EDUCATIONAL PIPELINE. a. Develop more effective strategies to increase student enrollments in existing RN and LPN programs and recruit a more diverse student population. (1) Increase outreach to youth through partnerships with K-16 education, with particular attention to middle school students. Many more college-bound youth must be recruited into nursing careers. As focus groups conducted with students have shown, attitudes towards nursing as a career are shaped well before college. Various strategies that target young people from kindergarten through high school have had some success in changing their views of nursing. These include pre-nursing academies or magnet schools that have a focus on nursing and other health careers; advertising and media campaigns geared toward attracting youth into nursing; organized programs, such as summer camps, that allow students to experience health care environments first-hand as well as outreach to middle- and high school guidance counselors who, in addition to parents, are key to decisions about higher education and career choices. The Recruitment Committee of the Maryland Commission on the Crisis of Nursing has developed a toolkit of information to help parents, teachers, and community organizations promote health careers and has developed a website together with the Association of Maryland Hospitals and Health Systems (www.marylandhealthcareers.org). Another resource is available from the U.S. Department of Health and Human Services, which recently launched the “Kids Into Health Careers” program.

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(2) Enhance recruitment efforts to reach out to underrepresented minorities and men. Recruitment of more underrepresented minorities and men is essential to building diversity and developing a nursing workforce that mirrors the general population. Nurses from ethnic/racial minority groups have the potential to provide more culturally competent care and improve access to care for minority populations. Schools should adopt more effective strategies to recruit students from underrepresented minority groups and provide an environment that promotes cultural awareness and provides faculty mentorship and advisement. Special recruitment initiatives are needed to enhance the image of nursing as a career for men to make them aware of the salary potential and career prospects available in nursing. (3) Target second degree/second career students by streamlining nursing curricula to offer accelerated entry-level BSN programs of 12-15 months. Building diversity in the nursing population and reaching out to underrepresented populations also includes generational diversity, attracting older students who may be considering a second career in nursing. Given the current economic climate, accelerated degree programs are quickly gaining momentum nationwide and should be more widely adopted in Maryland. Employers value graduates of accelerated programs for their multidimensional skill sets and years of academic and work experience. (4) Reduce financial barriers to nursing education by increasing scholarships and other financial aid. To promote access to nursing education, financial barriers must be reduced through incentives such as increased scholarships, student loans and other forms of assistance. Schools of nursing should be more proactive in raising not only state and federal aid on behalf of their students, but also funds from the private sector and the health care industry. Many students who work full-time and attend school part-time have difficulty balancing work and school responsibilities and take a longer time to complete their education. Increasing financial aid will permit more students to enroll in nursing programs on a full-time basis. Second-degree students, who frequently do not qualify for traditional types of scholarship, also need such assistance. (5) Support career ladders in nursing by developing sustainable career pathways for paraprofessionals. Opportunities should be provided for those already employed in health care, such as nurses’ aides and home health aides, to continue their education so that they can advance to LPN and RN positions. Encouraging career mobility would permit health care institutions to “grow their own” workforce. This would require partnerships between health care and

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academic institutions to provide advisement, develop mechanisms for evaluation of prior learning, and perhaps offer courses onsite in the workplace. Such career paths could increase the pool of applicants to nursing education programs and simultaneously retain workers in the health care industry. (6) Develop a coordinated statewide media and marketing campaign to improve the public image of nursing as a profession and to promote nursing as a career of choice. To counter negative stereotypes and improve the image of nursing, a statewide coordinated effort should be developed through a partnership among professional nursing associations, schools of nursing, government agencies, foundations, corporations, and the health care industry to influence public perceptions about nursing as a profession. Such a partnership would benefit from collaboration with public relations and marketing experts. Efforts could piggyback on national media campaigns, such as Johnson & Johnson’s “Campaign for Nursing’s Future.” b. Expand the capacity of nursing education programs to meet the projected statewide demand for nurses. (1) Coordinate statewide planning for increasing student admissions, enrollments, and graduations. To ensure that every qualified applicant has an opportunity to pursue a nursing education, admissions and enrollments must be coordinated among nursing programs and be based on statewide demand. Existing resources such as the Maryland Higher Education Commission, the Maryland Board of Nursing, and the Center for Health Workforce Development, University of Maryland, could provide the coordination and planning services needed for decision support. (2) Provide additional resources to promote the expansion of existing nursing education programs. If nursing programs are to expand their capacity to admit more students, they will require additional resources. These resources must be linked to increased admission, enrollment, and graduation targets; nursing education programs should be held accountable for meeting those targets. An existing source of funding, which could be enhanced, is the Health Shortage Personnel Incentive Grant Program. (3) Increase the supply of nursing faculty through fast-track preparation and the use of non-nurses in selected subject areas. A serious faculty shortage is anticipated as a result of the retirement of many current faculty and the small pool of nurses with advanced degrees available to assume faculty positions. The number of nursing faculty could be increased through fast-track preparation, for example, through the

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expansion of RN to MS programs. The definition of “nursing faculty” should be enlarged to include non-nurses in selected subject areas to augment instructional capacity in such non-clinical subjects as research methodology, informatics, and pathophysiology. To contain costs, more collaborative arrangements and joint appointments could be established between health care and academic institutions to share the limited pool of clinicians/faculty with advanced degrees in nursing. (4) Increase the use of pre-clinical simulation technologies and laboratories to augment capacity and reduce instructional costs. Building instructional capacity through innovative ways of teaching, if employed effectively, could increase productivity in nursing education programs. For example, pre-clinical simulation technologies allow students to practice technical procedures on “intelligent” manikins that are computerized and connected to state-of-the-art medical equipment in school laboratories. Self-paced instruction permits students to gain mastery of psychomotor skills and to work with less faculty supervision than is required in actual clinical settings. Another trend is the use of “standardized patients”: actors trained to role-play patients with specific health conditions. These kinds of experiences offers safe learning, practice, and evaluation opportunities and reduce instructional costs by decreasing faculty-student ratios. (5) Increase the accessibility and flexibility of educational programs through distance learning technologies and additional scheduling and outreach options. Nursing education programs can expand their outreach to educationally and geographically underserved regions of the state with the help of stateof-the-art interactive technologies, such as distance learning, audio/video simulcast, and Web-based courses. To meet the needs of students who are employed full-time, institutions can provide greater flexibility by expanding program delivery options to include evenings, weekends, summers, and “on-site” in the workplace. (6) Develop curricula that reflect changes in demographics and in the organization of health care delivery. Nurses must be prepared to work in an ever-changing health care environment. Curricula should place more emphasis on geriatrics to align nursing education with the current and future needs of a growing elderly population. To improve nurses’ competencies in supervisory and administrative positions, leadership and management content should be enhanced in the curriculum. Informatics also is an area of increasing importance in the management of nursing care and for clinical decision support. Because collaborative team practice is a hallmark of health care delivery in a managed care environment and a way to improve safe practices at the delivery level, health professions schools should identify

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core content and clinical experiences to foster interdisciplinary education for collaborative practice. (7) Strengthen strategic alliances with international partners. Maryland’s health care and educational institutions should strengthen relationships with their counterparts in other countries that are interested in enhancing the education and training of nurses, especially those coming to American markets. Foreign nurse graduates have augmented the U.S. nursing workforce during previous shortages and will continue to play an important role. Hospitals have been recruiting internationally; however, the international pool is not unlimited, and other countries, particularly the Philippines, Canada, and Ireland, are experiencing nursing shortages as well. However, some countries have nurses who may be willing to emigrate, particularly India, China, and Mexico. A role for Maryland’s health care and nursing educational institutions might be to assist in the development of educational programs abroad to prepare foreign nurse graduates for licensure in Maryland. The Maryland Board of Nursing would be key to such an effort. 2. REINVENT NURSING TO IMPROVE PRODUCTIVITY AND RETENTION: A number of actions can be taken to increase the satisfaction that nurses derive from their jobs. An equally important reason for redesigning nursing is to increase the productivity of nurses. It is clear that if efforts to increase the supply of nurses fall short of the demand, then changes in nursing practice must be implemented to utilize nurses more effectively. a. Redesign nursing work with meaningful input from nurses at all levels in the organization. (1) Staffing patterns and nursing workloads should be established on the basis of the degree of complexity of patient care and nurse qualifications and competencies. Differentiated practice models based on the level of patient acuity and the credentials and experience of nurses have been shown to improve job satisfaction, reduce nurse turnover rates and staffing costs, and reduce adverse events such as patient falls and medication errors. (2) New information systems technologies should be utilized to improve the quality and safety of patient care and to streamline reporting and documentation. Information systems technologies have been implemented in health care organizations for such functions as nurse scheduling, medication administration, clinical decision support, automated documentation, and computerized patients records. Such technologies could help to address

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nurses’ concerns about the burden of paperwork and documentation. In this connection, it would be useful to review regulatory requirements to determine ways in which federal and state reporting and documentation could be reduced. (3) Work processes that incorporate ergonomic principles should be developed to provide a safe practice environment for nurses. Wider use of lifting devices and other ergonomic improvements could help to reduce the high rate of injuries that nurses experience on the job. (4) To accommodate older nurses, more realistic and satisfying roles could be developed. New roles that might increase retention among older nurses could include serving as mentors for newly employed nurses and new nursing graduates and as in-house consultants. (5) Clerical and patient care support staff must be increased and their training improved to relieve nurses of the burden of patient care. The development of a corps of volunteers like the Americorps Program might be considered as well to provide an auxiliary work force. b. Improve salary and benefit packages. (1) Salaries should be reviewed to ensure that compensation strategies reflect differences in education, experience, and competencies, and that salary compression is addressed. (2) Benefit packages, including educational and retirement benefits, should be reviewed to ensure that they meet nurses’ needs. c. Facilitate the transition of new graduates to the workplace. Because of the high turnover rate of entry-level nurses, it is essential to place more emphasis on facilitating the transition of new graduates to the workplace. Some institutions are beginning to view preceptor and orientation programs as valuable recruitment and retention tools, and are emphasizing mentoring programs, expanding internships and externships, and establishing residency programs. Health care facilities and educational institutions should collaborate to design programs that provide a seamless transition to the workplace and better prepare graduates for the realities of the work world. d. Foster change in the culture of health care organizations to increase respect, visibility, and recognition of nurses. (1) Collaborative and multidisciplinary team approaches to accomplishing work should be implemented and rewarded. Recognition of nurses as full professional partners in patient care teams in light of their knowledge and expertise has the potential to improve patient 90

clinical outcomes as well as productivity and morale. Attention should be given to identifying and eliminating hostile work situations that diminish the role of the nurse. (2) Nurses should be empowered to participate in decisions regarding organizational and clinical matters. The Nursing Workforce Project found that nurses who believed they had input into decisions made at the unit and organizational level were more satisfied with their jobs than those who felt they had no influence. (3) Health care institutions should encourage and reward continuing professional education and training. Nurses should be encouraged to undertake continuing education and advanced training. Their educational attainments should serve as a basis for differentiated practice and compensation. (4) Health care institutions should invest in developing the competencies and effectiveness of front-line managers and strengthen executive-level nursing leadership. Nurse managers need authority and accountability for patient care delivery, personnel management, and financial resources within the organization. In order to better manage these areas of responsibility, health care institutions should provide opportunities for managerial and leadership training. (5) Hospitals and long term care institutions in Maryland should be encouraged to seek “Magnet” designation Magnet designation is awarded by the American Nurses Credentialing Center to hospitals and long term care institutions that meet selection criteria for best practices supporting professional nursing practice. Magnet recognition is considered a benchmark of excellence in nursing care and is associated with higher retention rates and greater success in recruitment. 3. SUPPORT RESEARCH AND EVALUATION TO IMPROVE DECISION-MAKING, ENCOURAGE INNOVATION, AND INFORM PUBLIC POLICY The Nursing Workforce Project has identified a lack of systematic approaches to collecting data about nursing education and the nurse workforce in Maryland, and inadequate information systems, standards, and structures to plan for future needs. a. Develop a standardized statewide approach to collecting educational and workforce data and analyzing and interpreting trends for planning, decision support, and resource allocation. The systematic and regular collection of key data elements will not only improve planning but can help anticipate the likelihood of recurring shortages

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by tracking and identifying trends in supply and demand. Government agencies such as the Maryland Higher Education Commission and the Maryland Board of Nursing in collaboration with the Center for Health Workforce Development could track and analyze data and regularly disseminate information on a statewide basis. b. Design, develop, and evaluate demonstration projects of new professional practice and innovative care delivery models. Partnerships should be encouraged between the health care industry and educational institutions for demonstration projects related to work redesign. These might include a wide range of interventions, services, and settings from hospital staffing ratios to the training of family caregivers. Rigorous studies of the effectiveness of staffing patterns, workforce reconfiguration, and variations in skill mix would contribute to the development of new professional practice and innovative care delivery models. c. Disseminate research and identify best practices through consensus conferences and meetings of statewide/regional nursing groups. Compilations of best practices and exemplars in recruitment and retention, and the results of research and demonstration projects should be identified and disseminated to nurses and health care administrators in Maryland and the region. d. Continue the Nurse Support Program of the HSCRC based on an evaluation of funded program outcomes. Previous funding for the Nurse Support Program has been dedicated to workforce recruitment and retention activities that support cost containment and contribute to access to patient care. Hospitals can continue to apply for new funding as it becomes available. The evaluation reports of these projects will be useful in identifying patterns of success. e. Establish the University of Maryland Center for Health Workforce Development as a clearinghouse for information on the nursing workforce. The Center for Health Workforce Development could serve as a catalyst for bringing together interested stakeholders and as a clearinghouse for information related to the nursing workforce in Maryland.

C. NEED FOR FURTHER RESEARCH
This report on the Nursing Workforce Project can be considered a call to action. The findings have yielded a multidimensional perspective on the present and future issues related to the nursing workforce in Maryland and can serve to educate stakeholders and the public regarding the urgent needs in nursing and the consequences of an inadequate workforce. The importance of the health care industry not only to the health of Maryland

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residents but also to the economic welfare of the state must be considered in relation to future planning and development of the workforce. Effective health policies intended to expand access, improve quality, and contain costs must be based on accurate, up-to-date information and on analyses of the supply, demand, distribution, and utilization of the nursing workforce. More systematic, coordinated data collection mechanisms and standardized reporting are required in Maryland in order to produce accurate, useful analyses of workforce issues and trends for planning purposes, decision support, and resource allocation. There is also a need to identify and examine innovative strategies that could be considered best practices or exemplars for nurse recruitment and retention. This report is seen as the first of several studies needed on health workforce issues in the state. Further investigations of emerging workforce needs in growing health care sectors —for example, assisted living and home care—would be useful. In addition, an effort should be made to develop the strategies needed to effectively expand the capacity of nursing education programs and to quantify the cost of such expansion. The findings of such studies could help inform and shape public policy as it relates to health workforce development in Maryland.

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REFERENCES
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American Nurses Association. Government Affairs (2003). State Legislative Trends Report. Available: http://www.nursingworld.org/gova/state.htm American Organization of Nurse Executives (AONE) (2002). Acute Care Hospital Survey of RN Vacancy and Turnover Rates. Study conducted by the HSM Group. Association of Maryland Hospitals and Health Systems (MHA) (2001). State of the State’s Hospitals. January. ___________ (2002). The Nursing Shortage: Impact on Hospital Finances and Programmatic Initiatives. Presentation to the Maryland Health Services Cost Review Commission, September 4. ___________ (2003). Personnel Fact Sheet. Available: http://www.mdhospitals.org/Facts/ personnel.fact.sheet.pdf Bednash, G. (2001). A nursing leader speaks out on the nursing shortage: Creating a career destination of choice. Policy, Politics and Nursing Practice 2(3):191-195. Berlin, L.E. and Sechrist, K.R. (2002). The shortage of doctorally prepared nursing faculty: a dire situation. Nursing Outlook 50:50-56. Buerhaus, P.I. and Staiger, D.O. (1996). Managed care and the nurse workforce. JAMA 276(18):1487-1493. ___________ (1999). Trouble in the nurse labor market? Recent trends and future outlook. Health Affairs 18(1):214-22. Buerhaus, P.I., Staiger, D.O., Auerbach, D.I. (2000a). Implications of an aging registered nurse workforce. JAMA 283(22):2948-54. ___________ (2000b). Policy responses to an aging registered nurse workforce. Nursing Economics 18(6):278-285. ___________ (2000c). Why are shortages of hospital RNs concentrated in specialty care units. Nursing Economics 18(3):1-6. Coffman, J.M., Seago, J.A., Spetz. J. (2002). Minimum nurse-to-patient ratios in acute care hospitals in California. Health Affairs 21(5):53-64. Commonwealth Fund (2001). How the slowing U.S. economy threatens employer-based health insurance. November. Community Foundation of the Eastern Shore (2002). The Shortage of Nurses at Hospitals, Nursing Homes and Other Medical Facilities on the Lower Eastern Shore of Maryland. Salisbury, MD. May 21. Decker, F.H., Dollard, K.J., Kraditor, K.R. (2001). Staffing of nursing services in nursing homes: Present issues and prospects for the future. Seniors Housing & Care Journal 9:3-26.

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Fagin, C.M. (2001). When Care Becomes a Burden: Diminishing Access to Adequate Nursing. New York: Milbank Memorial Fund. Available: http://www.milbank.org/reports/010216fagin.html Federal Interagency Forum on Aging Related Statistics (2000). Older Americans 2000: Key Indicators of Well-Being. First Consulting Group (2002). The Nursing Shortage: Can Technology Help? Oakland: California HealthCare Foundation. Florida Hospital Association (2002). FHA Nurse Staffing Issues Survey: Florida’s Nursing Shortage Continues. Orlando, FL. Guterl, G. O. (2002). Maryland Commission on the Crisis in Nursing. Advance for Nurses. Feb. 25. Available: http://www.advancefornurses.com/promo/Shortage_Issues/feb25_02feature1.html Health Resources and Services Administration (HRSA). National Center for Health Workforce Analysis (2002). Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020. U.S. Department of Health and Human Services. Available: http://bhpr.hrsa.gov/healthworkforce/rnproject/report.htm Hinshaw, A.S. (2001). A continuing challenge: The shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing 6(1):manuscript 3. Available: http://www.nursingworld.org/ojin/topic14/tpc14_3.htm. Home care nursing shortage must be reversed (2001). Caring July:42-43. Hospital & Healthsystem Association of Pennsylvania (2002). Pennsylvania Nurses: Meeting the Demand for Nursing Care in the 21st Century: 2002 Update. Harrisburg, PA. Interstudy Publications (2002). HMO enrollment stabilizing, Medicaid continues to grow. Press release May 7. Available: http://www.interstudypublications.com Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. ___________ (1999). To Err is Human. Washington, DC: National Academy Press. Maryland Board of Nursing (2002). Nursing demographic data, 1997-2001. Maryland Colleagues in Caring (2001). Nursing Student Survey. Maryland Health Care Commission (2002). Final Report on the Study of Patient Safety in Maryland. Available: www.hmcc.state.md.us./legislature/finalrpt.pdf Maryland Health Care Commission (2003). State Health Care Expenditures: Experience from 2001. Available: www.mhcc.state.md.us Maryland State Data Center (2002). Demographic and Socio-Economic Outlook.

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National Academy of Sciences (2001). Health care costs, policies, and misperceptions pose obstacles to obtaining insurance. Press release, October 11. National Conference of State Legislatures (2002). Nursing Shortages. Issue Brief. Health Policy Tracing Service. October 1. National League for Nursing (2002). Unpublished graduation data. National Sample Survey of Registered Nurses (NSSRN) (2000). The Registered Nurse Population. Findings from the National Sample Survey of Registered Nurses. Health Resources and Services Administration, U.S. Department of Health and Human Services. Available: http://bhpr.hrsa.gov/healthworkforce/rnsurvey. Needleman, J., Buerhaus, P.I., et al. (2001). Nurse Staffing and Patient Outcomes in Hospitals. Health Resources and Services Administration, U.S. Department of Health and Human Services. Available: http://bhpr.hrsa.gov/nursing/staffstudy.htm Norrish, B. R. and Rundall, T. G. (2001). Hospital restructuring and the work of registered nurses. Millbank Quarterly 79(1):55-79. North Carolina Center for Nursing (2002). Staff Nurse Satisfaction, Patient Loads, and Short Staffing Effects in North Carolina. Northwest Health Foundation (2001). Oregon’s Nursing Shortage: A Public Health Crisis in the Making. Issue Brief No. 1. Portland, OR. Available: www.nwhf.org Nurse Licensure Compact Administrators (2002). Nurse Licensure Compact. Available: www.ncsbn.org Nurseweek/AONE (2002). Survey of Registered Nurses. Conducted by Harris Interactive. Available: http://www.nurseweek.com/survey/summary.asp Salsberg, E. (2002). Assuring an adequate supply of health workers to provide high quality care to America’s seniors. Testimony to the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. Miami: January 14. Center for Health Workforce Studies, School of Public Health, University at Albany, SUNY. Staiger, D.O., Auerbach, D.I., Buerhaus, P.I. (2000). Expanding career opportunities for women and the declining interest in nursing as a career. Nursing Economics 18(5):230-236. Sochalski, J. (2002). Nursing shortage redux: Turning the corner on an enduring problem. Health Affairs 21(5):157-164. Southern Regional Education Board (SREB) Council on Collegiate Education for Nursing (2001). SREB Study Indicates Serious Shortage of Nursing Faculty. Available: http://www.sreb.org/programs/Nursing/publications/Nursing_Faculty.pdf

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Tri-Council for Nursing (2001). Strategies to Reverse the New Nursing Shortage. Policy Statement. Washington, DC: American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), the American Organization of Nurse Executives (AONE) and the National League for Nursing (NLN). Available: http://www.nln.org/aboutnln/news_tricouncil2.htm U.S. Administration on Aging (2001a). A Profile of Older Americans: 2001, Data from the Internet releases of the U.S. Bureau of the Census and the National Center for Health Statistics. ___________ (2001b). A Profile of Older Americans: 2001– Health, Health Care, and Disability. Data from the Internet releases of the U.S. Bureau of the Census and the National Center for Health Statistics; and unpublished tables from the Bureau of Labor Statistics.

___________ (1998). Projections of the 65+ Population of States: 1995 to 2025. U.S. Agency for Health Care Policy and Research (2000). Addressing Racial and Ethnic Disparities in Health Care. U.S. Bureau of Labor Statistics (2002). Occupational Outlook Handbook for Registered Nurses.
U.S. Census Bureau (2000). Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100. NP-D1-A. Washington, DC. http://www.census.gov/population/www/projections/natsum.html (Accessed August 20, 2002) University of Maryland School of Nursing (2001). Nursing School Focus Groups. Prepared by Hollander Cohen & McBride. Baltimore, MD. Voluntary Hospitals of America (2002). The business case for work force stability: study summary. Available: https://www.vha.com/publicreleases/pagebuilder.asp?url=/publicreleases/021111.asp

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APPENDIX A CENTER FOR HEALTH WORKFORCE DEVELOPMENT ADVISORY COMMITTEE
Dr. Robert A. Barish Associate Dean for Clinical Affairs University of Maryland School of Medicine Dr. Georges Benjamin Executive Director American Public Health Association Dr. Frank Calia Vice Dean and Professor University of Maryland School of Medicine Ms. Eleanor M. Carey President Governor’s Workforce Investment Board Ms. Donna M. Dorsey Executive Director Maryland Board of Nursing Dr. Patricia S. Florestano Regent University System of Maryland Mr. Donald C. Fry President Greater Baltimore Committee Mr. Warren Green President and Chief Executive Officer Sinai Hospital, LifeBridge Health Dr. Jesse J. Harris Dean and Professor University of Maryland School of Social Work 100 The Honorable Paula C. Hollinger Senator- District 11 Maryland General Assembly Mr. James Hughes Vice President for Research and Development University of Maryland Baltimore Ms. Donna L. Jacobs Senior Vice President Government and Regulatory Affairs University of Maryland Medical System Dr. David A. Knapp Dean University of Maryland School of Pharmacy Ms. Carolyn McGuire-Frenkil President Substance Abuse Services, Inc. Dr. Malinda B. Orlin Vice President for Academic Affairs Dean, Graduate School University of Maryland Baltimore Dr. Marian Osterweis Executive Vice President and Director Division of Global Health Association of Academic Health Centers Mr. Calvin M. Pierson President Maryland Hospital Association

Dr. Carmen V. Russo Chief Executive Officer Baltimore City Public School System Mr. Kenneth A. Samet President and Chief Operating Officer MedStar Health Mr. Alan Silverstone Health Care Consultant Dr. Donald J. Slowinski, Sr. Commissioner Maryland Higher Education Commission Mr. Sanford V. Teplitzky Chairman, Health Law Department Ober, Kaler, Grimes, & Shriver Mr. Vernon Thompson Deputy Secretary Maryland Department of Business and Economic Development Mr. Robert L. Williams Vice President and Executive Director (retired) Kaiser Permanente Ms. Adele Wilzack President Health Facilities Association of Maryland Mr. David Wolf Executive Vice President CareFirst BlueCross BlueShield

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APPENDIX B DETAILED PROJECTION METHODOLOGY AND CALCULATIONS
DEMAND-SIDE METHODOLOGY
To determine the demand for RNs in Maryland, RESI used a variety of data, including the size of the current and prospective population, changing composition by age and RN vacancies currently prevailing in Maryland. Using data from the state Board of Nursing and U.S. Census population data for Maryland, RESI calculated the per capita number of active RNs for both the overall population and the population aged 65 and over. RESI then calculated the average number of RN vacancies for the period 1999 through 2001. To eliminate the double counting of agency nurses included in the staffing vacancies, RESI subtracted the average number of agency nurses employed from 2001 to 2002.
Population Projections for Maryland, July 2000-2015
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 MD Population Projections 5,296,486 5,343,859 5,391,232 5,438,605 5,485,978 5,533,350 5,571,240 5,609,130 5,647,020 5,684,910 5,722,800 5,760,720 5,798,640 5,836,560 5,874,480 5,912,400

Calculations:

Years 2001-2004 5,533,350 - 5,296,486 = 236,864 236,864/ 5yrs = 47,373 increase in the population each year from 2000 to 2005 assuming constant growth Years 2006-2009 5,722,800 - 5,533,350 = 189,450 189,450/ 5 yrs = 37,890 increase in the population each year from 2005 to 2010 assuming constant growth Years 2011-2014 5,912,400 - 5,722,800 = 189,600 189,600/ 5yrs = 37,920 increase in the population each year from 2010 to 2015 assuming constant growth

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RESI applied the RN per capita ratio to the projected population for the state to determine the estimated demand for RNs over the period 2002 through 2012. RESI then estimated RN demand based on the total projected population as well as the projected population of the 65 and over cohort.
Ratio of RNs to Total Population:
A) B) C) D) E) F) G) Maryland Total Population: MD Registered Nurses: MD Hospital Vacancy Rate: RNs Demanded (=B*(1+C)): Agency Nurses: Adjusted RN Demand (=D-E): Ratio (=F/A): 3-Year Average RN:Total Population Ratio: 1999 5,254,50 9 49,936 11.0% 55,429 1,642 53,787 0.010 2000 5,296,48 6 46,421 13.9% 52,874 1,642 51,232 0.009 2001 5,375,156 50,674 15.6% 58,579 1,642 56,937 0.011

0.010

Ratio of RNs to Population 65+:
A) B) C) D) E) F) G) Maryland Total Population: MD Registered Nurses: MD Hospital Vacancy Rate: RNs Demanded (=B*(1+C)): Agency Nurses: Adjusted RN Demand (=D-E): Ratio (=F/A): 3-Year Average RN:Population 65+ Ratio: 1999 585,60 0 49,936 11.0% 55,429 1,642 53,787 0.092 2000 589,00 0 46,421 13.9% 52,874 1,642 51,232 0.087 2001 593,400 50,674 15.6% 58,579 1,642 56,937 0.096

0.092

RESI then constructed an equation to link the two discrete impacts of population size and age together. To create a starting point for 2001 (the first-year forecast), RESI adjusted current demand by the average number of RN job vacancies (based on RN vacancies at Maryland hospitals) for the period 1999 through 2001. One of the central issues of the methodology utilized here is whether this vacancy rate is applicable to the entire RN profession in Maryland, since the vacancy rate figure characterizes only the situation in hospitals and not among other types of health providers. Because RNs in Maryland hospitals earn more than their counterparts in other health providing segments, it is reasonable to assume that the RN vacancy rate among other non-hospital healthcare segments may be higher than the hospital vacancy rate utilized. Therefore, initial demand for RNs would tend to be underestimated. It should also be noted that three-fifths of all RNs work in a hospital setting.4

4

US Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook for Registered Nurses, 2002.

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Projected RN Demand in Maryland
2002 A) B) C) Total Population Average Ratio Projected Demand (=A*B): 5,391,232 0.01 54,814 2003 5,438,605 0.01 55,296 2004 5,485,978 0.01 55,777 2005 5,533,350 0.01 56,259 2006 5,571,240 0.01 56,644 2007 5,609,130 0.01 57,029 2008 5,647,020 0.01 57,415 2009 5,684,910 0.01 57,800 2010 5,722,800 0.01 58,185 2011 5,760,720 0.01 58,571 2012 5,798,640 0.01 58,956

D) E) F)

Population 65+ Average Ratio Projected Demand (=D*E):

597,800 0.092 54,755

602,200 0.092 55,158

606,600 0.092 55,561

611,000 0.092 55,964

626,200 0.092 57,356

641,400 0.092 58,748

656,600 0.092 60,140

671,800 0.092 61,533

687,000 0.092 62,925

702,200 0.092 64,317

717,400 0.092 65,709

G)

BASELINE RN Demand (=average(C,F)): 54,784 55,227 55,669 56,111 57,000 57,889 58,777 59,666 60,555 61,444 62,333

SUPPLY-SIDE METHODOLOGY
To determine the supply of RNs in Maryland, RESI first identified the number of new RN licensees in Maryland for 1998-2001 from Maryland Board of Nursing data. These new licensees include both exam and endorsement licensees, therefore taking into account both new graduates and RNs moving into the state. RESI then averaged these figures to determine the average number of new entrants into the RN labor pool.
New RN Licensees in Maryland
1998 1999 2000 2001 4-Year Average 2,599 2,658 3,976 2,546 2,945

RESI also calculated the number of new entrants per age category based on data provided by the Maryland Board of Nursing.
Percent of New Licensees per Age Category
Age Category 18-27 28-37 38-47 48-57 58-67 68+ 1998 696 1,048 610 188 32 6 1999 881 974 576 184 28 0 2000 982 921 521 182 28 0 3-Year Average 33% 37% 22% 7% 1% 0%

The next step was to identify the trend in new graduates (associate degree, hospital diploma and baccalaureate) to determine the growth rate of new entrants into the RN labor pool. RESI calculated a negative 10 percent (-10%) annual growth rate5 (baseline scenario) from existing data obtained from the National League for Nursing. Using this rate as the baseline growth, RESI then assumed a 0 percent annual growth rate (lower bound) and a −20 percent annual growth rate (upper bound) in its efforts to provide reasonable parameters around the baseline rate of growth. It should be noted that the extent to which these parameters become relevant is a function largely of public policy over the next decade. A lax public policy will mean
5

National League for Nursing unpublished graduation data.

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continued shortfalls in nursing capacity. A more focused and aggressive public policy will help to close the gap. In fact, national data suggests that the –20 percent annual growth rate may itself be a rather conservative/optimistic one. For example, The National Council of State Boards of Nursing reported a 28.7% decrease in RN graduates taking the NCLEX-RN exam from 1995 through 2001.6 Moreover, the National League for Nursing reported a 41% decrease in RN graduates (diploma, ADN, and BSN) over a 5-year period.7 RESI applied these three growth rates over the ten-year period (2002-2012) to the average total number of new licensees to determine the number of new entrants per year. RESI’s next step was to identify the percentage breakdown of new entrants by age category from 19982001 from the Maryland Board of Nursing data. RESI then applied the percentage breakdown of new licensees by age to total new entrants by year. This calculation yielded the number of new entrants in each age category for each year in the model.
New Licensees Per Year by Age Category, Optimistic Scenario (0% Growth)
2002 18-27 28-37 38-47 48-57 58-67 68+ TOTA L 959 1,10 3 640 208 33 2 2,94 5 2003 959 1,10 3 640 208 33 2 2,94 5 2004 959 1,10 3 640 208 33 2 2,94 5 2005 959 1,10 3 640 208 33 2 2,94 5 2006 959 1,10 3 640 208 33 2 2,94 5 2007 959 1,10 3 640 208 33 2 2,94 5 2008 959 1,10 3 640 208 33 2 2,94 5 2009 959 1,10 3 640 208 33 2 2,94 5 2010 959 1,10 3 640 208 33 2 2,94 5 2011 959 1,10 3 640 208 33 2 2,94 5 2012 959 1,103 640 208 33 2 2,94 5

New Licensees Per Year by Age Category, Middle Scenario (-10% Growth)
2002 18-27 28-37 38-47 48-57 58-67 68+ TOTA L 862 991 575 187 30 2 2,64 6 2003 774 891 517 168 27 2 2,37 8 2004 696 800 464 151 24 2 2,13 7 2005 625 719 417 135 22 1 1,92 0 2006 562 646 375 122 19 1 1,72 6 2007 505 581 337 109 17 1 1,55 1 2008 454 522 303 98 16 1 1,39 3 2009 408 469 272 88 14 1 1,25 2 2010 366 421 244 79 13 1 1,12 5 2011 329 379 220 71 11 1 1,01 1 2012 296 340 197 64 10 1 909

6 7

American Association of Colleges of Nursing “Nursing Shortage Fact Sheet”. National League for Nursing unpublished graduation data.

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New Licensees Per Year by Age Category, Pessimistic Scenario (-20% Growth)
2002 18-27 28-37 38-47 48-57 58-67 68+ TOTA L 767 882 512 166 26 2 2,35 6 2003 614 706 409 133 21 1 1,88 5 2004 491 565 328 106 17 1 1,50 8 2005 393 452 262 85 14 1 1,20 6 2 006 314 361 210 68 11 1 965 2 007 251 289 168 54 9 1 772 2 008 201 231 134 44 7 0 618 2 009 161 185 107 35 6 0 494 2 010 129 148 86 28 4 0 395 2011 103 118 69 22 4 0 316 2012 82 95 55 18 3 0 253

RESI then determined the labor force participation rates (LFPRs) by age. Average LFPRs were utilized when age categories did not match precisely. The Maryland Board of Nursing provided the number of active nurses by age category for 1998-2001. The actual labor pool available (though not all RNs were active) was calculated by applying the LFPRs to the number of active nurses by age category.
Labor Force Participation Rate:
Age 18-19 20-24 25-29 18-27 25-29 30-34 35-39 28-37 35-39 40-44 45-49 38-47 45-49 50-54 55-59 48-57 55-59 60-64 65-69 58-67 65-69 70 + 68 + LFPR 63.3 77.9 84.6 75.27 84.6 84.7 84.4 84.57 84.4 85.3 84.5 84.73 84.5 80.3 68.8 77.87 68.8 47.1 24.4 46.77 24.4 8.3 16.35

RESI employed several assumptions in creating the model used to predict RN supply in Maryland. In projecting active RNs by age category for 2002-2012, RESI assumed an equal share of RN population across each age category (i.e., 10% of total number in age category 107

per year). RESI then projected the growth of RN population based on the addition of new entrants per year per age category + 10% of previous year’s PREVIOUS age category + 90% of previous year’s SAME age category, and multiplied by the LFPR appropriate to the age category, and so on.
Historical Data: RN Supply
1998 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 2,725 13,116 20,257 15,800 10,575 4,410 Active RNs 2,049 11,083 17,158 12,302 4,945 721 48,258 Labor Pool 3,755 14,599 20,542 15,696 9,795 3,523 1999 Active RNs 2,824 12,336 17,399 12,221 4,580 576 49,936 Labor Pool 4,899 13,375 18,848 14,341 8,221 2,820 2000 Active RNs 3,684 11,302 15,964 11,166 3,844 461 46,421 Labor Pool 3,650 12,860 20,459 17,454 11,563 4,502 2001 Active RNs 2,745 10,867 17,329 13,590 5,407 736 50,674

Optimistic Scenario:
Projected Optimistic RN Supply, 2002-2005
2002 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 4,244 13,042 20,339 17,963 12,185 5,210 Active RNs 3,192 11,021 17,227 13,986 5,698 852 51,975 Labor Pool 4,779 13,266 20,249 18,408 12,796 5,910 2003 Active RNs 3,594 11,209 17,151 14,332 5,983 966 53,236 Labor Pool 5,260 13,520 20,191 18,800 13,390 6,601 2004 Active RNs 3,956 11,424 17,101 14,637 6,261 1,079 54,459 Labor Pool 5,693 13,797 20,163 19,146 13,964 7,282 2005 Active RNs 4,281 11,658 17,078 14,907 6,530 1,191 55,646

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Projected Optimistic RN Supply, 2006-2009
2006 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 6,083 14,090 20,166 19,456 14,515 7,952 Active RNs 4,574 11,906 17,081 15,148 6,787 1,300 56,797 Labor Pool 6,434 14,392 20,199 19,734 15,042 8,611 2007 Active RNs 4,838 12,161 17,108 15,365 7,034 1,408 57,915 Labor Pool 5,790 13,596 19,618 19,781 15,512 9,254 2008 Active RNs 4,354 11,489 16,616 15,401 7,253 1,513 56,627 Labor Pool 5,211 12,816 19,016 19,765 15,939 9,880 2009 Active RNs 3,919 10,829 16,106 15,389 7,453 1,615 55,311

Projected Optimistic RN Supply, 2010-2012
2010 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 4,690 12,055 18,396 19,690 16,321 10,486 Active RNs 3,527 10,187 15,581 15,330 7,632 1,714 53,971 Labor Pool 4,221 11,319 17,762 19,560 16,658 11,069 2011 Active RNs 3,174 9,564 15,044 15,230 7,789 1,810 52,611 Labor Pool 3,799 10,609 17,117 19,380 16,948 11,628 2012 Active RNs 2,857 8,965 14,498 15,090 7,925 1,901 51,236

Baseline Scenario:

Projected Baseline RN Supply, 2002-2005
2002 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 4,147 12,931 20,274 17,941 12,182 5,210 Active RNs 3,119 10,926 17,172 13,969 5,696 852 51,735 Labor Pool 4,428 12,853 20,004 18,325 12,782 5,909 2003 Active RNs 3,330 10,860 16,944 14,268 5,977 966 52,345 Labor Pool 4,548 12,657 19,664 18,615 13,356 6,597 2004 Active RNs 3,420 10,695 16,655 14,494 6,245 1,079 52,587 Labor Pool 4,547 12,368 19,266 18,818 13,897 7,274 2005 Active RNs 3,419 10,451 16,318 14,652 6,498 1,189 52,527

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Projected Baseline RN Supply, 2006-2009
2006 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 4,458 12,007 18,821 18,942 14,402 7,937 Active RNs 3,353 10,146 15,941 14,748 6,734 1,298 52,220 Labor Pool 4,309 11,593 18,337 18,994 14,866 8,584 2007 Active RNs 3,240 9,796 15,531 14,789 6,951 1,404 51,711 Labor Pool 3,878 10,864 17,662 18,928 15,279 9,213 2008 Active RNs 2,916 9,180 14,960 14,738 7,144 1,506 50,444 Labor Pool 3,490 10,165 16,982 18,802 15,644 9,819 2009 Active RNs 2,624 8,590 14,384 14,639 7,315 1,605 49,158

Projected Baseline RN Supply, 2010-2012
2010 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 3,141 9,498 16,301 18,620 15,960 10,402 Active RNs 2,362 8,026 13,807 14,497 7,463 1,701 47,855 Labor Pool 2,827 8,862 15,620 18,388 16,226 10,957 2011 Active RNs 2,126 7,489 13,231 14,317 7,587 1,792 46,540 Labor Pool 2,544 8,259 14,945 18,111 16,442 11,484 2012 Active RNs 1,913 6,979 12,658 14,101 7,688 1,878 45,217

Pessimistic Scenario:
Projected Pessimistic RN Supply, 2002-2005
2002 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 4,053 12,822 20,211 17,921 12,179 5,210 Active RNs 3,047 10,834 17,119 13,953 5,695 852 51,501 Labor Pool 4,138 12,510 19,800 18,256 12,770 5,908 2003 Active RNs 3,112 10,571 16,770 14,214 5,971 966 51,605 Labor Pool 4,039 12,034 19,280 18,479 13,329 6,595 2004 Active RNs 3,037 10,169 16,331 14,388 6,233 1,078 51,235 Labor Pool 3,836 11,466 18,690 18,602 13,851 7,269 2005 Active RNs 2,885 9,689 15,830 14,484 6,477 1,188 50,553

Projected Pessimistic RN Supply, 2006-2009
2006 Labor Pool 18-27 28-37 3,581 10,851 Active RNs 2,693 9,169 Labor Pool 3,305 10,219 2007 Active RNs 2,486 8,635 Labor Pool 2,975 9,527 2008 Active RNs 2,237 8,051 Labor Pool 2,677 8,872 2009 Active RNs 2,013 7,497

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38-47 48-57 58-67 68+ Total

18,053 18,639 14,331 7,927

15,291 14,512 6,701 1,296 49,663

17,388 18,598 14,764 8,568

14,728 14,481 6,904 1,401 48,633

16,671 18,477 15,148 9,187

14,120 14,386 7,083 1,502 47,380

15,957 18,297 15,481 9,783

13,515 14,246 7,239 1,600 46,110

Projected Pessimistic RN Supply, 2010-2012
2010 Labor Pool 18-27 28-37 38-47 48-57 58-67 68+ Total 2,410 8,253 15,248 18,063 15,762 10,353 Active RNs 1,812 6,973 12,915 14,064 7,370 1,693 44,828 Labor Pool 2,169 7,668 14,549 17,781 15,992 10,894 2011 Active RNs 1,631 6,480 12,323 13,844 7,478 1,781 43,537 Labor Pool 1,952 7,118 13,861 17,458 16,171 11,404 2012 Active RNs 1,468 6,015 11,740 13,593 7,562 1,865 42,242

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APPENDIX C MARYLAND’S HOSPITAL ALL-PAYER SYSTEM AND THE NURSING SHORTAGE
Maryland has a unique hospital payment system. Since the majority of working nurses work in hospitals, the hospital payment system cannot help but affect the nurse labor market. The original preamble to Medicare said, in effect, that Medicare would not influence the practice of Medicine. The idea that one can establish a huge financing system without influencing behavior in markets one is financing seems naive at best. The issue is not whether the all-payer system affects the nursing market in Maryland, but how. In 1971, the Maryland legislature created the Health Services Cost Review Commission (HSCRC). Effective July 1, 1974, no hospital other than state-owned psychiatric hospitals, could charge at rates other than those approved by the HSCRC, and no payer could pay at rates other than those approved by the HSCRC. Since federal law takes precedence over state law as regards to Medicare and Medicaid, those two payers were exempt from the state requirement that all payers pay on the basis of HSCRC-approved rates. Effective July 1, 1977, the federal government agreed to waive its precedence regarding Medicare and Medicaid, an agreement later written into federal law (the Mikulski amendment). Thus, beginning on July 1, 1977, and so long as the conditions for meeting the Medicare and Medicaid waiver are met, Maryland’s hospital system covers all payers. Medicare and Medicaid beneficiaries receive about half the care provided by acute care hospitals, and Maryland is the only state still to have a Medicare and Medicaid waiver. Since the rates set by the HSCRC are both a maximum and a minimum, managed care plans cannot negotiate for huge discounts—they pay hospitals the same unit rates as other payers and, as regards hospital services, save money to the extent they can reduce length-of-stay, admissions rates, and the use of ancillary tests, i.e., by managing care. Labor costs, both wages and fringes, account for about 50% of acute hospital costs. Nursing costs account for about 30% of labor costs, making nursing costs account for about 15% of hospital costs. The HSCRC must assure the public that aggregate hospital costs are reasonably related to aggregate hospital services and that aggregate hospital revenues are reasonably related to aggregate hospital costs. Like Medicare, the HSCRC’s rate setting system largely depends upon annual updates that incorporate increases in the prices of goods and services that hospitals buy. The most important such service is labor, including nursing. For many years the HSCRC has measured the inflationary impact of hospital labor by the annual increase in the Average Hourly Earnings (AHE) of Hospital Workers, a statistic published monthly by the federal Bureau of Labor Statistics. Thus, the measure of inflation is designed to allow Maryland hospitals to keep up with the increases in wages paid nationally. As with other 112

prospective payment systems, the HSCRC approves an amount of revenue, but hospitals are free to spend that money as they see fit. One of the current debates is that the Maryland Hospital Association has argued that for the last two years (2000-2002), the wages paid to RNs has increased faster than the AHE. The data supports that argument. That does not necessarily mean that hospitals should get more money. For example, given that the nursing shortage is a national problem, one would expect that RN wage increases would be higher than the average hospital wage increase as captured by the AHE. That is, the AHE embodies both the higher wage increases given nurses and the lower wage increases given other hospital employees. A second issue is that while hospitals may have appropriately paid wage increases that are higher than the AHE over the past two years, that may represent catch-up of years of paying RNs lower wage increases than the AHE. These are both appropriate issues for analysis. Up until October 1, 2002, the HSCRC’s use of the AHE of hospital workers to measure hospital wage inflation differed markedly from the measure used by Medicare. Medicare used an index of inflation that gave only 30% weight to hospital workers and the other 70% weight to workers in the rest of the economy. Medicare was afraid that measuring inflation by using a measure based upon 100% hospital workers would be circular. This is because Medicare is such a large national payer that its actions would significantly influence payments to hospital workers. The HSCRC knew that its actions, which only impacted Maryland hospitals, could not materially affect hospital wages nationally. Effective with the start of federal fiscal year 2003, Medicare began using 100% hospital employee information to measure inflation of hospital wages and fringe benefits, as the HSCRC has been doing for years. Medicare made the change after it decided that the market for hospital workers was both different than other labor markets and subject to effective market constraints. The inflation index used by the HSCRC is a fixed weight index. It measures inflation as if hospitals are buying the same market basket of inputs from year to year. This construct of measuring inflation, which is common to all index numbers such as the CPI, does not finance changes in the mix of inputs. This has become particularly contentious as hospitals have seen the mix of nurses between employed nurses and agency nurses change toward a more costly mix. There are both measurement and policy questions related to the issue of financing a shift toward agency nurses. In Maryland, those issues are debated before the HSCRC and not only resolved in the marketplace. One significant advantage of the all-payer system is that the HSCRC can address certain public policy issues knowing it will be able to finance that program equitably. The HSCRC has twice done that with regard to the nursing shortage. In the late 1970s, in response to an earlier nursing shortage, the HSCRC initiated the Nurse Education Support Program (NESP). Before announcing the program, the HSCRC obtained verbal support from the major payers: Medicare, Medicaid, Blue Cross and the Health Insurance Association of America. The NESP, administered and co-developed by Hilda Mae Snoops, RN (a federal employee assigned full-time to the HSCRC via an intergovernmental transfer), asked hospitals to submit proposals to increase the supply of RNs, largely through scholarship assistance, with the cost of the assistance added to 113

hospital rates. The total amount allowed was 0.1% of hospital revenue, or about $1.25 million per year at that time. The Commission, which had been helping to fund hospitalbased diploma nursing programs, also provided significant funding for the reestablishment of the Johns Hopkins School of Nursing. The NESP remained in place for many years but was ended before the current, and most severe, nursing shortage began. In 2001, the HSCRC, again with payer support, instituted a second program, the Nurse Support Program (NSP), to help finance an increase in the supply and retention of nurses. Again, the financing was 0.1% of hospital revenue, but given inflation and the growth in hospital volume, the funding level equated to about $6 million per year. Those dollars have been added to hospital rates based upon successful proposals. The magnitude of the funding level might be compared with recent federal legislation. The recently enacted legislation (the Nurse Reinvestment Act) authorized national spending of $100 million, though that is still subject to the appropriation process. Since Maryland employs less than 2% of the nation’s RNs, it is reasonable to think of the Maryland equivalent of national spending as less than $2 million. Thus, compared to the national initiative, the Maryland initiative has a significantly higher funding level. Economists discuss the demand for labor as a derived demand. The amount an employer is willing to pay for labor depends upon the productivity of the worker and the added revenue the employer can get when selling the product of that labor. In Maryland, the price at which hospitals can sell is determined by the HSCRC. At the same time, the NSP is designed to add to the supply of nurses. Thus, it is very important that the HSCRC consider its impact on the nurse labor market as it strives to assure the paying public that the aggregate costs of hospital services are reasonably related to the services hospitals provide.

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