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entitled 'Nursing Workforce: HHS Needs Methodology to Identify 
Facilities with a Critical Shortage of Nurses' which was released on 
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April 30, 2007: 

The Honorable Edward M. Kennedy: 
Chairman: 
The Honorable Michael B. Enzi: 
Ranking Member: 
Committee on Health, Education, Labor and Pensions: 
United States Senate: 

The Honorable John D. Dingell: 
Chairman: 
The Honorable Joe Barton: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

Subject: Nursing Workforce: HHS Needs Methodology to Identify 
Facilities with a Critical Shortage of Nurses: 

Registered nurses (RN) are the single largest group of health care 
providers in the United States, with more than 2.4 million people 
employed as RNs in 2004.[Footnote 1] Basic RN training may be completed 
through a 2-year associate's degree, a 3-year diploma, or a 4-year 
bachelor's degree. RNs work in a wide variety of settings, including 
hospitals, nursing homes, physicians' offices, and public health 
clinics. Reports by government agencies and others have raised concerns 
about nurse shortages. In 2001, we reported on an emerging shortage of 
RNs to fill vacant positions across a range of health care 
settings.[Footnote 2] The Health Resources and Services Administration 
(HRSA), an agency in the Department of Health and Human Services (HHS), 
estimated that the supply of RNs nationally fell approximately 111,000 
short of demand in 2000 (5.5 percent) and projected the gap would widen 
in the ensuing years.[Footnote 3] 

A shortage of RNs, like general workforce shortages, occurs when the 
demand for RNs exceeds supply.[Footnote 4] The supply of RNs, or the 
number of RNs employed, is influenced by multiple factors, including 
the size of the overall labor force, the number of licensed RNs 
choosing to work in nursing, the number of new RNs graduating from 
nursing school, the capacity of nursing schools, and funding available 
for higher education. Demand, or the number of RNs that employers would 
like to hire, is also affected by multiple factors, including 
demographic characteristics and health status of the population, 
economic factors such as personal income and health insurance coverage, 
and characteristics of the health care system such as nurse wages and 
health care reimbursement rates. Having an adequate supply of RNs is 
important because reports have established a positive relationship 
between the quality of care and RN staffing levels in settings such as 
hospitals and nursing homes.[Footnote 5] 

To support the recruitment and retention of RNs in health care 
facilities with a critical shortage of nurses, Congress passed the 
Nurse Reinvestment Act of 2002 (NRA).[Footnote 6] The NRA established 
the Nursing Scholarship Program (NSP) to provide scholarships for 
individuals to attend schools of nursing.[Footnote 7] The NRA also 
modified an existing program, the Nursing Education Loan Repayment 
Program (NELRP), which was established by Congress in 1992 to help 
repay education loans for RNs. Under both programs, awardees must agree 
to work for at least 2 years in a health care facility with a critical 
shortage of nurses, with preference given to qualified applicants with 
the greatest financial need.[Footnote 8] To implement this, HRSA, which 
administers both programs, designates several types of facilities as 
having a critical shortage of nurses for the purposes of the NSP and 
NELRP.[Footnote 9] The Secretary of HHS is required to report annually 
to Congress on various aspects of the programs including the locations 
where award recipients are fulfilling their service 
obligation.[Footnote 10] 

The NRA directed us to conduct several studies related to the 
nationwide shortage of nurses.[Footnote 11] As discussed with the 
committees of jurisdiction, in this report we are: (1) providing 
information on how the number of employed RNs and the shortage of RNs 
has changed since 2000, both nationally and across states; and (2) 
describing characteristics of NELRP and NSP awardees and examining 
whether these programs have improved the supply of RNs in facilities 
with critical shortages of nurses. 

To determine how the employment of RNs changed since 2000 and how it 
varied across states, we analyzed data on RN employment from the 2000 
and 2004 National Sample Survey of Registered Nurses (NSSRN). This 
survey has been conducted by HRSA approximately every 4 years since 
1977.[Footnote 12] We also analyzed data on newly licensed RNs from the 
National Council of State Boards of Nursing to identify the number of 
potential new RNs entering the workforce each year from 2000 through 
2005. To determine whether the nursing shortage has changed since 2000, 
we conducted interviews of experts, researchers, HRSA officials, and 
provider and professional associations. We also reviewed current 
literature and research on the RN workforce. Further, we compared 
HRSA's most recent state-level shortage estimates from 2000 to the 
growth in RN employment from 2000 to 2004;[Footnote 13] examined 
changes in state-level per capita RN employment from 2000 to 2004; 
analyzed annual Current Population Survey (CPS) data from 1999 through 
2005 on RN earnings growth relative to the overall workforce;[Footnote 
14] and examined trends reported by the American Hospital Association 
(AHA) in hospital RN vacancy rates--that is, the number of unfilled 
employment positions at hospitals. 

To describe the characteristics of NELRP and NSP awardees, we analyzed 
HRSA administrative data, reviewed published reports on the programs, 
and interviewed HRSA officials. We relied on data about the programs 
from fiscal year 2004 to make comparisons of the awardees to the 
overall RN workforce and RN student and recent graduate populations 
because data from 2004 were the most recent data on the RN workforce 
available. Data on employment location of the programs' awardees for 
the fiscal years 2003 through 2005 period were obtained from both 
published reports on the programs and HRSA officials. To examine 
whether these programs have improved the supply of RNs in facilities 
with a critical shortage of nurses we reviewed past and current program 
guidance, reviewed published reports on the programs, and interviewed 
HRSA officials and research contractors. 

Our review focused only on registered nurses (RN), and our results 
cannot be generalized to other types of nurses, such as licensed 
practical nurses (LPN). We also did not conduct assessments of 
projected shortages. We used the most recent data available, which were 
from 2004 for some sources and from 2005 for other sources, as we 
noted. We assessed the reliability of data used in our analyses and 
determined them to be sufficiently reliable for our purposes. We 
performed this work from March 2006 through March 2007 in accordance 
with generally accepted government auditing standards. 

Results in Brief: 

Between 2000 and 2004, the number of employed RNs in the United States 
grew by 10 percent, with a total of 2.4 million RNs employed in nursing 
in 2004. Most of the increase occurred in hospitals and ambulatory care 
settings, and the extent of employment growth varied widely among 
states. For example, among the 48 states where the number of employed 
RNs increased, the growth in employment ranged from 2 percent in 
Connecticut to 47 percent in New Hampshire. Despite evidence of growth 
in RN employment between 2000 and 2004, there are no data available for 
estimating the magnitude of changes in the shortage of RNs over this 
time period. Estimating changes in the RN shortage requires data on 
both the supply of and the demand for RNs in 2000 and 2004. Although 
there are data indicating that the supply or number of employed RNs 
increased, there are no data--either nationally or at the state level-
-on RN demand in 2004, because demand estimates have not been updated 
since 2000. However, several indirect measures suggest that the 
shortage of RNs has eased since 2000. For example, RN employment growth 
from 2000 to 2004 was generally strongest in those states that HRSA 
designated as having greater shortages in 2000. In addition, between 
2000 and 2004 the number of employed RNs relative to the size of the 
general population increased from 782 per 100,000 people in 2000 to 825 
per 100,000 people in 2004--reflecting an increase in RN supply 
relative to one measure of demand for RNs. Finally, the rate of 
unfilled RN positions in hospitals declined nationally from 13 percent 
in 2001 to 9 percent in 2005. 

Recipients of NSP and NELRP awards are more likely to be from a 
minority group and are more likely to have received or be pursuing a 4- 
year bachelor's degree rather than a 2-year associate's degree when 
compared to the overall RN workforce. In both programs, an applicant's 
minority status is not used as a criterion in making awards. In 2004, 
11 percent of the overall nursing workforce was minority while 
minorities made up 36 percent of NSP awardees and 21 percent of NELRP 
awardees. NSP and NELRP awardees are required to be employed in one of 
the types of facilities identified by HRSA as having a critical 
shortage of nurses. However, HRSA does not have a sound basis for 
determining the number of RNs needed for that facility to be considered 
as one experiencing a critical shortage of RNs. Consequently, we cannot 
identify which facilities fall into this category. Furthermore, 
awardees may not be serving in facilities actually experiencing a 
nursing shortage. HRSA is working to develop an approach for 
identifying facilities with critical shortages of RNs, and researchers 
contracted by HRSA have produced a report detailing an approach that 
uses available county-level data to determine facilities that could be 
identified as having critical shortages of RNs. This report is 
currently under review, so HRSA's efforts at developing an empirically- 
based approach for identifying facilities with critical shortages of 
RNs have not been completed. 

In order to target funding effectively for the Nursing Education Loan 
Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to 
nurses working in health care facilities with a critical shortage of 
nurses, we recommend that the Secretary of HHS: (1) identify the 
specific steps and a time frame for implementing an empirical 
methodology for identifying health care facilities with a critical 
shortage of nurses; and (2) direct the Administrator of HRSA to include 
a description of steps taken and progress on its time frame for 
implementing such methodology in HRSA's annual report to Congress on 
these programs. 

In commenting on a draft of this report, HHS provided technical 
comments, which we incorporated as appropriate. 

Background: 

Hospitals employ the largest share of the RN workforce with 56 percent 
of RNs employed in hospital settings in 2004. After hospitals, 12 
percent of RNs were employed in ambulatory care, 11 percent in public 
or community health settings, and 6 percent in nursing homes and 
extended care facilities. The remaining 15 percent were employed in a 
variety of other settings such as nursing education and insurance 
companies. Although basic RN education may be completed through a 2- 
year associate's degree, a 3-year diploma program, or a 4-year 
bachelor's degree, the largest proportion of RNs has an associate's 
degree, with 44 percent of the current RN workforce and 61 percent of 
newly licensed RNs having an associate's degree.[Footnote 15] (See fig. 
1.) Once they have completed their education, RNs must meet state 
licensing requirements and pass a national licensing examination. 

Figure 1: Percentage of Employed Registered Nurses by Initial Degree 
Type, 2004: 

[See PDF for image] 

Source: HRSA and National Council of State Boards of Nursing. 

Note: Data are from HRSA's 2004 National Sample Survey of Registered 
Nurses and the National Council of State Boards of Nursing's 2004 
National Council Licensing Examination (NCLEX) statistics. 

[End of figure] 

Although numerous reports of an emerging nursing shortage have been 
published by researchers, provider associations, and government 
agencies, nurse shortages have historically been cyclical, with periods 
of shortage alternating with periods of equilibrium or surplus. There 
is often a time lag in the adjustment of RN supply to increased demand, 
in part due to the time it takes for a new RN to complete the 
educational requirements for licensure. Future demand for RNs is 
expected to increase dramatically as members of the baby boom 
generation reach their 70s, 80s and beyond--ages at which use of health 
care typically increases. While the population aged 65 and older is 
expected to double between 2000 and 2030, the number of women between 
25 and 54 years of age, who have traditionally formed the core of the 
nurse workforce, is expected to remain relatively unchanged. The Bureau 
of Labor Statistics (BLS) projected that in order to accommodate growth 
in demand for RNs and to replace RNs leaving the workforce, 120,000 new 
nurses will be needed per year from 2004 through 2014. 

To support the recruitment and retention of RNs, the NSP and NELRP 
programs provide awards to nursing students or working nurses, 
respectively, in exchange for a minimum of 2 years service at a health 
care facility with a critical shortage of nurses. The NELRP provides 
loan repayment awards of up to 85 percent of educational loans and the 
NSP provides scholarship awards to individuals attending an accredited 
school of nursing. From fiscal years 2003 through 2005, HRSA granted 
2,262 loan repayment awards totaling $51 million and 419 scholarship 
awards totaling $18.9 million. (See table 1.) Total funding and the 
number of awards granted under both programs have increased since 
fiscal year 2003. In fiscal year 2005, HRSA provided NELRP awards to 
803 individuals, or 18 percent of applicants, with a median award of 
$20,925. For the NSP, HRSA provided awards to 212 individuals, or 6 
percent of applicants, with a median award of $38,078. 

Table 1: Nursing Education Loan Repayment Program and Nursing 
Scholarship Program Applicants, Awards, and Funding, Fiscal Years 2003- 
2005: 

Nursing Education Loan Repayment Program (NELRP). 

Applicants; 
2003: 8,231; 
2004: 4,873; 
2005: 4,465; 
2003- 2005 Total: 17,569. 

Awards; 
2003: 602; 
2004: 857; 
2005: 803; 
2003-2005 Total: 2,262. 

Total Award Funding; 
2003: $14.4 million; 
2004: $17.6 million; 
2005: $19.0 million; 
2003-2005 Total: $51.0 million. 

Median Award Amount; 
2003: $20,911; 
2004: $17,379; 
2005: $20,925; 
2003-2005 Total: [Empty]. 

Nursing Scholarship Program (NSP). 

Applicants; 
2003: 4,408; 
2004: 3,476; 
2005: 3,482; 
2003- 2005 Total: 11,366. 

Awards; 
2003: 81; 
2004: 126; 
2005: 212; 
2003-2005 Total: 419. 

Total Award Funding; 
2003: $3.3 million; 
2004: $5.9 million; 
2005: $9.7 million; 
2003-2005 Total: $18.9 million. 

Median Award Amount; 
2003: $34,920; 
2004: $38,387; 
2005: $38,078; 
2003-2005 Total: [Empty]. 

Source: HRSA. 

[End of table] 

Number of Employed RNs Increased since 2000, Although Gains Varied 
among States, and Indirect Evidence Suggests Shortage Has Eased: 

Between 2000 and 2004, the number of employed RNs in the United States 
grew by 10 percent. Most of the increase occurred in hospitals and 
ambulatory care settings, and the extent of employment growth varied 
widely among states. Despite evidence of growth in RN employment 
between 2000 and 2004, we are unable to estimate the magnitude of 
changes in the shortage of RNs over this time period. Estimating 
changes in the RN shortage requires data on both the supply of and the 
demand for RNs in 2000 and 2004. While HRSA's National Sample Survey of 
Registered Nurses provides data on the number of employed RNs in 2000 
and 2004, HRSA's estimates of demand for RNs have not been updated 
since 2000. However, indirect evidence suggests that the shortage of 
RNs has eased since 2000. This evidence includes strong growth in RN 
employment in the states HRSA designated as having a shortage in 2000 
and increases in the number of employed RNs relative to the size of the 
general population. In addition, after several years of strong relative 
earnings growth for RNs following reports of an emerging shortage 
around 2000, RN earnings have grown at a rate comparable to the overall 
workforce in recent years. 

Number of Employed RNs Increased between 2000 and 2004, and Gains 
Varied by Facility Type and among States: 

According to data from HRSA's 2000 and 2004 National Sample Survey of 
Registered Nurses, the number of employed RNs, either full-time or part-
time, increased 10 percent between 2000 and 2004, with a total of 2.4 
million RNs employed in nursing in 2004.[Footnote 16] The number of RNs 
employed full-time grew by 8 percent from 2000 to 2004, while those 
employed part-time, representing approximately 30 percent of all 
employed RNs in 2004, grew by 15 percent. In addition, of all licensed 
RNs, the percentage who were employed in nursing, either full-time or 
part-time, increased from 81.7 percent in 2000 to 83.2 percent in 2004; 
this compares to 82.7 percent in 1992 and 1996, and to rates at or 
below 80 percent throughout the 1980s. Nationally, between 2000 and 
2004, the extent of increases in the number of RNs employed varied by 
facility type or setting, with the greatest gains occurring in 
hospitals and ambulatory care settings such as physicians' offices, 
clinics, and ambulatory surgical centers. (See table 2.) These settings 
accounted for most of the change in the number of employed RNs over the 
4 years. Employment gains also occurred in teaching positions 
associated with nursing education, while the number of RNs employed in 
public and community health settings declined. Between 2000 and 2004, 
the number of RNs employed in long-term care facilities remained 
essentially unchanged. 

Table 2: Changes in RN Employment by Facility Type or Setting, 2000- 
2004: 

Facility type or setting: All facility types or settings; 
2000 Employment: 2,201,813; 
2004 Employment: 2,421,351; 
Change 2000-2004: 219,538. 

Facility type or setting: Hospitals; 
2000 Employment: 1,300,323; 
2004 Employment: 1,360,847; 
Change 2000-2004: 60,524. 

Facility type or setting: Ambulatory care; 
2000 Employment: 209,324; 
2004 Employment: 277,774; 
Change 2000-2004: 68,450. 

Facility type or setting: Public/community health; 
2000 Employment: 282,618; 
2004 Employment: 259,911; 
Change 2000-2004: -22,707. 

Facility type or setting: Long-term care facility; 
2000 Employment: 152,894; 
2004 Employment: 153,172; 
Change 2000-2004: 278. 

Facility type or setting: School/student health; 
2000 Employment: 83,269; 
2004 Employment: 78,022; 
Change 2000-2004: -5,247. 

Facility type or setting: Nursing education; 
2000 Employment: 46,655; 
2004 Employment: 63,444; 
Change 2000-2004: 16,789. 

Facility type or setting: Occupational health; 
2000 Employment: 36,395; 
2004 Employment: 22,447; 
Change 2000-2004: -13,948. 

Facility type or setting: Other and unknown; 
2000 Employment: 90,335; 
2004 Employment: 205,736; 
Change 2000-2004: 115,401. 

Source: HRSA. 

Note: Data are from the 2000 and 2004 National Sample Survey of 
Registered Nurses. Numbers represent RNs employed both full-time and 
part-time. Estimated numbers may not equal totals due to rounding. 

[End of table] 

While the number of employed RNs increased nationally from 2000 to 
2004, the growth varied widely among states. According to data from 
HRSA's 2000 and 2004 National Sample Survey of Registered Nurses, all 
but three states--Louisiana, Massachusetts, and Rhode Island--posted 
gains in RN employment between 2000 and 2004 (see enc. I). Among the 48 
states where the number of employed RNs increased, the growth in 
employment ranged from 2 percent in Connecticut to 47 percent in New 
Hampshire. Growth exceeded 15 percent in 11 states, and ranged from 10 
to 15 percent in 15 other states. 

The growth in the number of employed RNs is due in part to an increase 
in the number of newly licensed nursing school graduates entering the 
workforce.[Footnote 17] The number of newly licensed RNs available to 
enter the workforce, as reflected in the annual number of RNs passing 
the national licensing examination, grew from approximately 75,000 in 
2000 to 101,000 in 2004 and 113,000 in 2005, an increase of 51 percent 
from 2000 to 2005 (see fig. 2).[Footnote 18] From 2000 to 2005, the 
number of newly licensed RNs educated in the United States increased 41 
percent from 69,569 to 98,363, and the number of newly licensed RNs who 
were educated outside the United States grew by 182 percent from 5,231 
to 14,750. 

Figure 2: Number of RNs Passing the National Licensing Exam, by Year, 
U.S.-and Foreign-Educated, 2000-2005: 

[See PDF for image] 

Source: GAO analysis of National Council of State Boards of Nursing 
data. 

[End of figure] 

Indirect Evidence Suggests Shortage of RNs Has Eased since 2000: 

Although there are data indicating that the supply of RNs--that is, the 
number employed--increased between 2000 and 2004, we are unable to 
estimate changes in the shortage of RNs over this time period. 
Estimating changes in the RN shortage requires data on both the supply 
of and the demand for RNs in 2000 and 2004. While HRSA's National 
Sample Survey of Registered Nurses provides data on the number of 
employed RNs in 2000 and 2004, HRSA's estimates of demand for RNs have 
not been updated since 2000.[Footnote 19] Furthermore, HRSA's estimates 
of RN supply and demand are at the state level and cannot provide 
information on whether there is a shortage within states, in rural or 
urban areas, or among facilities or other settings.[Footnote 20] 

Despite the absence of data to assess directly the magnitude of changes 
in the RN shortage between 2000 and 2004, indirect evidence suggests 
that the overall shortage of RNs has eased since 2000. This evidence 
consists of (1) relatively strong growth in the number of employed RNs 
in the states designated by HRSA as having shortages in 2000, (2) 
growth in the number of employed RNs relative to the size of the 
general population, (3) growth in the earnings of RNs that is 
consistent with the earnings growth for the overall U.S. workforce in 
recent years, and (4) reported decreases in the number of unfilled 
employment positions for hospital RNs. 

First, RN employment growth from 2000 to 2004 was generally strongest 
in those states that HRSA designated as having greater shortages in 
2000.[Footnote 21] (See fig. 3.) HRSA estimates of RN shortages in 2000 
show that 30 states were estimated to have a shortage; 9 states were 
estimated to have a surplus, and 12 states had no clear shortage or 
surplus in 2000.[Footnote 22] In the states HRSA estimated as having 
shortages in 2000, growth in employed RNs averaged about 14 percent 
from 2000 to 2004, while states that HRSA designated as having 
surpluses in 2000 averaged about 5-percent growth.[Footnote 23] 
Arizona, the state with the largest estimated shortage in 2000, had 
almost a 23 percent growth in RN employment from 2000 to 2004. Montana, 
the state with the largest estimated surplus in 2000, experienced a 3 
percent growth in employment between 2000 and 2004. (See enc. II.) 

Figure 3: Full-time equivalent (FTE) RN Employment Growth by State, 
2000-2004: 

[See PDF for image] 

Source: HRSA and GAO analysis of HRSA data. Copyright Corel Corp. All 
rights reserved (map). 

Note: RN employment based on FTEs. 

[End of figure] 

Second, between 2000 and 2004 the number of employed RNs relative to 
the size of the general population increased, reflecting an increase in 
RN supply relative to one measure of demand. According to HRSA's 
National Sample Survey of Registered Nurses, nationally there were 825 
employed RNs per 100,000 people in 2004, compared with 782 per 100,000 
in 2000 and 798 per 100,000 in 1996. Between 2000 and 2004, on a per 
capita basis, the number of employed RNs increased by 5.5 percent. This 
followed a 2 percent decline in per capita RN employment between 1996 
and 2000. (See enc. III.) Changes in the per capita RN employment 
varied across states between 2000 and 2004. (See fig. 4.) 

Figure 4: Change in State Per Capita RN Employment, 2000-2004: 

[See PDF for image] 

Source: GAO analysis of HRSA data. Copyright Corel Corp. All rights 
reserved (map). 

[End of figure] 

Third, after several years of strong relative earnings growth for RNs 
following reports of an emerging shortage around 2000, RN earnings have 
grown at a rate comparable to the overall workforce during the most 
recent period from 2003 through 2005.[Footnote 24] (See fig. 5.) In a 
period of shortage, wage or earnings growth for RNs would be expected 
to exceed the earnings growth for all workers as employers raise wages 
to attract more RNs. Growth in RN earnings lagged behind earnings 
growth for all workers through most of the 1990s, and in particular in 
the mid-1990s period. During the 2001 through 2003 period, earnings 
growth for RNs averaged 4.4 percent per year while earnings for all 
workers grew by an average of 2.5 percent per year. During the most 
recent period, however, from 2003 through 2005, RN earnings rose at an 
average annual rate of 2.2 percent, the same as for all workers. 

Figure 5: Earnings Growth for Registered Nurses and All Workers, 1999- 
2005: 

[See PDF for image] 

Source: GAO analysis of Bureau of Labor Statistics data. 

Note: Data are from the Current Population Survey (CPS) monthly 
household survey and represent 3-year annual averages. 

[End of figure] 

Fourth, reports of declines in the percentage of unfilled employment 
positions at some facilities that employ RNs are also evidence of an 
easing of the RN shortage because they indicate less unmet employer 
demand for RNs. Although no comprehensive data exist on how many of 
these positions go unfilled each year, some trade associations gather 
information on such employment vacancies from member surveys. For 
example, the AHA reported a national decline in the rate of unfilled RN 
positions in hospitals, from 13 percent in 2001 to 9 percent in 2005. 
The extent of the decline varied across regions of the country. For 
example, AHA reported that from 2001 through 2005 the greatest decline 
in the rate of employment vacancies occurred among hospitals in the 
West, where the average rate of RN vacancies fell from 15 to 9 percent. 
In contrast, the smallest decline occurred among hospitals in the 
South, where during the same time period, the average rate of RN 
vacancies fell from 13 to 10 percent. 

Characteristics of NELRP and NSP Awardees Differ from the Overall RN 
Workforce, and GAO Cannot Assess Programs' Effect on Nursing Supply: 

As a group, NSP and NELRP awardees have a higher percentage of 
minorities and are more likely to have received or be pursuing 4-year 
bachelor's degrees rather than 2-year associate's degrees than the 
overall RN workforce. Although NSP and NELRP awardees are required to 
be employed in one of the types of facilities identified by HRSA in 
order to meet the NRA requirement intended to address critical nursing 
shortages, we cannot assess whether the two programs have improved the 
supply of RNs in facilities with critical shortages of RNs. HRSA does 
not have a sound basis for identifying critical shortage facilities, 
and as a result, awardees of the programs may not be serving in 
facilities actually experiencing such shortages. HRSA is working to 
develop an empirically-based approach for identifying facilities with 
critical shortages of RNs, but these efforts have not yet been 
completed. 

NSP and NELRP Awardees Have a Higher Percentage of Minorities and 
Obtain Higher Degrees than Overall RN Workforce: 

In our comparison of minority status, we found that as a group, 
awardees of the NSP and NELRP have a higher percentage of minorities 
than the overall nursing workforce, but are similar to current nursing 
school students and recent graduates.[Footnote 25] (See fig. 6.) In 
both programs, an applicant's minority status is not used as a 
criterion in making awards. While minorities made up 11 percent of the 
overall RN workforce in 2004, they constituted 36 percent of NSP 
awardees, 21 percent of NELRP awardees and 26 and 22 percent of nursing 
school students and graduates, respectively.[Footnote 26] (See enc. IV 
for more detailed data on NELRP and NSP awardees.) 

Figure 6: Percentage of Minorities among Awardees in the NSP and NELRP, 
RN Students and RN Graduates, and the Overall RN Workforce, 2004: 

[See PDF for image] 

Source: HRSA and National League for Nursing (NLN). 

Note: Minorities include African Americans, Hispanics, American 
Indians, Native Hawaiians, Native Alaskans, Asians, and Pacific 
Islanders. NSP and NELRP awardee data are for fiscal year 2004. 

[End of figure] 

Awardees of the NSP and NELRP programs are also more likely to be 
pursuing or have received higher degrees than the overall RN workforce 
or current nursing student population. In fiscal year 2004, the 
percentage of NSP awardees pursuing a bachelor's degree was higher than 
it was among the nursing student population.[Footnote 27] While 49 
percent of the nursing student population was pursuing a bachelor's or 
graduate degree in 2004, 70 percent of NSP awardees were pursuing this 
degree. (See fig. 7.) Similarly, in the NELRP, the majority of awards 
in fiscal year 2004 were given to applicants with bachelor's or higher 
degrees. This is largely due to the way in which awards are funded, 
with preference given to those with greatest financial need. Applicants 
who obtain higher level degrees (bachelor's or graduate degrees) are 
likely to have higher levels of debt than those with an associate's 
degree. 

Figure 7: Degree Types of NSP and NELRP Awardees Compared to Nursing 
School Students, Graduates, and the RN Workforce, 2004: 

[See PDF for image] 

Source: HRSA and NLN data. 

Note: NSP and NELRP awardee data are for fiscal year 2004. 

[End of figure] 

Other characteristics of NSP and NELRP awardees include the type of 
facility in which the awardees work. As of fiscal year 2005, 78 of 419 
NSP awardees had completed their education and had begun their service 
in a critical shortage facility. Of these, 71 were serving in 
hospitals, 3 in Indian Health Service Health Centers, and 1 each in a 
home health agency, hospice, nursing home, and skilled nursing 
facility. As shown in table 3, the majority of NELRP awardees were 
completing their service requirement in disproportionate share 
hospitals and public health departments as of fiscal year 2005. In 
addition, most NELRP awardees were working in not-for-profit facilities 
and in facilities located in the South and West.[Footnote 28] 

Table 3: Work Locations of Nursing Education Loan Repayment Program 
Awardees, Fiscal Years 2003-2005: 

Total Awardees; 
Year: 2003: 602; 
Year: 2004: 857; 
Year: 2005: 803. 

Facility type; 
Disproportionate share hospital[A]; 
Year: 2003: 473; 
Year: 2004: 531; 
Year: 2005: 663. 

Facility type; 
Public health department; 
Year: 2003: 91; 
Year: 2004: 128; 
Year: 2005: 85. 

Facility type; 
Nursing home; 
Year: 2003: 38; 
Year: 2004: 66; 
Year: 2005: 32. 

Facility type; 
Federally-designated community health center; 
Year: 2003: 0; 
Year: 2004: 3; 
Year: 2005: 19. 

Facility type; 
Hospital; 
Year: 2003: 0; 
Year: 2004: 52; 
Year: 2005: 0. 

Facility type; 
Rural health clinic; 
Year: 2003: 0; 
Year: 2004: 4; 
Year: 2005: 4. 

Facility type; 
Indian Health Service health center; 
Year: 2003: 0; 
Year: 2004: 1; 
Year: 2005: 0. 

Facility type; 
Other not-for-profit health facility; 
Year: 2003: 0; 
Year: 2004: 72; 
Year: 2005: 0. 

Facility ownership status; 
Not-for-profit; 
Year: 2003: 425; 
Year: 2004: 411; 
Year: 2005: 510. 

Facility ownership status; 
For-profit; 
Year: 2003: 177; 
Year: 2004: 446; 
Year: 2005: 293. 

Region of facility[B]; 
Northeast; 
Year: 2003: 88; 
Year: 2004: 103; 
Year: 2005: 111. 

Region of facility[B]; 
Midwest; 
Year: 2003: 107; 
Year: 2004: 246; 
Year: 2005: 160. 

Region of facility[B]; 
South; 
Year: 2003: 243; 
Year: 2004: 270; 
Year: 2005: 299. 

Region of facility[B]; 
West; 
Year: 2003: 164; 
Year: 2004: 238; 
Year: 2005: 233. 

Region of facility[B]; 
Urban; 
Year: 2003: 566; 
Year: 2004: 770; 
Year: 2005: 713. 

Region of facility[B]; 
Rural; 
Year: 2003: 36; 
Year: 2004: 87; 
Year: 2005: 90. 

Source: HRSA. 

[A] Disproportionate share hospitals receive supplemental payments 
through the Medicare or Medicaid programs to subsidize the costs 
associated with providing care to a high proportion of low-income 
patients. 

[B] Regions consist of the following: Northeast--Maine, New Hampshire, 
Vermont, Massachusetts, Rhode Island, Connecticut, New York, New 
Jersey, Pennsylvania; Midwest--Ohio, Indiana, Illinois, Michigan, 
Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, 
Nebraska, Kansas; South--Delaware, Maryland, District of Columbia, 
Virginia, West Virginia, North Carolina, South Carolina, Georgia, 
Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, 
Louisiana, Oklahoma, Texas; and West--Montana, Idaho, Wyoming, 
Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, 
California, Alaska, Hawaii. 

[End of table] 

Effect of NELRP and NSP Cannot Be Assessed Because HRSA Lacks a Sound 
Basis for Identifying Facilities with a Critical Shortage of RNs: 

We cannot assess whether the NELRP and NSP have improved the supply of 
RNs at facilities that actually have critical shortages of RNs because 
HRSA does not have a sound basis for identifying facilities with 
critical shortages of RNs. To meet the requirement established by NRA 
designed to help facilities with critical shortages, HRSA uses its list 
of critical shortage facility types. HRSA created the list based on the 
assumption that the facility types on the list target the underserved 
and are generally believed to be facing nursing shortages. In addition, 
the Secretary of HHS determined that the NELRP should emphasize serving 
the underserved, improving the public health infrastructure, and 
addressing needs at nursing homes, so the agency currently gives 
preference to loan repayment applicants working in disproportionate 
share hospitals, community health centers, rural health clinics, Indian 
Health Service health centers, public health departments or clinics, 
and nursing homes. Some awardees of the NELRP must submit a letter or 
other documentation from their employer that provides support that the 
awardee is employed at one of the critical shortage facility types. 
Although HRSA uses the list of facility types in making awards to NELRP 
and NSP applicants, HRSA does not determine the number of RNs needed 
for a facility to be considered as one experiencing a critical shortage 
of RNs. As a result, HRSA does not know the extent to which specific 
facilities served by NELRP and NSP awardees are actually experiencing 
critical nursing shortages. Therefore, we cannot assess whether the two 
programs have increased the supply of RNs at facilities with critical 
shortages. 

HRSA began using the current list of facility types after passage of 
the NRA. Prior to the NRA, the law required that preference be given to 
qualified applicants who agreed to work in certain health facilities 
located in geographic areas with a shortage of and need for 
nurses.[Footnote 29] To implement this, HRSA considered whether the 
facility was located in what was known as a nurse shortage county or in 
a Health Professional Shortage Area (HPSA).[Footnote 30] However, HRSA 
recognized limitations in both the county and the HPSA definitions. 
According to HRSA officials, the nurse shortage county designation was 
not sufficiently reflective of the entire nursing workforce because it 
was based only on hospital data. Similarly, according to HRSA 
officials, HPSAs are designed for the placement of primary care 
physicians, and RN work settings are both more diverse and more complex 
than those of physicians.[Footnote 31] As a result of these limitations 
to both the nurse shortage counties and HPSAs, and because the NRA 
deleted the requirement that preference be given to applicants serving 
in certain facilities located in geographic areas with a shortage of 
and need for nurses, HRSA discontinued the use of geographic areas in 
favor of using only the list of critical shortage facility types. At 
the same time, HRSA officials acknowledged that this new approach did 
not represent a scientific or empirical method for identifying actual 
shortage facilities and was only intended as an interim approach to 
meet the short-term needs of the program. 

HRSA has efforts underway to develop a new approach for identifying 
facilities experiencing critical shortages of RNs, though these efforts 
have not been completed. In 2004 HRSA contracted with researchers at 
the Center for Health Workforce Studies at the State University of New 
York (SUNY) at Albany to develop an empirical, data-driven method for 
identifying "health care facilities with a critical shortage of RNs." 
According to the SUNY researchers, among the contract's guiding 
principles were that the approach had to (1) be practical, that is, not 
overly burdensome on facilities or HRSA; (2) be applicable to all 
facility types; (3) use data that were easy to access and available 
over time; and (4) be easy to update. 

The first approach the SUNY researchers developed and tested was a 
facility-based model using data from North Carolina and North Dakota, 
two states that are recognized as having good facility-level data on RN 
staffing, vacancy rates, and turnover. However, the researchers found 
that these data were not sufficiently reliable predictors of whether a 
facility had an RN shortage. Also, the analysis required data that are 
not collected and reported by health care facilities in most states. 
The SUNY researchers concluded that the burden and cost of gathering 
facility/provider-level data from every health facility or provider in 
every state rendered this approach impractical. As a result, the 
researchers began work on an approach that could use available county- 
level data to determine which geographic areas could be defined as 
having critical shortages of RNs, so that the facilities in such areas 
could be identified as having critical shortages of RNs.[Footnote 32] 
HRSA received the final report on the results of this work from the 
SUNY researchers in February 2007. The report contains a recommended 
method for estimating the extent of nursing shortages in all counties 
in the United States. The advisory committee for this study recommended 
that before any method is adopted by HRSA it be validated in a number 
of states, facilities, and settings. As of March 2007, the report and 
its recommendations were under review, and HRSA officials said they 
plan to publish the results sometime in 2007. 

Conclusions: 

HRSA is in its fifth year granting awards under the Nursing Education 
Loan Repayment Program (NELRP) and the Nursing Scholarship Program 
(NSP) since passage of the Nurse Reinvestment Act. While these two 
programs are aimed at encouraging graduating and employed nurses to 
work in facilities with a critical shortage of nurses, they may not 
always be achieving their intended goals. Because HRSA does not have a 
sound basis for identifying facilities with a critical shortage of RNs, 
HRSA's awardees may be working in facilities that may not be actually 
experiencing such shortages. HRSA received a report from its 
contractors that identifies available data and an approach to identify 
such facilities, and, as of March 2007, the report and its 
recommendations were under review. Because these two HRSA programs are 
able to support relatively few nurses, it is important that HRSA ensure 
that its work to develop a methodology for identifying facilities with 
a critical shortage of nurses is completed so that the resources of 
these programs can be targeted effectively to meet their intended 
purpose. 

Recommendations for Executive Action: 

In order to target funding effectively for the Nursing Education Loan 
Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) to 
nurses working in health care facilities with a critical shortage of 
nurses, we recommend that the Secretary of HHS take the following 
steps: 

1. identify the specific steps and a time frame for implementing an 
empirical methodology for identifying health care facilities with a 
critical shortage of nurses; and: 

2. direct the Administrator of HRSA to include a description of steps 
taken and progress on its time frame for implementing such methodology 
in HRSA's annual report to Congress on these programs. 

Agency Comments: 

In commenting on a draft of this report, HHS provided technical 
comments, which we incorporated as appropriate. 

We are sending copies of this report to the Secretary of HHS, the 
Administrator of HRSA, and other interested parties. We will also make 
copies available to others on request. In addition, the report is 
available at no charge on the GAO Web site at http://www.gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. If you or your 
staff members have any questions about this report, please contact 
Kathleen King at (202) 512-7119 or kingk@gao.gov. Major contributors to 
this report are listed in enclosure V. 

Signed by: 

Kathleen King: 
Director, Health Care: 

Enclosures - 5: 

[End of section] 

Enclosure I: Change in Number of Registered Nurses (RN) Employed in 
Nursing, by State, 2000-2004: 

State: Alaska; 
2000 RN employment: 4,914; 
2004 RN employment: 6,777; 
Percent change in RN employment 2000-2004: 37.9. 

State: Alabama; 
2000 RN employment: 34,073; 
2004 RN employment: 36,538; 
Percent change in RN employment 2000-2004: 7.2. 

State: Arkansas; 
2000 RN employment: 18,752; 
2004 RN employment: 20,115; 
Percent change in RN employment 2000-2004: 7.3. 

State: Arizona; 
2000 RN employment: 32,222; 
2004 RN employment: 39,136; 
Percent change in RN employment 2000-2004: 21.5. 

State: California; 
2000 RN employment: 184,329; 
2004 RN employment: 211,531; 
Percent change in RN employment 2000-2004: 14.8. 

State: Colorado; 
2000 RN employment: 31,695; 
2004 RN employment: 34,654; 
Percent change in RN employment 2000-2004: 9.3. 

State: Connecticut; 
2000 RN employment: 32,073; 
2004 RN employment: 32,718; 
Percent change in RN employment 2000-2004: 2.0. 

State: Dist. of Col; 
2000 RN employment: 9,583; 
2004 RN employment: 11,583; 
Percent change in RN employment 2000-2004: 20.9. 

State: Delaware; 
2000 RN employment: 7,337; 
2004 RN employment: 8,633; 
Percent change in RN employment 2000-2004: 17.7. 

State: Florida; 
2000 RN employment: 125,439; 
2004 RN employment: 132,758; 
Percent change in RN employment 2000-2004: 5.8. 

State: Georgia; 
2000 RN employment: 55,881; 
2004 RN employment: 66,512; 
Percent change in RN employment 2000-2004: 19.0. 

State: Hawaii; 
2000 RN employment: 8,518; 
2004 RN employment: 9,335; 
Percent change in RN employment 2000-2004: 9.6. 

State: Idaho; 
2000 RN employment: 8,230; 
2004 RN employment: 8,753; 
Percent change in RN employment 2000-2004: 6.4. 

State: Illinois; 
2000 RN employment: 101,660; 
2004 RN employment: 113,779; 
Percent change in RN employment 2000-2004: 11.9. 

State: Indiana; 
2000 RN employment: 46,244; 
2004 RN employment: 54,624; 
Percent change in RN employment 2000-2004: 18.1. 

State: Iowa; 
2000 RN employment: 31,020; 
2004 RN employment: 32,664; 
Percent change in RN employment 2000-2004: 5.3. 

State: Kansas; 
2000 RN employment: 23,779; 
2004 RN employment: 24,869; 
Percent change in RN employment 2000-2004: 4.6. 

State: Kentucky; 
2000 RN employment: 33,655; 
2004 RN employment: 37,631; 
Percent change in RN employment 2000-2004: 11.8. 

State: Louisiana; 
2000 RN employment: 37,275; 
2004 RN employment: 35,369; 
Percent change in RN employment 2000-2004: -5.1. 

State: Maine; 
2000 RN employment: 13,072; 
2004 RN employment: 15,077; 
Percent change in RN employment 2000-2004: 15.3. 

State: Maryland; 
2000 RN employment: 45,323; 
2004 RN employment: 47,124; 
Percent change in RN employment 2000-2004: 4.0. 

State: Massachusetts; 
2000 RN employment: 75,795; 
2004 RN employment: 75,398; 
Percent change in RN employment 2000-2004: -0.5. 

State: Michigan; 
2000 RN employment: 79,353; 
2004 RN employment: 84,967; 
Percent change in RN employment 2000-2004: 7.1. 

State: Minnesota; 
2000 RN employment: 47,102; 
2004 RN employment: 51,914; 
Percent change in RN employment 2000-2004: 10.2. 

State: Mississippi; 
2000 RN employment: 21,338; 
2004 RN employment: 24,009; 
Percent change in RN employment 2000-2004: 12.5. 

State: Missouri; 
2000 RN employment: 53,730; 
2004 RN employment: 57,365; 
Percent change in RN employment 2000-2004: 6.8. 

State: Montana; 
2000 RN employment: 7,327; 
2004 RN employment: 7,914; 
Percent change in RN employment 2000-2004: 8.0. 

State: North Carolina; 
2000 RN employment: 69,057; 
2004 RN employment: 76,761; 
Percent change in RN employment 2000-2004: 11.2. 

State: North Dakota; 
2000 RN employment: 7,039; 
2004 RN employment: 7,484; 
Percent change in RN employment 2000-2004: 6.3. 

State: Nebraska; 
2000 RN employment: 16,399; 
2004 RN employment: 18,532; 
Percent change in RN employment 2000-2004: 13.0. 

State: New Hampshire; 
2000 RN employment: 11,321; 
2004 RN employment: 16,670; 
Percent change in RN employment 2000-2004: 47.2. 

State: New Jersey; 
2000 RN employment: 67,280; 
2004 RN employment: 72,980; 
Percent change in RN employment 2000-2004: 8.5. 

State: New Mexico; 
2000 RN employment: 11,932; 
2004 RN employment: 13,570; 
Percent change in RN employment 2000-2004: 13.7. 

State: Nevada; 
2000 RN employment: 10,384; 
2004 RN employment: 14,095; 
Percent change in RN employment 2000-2004: 35.7. 

State: New York; 
2000 RN employment: 160,009; 
2004 RN employment: 174,208; 
Percent change in RN employment 2000-2004: 8.9. 

State: Ohio; 
2000 RN employment: 100,144; 
2004 RN employment: 112,806; 
Percent change in RN employment 2000-2004: 12.6. 

State: Oklahoma; 
2000 RN employment: 21,905; 
2004 RN employment: 24,433; 
Percent change in RN employment 2000-2004: 11.5. 

State: Oregon; 
2000 RN employment: 27,121; 
2004 RN employment: 30,850; 
Percent change in RN employment 2000-2004: 13.7. 

State: Pennsylvania; 
2000 RN employment: 123,997; 
2004 RN employment: 127,013; 
Percent change in RN employment 2000-2004: 2.4. 

State: Rhode Island; 
2000 RN employment: 11,542; 
2004 RN employment: 11,368; 
Percent change in RN employment 2000-2004: -1.5. 

State: South Carolina; 
2000 RN employment: 29,226; 
2004 RN employment: 30,711; 
Percent change in RN employment 2000-2004: 5.1. 

State: South Dakota; 
2000 RN employment: 8,511; 
2004 RN employment: 9,278; 
Percent change in RN employment 2000-2004: 9.0. 

State: Tennessee; 
2000 RN employment: 49,626; 
2004 RN employment: 54,338; 
Percent change in RN employment 2000-2004: 9.5. 

State: Texas; 
2000 RN employment: 126,436; 
2004 RN employment: 145,336; 
Percent change in RN employment 2000-2004: 14.9. 

State: Utah; 
2000 RN employment: 13,229; 
2004 RN employment: 15,778; 
Percent change in RN employment 2000-2004: 19.3. 

State: Vermont; 
2000 RN employment: 5,829; 
2004 RN employment: 6,444; 
Percent change in RN employment 2000-2004: 10.6. 

State: Virginia; 
2000 RN employment: 50,359; 
2004 RN employment: 56,726; 
Percent change in RN employment 2000-2004: 12.6. 

State: Washington; 
2000 RN employment: 43,482; 
2004 RN employment: 48,421; 
Percent change in RN employment 2000-2004: 11.4. 

State: West Virginia; 
2000 RN employment: 15,523; 
2004 RN employment: 16,042; 
Percent change in RN employment 2000-2004: 3.3. 

State: Wisconsin; 
2000 RN employment: 47,895; 
2004 RN employment: 51,679; 
Percent change in RN employment 2000-2004: 7.9. 

State: Wyoming; 
2000 RN employment: 3,849; 
2004 RN employment: 4,079; 
Percent change in RN employment 2000-2004: 6.0. 

State: United States; 
2000 RN employment: 2,201,813; 
2004 RN employment: 2,421,351; 
Percent change in RN employment 2000-2004: 10.0. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) data. 

Note: Data are from the 2000 and 2004 National Sample Survey of 
Registered Nurses, HRSA. 

[End of table] 

[End of section] 

Enclosure II: Change from 2000 to 2004 in Full-time equivalent (FTE) 
Registered Nurse (RN) Employment by Degree of State Shortage in 2000 as 
Estimated by the Health Resources and Services Administration (HRSA): 

States with a shortage in 2000. 

State: Arizona; 
Percent FTE RN shortage estimated by HRSA, 2000: -17.3; 
Percent change in FTE RN employment 2000-2004: 22.6. 

State: Tennessee; 
Percent FTE RN shortage estimated by HRSA, 2000: -13.4; 
Percent change in FTE RN employment 2000-2004: 10.3. 

State: New Jersey; 
Percent FTE RN shortage estimated by HRSA, 2000: -12.9; 
Percent change in FTE RN employment 2000-2004: 5.0. 

State: Connecticut; 
Percent FTE RN shortage estimated by HRSA, 2000: -12.4; 
Percent change in FTE RN employment 2000-2004: 1.1. 

State: Maine; 
Percent FTE RN shortage estimated by HRSA, 2000: -11.7; 
Percent change in FTE RN employment 2000-2004: 17.0. 

State: Delaware; 
Percent FTE RN shortage estimated by HRSA, 2000: -11.1; 
Percent change in FTE RN employment 2000-2004: 19.4. 

State: Nevada; 
Percent FTE RN shortage estimated by HRSA, 2000: -10.9; 
Percent change in FTE RN employment 2000-2004: 36.6. 

State: New York; 
Percent FTE RN shortage estimated by HRSA, 2000: -10.9; 
Percent change in FTE RN employment 2000-2004: 8.8. 

State: Colorado; 
Percent FTE RN shortage estimated by HRSA, 2000: -10.7; 
Percent change in FTE RN employment 2000-2004: 10.2. 

State: Massachusetts; 
Percent FTE RN shortage estimated by HRSA, 2000: -10.5; 
Percent change in FTE RN employment 2000-2004: -0.9. 

State: Rhode Island; 
Percent FTE RN shortage estimated by HRSA, 2000: -10.1; 
Percent change in FTE RN employment 2000-2004: -2.7. 

State: Virginia; 
Percent FTE RN shortage estimated by HRSA, 2000: -9.8; 
Percent change in FTE RN employment 2000-2004: 9.9. 

State: New Hampshire; 
Percent FTE RN shortage estimated by HRSA, 2000: -9.7; 
Percent change in FTE RN employment 2000-2004: 44.7. 

State: Indiana; 
Percent FTE RN shortage estimated by HRSA, 2000: -9.6; 
Percent change in FTE RN employment 2000-2004: 20.4. 

State: Hawaii; 
Percent FTE RN shortage estimated by HRSA, 2000: -9.2; 
Percent change in FTE RN employment 2000-2004: 6.1. 

State: Washington; 
Percent FTE RN shortage estimated by HRSA, 2000: -9.2; 
Percent change in FTE RN employment 2000-2004: 15.7. 

State: Texas; 
Percent FTE RN shortage estimated by HRSA, 2000: -8.9; 
Percent change in FTE RN employment 2000-2004: 11.3. 

State: Utah; 
Percent FTE RN shortage estimated by HRSA, 2000: -8.1; 
Percent change in FTE RN employment 2000-2004: 19.3. 

State: Missouri; 
Percent FTE RN shortage estimated by HRSA, 2000: -7.9; 
Percent change in FTE RN employment 2000-2004: 3.9. 

State: Arkansas; 
Percent FTE RN shortage estimated by HRSA, 2000: -7.7; 
Percent change in FTE RN employment 2000-2004: 6.8. 

State: California; 
Percent FTE RN shortage estimated by HRSA, 2000: -7.6; 
Percent change in FTE RN employment 2000-2004: 13.8. 

State: New Mexico; 
Percent FTE RN shortage estimated by HRSA, 2000: -7.4; 
Percent change in FTE RN employment 2000-2004: 14.7. 

State: Georgia; 
Percent FTE RN shortage estimated by HRSA, 2000: -6.8; 
Percent change in FTE RN employment 2000-2004: 18.4. 

State: Ohio; 
Percent FTE RN shortage estimated by HRSA, 2000: -5.4; 
Percent change in FTE RN employment 2000-2004: 11.5. 

State: Nebraska; 
Percent FTE RN shortage estimated by HRSA, 2000: -5.2; 
Percent change in FTE RN employment 2000-2004: 15.7. 

State: Pennsylvania; 
Percent FTE RN shortage estimated by HRSA, 2000: -4.9; 
Percent change in FTE RN employment 2000-2004: 2.4. 

State: Alaska; 
Percent FTE RN shortage estimated by HRSA, 2000: -4.5; 
Percent change in FTE RN employment 2000-2004: 36.9. 

State: Oregon; 
Percent FTE RN shortage estimated by HRSA, 2000: -3.8; 
Percent change in FTE RN employment 2000-2004: 13.8. 

State: Iowa; 
Percent FTE RN shortage estimated by HRSA, 2000: -3.5; 
Percent change in FTE RN employment 2000-2004: 6.0. 

State: Minnesota; 
Percent FTE RN shortage estimated by HRSA, 2000: -3.5; 
Percent change in FTE RN employment 2000-2004: 8.3. 

States with no clear RN shortage or surplus in 2000[A]. 

State: Alabama; 
Percent FTE RN shortage estimated by HRSA, 2000: -2.9; 
Percent FTE RN shortage estimated by HRSA, 2000-2004: 2.4. 

State: Florida; 
Percent FTE RN shortage estimated by HRSA, 2000: -2.8; 
Percent change in FTE RN employment 2000-2004: 4.2. 

State: Dist. of Col; 
Percent FTE RN shortage estimated by HRSA, 2000: -2.4; 
Percent change in FTE RN employment 2000-2004: 14.8. 

State: Maryland; 
Percent FTE RN shortage estimated by HRSA, 2000: -1.4; 
Percent change in FTE RN employment 2000-2004: 3.7. 

State: Michigan; 
Percent FTE RN shortage estimated by HRSA, 2000: -1.3; 
Percent change in FTE RN employment 2000-2004: 6.3. 

State: Vermont; 
Percent FTE RN shortage estimated by HRSA, 2000: -0.5; 
Percent change in FTE RN employment 2000-2004: 8.9. 

State: South Carolina; 
Percent FTE RN shortage estimated by HRSA, 2000: -0.4; 
Percent change in FTE RN employment 2000-2004: 4.0. 

State: Mississippi; 
Percent FTE RN shortage estimated by HRSA, 2000: 0.0; 
Percent change in FTE RN employment 2000-2004: 10.8. 

State: North Dakota; 
Percent FTE RN shortage estimated by HRSA, 2000: 0.2; 
Percent change in FTE RN employment 2000-2004: 10.6. 

State: North Carolina; 
Percent FTE RN shortage estimated by HRSA, 2000: 1.0; 
Percent change in FTE RN employment 2000-2004: 9.0. 

State: Illinois; 
Percent FTE RN shortage estimated by HRSA, 2000: 1.6; 
Percent change in FTE RN employment 2000-2004: 9.2. 

State: Wyoming; 
Percent FTE RN shortage estimated by HRSA, 2000: 2.0; 
Percent change in FTE RN employment 2000-2004: 4.7. 

States with a surplus in 2000. 

State: Oklahoma; 
Percent FTE RN shortage estimated by HRSA, 2000: 4.6; 
Percent change in FTE RN employment 2000-2004: 10.0. 

State: Kentucky; 
Percent FTE RN shortage estimated by HRSA, 2000: 5.9; 
Percent change in FTE RN employment 2000-2004: 11.2. 

State: Wisconsin; 
Percent FTE RN shortage estimated by HRSA, 2000: 6.2; 
Percent change in FTE RN employment 2000-2004: 6.4. 

State: South Dakota; 
Percent FTE RN shortage estimated by HRSA, 2000: 8.1; 
Percent change in FTE RN employment 2000-2004: 5.3. 

State: Idaho; 
Percent FTE RN shortage estimated by HRSA, 2000: 8.5; 
Percent change in FTE RN employment 2000-2004: 9.4. 

State: Louisiana; 
Percent FTE RN shortage estimated by HRSA, 2000: 9.0; 
Percent change in FTE RN employment 2000-2004: -6.7. 

State: Kansas; 
Percent FTE RN shortage estimated by HRSA, 2000: 9.0; 
Percent change in FTE RN employment 2000-2004: 0.6. 

State: West Virginia; 
Percent FTE RN shortage estimated by HRSA, 2000: 10.3; 
Percent change in FTE RN employment 2000-2004: 2.1. 

State: Montana; 
Percent FTE RN shortage estimated by HRSA, 2000: 14.5; 
Percent change in FTE RN employment 2000-2004: 3.1. 

State: United States; 
Percent FTE RN shortage estimated by HRSA, 2000: -5.5; 
Percent change in FTE RN employment 2000-2004: 8.9. 

Source: HRSA and GAO analysis of HRSA data. 

Notes: HRSA's shortage estimates are for 2000. GAO analysis is of data 
from the 2000 and 2004 National Sample Survey of Registered Nurses, 
HRSA. 

[A] Due to uncertainties in the estimation process, only states with a 
difference between supply and demand of greater than 3 percent were 
considered to have a shortage or surplus. 

[End of table] 

[End of section] 

Enclosure III: Change in Registered Nurse (RN) Employment per 100,000 
Population, by State, 2000-2004: 

State: Alaska; 
Employed RNs per 100,000 persons: 2000: 784; 
Employed RNs per 100,000 persons: 2004: 1034; 
Percent change 2000-2004: 31.9. 

State: Alabama; 
Employed RNs per 100,000 persons: 2000: 766; 
Employed RNs per 100,000 persons: 2004: 807; 
Percent change 2000-2004: 5.4. 

State: Arizona; 
Employed RNs per 100,000 persons: 2000: 628; 
Employed RNs per 100,000 persons: 2004: 681; 
Percent change 2000-2004: 8.4. 

State: Arkansas; 
Employed RNs per 100,000 persons: 2000: 701; 
Employed RNs per 100,000 persons: 2004: 731; 
Percent change 2000-2004: 4.3. 

State: California; 
Employed RNs per 100,000 persons: 2000: 544; 
Employed RNs per 100,000 persons: 2004: 589; 
Percent change 2000-2004: 8.3. 

State: Colorado; 
Employed RNs per 100,000 persons: 2000: 737; 
Employed RNs per 100,000 persons: 2004: 753; 
Percent change 2000-2004: 2.2. 

State: Connecticut; 
Employed RNs per 100,000 persons: 2000: 942; 
Employed RNs per 100,000 persons: 2004: 934; 
Percent change 2000-2004: 
-0.8. 

State: Delaware; 
Employed RNs per 100,000 persons: 2000: 936; 
Employed RNs per 100,000 persons: 2004: 1040; 
Percent change 2000-2004: 11.1. 

State: Dist. of Col; 
Employed RNs per 100,000 persons: 2000: 1675; 
Employed RNs per 100,000 persons: 2004: 2093; 
Percent change 2000-2004: 25.0. 

State: Florida; 
Employed RNs per 100,000 persons: 2000: 785; 
Employed RNs per 100,000 persons: 2004: 763; 
Percent change 2000-2004: -2.8. 

State: Georgia; 
Employed RNs per 100,000 persons: 2000: 683; 
Employed RNs per 100,000 persons: 2004: 753; 
Percent change 2000-2004: 10.2. 

State: Hawaii; 
Employed RNs per 100,000 persons: 2000: 703; 
Employed RNs per 100,000 persons: 2004: 739; 
Percent change 2000-2004: 5.1. 

State: Idaho; 
Employed RNs per 100,000 persons: 2000: 636; 
Employed RNs per 100,000 persons: 2004: 628; 
Percent change 2000-2004: -1.3. 

State: Illinois; 
Employed RNs per 100,000 persons: 2000: 819; 
Employed RNs per 100,000 persons: 2004: 895; 
Percent change 2000-2004: 9.3. 

State: Indiana; 
Employed RNs per 100,000 persons: 2000: 761; 
Employed RNs per 100,000 persons: 2004: 876; 
Percent change 2000-2004: 15.1. 

State: Iowa; 
Employed RNs per 100,000 persons: 2000: 1060; 
Employed RNs per 100,000 persons: 2004: 1106; 
Percent change 2000-2004: 4.3. 

State: Kansas; 
Employed RNs per 100,000 persons: 2000: 885; 
Employed RNs per 100,000 persons: 2004: 909; 
Percent change 2000-2004: 2.7. 

State: Kentucky; 
Employed RNs per 100,000 persons: 2000: 833; 
Employed RNs per 100,000 persons: 2004: 908; 
Percent change 2000-2004: 9.0. 

State: Louisiana; 
Employed RNs per 100,000 persons: 2000: 834; 
Employed RNs per 100,000 persons: 2004: 783; 
Percent change 2000-2004: -6.1. 

State: Maine; 
Employed RNs per 100,000 persons: 2000: 1025; 
Employed RNs per 100,000 persons: 2004: 1145; 
Percent change 2000-2004: 11.7. 

State: Maryland; 
Employed RNs per 100,000 persons: 2000: 856; 
Employed RNs per 100,000 persons: 2004: 848; 
Percent change 2000-2004: -0.9. 

State: Massachusetts; 
Employed RNs per 100,000 persons: 2000: 1194; 
Employed RNs per 100,000 persons: 2004: 1175; 
Percent change 2000-2004: 
-1.6. 

State: Michigan; 
Employed RNs per 100,000 persons: 2000: 798; 
Employed RNs per 100,000 persons: 2004: 840; 
Percent change 2000-2004: 5.3. 

State: Minnesota; 
Employed RNs per 100,000 persons: 2000: 957; 
Employed RNs per 100,000 persons: 2004: 1018; 
Percent change 2000-2004: 6.4. 

State: Mississippi; 
Employed RNs per 100,000 persons: 2000: 750; 
Employed RNs per 100,000 persons: 2004: 827; 
Percent change 2000-2004: 10.3. 

State: Missouri; 
Employed RNs per 100,000 persons: 2000: 960; 
Employed RNs per 100,000 persons: 2004: 997; 
Percent change 2000-2004: 3.9. 

State: Montana; 
Employed RNs per 100,000 persons: 2000: 812; 
Employed RNs per 100,000 persons: 2004: 854; 
Percent change 2000-2004: 5.2. 

State: Nebraska; 
Employed RNs per 100,000 persons: 2000: 958; 
Employed RNs per 100,000 persons: 2004: 1061; 
Percent change 2000-2004: 10.8. 

State: Nevada; 
Employed RNs per 100,000 persons: 2000: 520; 
Employed RNs per 100,000 persons: 2004: 604; 
Percent change 2000-2004: 16.2. 

State: New Hampshire; 
Employed RNs per 100,000 persons: 2000: 916; 
Employed RNs per 100,000 persons: 2004: 1283; 
Percent change 2000-2004: 40.1. 

State: New Jersey; 
Employed RNs per 100,000 persons: 2000: 800; 
Employed RNs per 100,000 persons: 2004: 839; 
Percent change 2000-2004: 4.9. 

State: New Mexico; 
Employed RNs per 100,000 persons: 2000: 656; 
Employed RNs per 100,000 persons: 2004: 713; 
Percent change 2000-2004: 8.7. 

State: New York; 
Employed RNs per 100,000 persons: 2000: 843; 
Employed RNs per 100,000 persons: 2004: 906; 
Percent change 2000-2004: 7.5. 

State: North Carolina; 
Employed RNs per 100,000 persons: 2000: 858; 
Employed RNs per 100,000 persons: 2004: 899; 
Percent change 2000-2004: 4.8. 

State: North Dakota; 
Employed RNs per 100,000 persons: 2000: 1096; 
Employed RNs per 100,000 persons: 2004: 1180; 
Percent change 2000-2004: 7.7. 

State: Ohio; 
Employed RNs per 100,000 persons: 2000: 882; 
Employed RNs per 100,000 persons: 2004: 984; 
Percent change 2000-2004: 11.6. 

State: Oklahoma; 
Employed RNs per 100,000 persons: 2000: 635; 
Employed RNs per 100,000 persons: 2004: 693; 
Percent change 2000-2004: 9.1. 

State: Oregon; 
Employed RNs per 100,000 persons: 2000: 793; 
Employed RNs per 100,000 persons: 2004: 858; 
Percent change 2000-2004: 8.2. 

State: Pennsylvania; 
Employed RNs per 100,000 persons: 2000: 1010; 
Employed RNs per 100,000 persons: 2004: 1024; 
Percent change 2000-2004: 1.4. 

State: Rhode Island; 
Employed RNs per 100,000 persons: 2000: 1101; 
Employed RNs per 100,000 persons: 2004: 1052; 
Percent change 2000-2004: 
-4.5. 

State: South Carolina; 
Employed RNs per 100,000 persons: 2000: 728; 
Employed RNs per 100,000 persons: 2004: 732; 
Percent change 2000-2004: 0.5. 

State: South Dakota; 
Employed RNs per 100,000 persons: 2000: 1128; 
Employed RNs per 100,000 persons: 2004: 1204; 
Percent change 2000-2004: 6.7. 

State: Tennessee; 
Employed RNs per 100,000 persons: 2000: 872; 
Employed RNs per 100,000 persons: 2004: 921; 
Percent change 2000-2004: 5.6. 

State: Texas; 
Employed RNs per 100,000 persons: 2000: 606; 
Employed RNs per 100,000 persons: 2004: 646; 
Percent change 2000-2004: 6.6. 

State: Utah; 
Employed RNs per 100,000 persons: 2000: 592; 
Employed RNs per 100,000 persons: 2004: 660; 
Percent change 2000-2004: 11.5. 

State: Vermont; 
Employed RNs per 100,000 persons: 2000: 957; 
Employed RNs per 100,000 persons: 2004: 1037; 
Percent change 2000-2004: 8.4. 

State: Virginia; 
Employed RNs per 100,000 persons: 2000: 711; 
Employed RNs per 100,000 persons: 2004: 760; 
Percent change 2000-2004: 6.9. 

State: Washington; 
Employed RNs per 100,000 persons: 2000: 738; 
Employed RNs per 100,000 persons: 2004: 781; 
Percent change 2000-2004: 5.8. 

State: West Virginia; 
Employed RNs per 100,000 persons: 2000: 858; 
Employed RNs per 100,000 persons: 2004: 884; 
Percent change 2000-2004: 3.0. 

State: Wisconsin; 
Employed RNs per 100,000 persons: 2000: 893; 
Employed RNs per 100,000 persons: 2004: 938; 
Percent change 2000-2004: 5.0. 

State: Wyoming; 
Employed RNs per 100,000 persons: 2000: 780; 
Employed RNs per 100,000 persons: 2004: 805; 
Percent change 2000-2004: 3.2. 

State: United States; 
Employed RNs per 100,000 persons: 2000: 782; 
Employed RNs per 100,000 persons: 2004: 825; 
Percent change 2000-2004: 5.5. 

Source: Source: GAO analysis of Health Resources and Services 
Administration (HRSA) data. 

Note: Data are from the 2000 and 2004 National Sample Survey of 
Registered Nurses, HRSA. 

[End of table] 

[End of section] 

Enclosure IV: Characteristics of Nursing Education Loan Repayment 
Program (NELRP) and Nursing Scholarship Program (NSP) Awardees: 

Table 6: Race and Ethnicity of Registered Nurse (RN) Workforce, Nursing 
School Graduates, and NELRP Awardees, 2004: 

Race and ethnicity: White (non-Hispanic); 
2004 RN workforce (percent): 81.2; 
2004 Nursing school graduates (percent): 73.6; 
2004 NELRP awardees (percent): 70.1. 

Race and ethnicity: Black (non-Hispanic); 
2004 RN workforce (percent): 4.4; 
2004 Nursing school graduates (percent): 10.4; 
2004 NELRP awardees (percent): 9.7. 

Race and ethnicity: Asian/Pacific Islander[A]; 
2004 RN workforce (percent): 3.3; 
2004 Nursing school graduates (percent): 3.6; 
2004 NELRP awardees (percent): 3.0. 

Race and ethnicity: American Indian/Alaska Native; 
2004 RN workforce (percent): 0.3; 
2004 Nursing school graduates (percent): 0.9; 
2004 NELRP awardees (percent): 0.7. 

Race and ethnicity: Hispanic (any race); 
2004 RN workforce (percent): 1.7; 
2004 Nursing school graduates (percent): 6.0; 
2004 NELRP awardees (percent): 5.7. 

Race and ethnicity: Other/unknown[B]; 
2004 RN workforce (percent): 9.0; 
2004 Nursing school graduates (percent): 5.5; 
2004 NELRP awardees (percent): 10.7. 

Source: Health Resources and Services Administration (HRSA), National 
League for Nursing, and GAO analysis of HRSA administrative data. 

[A] Includes Native Hawaiians among the RN workforce and NELRP 
awardees. 

[B] Includes 1.5 percent identified as two or more races among the 2004 
RN workforce. 

[End of table] 

Table 7: Race and Ethnicity of RN Workforce, Nursing School Students, 
and NSP Awardees, 2004: 

Race and ethnicity: White (non-Hispanic); 
2004 RN workforce (percent): 81.2; 
2004 Nursing school students (percent): 69.2; 
2004 NSP awardees (percent): 61.9. 

Race and ethnicity: Black (non-Hispanic); 
2004 RN workforce (percent): 4.4; 
2004 Nursing school students (percent): 13.0; 
2004 NSP awardees (percent): 29.4. 

Race and ethnicity: Asian/Pacific Islander[A]; 
2004 RN workforce (percent): 3.3; 
2004 Nursing school students (percent): 5.4; 
2004 NSP awardees (percent): 2.4. 

Race and ethnicity: American Indian/Alaska Native; 
2004 RN workforce (percent): 0.3; 
2004 Nursing school students (percent): 0.8; 
2004 NSP awardees (percent): 0.8. 

Race and ethnicity: Hispanic (any race); 
2004 RN workforce (percent): 1.7; 
2004 Nursing school students (percent): 5.7; 
2004 NSP awardees (percent): 1.6. 

Race and ethnicity: Other/unknown[B]; 
2004 RN workforce (percent): 9.0; 
2004 Nursing school students (percent): 5.9; 
2004 NSP awardees (percent): 4.0. 

Source: HRSA, National League for Nursing, and GAO analysis of HRSA 
administrative data. 

[A] Includes Native Hawaiians among the RN workforce and NSP awardees. 

[B] Includes 1.5 percent identified as two or more races among the 2004 
RN workforce. 

[End of table] 

[End of section] 

Enclosure V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Kathleen King, (202) 512-7119 or kingk@gao.gov: 

Acknowledgments: 

In addition to the contact names above, Linda T. Kohn, Assistant 
Director; Eric Anderson, Krister Friday, Romonda McKinney, Dae Park, 
Ollie Richie, and Jessica C. Smith made key contributions to this 
report. 

(290529): 

FOOTNOTES 

[1] This includes RNs employed both full-time and part-time. Data for 
2004 were the most recent available on the overall RN workforce. 

[2] GAO, Nursing Workforce: Emerging Nurse Shortages Due to Multiple 
Factors, GAO-01-944 (Washington, D.C.: July 10, 2001). 

[3] HRSA Bureau of Health Professions, Projected Supply, Demand, and 
Shortages of Registered Nurses: 2000-2020 (Rockville, Md., 2002). 

[4] For a recent study of labor shortages, the Department of Labor 
defined a shortage as "a market disequilibrium between supply and 
demand in which the quantity of workers demanded exceeds the supply 
available and willing to work at a particular wage and working 
conditions at a particular place and point in time." See The Urban 
Institute, Skill Shortages and Mismatches in Nursing Related Health 
Care Employment (Washington, D.C., April 2002). 

[5] See J. Needleman et al., Nurse Staffing and Patient Outcomes in 
Hospitals, Final Report for HRSA, Contract No. 230-99-0021, Harvard 
School of Public Health (Boston, Mass., 2001). See also M.W. Stanton 
and M.K. Rutherford, Hospital Nurse Staffing and Quality of Care, 
Agency for Healthcare Research and Quality (Rockville, Md., 2004). 

[6] Pub. L. No. 107-205, 116 Stat. 813 (2002). 

[7] In this report, we consider any RN training program, including 2- 
year, 3-year, and 4-year programs, to be a school of nursing. 

[8] According to program guidance, for the NELRP, applicants with the 
"greatest financial need" are those with nursing educational loans 40 
percent or greater than their annualized salary. For the NSP, 
applicants with the greatest financial need were defined as those who 
had zero expected family contribution on their federal financial aid 
application. NSP awardees begin to fulfill their service obligation 
after graduation from nursing school. Because NELRP awardees have 
already completed nursing school, they begin to fulfill their 
obligation upon receipt of the award. 

[9] For the NSP, the facility types are: (1) Indian Health Service 
health center; (2) rural health clinic; (3) Native Hawaiian health 
center; (4) nursing home; (5) home health agency; (6) federally- 
designated migrant health center; (7) hospice program; (8) federally- 
designated community health center; (9) state or local public health 
department including a clinic within the department; (10) federally- 
designated health care for the homeless health center; (11) skilled 
nursing facility; (12) federally-qualified look-alike health center (a 
migrant, community, or health care for the homeless health center 
meeting federal Public Health Service grant requirements but not 
currently receiving such funds); and (13) ambulatory surgical center; 
and (14) hospital. The NELRP includes these facility types but 
separates hospitals into three subtypes: federal hospital; 
disproportionate share hospital (a hospital that receives supplemental 
payments through the Medicare or Medicaid programs to subsidize the 
costs of caring for a high proportion of low-income patients); and 
nonfederal, nondisproportionate share hospital. 

[10] HRSA has prepared and provided these reports on behalf of the 
department. 

[11] Pub. L. No. 107-205,  204, 116 Stat. 811, 818-19. 

[12] This survey was first conducted in 1977, again in 1980, and every 
4 years thereafter. The most recent survey was conducted in 2004. 

[13] In this report, we use the term "state" to refer to the 50 states 
and the District of Columbia. 

[14] The Current Population Survey is a monthly survey of households 
conducted by the Bureau of the Census for the Bureau of Labor 
Statistics (BLS). 

[15] RNs may also obtain graduate nursing degrees that may qualify them 
to teach in a university setting or work as a nurse practitioner or as 
other advanced nursing specialists. 

[16] This represents a sizable increase compared to the previous 4 
years when RN employment grew by about 4 percent from 1996 to 2000. 

[17] To be licensed as an RN in a state, a nurse must graduate from an 
approved nursing program and pass a national licensing exam developed 
by the National Council of State Boards of Nursing. 

[18] We use the number of nurses passing the national RN licensing exam 
to approximate the number of newly licensed RNs. Some states may impose 
additional requirements prior to issuing a license. 

[19] HRSA has a contract to update its model for estimating demand, but 
the update is not expected to be available until 2008. 

[20] In our 2001 report, we noted that available national data were not 
adequate to describe the nature and extent of nurse shortages across 
states or provider types. 

[21] See HRSA Bureau of Health Professions, Projected Supply. 

[22] Due to uncertainties in the estimation process, only states with a 
difference between supply and demand of greater than 3 percent were 
considered to have a shortage or surplus. 

[23] Because HRSA calculated state RN shortage estimates based on full- 
time equivalents (FTE), we calculated state-level RN employment change 
in terms of FTEs for this comparison. An FTE is the percentage of time 
a staff member works, represented as a decimal. A full-time person is 
1.00, a half-time person is .50 and a quarter-time person is .25. 

[24] According to labor economists, in a condition of shortage, where 
demand exceeds the supply of workers, labor market data will generally 
show strong employment and wage growth for an occupation relative to 
the workforce overall. See C. Veneri, "Can occupational labor shortages 
be identified using available data?" Monthly Labor Review, March 1999. 

[25] Because the NELRP provides awards to RNs with student loan debt, 
we use nursing school graduates as the closest comparison group for 
NELRP awardees. Similarly, because the NSP provides awards to 
individuals entering nursing school, we use nursing school students as 
the best comparison for NSP awardees. 

[26] While race and ethnicity are not criteria for awards for the NSP 
or NELRP, the Institute of Medicine and the National Advisory Council 
on Nurse Education and Practice (NACNEP), an advisory body for HRSA on 
nurse workforce issues, have identified the need to increase racial and 
ethnic diversity among RNs and other health professionals. 

[27] While the educational degree type is not a criterion for NSP 
awards, the NACNEP and the American Association of Colleges of Nursing 
have called for increasing the proportion of bachelor's-prepared RNs in 
the workforce. As of 2004, 53 percent of the RN workforce held a 
bachelor's or higher degree. 

[28] HRSA established preference categories to target certain facility 
types on the list. For example, priority for NELRP awards in fiscal 
year 2005 was given to RNs working in disproportionate share hospitals, 
nursing homes, state or local public health departments, federally- 
designated community health centers, federally-designated migrant 
health centers, or rural health clinics. 

[29] These facilities included an Indian Health Service health center, 
native Hawaiian health center, public hospital, migrant health center, 
community health center, rural health clinic, or public or nonprofit 
private health facility determined by the Secretary to have a critical 
shortage of nurses. The law also required preference be given to 
qualified applicants with the greatest financial need. 

[30] The nurse shortage county designation was developed using AHA 
hospital survey data. It was based on the number of full-time 
equivalent nursing staff relative to the average daily census among 
hospitals in a county. HRSA designates HPSAs based on the ratio of the 
number of primary care physicians relative to the population, among 
other factors. A HPSA can be a distinct geographic area such as a 
county, a specific population group within an area, or a specific 
health care facility. 

[31] HPSAs are used by HRSA for primary care physicians. See GAO, 
Health Professional Shortage Areas: Problems Remain with Primary Care 
Shortage Area Designation System, GAO-07-84 (Washington, D.C.: Oct. 24, 
2006). 

[32] In contrast to the facility-based methodology initially developed 
by the SUNY researchers, this approach considered other sources of 
data, including the decennial Census, the American Community Survey, 
the National Sample Survey of Registered Nurses, and the Area Resource 
File. 

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