- Email: [email protected]
State funding for higher education and RN replacement rates by state: A case for nursing by the numbers in state legislatures
State funding for higher education and RN replacement rates by state: A case for nursing by the numbers in state legislatures L. Antoinette Bargagliotti, DNSc, RN, ANEF
Amid an enduring nursing shortage and state budget shortfalls, discerning how the percentage of state funding to higher education and other registered nurse (RN) workforce variables may be related to the RN replacement rates (RNRR) in states has important policy implications. Regionally, the age of RNs was inversely related to RNRR. State funding in 2000 significantly predicted the 2004 RNRR, with the percentage of LPNs in 2004 adding to the model. The stability of the model using 2000 and 2004 funding data suggests that state funding creates a climate for RNRR.
shortage, the supply/demand nature of this shortage, and the current fiscal climate within states.
THE NURSING SHORTAGE RNs are the single largest healthcare provider group in the United States. By 2016, their numbers are expected to increase by 23%,1 with the single largest numerical growth in jobs (587 000) of all occupations in the United States.2,3 By 2020, the United States projects a national shortfall of 1 million RNs.4 The 2006 8.5% increase in nursing graduates5 reflects the significant professional effort to address the supply side of the shortage. Efforts to increase capacity within nursing programs have been stymied by a concurrent nurse faculty shortage that in 2006 resulted in turning away 20% of qualified applicants to BSN programs and 37% of ASN applicants to nursing programs across the nation. 5 For example, in BSN and entry-level MSN programs, the 32 7976 qualified applicants who were turned away because of faculty shortages in 2004 grew to be 49 9487 in 2008. The grim outline of the nursing faculty shortage was revealed in a 2002 national faculty survey that indicated 75% of faculty anticipated retiring by 2019. In addition, 1800 full-time faculty were leaving their positions each year, and the percentage of full-time faculty in programs had decreased over the preceding decade from 71% to 61%.8 One explanation for the nurse faculty shortage is the financial incentive for nurses to practice rather than teach. For example, a 2003 salary comparison indicated that the mean salary of Master’sprepared faculty in baccalaureate and graduate programs was 25% lower ($60 397) than their nurse practitioner colleagues in emergency departments ($80 697).9 A 2005-2006 national survey of nursing faculty indicated that only 12.8% reported satisfaction with their salaries.10 In a comparison of nursing salaries with the salaries of similarly ranked faculty in other disciplines, nursing faculty salaries trailed by 21% in public institutions and by 32% in private institutions.10 This may be because only one-third of nursing faculty held earned doctoral degrees in contrast to 60% of their counterparts in other disciplines. More specifically, approximately half of
T
he purpose of this study was to explore the relationship between the demographic variables of the licensed nursing work force and state higher education funding data using the states as the unit of analysis. Comparing the states in terms of their numbers of new graduates, levels of education, registered nurse (RN) replacement rates (RNRR; first time takers of the NCLEX-RN/actively licensed RNs in the state), skill mix of licensed nurses (licensed practical nurses [LPNs]/RN and associate of science in nursing [ASN]/ bachelor of science in nursing [BSN]), and the percentages of state budgets allocated to higher education within the states begins to illuminate the nursing academic fiscal climate at the state and regional level. More simply stated, will the data support the oft-heard contention that funding directs the percentages of graduates who are BSN prepared and that LPNs are ‘‘downwardly substituted’’ for RNs? Why the relationship between state funding and RNRR may be important to discern can be found in the nursing and nurse faculty
L. Antoinette Bargagliotti, DNSc, RN, ANEF, is a Professor, University of Memphis Loewenberg School of Nursing, Memphis, TN. Corresponding author: Dr. L. Antoinette Bargagliotti, 100 Newport Hall, University of Memphis Loewenberg School of Nursing, Memphis, TN 38152. E-mail: [email protected] Nurs Outlook 2009;57:274-280. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.06.002
274
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K
State funding
Bargagliotti
faculty with baccalaureate and higher degree, 6.6% of ASN, and 5% of diploma faculty held earned doctoral degrees.8 The nursing faculty salary compression is accentuated by comparative data of nursing instructional costs.
INSTRUCTIONAL NURSING COSTS The Delaware study of productivity and costs of higher education reported that in 1998 and in 2001, nursing and all disciplines in engineering had the highest direct instructional costs in responding institutions per student credit hour ($318 in comprehensive universities and $388 in research universities) of all disciplines across three levels of degree granting institutions.11 Notably, this study did not include the costs of medicine, dentistry, pharmacy, or other health science disciplines. However, because there are 104 academic health science centers and 683 university nursing programs in the United States, these findings are relevant to the majority (85%) of university-based nursing programs.
WORKING HARD TO MATCH DEMAND The daunting professional task of matching RN supply to demand is reflected in hospital data. The 2007 RN FTE per adjusted hospital admission in US hospitals matched the 1987 level of 0.01929,12 although the number of licensed RNs slightly more than doubled during these same two decades.13,14 To add 1.3 million RNs to the workforce during these same two decades, the number of prelicensure programs increased by 16% to 1626, with a 46% increase in BSN programs to 683, a 27% increase in ASN programs to 1000, and a 278% decrease in diploma programs to 75.15 By 2002, 44 states had convened task forces to address the nursing shortage within their state.16 The efforts of nurses within individual states, such as Maine17 California,18-20 Florida,18 Iowa,18 Mississippi,18 New Jersey,18 North Carolina,18 Georgia,18 Texas,18,20 Indiana,19 Utah,19 Massachusetts,20 Maryland,20 Montana,20 Nebraska,20 and New York20 attest to the value of strategic partnerships to address workforce shortages. A study of efforts to address faculty nursing shortages found that these efforts fall within the four domains of advocacy, educational partnerships, academic innovation, and external funding.21 Without entering the maze of all the financial sources that fuel nursing education,19,22 the substantive contributions of private education to the RN workforce; the heroic efforts of foundations, such as the Robert Wood Johnson Foundation; the significant support from Johnson and Johnson; and the strategic philanthropic contributions and the extraordinarily creative efforts of nurses who have forged strategic partnerships to fund nursing education across the nation,17-20 this analysis used only the percentage of state funding allocated to higher S
education. This study was based on the assumption that the percentage of state budgets allocated to higher education reflects a fiscal climate for higher education that affects nursing education and the resultant RN workforce. State funding to higher education is the pool of funding from which nursing and other academic disciplines receive their support.19 The percentage of state budget that is annually (or in Texas, biennially) allocated to higher education filters through complex formulas, originally based on inputs such as credit hours and now modified to include performance funding, to emerge as block grants to colleges and universities.19,22 A hallmark of all funding formulas is that they were designed to depoliticize the process at the state level while retaining each institution’s ability to independently allocate funds within the college or university.19,22 For this reason, state formulas that may have included nursing productivity that increased funding to the institution may not translate into increased funding allocated to the nursing unit. Ironically, the funding formulas that were designed to allocate state funding equitably make it difficult to strategically address specific priorities within the state.19
STATE FUNDING FOR HIGHER EDUCATION State funding for higher education becomes increasingly important when 44 states are predicting a budget deficit for 2009, with the highest predicted budget deficits being reported by California (35.5%), Arizona (34.8%), Alabama and Florida (22%), and Illinois (22.2%). Only six states—Montana, Nebraska, North Dakota, Texas, Wyoming, and West Virginia—are projecting sufficient state revenues.23 Despite their current budgetary shortfalls, states rather than the federal government, have had the primary responsibility to fund public higher education since 1862, when President Lincoln signed the Morrill Act.24 Designed to make higher education available to the ‘‘industrial classes,’’ the Morrill Act ceded federal land to the states to build land grant universities in exchange for the states taking on the responsibility to build and fund them. The egalitarian approach of using state tax dollars to fund public higher education continues to be evident in 21st century colleges and universities. Despite claims that the cost of public higher education has been cost shifted to students, student tuition contributed only 36% ($114.1 billion) to the general revenue of publicly funded colleges and universities in 2006.25 In the decade between 1996 and 2006, revenues (per FTE student by either state or tuition source in the United States) to public colleges and universities increased by only 1% ($9777 vs $9891 in inflation-adjusted dollars).25 This is a remarkably low increase for public higher education funding.
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
275
State funding
Bargagliotti
Eroding the amount of money allocated to higher education from state budgets is enrollment growth that is not occurring equally across the United States. States with the fastest enrollment increases (a 5-year rate >25% between 2002-2007) were South Dakota, New Jersey, North Carolina, Kansas, Nevada, and Florida.25 During that same period (2002-2007), the slowest enrollment states (<6.5% over 5 years) were Iowa, Michigan, Washington, Idaho, and Louisiana.26
Table 1. Extremes of State Budget Allocation to Higher Education in 18 2007 States Allocating Highest Percentage
HIGHER EDUCATION’S PERCENTAGE OF STATE BUDGETS The average allocation of state budget to public higher education among all 50 states in 2007 was 7.4%.26 Table 1 compares the states allocating the highest percentage of their budgets in 2007 to those states allocating <5% of their budgets. Notably, the states allocating <5% of their budgets to higher education include all of the New England and Middle Atlantic states.
How do the states differ in their production of new nurses, licensed nursing skill mix (RN and LPN), percentages of new BSN graduates, RN replacement rates, and state funding to higher education? How is the RN replacement rate affected by the following variables: age of nurses in the state/region, skill mix of licensed nurses, and the percentage of state budget allocated to higher education? How does the percentage of state budget allocated to higher education affect the number of baccalaureate nursing graduates, RN density in a state, and the percentage of LPNs in the state?
METHODOLOGY This study conducted a secondary analysis of nursing workforce data reported in the 2004 National Sample Survey of Registered Nurses (NSSRN)27 and the NCSBN 2004 Nurse licensee volume and NCLEX examination statistics28 and compared it with the percentage of state budget allocated to higher education in 2000,28 2002, and 200429 (as an approximate measure of the state fiscal climate for higher education). Because nursing students spend from 1 to 4 or more years in nursing educational programs, the state funding data for fiscal years 2000, 2002, and 2004 were tested. Because all of the data from this study are from publicly available reports and there were no human subjects used in this study, Institutional Review Board approval was not obtained for the study. The RNRR was calculated for all 50 states as the number of first-time takers of the NCLEX-RN/number
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
Mississippi Alabama North Dakota North Carolina*
11.4% 11.1% 10.5% 10.4%
Florida* New York New Jersey* Pennsylvania Maine Connecticut Rhode Island Massachusetts Vermont New Hampshire
4.9% 4.8% 4.8% 4.7% 4.6% 4.3% 4.0% 3.7% 3.3% 2.7%
of licensed RNs in each state. The RN age data (mean age of RNs by nine regions) and the percentage of RNs over the age of 50 and under the age of 30 in these nine regions were obtained from the NSSRN.26 To compare similar data (RNRR and age) for each of the 9 regions in the NSSRN, a mean RNRR was calculated for each of the 9 regions. The percentage of LPNs was obtained from NCSBN data by state and divided by the total number of all licensed nurses (LPNs and RNs) reported by NCSBN for 2000 and 2004. Data were analyzed using SPSS software, version 15.0 for Windows, (SPSS, Inc., Chicago, IL). Descriptive statistics were used to compare all variables and to calculate the RNRR by state and region. The Pearson product moment correlation statistic was used to identify relationships between all of the variables. Variables that displayed a relationship to RNRR were entered as independent variables into a stepwise linear regression model, with RNRR as the dependent variable. To address the question of the time effect of state funding on RNRR, fiscal years 2000,29 2002,29 and 200430 state funding were entered as independent variables in three separate regression analyses, as well as the sequential addition of 2000, 2002, and 2004 in a separate regression analysis.
The research questions for this study were:
V
13.4% 12.2%
*Among states experiencing fastest enrollment increases (5-year rate of enrollment increases >25%).
RESEARCH QUESTIONS
276
New Mexico Wyoming
States Allocating <5%
FINDINGS Using 2004 data from the NCSBN Annual Report and the NSSRN as the dataset, simple descriptive statistics for each of the 50 states were calculated. The average US state had 66 431 active RNs and produced 1773 new nurses eligible for RN licensure (40% of new graduates were from BSN programs). In 2004, 9 states collectively produced 40% of the new graduate addition
O
U T L O O K
State funding
Bargagliotti
to the US RN workforce: New York (6232), California (6135), Texas (5677), Florida (4906), Pennsylvania (4466), Ohio (4097), Illinois (3183), Michigan (2895), and North Carolina (2830). The states graduating the highest percentages of baccalaureate graduates in 2004 were: Alaska (70%); Hawaii (65%); Nebraska (59%); Louisiana (58%); and South Dakota, Georgia, and Connecticut (52%). States graduating the lowest percentages of RNs at the baccalaureate level included: Wyoming (13%); New York, New Jersey, and Iowa (22%); Mississippi (25%); New Mexico and Florida (26%); and California (27%). There was not a significant statistical relationship (r [47] ¼ 0.12, P ¼ 0.418) between the percentage of state budget devoted to higher education and the percentage of new graduates from baccalaureate programs. The average percentage of all licensed nurses (RNs and LPNs) who are LPNs across all 50 states was 21%. Minnesota, Delaware, Georgia, and Illinois were omitted from this analysis because of missing data. States with the lowest percentages of LPNs were: Alaska (8%), Oregon (10%), Nevada (12%), Rhode Island (13%), and Utah (14%). States with the highest percentages of LPNs were: Oklahoma (34%), Louisiana (32%), North Dakota and Tennessee (28%), and Arkansas (25%).27 Although the percentage of licensed nurses who are LPNs in a state was not statistically related to RN density (number of RNs/population of the state), this percentage was significantly related to the following variables: RNs (r [46] ¼ 0.516, P < 001); RNRR (r [46] ¼ .43, P ¼ .003); number of BSN graduates (r [46] ¼ .39, P ¼ .007); and number of new graduates (r [46] ¼ .318, P ¼ .03).
The RNRR was calculated as the number of new graduates/licensed RNs in the state. These state data are displayed in Table 2 by the 9 regions that are used in the NSSRN to visually indicate regional effects. The RNRR ranged from 1 to 5% with a median and mean value of 3%. There were only three outlier states, Alaska at 1% and South Dakota and Utah at 5%. As Table 2 indicates, there are more states producing less than the US average (n ¼ 16) than are producing more (n ¼ 10), with the New England and West Coast (Pacific regional) states having the lowest RN replacement rates. The relationship between age and RNRR, as displayed in Table 3, was regionally evaluated using the 9 NSSRN US regions. Regionally, there are strong statistical relationships between RNRR and median age (r [9] ¼ –0.93, P ¼ .001); percentage of nurses over the age of 50 (r [9] ¼ –0.815, P ¼ .007); and RNs under the age of 30 (r [9] ¼ 0.881, P ¼ . 002). As Table 4 indicates, a stepwise linear regression model indicated that the only 2 significant predictors of 2004 RNRR in the states were the percentage of state budget fiscal year 2000 used for higher education (R2 ¼ .268, P ¼ .000) and the percentage of LPNs in 2004 (DR2 ¼ .09, P ¼ .000) entered into the regression equation in that order. Entering 2004 state higher education funding as the first variable yielded a similar model (R2 ¼ .253, P ¼ .000), with the second step variable, 2004 LPN percentage, adding to the explained variance (DR2 ¼ .08, P ¼ .000). Entering 2002 state funding data as the first independent variable explained 27% of the variance (R2 ¼ .271, P ¼.000), but LPNs were excluded from the model. The percentage of LPNs in 2000 did not improve the variance explained by the 2004 LPN percentage.
Table 2. States by Region and RN Replacement Rate 2004 RN
New England
Middle Atlantic
E. North Central
W. North Central
S. Atlantic
E. South Central
W. South Central
Mountain
Pacific
RR
X [ 2%
X [ 2%
X [ 3%
X [ 4%
X [ 3%
X [ 4%
X [ 3%
X [ 3%
X [ 2%
CT MA NH RI VT ME
NJ PA
MO
GA
AR
CO NV
AK CA OR WA
KS
FL MD NC VA W VA DE SC
KY TN
TX
AL MS
LA OK
AZ ID MT NM MN WY
1% 2%
3%
4%
5%
NY
IL IN MI OH WI
IA NE ND SD
HI
UT
S
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
277
State funding
Bargagliotti
Table 3. RN Age Group by Geographic Region of United States6 and Mean Regional RNRR Mean RN replacement rate (region) Median age (y) % RNs <30 % RNs >50
New England
M. Atlantic
E. North Central
W. North Central
S. Atlantic
E. South Central
W. South Central
Mountain
Pacific
X [ 2%
X [ 2%
X [ 3%
X [ 4%
X [ 3%
X [ 4%
X [ 3%
X [ 3%
X [ 2%
49 8% 41%
48 4.9% 43.5%
47 9.1% 38.3%
46 10.6% 21.2%
47 7.9% 40.9%
45 11.7% 33.1%
47 9.7% 38.5%
48 8.6% 43.3%
49 6.9% 47%
The registered nurse population: Findings from the March 2004 national sample survey, p. A-60.20
DISCUSSION
the midst of a significant nursing shortage. The RNRR may be more sensitive to increases and decreases in the numbers of new nurses than is the RN density of the state. Another important indicator for the states may be the percentage of their new graduates who are BSN graduates or who become baccalaureate prepared after graduating from diploma or associate degree programs. The variability across states in the percentages of new BSN nurses coupled with the percentage of nursing faculty holding earned doctoral degrees (30% across all programs) underscore the educational distance to be traversed by a profession desiring baccalaureate education. Although it may have been expected that the state fiscal climate would be related to relative percentages of ASN and BSN graduates and downward substitution of LPNs for RNs, these data do not support those beliefs. With an aging RN workforce and a workforce shortage that will be accelerated by the retirement of RNs, the troubling finding was the strongly inverse relationship between the percentages of nurses over 50 and the RN replacement rate. As nursing seeks to recruit younger people into the profession, it will be important to continue to evaluate this generational finding. As the regional data indicate, all 9 regions of the US have similar mean ages of RNs who are approximately 46 years old. Although there are anecdotal data that may have explanatory power, further research in this area will be important. Although nursing education is financed through a myriad of sources, the most imprecise measure, the percentage of state funding to all of higher education does significantly explain some of the variance in the RNRR. The modest statistical contribution of state funding for higher education to RN replacement rates begins to illuminate how important advocacy for nursing education is within the states, as well as with the various professional associations of governors and their professional staff. The profession of nursing has an admirable history and legacy of successfully influencing federal funding to nursing education. Effective lobbying at the state level within 50 different states is challenging because of the
As the nursing profession seeks ways to address the nursing shortage, these data offer some suggestions and puzzling questions. Because more than one in three new nurses graduates from only 6 states, what occurs within these states (California, New York, Texas, Florida, Ohio, and Illinois) is important to the supply of new nurses in the United States. In the first quarter of fiscal year 2009, three of these states (California, Florida, and Illinois) are projecting the greatest state budget deficits. California, notably the highest producer of new RNs, outstrips all other states for having the lowest density of RNs in the United States, producing a lower percentages of BSN nurses, and now enduring the largest state budget deficit at 35.5%. Similarly, Florida, a high producer of RNs, is also facing one of the largest state budget deficits in 2009. In addition, Florida is also one of 6 states with the highest college enrollment rate increases (>25% over 5 years) in the United States.26 As states seek to address the nursing shortage within their states, monitoring the state RN replacement rate may prove to be a useful barometer of success. There was remarkably minimal variability in the RNRR in
Table 4. Stepwise Linear Regression Predicting 2004 RNRR Variable
R2 D R2
R
P value
F
Step 1 Fiscal year 2000* % .518 .268 .268 16.125 .000 State Funding to Higher Education Step 2 2004 LPN .596 .355 .09 11.847 .000 percentage *Fiscal year 2004 funding yielded a similar model (R2 ¼ .34, P < .000).
278
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K
State funding
Bargagliotti
cultural differences within these states and the strategic importance of continually nurturing effective lobbying relationships. Although nursing deans and faculty in state colleges and universities are state employees who, in many states may be legally prohibited from directly lobbying legislators for direct funding of programs without specific invitation, these data indicate why state nursing associations and state nursing leaders want to influence the percentage of funding to higher education. The data suggest that friend raising with the professional associations of state governors and their staffs may be important for the profession of nursing to seriously consider. Nursing’s professional organizations can recognize that the professional associations that support state governors and their financial and higher education leaders are a primary source of information for state governors and their staffs. Developing strong information-sharing relationships with these strategically important professional organizations is important for nursing. The additional finding that the percentage of LPNs is a predictor of RN replacement rate and a predictor of higher percentages of baccalaureate graduates are puzzling findings that warrant further investigation.
LIMITATIONS History is an important limitation of this study. These data were not collected at the same time. Although the NCSBN data from 2004 were used to stay constant with the NSSRN, which is also dated at 2004, these data were collected at different times. What state funding time frame is more predictive of the output of nursing programs is unclear because the amount of time in prelicensure nursing programs varies from 1 to 4 or more years. Because this was an exploratory study, multiple funding year data (fiscal years 2000, 2002, and 2004) were used to address this question. An important limitation of the study is that the route between how much the state allocates to higher education and the resources made available to a school of nursing is circuitous, highly variable among the states, and continually changing. Although the percentage of state funding to higher education is the one funding variable that is consistently present in all 50 states, it is the least precise measure of funding to a nursing program. Using the first-takers of the NCLEX-RN examination as an estimate of new graduates entering the workforce does not allow the substantive contributions of private and secular colleges and universities to be differentiated. More importantly, using first-time takers of the NCLEXRN as a measure of new graduates entering the workforce is a proxy variable that assumes all first-time takers eventually become licensed within a year. Although the percentage that does not become licensed is small, using this measure overestimates the number.
S
There is notably greater precision with the National Council data concerning the number of students taking an examination and having active licenses in a state than there is with the predictive modeling used in the NSSRN.
REFERENCES 1. Dohm A, Shniper L. Employment outlook: 2006-2016. Occupational employment projections to 2016. Monthly Labor Review 2007;11:86-125. 2. Bureau of Labor Statistics; US Department of Labor. Tomorrow’s jobs. Occupational Outlook Handbook, 2008-2009 edition. Available at: http://www.bls.gov/oco/oco2003.htm. Accessed April 29, 2009. 3. Bureau of Labor Statistics; US Department of Labor. Registered nurses. Occupational Outlook Handbook, 2008-2009 edition. Available at: http://www.bls.gov/oco/ocos083.htm. Accessed April 29, 2009. 4. Health Resources and Service Administration; US Department of Health and Human Services, 2004. What is Behind HRSA’s Projected Supply, Demand and Shortage of Registered Nurses? Available at :http://bhpr.hrsa.gov/healthwork force/reports/behindrnprojections/index.htm. Accessed April 30, 2009. 5. National League for Nursing. NLN member update: February 11, 2008 Newsletter, No. 3. Available at: http://www.nln.org/ newsletter/feb112008.htm. Accessed May 1, 2009. 6. Berlin LE, Wilsey SJ, Bednash GD. 2004-2005 enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing; 2005. 7. American Association of Colleges of Nursing. Nursing Faculty Shortage Fact Sheet. Available at: http://www.aacn. nche.edu/Media/FactSheets/NursingShortage.htm. Accessed May 1, 2009. 8. National League for Nursing. Nurse Faculty Shortage. Available at: http://www.nln.org/aboutnln/shortage_info.htm. Accessed May 1, 2009. 9. American Association of Colleges of Nursing. AACN Nursing Faculty Shortage Fact Sheet. March 8, 2004. Available at: http://www.aacn.nche.edu/Media/Backgrounders/faculty shortage.htm. Accessed April 30, 2009. 10. Kaufman K. Compensation for nurse educators: findings from the NLN/Carnegie National survey with implications for recruitment and retention. Perspect Nurs Educ 2007;23:223-5. 11. Middaugh MF, Graham R, Shahld A. A Study of Higher Education Instructional Expenditures: The Delaware Study of Instructional Costs. Washington, DC: National Center for Educational Statistics; 2003. 12. American Hospital Association. Trendwatch Chartbook 2009. Available at: http://www.aha.org/aha/research-andtrends/chartbook/ch5.html. Accessed May 1, 2009. 13. National Council of State Boards of Nursing. NCLEX Examination Pass Rates. Available at: https://www.ncsbn.org/ 1237.htm. Accessed April 29, 2009. 14. National Council of State Boards of Nursing. NCLEX Licensure and NCLEX Examination Statistics, 1987. Available at: https://www.ncsbn.org/1236.htm. Accessed May 1, 2009.
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
279
State funding
Bargagliotti 22. Horns PN, Turner PS. Funding in higher education: where does nursing fit. J Prof Nurs 2006;22:221-5. 23. Kaiser Family Foundation. State Budget shortfall, SFY2009. Available at: http://www.statehealthfacts.org/comparemapre port.jsp?rep¼48&cat¼1. Accessed April 25, 2009. 24. Martin MV. The land grant university in the 21st century. J Agricultural Appl Econ 2001;33:377-80. 25. State Higher Education Executive Officers. State Higher Education Finance FY2006: Executive Summary. 2007. 26. State Higher Education Officers. State Higher Education Finance FY 2007: Executive Summary. 2008. 27. Health Resources and Services Administration. US Department of Health and Human Services. The registered nurse population: findings from the March 2004 national sample survey of registered nurses, 2007. Available at: http://bhpr.hrsa. gov/healthworkforce/rnsurvey04/. Accessed February 5, 2008. 28. National Council of State Boards of Nursing. 2004 Nurse licensee volume and NCLEX examination statistics. NCSBN Research Brief 2005;20. 29. State Higher Education Executive Officers. State Higher Education Finance FY 2004. 2005. 30. State Higher Education Executive Officers. State Higher Education Finance FY 2006. 2007.
15. National League for Nursing. NLN Data View, 2009. Available at: http://www.nln.org/research/slides/topic_nursing _programs.htm. Accessed April 29, 2009. 16. Center for Health Workforce Studies. State Responses to Health Worker Shortages: Results of a 2002 Survey of States. Rensselaer, NY: Center for Health Workforce Studies; 2002. 17. Kirschling JM, Harvey-McPherson L, Curley D. Maine’s nursing workforce legislation: lessons from a rural state. Nurs Outlook 2008;56:63-9. 18. Cleary B, Rice R, Brunell ML, Dickson G, Gloor E, Jones D, et al. Strategic state-level nursing workforce initiatives: taking the long view. Nurs Admin Q 2005;29:162-70. 19. Health Resources and Services Administration. U.S. Department of Health and Human Services. Nursing Education in Five States: 2005. The Importance of State Appropriations to Sustain Nursing School Capacity in States with Acute Nursing Shortages. Available at http://bhpr.hrsa.gov/healthworkforce/ reports/nursing/nursinged5/default.htm. Accessed May 2, 2009. 20. Moskowitz MC. State Actions and the Health Workforce Crisis. Washington, DC: Association of Academic Health Science Centers; 2007. 21. Allan JD, Aldebron J. A systematic assessment of strategies to address the nursing faculty shortage. U.S. Nurs Outlook 2008;56:286-97.
280
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K
Amid an enduring nursing shortage and state budget shortfalls, discerning how the percentage of state funding to higher education and other registered nurse (RN) workforce variables may be related to the RN replacement rates (RNRR) in states has important policy implications. Regionally, the age of RNs was inversely related to RNRR. State funding in 2000 significantly predicted the 2004 RNRR, with the percentage of LPNs in 2004 adding to the model. The stability of the model using 2000 and 2004 funding data suggests that state funding creates a climate for RNRR.
shortage, the supply/demand nature of this shortage, and the current fiscal climate within states.
THE NURSING SHORTAGE RNs are the single largest healthcare provider group in the United States. By 2016, their numbers are expected to increase by 23%,1 with the single largest numerical growth in jobs (587 000) of all occupations in the United States.2,3 By 2020, the United States projects a national shortfall of 1 million RNs.4 The 2006 8.5% increase in nursing graduates5 reflects the significant professional effort to address the supply side of the shortage. Efforts to increase capacity within nursing programs have been stymied by a concurrent nurse faculty shortage that in 2006 resulted in turning away 20% of qualified applicants to BSN programs and 37% of ASN applicants to nursing programs across the nation. 5 For example, in BSN and entry-level MSN programs, the 32 7976 qualified applicants who were turned away because of faculty shortages in 2004 grew to be 49 9487 in 2008. The grim outline of the nursing faculty shortage was revealed in a 2002 national faculty survey that indicated 75% of faculty anticipated retiring by 2019. In addition, 1800 full-time faculty were leaving their positions each year, and the percentage of full-time faculty in programs had decreased over the preceding decade from 71% to 61%.8 One explanation for the nurse faculty shortage is the financial incentive for nurses to practice rather than teach. For example, a 2003 salary comparison indicated that the mean salary of Master’sprepared faculty in baccalaureate and graduate programs was 25% lower ($60 397) than their nurse practitioner colleagues in emergency departments ($80 697).9 A 2005-2006 national survey of nursing faculty indicated that only 12.8% reported satisfaction with their salaries.10 In a comparison of nursing salaries with the salaries of similarly ranked faculty in other disciplines, nursing faculty salaries trailed by 21% in public institutions and by 32% in private institutions.10 This may be because only one-third of nursing faculty held earned doctoral degrees in contrast to 60% of their counterparts in other disciplines. More specifically, approximately half of
T
he purpose of this study was to explore the relationship between the demographic variables of the licensed nursing work force and state higher education funding data using the states as the unit of analysis. Comparing the states in terms of their numbers of new graduates, levels of education, registered nurse (RN) replacement rates (RNRR; first time takers of the NCLEX-RN/actively licensed RNs in the state), skill mix of licensed nurses (licensed practical nurses [LPNs]/RN and associate of science in nursing [ASN]/ bachelor of science in nursing [BSN]), and the percentages of state budgets allocated to higher education within the states begins to illuminate the nursing academic fiscal climate at the state and regional level. More simply stated, will the data support the oft-heard contention that funding directs the percentages of graduates who are BSN prepared and that LPNs are ‘‘downwardly substituted’’ for RNs? Why the relationship between state funding and RNRR may be important to discern can be found in the nursing and nurse faculty
L. Antoinette Bargagliotti, DNSc, RN, ANEF, is a Professor, University of Memphis Loewenberg School of Nursing, Memphis, TN. Corresponding author: Dr. L. Antoinette Bargagliotti, 100 Newport Hall, University of Memphis Loewenberg School of Nursing, Memphis, TN 38152. E-mail: [email protected] Nurs Outlook 2009;57:274-280. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.06.002
274
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K
State funding
Bargagliotti
faculty with baccalaureate and higher degree, 6.6% of ASN, and 5% of diploma faculty held earned doctoral degrees.8 The nursing faculty salary compression is accentuated by comparative data of nursing instructional costs.
INSTRUCTIONAL NURSING COSTS The Delaware study of productivity and costs of higher education reported that in 1998 and in 2001, nursing and all disciplines in engineering had the highest direct instructional costs in responding institutions per student credit hour ($318 in comprehensive universities and $388 in research universities) of all disciplines across three levels of degree granting institutions.11 Notably, this study did not include the costs of medicine, dentistry, pharmacy, or other health science disciplines. However, because there are 104 academic health science centers and 683 university nursing programs in the United States, these findings are relevant to the majority (85%) of university-based nursing programs.
WORKING HARD TO MATCH DEMAND The daunting professional task of matching RN supply to demand is reflected in hospital data. The 2007 RN FTE per adjusted hospital admission in US hospitals matched the 1987 level of 0.01929,12 although the number of licensed RNs slightly more than doubled during these same two decades.13,14 To add 1.3 million RNs to the workforce during these same two decades, the number of prelicensure programs increased by 16% to 1626, with a 46% increase in BSN programs to 683, a 27% increase in ASN programs to 1000, and a 278% decrease in diploma programs to 75.15 By 2002, 44 states had convened task forces to address the nursing shortage within their state.16 The efforts of nurses within individual states, such as Maine17 California,18-20 Florida,18 Iowa,18 Mississippi,18 New Jersey,18 North Carolina,18 Georgia,18 Texas,18,20 Indiana,19 Utah,19 Massachusetts,20 Maryland,20 Montana,20 Nebraska,20 and New York20 attest to the value of strategic partnerships to address workforce shortages. A study of efforts to address faculty nursing shortages found that these efforts fall within the four domains of advocacy, educational partnerships, academic innovation, and external funding.21 Without entering the maze of all the financial sources that fuel nursing education,19,22 the substantive contributions of private education to the RN workforce; the heroic efforts of foundations, such as the Robert Wood Johnson Foundation; the significant support from Johnson and Johnson; and the strategic philanthropic contributions and the extraordinarily creative efforts of nurses who have forged strategic partnerships to fund nursing education across the nation,17-20 this analysis used only the percentage of state funding allocated to higher S
education. This study was based on the assumption that the percentage of state budgets allocated to higher education reflects a fiscal climate for higher education that affects nursing education and the resultant RN workforce. State funding to higher education is the pool of funding from which nursing and other academic disciplines receive their support.19 The percentage of state budget that is annually (or in Texas, biennially) allocated to higher education filters through complex formulas, originally based on inputs such as credit hours and now modified to include performance funding, to emerge as block grants to colleges and universities.19,22 A hallmark of all funding formulas is that they were designed to depoliticize the process at the state level while retaining each institution’s ability to independently allocate funds within the college or university.19,22 For this reason, state formulas that may have included nursing productivity that increased funding to the institution may not translate into increased funding allocated to the nursing unit. Ironically, the funding formulas that were designed to allocate state funding equitably make it difficult to strategically address specific priorities within the state.19
STATE FUNDING FOR HIGHER EDUCATION State funding for higher education becomes increasingly important when 44 states are predicting a budget deficit for 2009, with the highest predicted budget deficits being reported by California (35.5%), Arizona (34.8%), Alabama and Florida (22%), and Illinois (22.2%). Only six states—Montana, Nebraska, North Dakota, Texas, Wyoming, and West Virginia—are projecting sufficient state revenues.23 Despite their current budgetary shortfalls, states rather than the federal government, have had the primary responsibility to fund public higher education since 1862, when President Lincoln signed the Morrill Act.24 Designed to make higher education available to the ‘‘industrial classes,’’ the Morrill Act ceded federal land to the states to build land grant universities in exchange for the states taking on the responsibility to build and fund them. The egalitarian approach of using state tax dollars to fund public higher education continues to be evident in 21st century colleges and universities. Despite claims that the cost of public higher education has been cost shifted to students, student tuition contributed only 36% ($114.1 billion) to the general revenue of publicly funded colleges and universities in 2006.25 In the decade between 1996 and 2006, revenues (per FTE student by either state or tuition source in the United States) to public colleges and universities increased by only 1% ($9777 vs $9891 in inflation-adjusted dollars).25 This is a remarkably low increase for public higher education funding.
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
275
State funding
Bargagliotti
Eroding the amount of money allocated to higher education from state budgets is enrollment growth that is not occurring equally across the United States. States with the fastest enrollment increases (a 5-year rate >25% between 2002-2007) were South Dakota, New Jersey, North Carolina, Kansas, Nevada, and Florida.25 During that same period (2002-2007), the slowest enrollment states (<6.5% over 5 years) were Iowa, Michigan, Washington, Idaho, and Louisiana.26
Table 1. Extremes of State Budget Allocation to Higher Education in 18 2007 States Allocating Highest Percentage
HIGHER EDUCATION’S PERCENTAGE OF STATE BUDGETS The average allocation of state budget to public higher education among all 50 states in 2007 was 7.4%.26 Table 1 compares the states allocating the highest percentage of their budgets in 2007 to those states allocating <5% of their budgets. Notably, the states allocating <5% of their budgets to higher education include all of the New England and Middle Atlantic states.
How do the states differ in their production of new nurses, licensed nursing skill mix (RN and LPN), percentages of new BSN graduates, RN replacement rates, and state funding to higher education? How is the RN replacement rate affected by the following variables: age of nurses in the state/region, skill mix of licensed nurses, and the percentage of state budget allocated to higher education? How does the percentage of state budget allocated to higher education affect the number of baccalaureate nursing graduates, RN density in a state, and the percentage of LPNs in the state?
METHODOLOGY This study conducted a secondary analysis of nursing workforce data reported in the 2004 National Sample Survey of Registered Nurses (NSSRN)27 and the NCSBN 2004 Nurse licensee volume and NCLEX examination statistics28 and compared it with the percentage of state budget allocated to higher education in 2000,28 2002, and 200429 (as an approximate measure of the state fiscal climate for higher education). Because nursing students spend from 1 to 4 or more years in nursing educational programs, the state funding data for fiscal years 2000, 2002, and 2004 were tested. Because all of the data from this study are from publicly available reports and there were no human subjects used in this study, Institutional Review Board approval was not obtained for the study. The RNRR was calculated for all 50 states as the number of first-time takers of the NCLEX-RN/number
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
Mississippi Alabama North Dakota North Carolina*
11.4% 11.1% 10.5% 10.4%
Florida* New York New Jersey* Pennsylvania Maine Connecticut Rhode Island Massachusetts Vermont New Hampshire
4.9% 4.8% 4.8% 4.7% 4.6% 4.3% 4.0% 3.7% 3.3% 2.7%
of licensed RNs in each state. The RN age data (mean age of RNs by nine regions) and the percentage of RNs over the age of 50 and under the age of 30 in these nine regions were obtained from the NSSRN.26 To compare similar data (RNRR and age) for each of the 9 regions in the NSSRN, a mean RNRR was calculated for each of the 9 regions. The percentage of LPNs was obtained from NCSBN data by state and divided by the total number of all licensed nurses (LPNs and RNs) reported by NCSBN for 2000 and 2004. Data were analyzed using SPSS software, version 15.0 for Windows, (SPSS, Inc., Chicago, IL). Descriptive statistics were used to compare all variables and to calculate the RNRR by state and region. The Pearson product moment correlation statistic was used to identify relationships between all of the variables. Variables that displayed a relationship to RNRR were entered as independent variables into a stepwise linear regression model, with RNRR as the dependent variable. To address the question of the time effect of state funding on RNRR, fiscal years 2000,29 2002,29 and 200430 state funding were entered as independent variables in three separate regression analyses, as well as the sequential addition of 2000, 2002, and 2004 in a separate regression analysis.
The research questions for this study were:
V
13.4% 12.2%
*Among states experiencing fastest enrollment increases (5-year rate of enrollment increases >25%).
RESEARCH QUESTIONS
276
New Mexico Wyoming
States Allocating <5%
FINDINGS Using 2004 data from the NCSBN Annual Report and the NSSRN as the dataset, simple descriptive statistics for each of the 50 states were calculated. The average US state had 66 431 active RNs and produced 1773 new nurses eligible for RN licensure (40% of new graduates were from BSN programs). In 2004, 9 states collectively produced 40% of the new graduate addition
O
U T L O O K
State funding
Bargagliotti
to the US RN workforce: New York (6232), California (6135), Texas (5677), Florida (4906), Pennsylvania (4466), Ohio (4097), Illinois (3183), Michigan (2895), and North Carolina (2830). The states graduating the highest percentages of baccalaureate graduates in 2004 were: Alaska (70%); Hawaii (65%); Nebraska (59%); Louisiana (58%); and South Dakota, Georgia, and Connecticut (52%). States graduating the lowest percentages of RNs at the baccalaureate level included: Wyoming (13%); New York, New Jersey, and Iowa (22%); Mississippi (25%); New Mexico and Florida (26%); and California (27%). There was not a significant statistical relationship (r [47] ¼ 0.12, P ¼ 0.418) between the percentage of state budget devoted to higher education and the percentage of new graduates from baccalaureate programs. The average percentage of all licensed nurses (RNs and LPNs) who are LPNs across all 50 states was 21%. Minnesota, Delaware, Georgia, and Illinois were omitted from this analysis because of missing data. States with the lowest percentages of LPNs were: Alaska (8%), Oregon (10%), Nevada (12%), Rhode Island (13%), and Utah (14%). States with the highest percentages of LPNs were: Oklahoma (34%), Louisiana (32%), North Dakota and Tennessee (28%), and Arkansas (25%).27 Although the percentage of licensed nurses who are LPNs in a state was not statistically related to RN density (number of RNs/population of the state), this percentage was significantly related to the following variables: RNs (r [46] ¼ 0.516, P < 001); RNRR (r [46] ¼ .43, P ¼ .003); number of BSN graduates (r [46] ¼ .39, P ¼ .007); and number of new graduates (r [46] ¼ .318, P ¼ .03).
The RNRR was calculated as the number of new graduates/licensed RNs in the state. These state data are displayed in Table 2 by the 9 regions that are used in the NSSRN to visually indicate regional effects. The RNRR ranged from 1 to 5% with a median and mean value of 3%. There were only three outlier states, Alaska at 1% and South Dakota and Utah at 5%. As Table 2 indicates, there are more states producing less than the US average (n ¼ 16) than are producing more (n ¼ 10), with the New England and West Coast (Pacific regional) states having the lowest RN replacement rates. The relationship between age and RNRR, as displayed in Table 3, was regionally evaluated using the 9 NSSRN US regions. Regionally, there are strong statistical relationships between RNRR and median age (r [9] ¼ –0.93, P ¼ .001); percentage of nurses over the age of 50 (r [9] ¼ –0.815, P ¼ .007); and RNs under the age of 30 (r [9] ¼ 0.881, P ¼ . 002). As Table 4 indicates, a stepwise linear regression model indicated that the only 2 significant predictors of 2004 RNRR in the states were the percentage of state budget fiscal year 2000 used for higher education (R2 ¼ .268, P ¼ .000) and the percentage of LPNs in 2004 (DR2 ¼ .09, P ¼ .000) entered into the regression equation in that order. Entering 2004 state higher education funding as the first variable yielded a similar model (R2 ¼ .253, P ¼ .000), with the second step variable, 2004 LPN percentage, adding to the explained variance (DR2 ¼ .08, P ¼ .000). Entering 2002 state funding data as the first independent variable explained 27% of the variance (R2 ¼ .271, P ¼.000), but LPNs were excluded from the model. The percentage of LPNs in 2000 did not improve the variance explained by the 2004 LPN percentage.
Table 2. States by Region and RN Replacement Rate 2004 RN
New England
Middle Atlantic
E. North Central
W. North Central
S. Atlantic
E. South Central
W. South Central
Mountain
Pacific
RR
X [ 2%
X [ 2%
X [ 3%
X [ 4%
X [ 3%
X [ 4%
X [ 3%
X [ 3%
X [ 2%
CT MA NH RI VT ME
NJ PA
MO
GA
AR
CO NV
AK CA OR WA
KS
FL MD NC VA W VA DE SC
KY TN
TX
AL MS
LA OK
AZ ID MT NM MN WY
1% 2%
3%
4%
5%
NY
IL IN MI OH WI
IA NE ND SD
HI
UT
S
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
277
State funding
Bargagliotti
Table 3. RN Age Group by Geographic Region of United States6 and Mean Regional RNRR Mean RN replacement rate (region) Median age (y) % RNs <30 % RNs >50
New England
M. Atlantic
E. North Central
W. North Central
S. Atlantic
E. South Central
W. South Central
Mountain
Pacific
X [ 2%
X [ 2%
X [ 3%
X [ 4%
X [ 3%
X [ 4%
X [ 3%
X [ 3%
X [ 2%
49 8% 41%
48 4.9% 43.5%
47 9.1% 38.3%
46 10.6% 21.2%
47 7.9% 40.9%
45 11.7% 33.1%
47 9.7% 38.5%
48 8.6% 43.3%
49 6.9% 47%
The registered nurse population: Findings from the March 2004 national sample survey, p. A-60.20
DISCUSSION
the midst of a significant nursing shortage. The RNRR may be more sensitive to increases and decreases in the numbers of new nurses than is the RN density of the state. Another important indicator for the states may be the percentage of their new graduates who are BSN graduates or who become baccalaureate prepared after graduating from diploma or associate degree programs. The variability across states in the percentages of new BSN nurses coupled with the percentage of nursing faculty holding earned doctoral degrees (30% across all programs) underscore the educational distance to be traversed by a profession desiring baccalaureate education. Although it may have been expected that the state fiscal climate would be related to relative percentages of ASN and BSN graduates and downward substitution of LPNs for RNs, these data do not support those beliefs. With an aging RN workforce and a workforce shortage that will be accelerated by the retirement of RNs, the troubling finding was the strongly inverse relationship between the percentages of nurses over 50 and the RN replacement rate. As nursing seeks to recruit younger people into the profession, it will be important to continue to evaluate this generational finding. As the regional data indicate, all 9 regions of the US have similar mean ages of RNs who are approximately 46 years old. Although there are anecdotal data that may have explanatory power, further research in this area will be important. Although nursing education is financed through a myriad of sources, the most imprecise measure, the percentage of state funding to all of higher education does significantly explain some of the variance in the RNRR. The modest statistical contribution of state funding for higher education to RN replacement rates begins to illuminate how important advocacy for nursing education is within the states, as well as with the various professional associations of governors and their professional staff. The profession of nursing has an admirable history and legacy of successfully influencing federal funding to nursing education. Effective lobbying at the state level within 50 different states is challenging because of the
As the nursing profession seeks ways to address the nursing shortage, these data offer some suggestions and puzzling questions. Because more than one in three new nurses graduates from only 6 states, what occurs within these states (California, New York, Texas, Florida, Ohio, and Illinois) is important to the supply of new nurses in the United States. In the first quarter of fiscal year 2009, three of these states (California, Florida, and Illinois) are projecting the greatest state budget deficits. California, notably the highest producer of new RNs, outstrips all other states for having the lowest density of RNs in the United States, producing a lower percentages of BSN nurses, and now enduring the largest state budget deficit at 35.5%. Similarly, Florida, a high producer of RNs, is also facing one of the largest state budget deficits in 2009. In addition, Florida is also one of 6 states with the highest college enrollment rate increases (>25% over 5 years) in the United States.26 As states seek to address the nursing shortage within their states, monitoring the state RN replacement rate may prove to be a useful barometer of success. There was remarkably minimal variability in the RNRR in
Table 4. Stepwise Linear Regression Predicting 2004 RNRR Variable
R2 D R2
R
P value
F
Step 1 Fiscal year 2000* % .518 .268 .268 16.125 .000 State Funding to Higher Education Step 2 2004 LPN .596 .355 .09 11.847 .000 percentage *Fiscal year 2004 funding yielded a similar model (R2 ¼ .34, P < .000).
278
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K
State funding
Bargagliotti
cultural differences within these states and the strategic importance of continually nurturing effective lobbying relationships. Although nursing deans and faculty in state colleges and universities are state employees who, in many states may be legally prohibited from directly lobbying legislators for direct funding of programs without specific invitation, these data indicate why state nursing associations and state nursing leaders want to influence the percentage of funding to higher education. The data suggest that friend raising with the professional associations of state governors and their staffs may be important for the profession of nursing to seriously consider. Nursing’s professional organizations can recognize that the professional associations that support state governors and their financial and higher education leaders are a primary source of information for state governors and their staffs. Developing strong information-sharing relationships with these strategically important professional organizations is important for nursing. The additional finding that the percentage of LPNs is a predictor of RN replacement rate and a predictor of higher percentages of baccalaureate graduates are puzzling findings that warrant further investigation.
LIMITATIONS History is an important limitation of this study. These data were not collected at the same time. Although the NCSBN data from 2004 were used to stay constant with the NSSRN, which is also dated at 2004, these data were collected at different times. What state funding time frame is more predictive of the output of nursing programs is unclear because the amount of time in prelicensure nursing programs varies from 1 to 4 or more years. Because this was an exploratory study, multiple funding year data (fiscal years 2000, 2002, and 2004) were used to address this question. An important limitation of the study is that the route between how much the state allocates to higher education and the resources made available to a school of nursing is circuitous, highly variable among the states, and continually changing. Although the percentage of state funding to higher education is the one funding variable that is consistently present in all 50 states, it is the least precise measure of funding to a nursing program. Using the first-takers of the NCLEX-RN examination as an estimate of new graduates entering the workforce does not allow the substantive contributions of private and secular colleges and universities to be differentiated. More importantly, using first-time takers of the NCLEXRN as a measure of new graduates entering the workforce is a proxy variable that assumes all first-time takers eventually become licensed within a year. Although the percentage that does not become licensed is small, using this measure overestimates the number.
S
There is notably greater precision with the National Council data concerning the number of students taking an examination and having active licenses in a state than there is with the predictive modeling used in the NSSRN.
REFERENCES 1. Dohm A, Shniper L. Employment outlook: 2006-2016. Occupational employment projections to 2016. Monthly Labor Review 2007;11:86-125. 2. Bureau of Labor Statistics; US Department of Labor. Tomorrow’s jobs. Occupational Outlook Handbook, 2008-2009 edition. Available at: http://www.bls.gov/oco/oco2003.htm. Accessed April 29, 2009. 3. Bureau of Labor Statistics; US Department of Labor. Registered nurses. Occupational Outlook Handbook, 2008-2009 edition. Available at: http://www.bls.gov/oco/ocos083.htm. Accessed April 29, 2009. 4. Health Resources and Service Administration; US Department of Health and Human Services, 2004. What is Behind HRSA’s Projected Supply, Demand and Shortage of Registered Nurses? Available at :http://bhpr.hrsa.gov/healthwork force/reports/behindrnprojections/index.htm. Accessed April 30, 2009. 5. National League for Nursing. NLN member update: February 11, 2008 Newsletter, No. 3. Available at: http://www.nln.org/ newsletter/feb112008.htm. Accessed May 1, 2009. 6. Berlin LE, Wilsey SJ, Bednash GD. 2004-2005 enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing; 2005. 7. American Association of Colleges of Nursing. Nursing Faculty Shortage Fact Sheet. Available at: http://www.aacn. nche.edu/Media/FactSheets/NursingShortage.htm. Accessed May 1, 2009. 8. National League for Nursing. Nurse Faculty Shortage. Available at: http://www.nln.org/aboutnln/shortage_info.htm. Accessed May 1, 2009. 9. American Association of Colleges of Nursing. AACN Nursing Faculty Shortage Fact Sheet. March 8, 2004. Available at: http://www.aacn.nche.edu/Media/Backgrounders/faculty shortage.htm. Accessed April 30, 2009. 10. Kaufman K. Compensation for nurse educators: findings from the NLN/Carnegie National survey with implications for recruitment and retention. Perspect Nurs Educ 2007;23:223-5. 11. Middaugh MF, Graham R, Shahld A. A Study of Higher Education Instructional Expenditures: The Delaware Study of Instructional Costs. Washington, DC: National Center for Educational Statistics; 2003. 12. American Hospital Association. Trendwatch Chartbook 2009. Available at: http://www.aha.org/aha/research-andtrends/chartbook/ch5.html. Accessed May 1, 2009. 13. National Council of State Boards of Nursing. NCLEX Examination Pass Rates. Available at: https://www.ncsbn.org/ 1237.htm. Accessed April 29, 2009. 14. National Council of State Boards of Nursing. NCLEX Licensure and NCLEX Examination Statistics, 1987. Available at: https://www.ncsbn.org/1236.htm. Accessed May 1, 2009.
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
279
State funding
Bargagliotti 22. Horns PN, Turner PS. Funding in higher education: where does nursing fit. J Prof Nurs 2006;22:221-5. 23. Kaiser Family Foundation. State Budget shortfall, SFY2009. Available at: http://www.statehealthfacts.org/comparemapre port.jsp?rep¼48&cat¼1. Accessed April 25, 2009. 24. Martin MV. The land grant university in the 21st century. J Agricultural Appl Econ 2001;33:377-80. 25. State Higher Education Executive Officers. State Higher Education Finance FY2006: Executive Summary. 2007. 26. State Higher Education Officers. State Higher Education Finance FY 2007: Executive Summary. 2008. 27. Health Resources and Services Administration. US Department of Health and Human Services. The registered nurse population: findings from the March 2004 national sample survey of registered nurses, 2007. Available at: http://bhpr.hrsa. gov/healthworkforce/rnsurvey04/. Accessed February 5, 2008. 28. National Council of State Boards of Nursing. 2004 Nurse licensee volume and NCLEX examination statistics. NCSBN Research Brief 2005;20. 29. State Higher Education Executive Officers. State Higher Education Finance FY 2004. 2005. 30. State Higher Education Executive Officers. State Higher Education Finance FY 2006. 2007.
15. National League for Nursing. NLN Data View, 2009. Available at: http://www.nln.org/research/slides/topic_nursing _programs.htm. Accessed April 29, 2009. 16. Center for Health Workforce Studies. State Responses to Health Worker Shortages: Results of a 2002 Survey of States. Rensselaer, NY: Center for Health Workforce Studies; 2002. 17. Kirschling JM, Harvey-McPherson L, Curley D. Maine’s nursing workforce legislation: lessons from a rural state. Nurs Outlook 2008;56:63-9. 18. Cleary B, Rice R, Brunell ML, Dickson G, Gloor E, Jones D, et al. Strategic state-level nursing workforce initiatives: taking the long view. Nurs Admin Q 2005;29:162-70. 19. Health Resources and Services Administration. U.S. Department of Health and Human Services. Nursing Education in Five States: 2005. The Importance of State Appropriations to Sustain Nursing School Capacity in States with Acute Nursing Shortages. Available at http://bhpr.hrsa.gov/healthworkforce/ reports/nursing/nursinged5/default.htm. Accessed May 2, 2009. 20. Moskowitz MC. State Actions and the Health Workforce Crisis. Washington, DC: Association of Academic Health Science Centers; 2007. 21. Allan JD, Aldebron J. A systematic assessment of strategies to address the nursing faculty shortage. U.S. Nurs Outlook 2008;56:286-97.
280
V
O L U M E
5 7
N
U M B E R
5
N
U R S I N G
O
U T L O O K