I.  THE NURSING PIPELINE

The supply of the nursing workforce is the sum of nurses in the pipeline—including students enrolled in nursing programs in the United States and abroad—and current nurses in the workforce. The current supply of nurses is not meeting today’s demand, and the gap is expected to worsen in the years to come.  To bolster the supply to meet current and future demand, policymakers, health care employers and educators are adopting various strategies, with most efforts focusing on the difficult task of expanding the capacity of nursing programs to admit sufficient numbers of nursing students.  This chapter examines the nursing education pipeline and determines the extent to which the five focus States are prepared to meet tomorrow’s demand.

Demand Projections

The demand for registered nurses across the country will outpace supply through 2020, the BHPr predicts. ^[1]   A 7 percent shortfall nationally of Registered Nurses (RNs) in 2005 is expected to jump to nearly 30 percent by 2020, translating into a shortage of more than 800,000 nurses nationally (figure 1).  Among the factors driving demand are a rapidly growing population—with much of the growth occurring in the elderly population—and medical advances that increase the need for nurses. ^[2]

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This National nursing shortage is affecting certain States and localities more than others.  Figure 2 shows that 30 States experienced shortages of RNs in 2000, including each of the five States studied in this report: California, Georgia, Indiana, Texas and Utah.  By 2020, the States with shortages are expected to increase to 44. ^[3]  

Figure 2.  States With Projected Shortages, 2000 and 2020

2000                                                          2020

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Source: Bureau of Health Professions, Health Resources and Services Administration, 2002.

The extent of the shortage varies by State.  Four of the focus States for this report are expected to fare worse than the nation by 2020.  As shown in table 1, California and Georgia—facing the most severe shortage by 2020—face a 40 percent shortage or more, and Indiana and Utah could experience shortages of at least 30 percent. Although Texas is somewhat better off than the nation as a whole, shortages there are nonetheless expected to reach 26 percent by 2020.  In short, what is already a problem is worsening at an alarming pace and, if not monitored, the five States studied face serious shortfalls in the years to come.

Table 1.  Projected Shortages, 2000-2020

Source: Health Resources and Services Administration, Bureau of Health Professions, 2002.

The demand for nurses is increasing for a number of reasons. Among them is a rapidly aging population.  As the baby boom generation ages, it will demand that more health care services be provided by more health care professionals.  During the next 25 years, the over-age-65 population will increase at five times the rate of those under age 65.  

At the same time that demand is intensifying, the supply of nurses is decreasing because today’s nurses also are growing older, and there are not enough new nursing school graduates to replace those who will soon retire.

Despite the dire forecasts, there are some positive signs.  After years of downward trends in enrollments and graduations—the number of graduates from all three types of RN programs declined by 31 percent between 1995 and 2000 ^[4] —schools across the country are reporting upward trends in the number of students and graduates.  Enrollments in entry-level baccalaureate programs were up by 11 percent in 2004 over the previous year, according to the American Association of Colleges of Nursing (AACN), marking the fourth consecutive year of growth since 2001 (figure 3). 

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Moreover, the National League for Nursing (NLN) reports that admissions and graduations for all three types of nursing programs—diploma, associate and baccalaureate programs—were up by about 6 percent between 2002 and 2003. 

Although these are impressive gains, a lack of institutional capacity is jeopardizing continued growth.  In 2004, nursing programs reportedly turned away 26,000 qualified applicants.  This trend, coupled with the slower enrollment growth in 2004 (see figure 3), suggest that “…some nursing programs have reached the limit on how far they can expand.” ^[5]  

In short, a serious lack of institutional capacity is limiting how many new nurses will emerge from the pipeline.  It is no surprise, then, that addressing this problem is a key concern for policymakers, nursing educators and the health care industry.  The following section describes the educational pipeline in general and for the five States studied in this report.

Educational Pipeline

The nursing pipeline refers to the process of educating nurses—which takes between two and five years—and takes into account the number of students applying to, enrolling in and graduating from nursing programs.  In addition to U.S.-educated nurses, the pipeline of future nurses also includes nurses educated abroad.  The pipeline is comprised of various steps (summarized below), each of which is a target of various policy measures designed to expand the size of each group.

• Applications. The pipeline begins with the applicants who apply to nursing programs.  The benefits of a large applicant pool are obvious.  For one, it allows nursing programs to admit more students—a critical element, in light of the growing need for more nursing graduates.  Second, a larger pool gives programs the ability to select those candidates who are academically prepared for the rigors of nursing education and who respond to the State’s specific needs, such as greater diversity or geographic distribution throughout the State.
• Admissions. Programs often turn away qualified candidates, particularly when the applicant pool is large and the program’s capacity is limited.  In response, strategies focus on expanding program capacity, primarily by increasing the faculty workforce.
• Enrollment.  Not all students who are admitted to nursing programs enroll; therefore, the enrollment numbers typically are lower than admissions.  To offset this, many programs over-admit students.
• Graduates.  The number of students enrolled in a program may drop due to expected attrition for academic or personal reasons.  Strategies focus on supporting students so they achieve academically and remain able to manage other responsibilities. 
• Licensure. Taking the licensing exam is the final step in becoming a nurse.  Schools have adopted various strategies to improve the percentage of students who pass these exams.

Policymakers and health care employers focus on expanding the pipeline because it is one way to increase the supply of nurses to meet demand.  Expanding the pipeline typically involves increasing the available labor pool, increasing diversity within that pool—nursing personnel remain predominately white and female—and reducing turnover or departure from the field by nurses who already are in the workforce. ^[6]

Path to Nursing

There are various ways to become a nurse.  The following are descriptions of the educational requirements for licensed practical nursing and registered nursing.

Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) care for the sick, injured, convalescent and disabled under the supervision of a physician or registered nurse. LPNs “…provide basic bedside care, may give injections or medications, change dressings, evaluate patient needs, implement care plans, and supervise nursing assistants.” ^[7]

Professional or Registered Nurses (RNs) have obtained the initial professional license of registered nurse. RNs “…interpret and respond to patient symptoms, reactions, and progress” and plan or direct care accordingly in a variety of settings, including specialized areas such as intensive care, obstetrics and public health. “They teach patients and families about proper health care, assist in patient rehabilitation, and provide emotional support to promote recovery. RNs use a broad knowledge base to administer treatments and make decisions about patients.” ^[8]

Structure of Nursing Education

Educational Program Leading to Licensure as a Practical Nurse (LPN). After completing a 1 year educational program, practical nurse program graduates are eligible to sit for the National Council of State Boards of Nursing Licensure Exam for Practical Nurses, also known as the NCLEX-PN exam. Approximately 1,152 State-approved LPN programs were offered in 2000 in the United States. ^[9]

Educational Programs Leading to Initial Professional Licensure (RN).  Students can prepare to become RNs in three ways.

• Diploma nursing programs are 2-3 year hospital-based programs that prepare students to deliver direct patient care in hospital settings. Some of these programs are affiliated with community and technical colleges. Diploma programs declined in number from 256 in 1985 to 76 in 2002. ^[10] These programs accounted for 5 percent of all RN programs in 2003, according to the NLN.
• Associate degree in nursing programs are 2-3 year programs, typically offered in community and technical colleges, that prepare students to provide direct patient care in a variety of settings. After a period of growth—between 1985 and 1995 the number of these programs increased by 13 percent—associate degree programs declined in number. In 2003, there were 846 such programs, down by 11 from 2002. ^[11]  Associate degree programs account for 59 percent of all RN programs, and about the same proportion—60 percent of all RN students—are admitted annually into such programs.
• Bachelor’s degree in nursing – entry level programs are 4 year programs that prepare students to practice in all health-care settings. The generic or entry-level baccalaureate program admits students who have no previous nursing education and awards a baccalaureate nursing degree upon completion.  According to the AACN, 566 schools offered generic, or entry-level, baccalaureate degrees in 2003. ^[12] These programs account for about 36 percent of all RN programs, and roughly the same percentage of students are admitted into them annually.
• Accelerated programs for non-nursing college graduates admit students who hold baccalaureate degrees in other disciplines but have no previous nursing education and award graduates a baccalaureate nursing degree. These fast-track programs typically take 12 to 18 months of full-time, year-round study. In 2004, 136 accelerated baccalaureate nursing programs were available in 37 States and the District of Columbia.  According to the AACN, 50 new accelerated baccalaureate programs currently are in the planning stages. ^[13]

Educational Programs Leading to Advanced Professional Licensure (RN)

• Bachelor’s degree in nursing – non-entry-level programs admit RNs with associate degrees or diplomas in nursing and award a baccalaureate nursing degree.  In 2004, there were 611 of these programs, also called RN completion or RN-to-Baccalaureate programs. ^[14]  

Advanced Education

• Master’s degree in nursing programs prepare students for education, management and advanced practice roles.  Practicing nurses who wishes to become advanced practice nurses or desire more advanced nurse education in a clinical specialty may choose to enroll in a master of science in nursing (MSN) program with a specialization in their chosen area of interest (e.g., family nurse practitioner, acute care clinical specialist) or a track in the chosen function (e.g., educator, health policy, ethics, administrator). Most of these students already will have earned their BSN degree, and a majority will already be licensed to practice nursing. In 2003, 400 institutions in the United States and its territories offered master’s degrees in nursing. ^[15]
• Accelerated master’s programs are available for individuals who have completed baccalaureate or other graduate degrees in fields other than nursing.  These programs include 12 months of intensive nursing education, after which the student is eligible to sit for the NCLEX-RN. Upon passage of the exam, the student then continues with the master’s portion of the program to complete the chosen specialization.  Thirty-seven institutions offer accelerated master’s programs in the United States and its territories, and programs at another 18 institutions are in the planning stages. ^[16]
• Doctoral degrees in Nursing (i.e., Ph.D., DNS, DNSc) represent the terminal degree in the field.  In 2003, 88 institutions offered doctoral degrees in nursing. ^[17]  In most large public universities and academic health centers, nursing faculty must hold a doctoral degree to teach in master’s and doctoral programs. This cadre of faculty are most often engaged in nursing research and the advancement of nursing sciences.

National and Five-State Trends in the Nursing Pipeline

Significant increases in the number of interested and qualified nursing program applicants suggest that interest in nursing is growing—likely due to a number of factors, including effective recruitment strategies, increased financial incentives for potential nurses and nursing instructors, improved work conditions and relatively sluggish job growth in other fields. 

Applications to nursing programs are on the rise nationally and in the five focus States, in many cases outpacing the capacity of nursing programs to accept all qualified candidates.  As a result, nursing programs are turning away qualified applicants or placing them on a waiting list. 

Applications for generic and RN-to-Baccalaureate programs were increasing in each of the five States, with every State but California reporting gains of 20 percent or higher (figure 4).

As in the nation as a whole, schools in the five focus States are turning away qualified applicants, as shown in figure 5.  Schools in California and Utah turned away more than 40 percent of qualified applicants to associate degree programs in 2002, and Georgia schools rejected 54 percent of qualified LPN applicants.

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Nursing programs from the five States reported that they could not accept more qualified applicants in 2002 because the programs lacked sufficient faculty and admission seats were filled.

Following years of downward trends, enrollments now are on the upswing nationally, as well as in the five States studied here.  As shown in figure 6, enrollment in generic or entry-level baccalaureate programs increased by 30 percent nationally between 1999 and 2003—from 62,821 in 1999 to 80,629 in 2003.

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As shown in figure 7, the number of students in master’s degree programs increased by 10 percent between 2001 and 2003, after a decline in the two previous years.

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Enrollment in doctoral programs, as shown in figure 8, increased by 14 percent—from 2,797 in 1999 to 3,198 in 2003.

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The National League for Nursing also reports an increase in enrollment between 2002 and 2003 in associate degree and diploma programs. Enrollment in associate degree programs jumped 9 percent—from 117,192 to 127,709—while enrollment in diploma programs saw a 14 percent increase—from 9,767 to 11,153. ^[18]

At the State level, nursing programs are reporting enrollment gains as well.  Figure 9 compares enrollments at two points in time. Enrollment between 1999 and 2000 in entry-level RN programs increased slightly in California, Georgia and Texas, while it dropped in Indiana and Utah.  Three years later, however, all five States reported one-year enrollment increases (from 2002 to 2003) in entry-level baccalaureate programs.  Georgia schools reported the largest annual enrollment increase, nearly 18 percent.  In short, enrollment trends are changing course in the five focus States. 

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Moreover, with a few exceptions, States reported continued enrollment gains for every degree type between 2002 and 2003.  As shown in Figure 10, doctoral programs reported a significant annual increase in enrollments in Texas and Utah—at 25 percent and 62 percent, respectively.  Enrollment in entry-level baccalaureate programs increased in all five States, ranging from an 18 percent jump in Georgia to a modest gain of 1.7 percent in California.  Enrollment in master’s degree programs was higher in 2003 than the previous year in every State except California, with gains of up to 20 percent in Indiana.

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In the United States, about 4 of every 10 graduates from nursing programs have received a baccalaureate degree, and nearly 6 in 10 received an associate degree (with just 3 percent having earned a diploma degree.)  As shown in figure 11, California and Utah have the highest proportion of graduates with associate degrees, at 74 and 71 percent, respectively.  The other three States have more BSN graduates as a percentage of all graduates in 2003 than the nation as a whole.

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Following a 6 year decline in graduations from entry-level baccalaureate programs, nursing programs began reporting an upward trend in the number of graduates in 2001.  As shown in figure 12, between 2001 and 2003, the number of generic baccalaureate graduates increased slightly, while graduations from master’s degree programs remained relatively stable from previous years, but overall were slightly lower than in 1999. 

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Graduations from entry-level baccalaureate programs continued to increase after 2003.  The AACN reported that graduations from entry-level baccalaureate nursing programs were up significantly in 2004: more than 27,000 new graduates were ready to join the workforce, a 14 percent increase from 2003.  These new data move graduation levels for generic baccalaureate programs above 1999 levels. ^[19]  

The number of graduates from entry-level baccalaureate programs in the five States also is on the rise, although modestly in some regions.  (The most recent graduation data that allows for comparison across the country examines regional rather than State graduation data.) 

As shown in figure 13, every region in the country graduated more entry-level baccalaureate students in 2003 than in 2002.  In the midwest region, where Indiana is located, there was a one-year increase of nearly 9 percent, while more modest gains of 2 percent occurred in the southern region (which includes Georgia and Texas). ^[20]

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In contrast, graduations from master’s and doctoral degree programs were down in almost every region.  The number of graduates from master’s degree programs dropped by almost 3 percent in the western region (which includes California and Utah).  The only region to see gains in master’s degree graduations was the midwest, which experienced a slight 1 year gain of 1 percent.  Significantly fewer doctoral graduations occurred in 2003 than in the previous year—ranging from a 4 percent drop in the west to a 12 percent drop in the midwest. 

Graduation rates are likely to increase as the larger classes of students enrolled in master’s and doctoral degree programs move through the pipeline; however, the flat or downward trend in graduations from these programs suggests that short-term relief to the growing crisis in the faculty workforce is yet to be attained. 

Passing the nurse licensure exam is the final step in the licensure process; therefore, the number of individuals who pass the registered and practical nurse licensure exams is a good indicator of how many new nurses are entering the profession, according to the National Council of State Boards of Nursing (NCSBN).

• RN Exam-Takers. The number of people who took the National Council Licensure Examination for RNs (NCLEX-RN) in 2004 was up by 15 percent from 2003.  In 2004, 121,006 RN candidates took the exam; in the same 9 month period in 2003, 105,410 RN candidates took the exam. The pass rate in 2004 was 73 percent; therefore, more than 88,000 new RNs were available for employment in 2004.
• PN Exam-Takers. Almost 4,000 more licensed practical nurse candidates took the National Council Licensure Examination for Practical Nurses (NCLEX-PN) in 2004 than in 2003, an increase of about 8 percent. In 2003, 43,563 LPN candidates took the exam, while 47,401 took it 1 year later. With a pass rate of 80 percent, about 38,000 new licensed practical nurses were available for employment in 2004.

A key concern for States is how to increase the pass rates on the NCLEX exams.  For example, after a steady decline in the pass rate for the NCLEX-RN exam, the California Board of Registered Nursing set up a task force in 2000 to identify factors that improve the pass rates for first-time takers and to make recommendations for achieving higher overall pass rates.  The task force surveyed nursing education administrators, who cited the following factors that adversely affect scores: English fluency, interval of time between graduation and test-taking, and number of hours the student works. ^[21]

Student Demographic Statistics

In addition to building a large enough nursing supply, policymakers and others also are seeking policies that will increase diversity, so that the nursing workforce more closely resembles the overall population. 

According to the National Advisory Council on Nurse Education and Practice (NACNEP), advisors to the HHS Secretary and Congress, “…a culturally diverse workforce is essential to meeting the health care needs of the Nation’s population.” ^[22]  Not only is the entire U.S. population becoming more diverse, but minority populations have higher rates of certain diseases, lower rates of successful treatment, and are more likely to reside in areas where shortages exist of health care providers.  Moreover, diversity in the health care workforce has been found to improve health care quality and outcomes, particularly among people of color.

Nationally, nursing students and graduates at all levels were more diverse in 2003 than in 1993, according to data compiled by the AACN. As shown in figure 14, minority students comprised nearly 25 percent of baccalaureate nursing programs in 2002, up from 17 percent in 1993. Nationally, schools reported increases in minority enrollment for master’s degree and doctoral programs as well—with master’s programs reporting a near doubling of minority enrollment, from 11 percent in 1993 to 21 percent in 2003.

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The five focus States also are achieving more diversity among nursing students and graduates.  This growing diversity among nursing students may be a result of strategies aimed at reducing barriers, such as financial assistance, loan repayment, tutoring, mentoring and creative approaches by nursing schools to recruit and retain students from diverse backgrounds ^[23]  Each of the five reported having a greater proportion of non-white enrollees in generic RN baccalaureate programs in 2001 than in 1997. ^[24]  In Texas, for example, the percentage of white enrollees dropped from 64 percent to 59 percent; at the same time, the proportion of Hispanic enrollees increased from 14 percent to 21 percent.

Graduates from RN-to-Baccalaureate programs were proportionately more diverse in 2001 than in 1997 in all five States. The percentage of African-American graduates doubled in Indiana and Texas, while the percentage of Hispanic graduates nearly doubled in California.

At the master’s level, the proportion of non-white graduates increased in every State but Indiana, which reported no change.  In Texas, the proportion of African-American graduates increased from 3 percent to 6 percent, and in Utah, the proportion of Hispanic graduates tripled from 2 percent to 6 percent.  The graduating classes from doctoral programs in three States—California, Georgia and Indiana—were more diverse in 2001 than in 1997. The percentage of African-American graduates increased from 14 percent to 25 percent in Georgia; Hispanic graduates increased from 7 percent to 11 percent in California; and Asian or Pacific Islander graduates increased by 14 percent in Indiana.

Nursing Faculty Trends

National and State economic conditions and demographic shifts influence necessary nursing pipeline expansion.  A significant constraint is the faculty shortage: without enough educators, programs are forced to turn away qualified and interested candidates.  This becomes a vicious cycle, as lack of faculty squeezes programs’ ability to enroll more students, resulting in fewer students who can pursue nursing education, thus curtailing the opportunity to expand the pipeline in the future. 

The faculty shortage has several causes.  For one, the teaching workforce reflects the demographic changes in the population at large: teachers are becoming older and closer to retirement.  Second, there is a lack of younger teachers.  As shown in figure 15, the median age of faculty in all five States increased by two to three years between 1997 and 2002.

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According to the National League for Nursing, the top reason faculty left in 2002 was retirement (36 percent), followed by those who “wanted a career change.”  Other reasons included relocation, health problems and termination. ^[25]

Furthermore, nursing instructors typically earn less and have less salary growth potential than their colleagues who hold clinical jobs.  Nurses can earn more in clinical practice with a master’s degree than in a faculty position that may require a doctoral degree. ^[26] Starting salaries for new graduates may exceed salaries of faculty who have both advanced degrees and experience.  

In addition to relatively low salaries, the demand for lengthy and costly education can deter nursing students.  According to the NLN, completing a doctorate degree (from the start of the doctorate program) takes 8.3 years in nursing, versus 6.8 years in other fields. ^[27]   Because of the lengthy process involved to become an educator, increasing the faculty workforce takes time.  A master’s degree is the minimum requirement for teaching in community college programs and clinical teaching in undergraduate programs. 

Unfortunately, near-term help may not be available.  In a 2002 survey, the Southern Regional Education Board (SREB) found that just 8 percent of the 2,837 graduates in their 16-State region were prepared as nurse educators. According to the NLN, trends in master’s program enrollments do not portend an increase in the number of nurse educators.  In 2003, 24,838 students were enrolled in master’s programs, a drop of nearly 20 percent from 1993.   Moreover, the number enrolled in educator tracks dropped from 3,301 in 1993 to 1,366 in 2003.  Although the number of graduates remained relatively stable between 1993 and 2003 (at 7,926 and 7,516, respectively), the number of graduates from educator tracks dropped from 755 in 1993 to 247 in 2003.

Current Workforce Supply

In addition to the prospective nurses in the educational pipeline, the total supply of nurses also is comprised of nurses who already are in the workforce.  Although this report focuses on nursing education, a discussion of nursing supply would be incomplete if it failed to address those nurses who already work in the field.  After downward trends between 1995 and 2000—when there was a 31 percent decrease in the number of graduates and half of all States saw a drop in their RN-to-population ratios—the supply of nurses now is increasing.  Among the ranks of the nursing workforce, more nurses are working full-time and more are employed in nursing (rather than other fields).  In 2000, there were 2.7 million licensed RNs in the United States, according to the National Center for Health Workforce Analysis (NCHWA) at the HRSA, BHPr.

Supply of Nurses

One measure of how well the nursing workforce is meeting demand is the number of employed nurses per 100,000 individuals. Although use of this number alone has limitations—States with more elderly residents may require more services and resources than other States that have more young or healthy residents, for example—it provides an overview of the availability of nurses among the State’s overall population.

As shown in table 2, certain States already were facing significant shortfalls in 2000.  Of the five focus States, all but Indiana were “red States” in 2000, meaning they were more than 10 percent below the National average of RNs per capita.  In California, there were 544 RNs per 100,000 people—the second lowest in the nation behind Nevada—and significantly below the U.S. average of 782. ^[28]  

Table 2.  RNs per Capita by State

Source: Health Resources and Services Administration, RN sample survey, 2000.

Mirroring the U.S. ratio, the nurse-to-population ratio increased in the five States between 1992 and 1996 and, with the exception of Indiana, which remained about the same, dropped between 1996 and 2000 (figure 16).  This downward trend will affect States for years to come, as they seek to build up the supply of RNs. 

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As shown in figure 17, among licensed practical nurses, three of the States—Georgia, Indiana and Texas—fare slightly better than the nation as a whole, while Utah and California fall below the National average—249 LPNs per 100,000 population—with 151 and 156 LPNs per capita.  

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In addition to expanding the educational pipeline, increasing the number of RNs also involves other efforts designed to bring former nurses back to the field.  In the United States as a whole, nearly 82 percent of nurses were employed in nursing.  As shown in table 3, the levels exist in the five States, ranging from 76 percent in Indiana to 85 percent in Utah.  Although the vast majority of RNs are working in the field, the nurses who have left the profession represent an opportunity for States, many of which are examining ways to entice RNs to return to the profession by improving working conditions and enhancing the public view of the nursing profession. 

Table 3.  Percent of RNs Employed in Nursing

Source: HRSA, BHPr, The Registered Nurse Population: 1992, 1996 and 2000 National Sample Survey of Registered Nurses.

As shown in figure 18, 72 percent of RNs were working full-time in 2000 in the United States, up from 69 percent in 1992.  That falls somewhere in the middle of the five States studied in this report; of these, California has the lowest percentage of full-time nurses and Texas the highest.

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For States that are urgently attempting to increase their workforce, part-time workers represent additional capacity that already is in the workforce.  In most of the five States, this percentage of full-time workers has not changed significantly since 1992 ^[29] except in Indiana, where the percentage of RNs working full-time dropped from 73 percent in 1992 to 68 percent in 2000.  However, finding ways to increase the number of full-time employees is a challenge in the nursing profession, which is comprised largely of older females who may be decreasing the number of hours for personal or health reasons that may include caring for dependent children or aging parents.  

UP CLOSE: FIVE STATES’ PIPELINES

This section examines more closely the nursing pipeline in each of the five States, as well as the specific issues facing them.  Although the States face common problems—and are on similar trajectories (e.g., growing demand, shrinking workforce) they also have differences in the challenges they face and the opportunities each has for turning around the problem. 

California

California’s nursing shortage already has hit, and projections for the future are dire.  According to the BHPr, the gap is expected to widen rapidly, with an expected shortage of more than 120,000 nurses by 2020.  As shown in figure 19, between 2005 and 2020 the shortfall of nurses is expected to grow by more than 500 percent, from 18,409 to 120,695.

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In 2002, hospitals reported a 15 percent vacancy rate. ^[30] In the coming years, the demand for nurses is expected to soar.  According to the State’s Employment Development Department, nearly 110,000 new RNs will be needed by 2010 to fill new jobs and those jobs left by departing nurses—a 40 percent increase in the number of RNs working in 2000. ^[31] In addition, the State projects an even higher demand for licensed vocational nurses—by 2010 the State will need an additional 25,000 LVNs, a 50 percent jump from the number of LVNs working in 2000. 

In addition to a shortage of nurses, there is a mismatch in the type of educational background most nurses have and what employers want, according to a California Strategic Planning Committee for Nursing (CSPCN) employer survey.  According to the survey, the demand for RNs with baccalaureate and master’s degrees was up by 9 percent and 10 percent, respectively, while the demand for RNs with associate degrees was down 6 percent. ^[32] In 2003, the State’s 91 basic RN programs graduated 4,736 RNs—of which 74 percent received associate degrees and 26 percent received BSN degrees. ^[33]  

Behind this growing problem: the size of the pipeline has not been keeping pace with population gains in California, according to the University of California San Francisco’s Center for Health Professions.  Between 1994 and 1998, the population grew 5 percent; at the same time, graduations from basic RN programs declined 8 percent and enrollments declined 33 percent. ^[34] Moreover, the State is relying on other States and countries to educate a substantial proportion of its workforce.  About half of California’s RNs received their nursing education in another State or country. ^[35]  

According to the California Strategic Planning Commission for Nursing, nursing programs are  “… almost universally oversubscribed and many, particularly in public institutions, still have long waiting lists.”  Still, nursing programs did not expand for more than 10 years—until 2000—when some programs expanded. ^[36] The increases in program capacity have been largely supported by partnerships between employers and educational institutions that aim to increase enrollment through local and regional initiatives. ^[37]

In the 2000 academic year there were about 40 percent more applicants Statewide for nursing programs than could be enrolled “because there was no space for them.” ^[38]  This lack of capacity persists.

• Entry-level RN programs reported that they turned away 317 qualified applicants in 2002—twice the number of applicants turned away in 2000. About one in five qualified applicants were turned away in 2002.  Among the schools that reported reasons for turning away potential students, more schools cited insufficient faculty than other reasons.
• Non-BSN programs, including LPN and associate level programs, turned away students in even larger numbers, according to the National League for Nursing.  In 2002, one-third of qualified applicants were not accepted and placed on waiting lists.

As a result of these capacity issues, the CSPCN concluded, “ … program capacity is clearly insufficient to meet projected demand and is dependent on adequate funding for faculty.” ^[39]  Furthermore, to meet employer and public demand for nursing, the CSPCN recommended a long-term increase in funding for nursing education at all levels to produce more new graduates from each level, including 15,031 additional associate degree graduates and 10,038 baccalaureate graduates. ^[40]   Moreover, the committee recommended additional funding to support master’s and doctoral programs; this is expected to create a larger pool of potential faculty. 

Despite the grim findings, there are some modest signs that certain schools of nursing are expanding and diversifying.  According to the American Association of Colleges of Nursing, nursing programs in California are enrolling more students, although the percentage increase in entry level programs from 2002 to 2003 was the smallest of the five States.  In 2003, enrollment in entry-level RN programs was up by 2 percent over the previous year, and enrollment in RN-to-Baccalaureate programs was up by 4.7 percent.  Enrollment in master’s degree and doctoral programs was down in 2003—with enrollment drops of 1 percent and 7 percent, respectively. California was the only State to report negative growth in graduate level training between 2002 and 2003. 

By 2002, the CSPCN reported that the proportion of ethnic minority students and male students increased.  The proportion of students from minority backgrounds accounted for over half the students enrolled and graduating from California nursing programs in 2002. ^[41]

Georgia

The supply of nurses is dropping at the same time that demand for health care services is rapidly rising.  Driving the demand is a rapidly growing and aging population (Georgia’s population growth ranks fourth in the nation), an aging nursing workforce that is approaching retirement, and an  insufficient pool of new nurses to replace outgoing nurses and meet the swelling demand.   As a result, by 2020, the BHPr anticipates a shortfall of more than 32,000 nurses (figure 20).

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According to the NLN, the State’s 35 basic RN programs produced 1,642 graduates in 2003, of whom 57 percent received BSN degrees and 43 percent received associate degrees in nursing. 

As in many States, the shortage has already impacted Georgia.  Hospitals are experiencing double-digit vacancy rates for RNs and LPNs—11 percent and 9 percent, respectively—and nursing homes reported at least 15 percent vacancy rates for both RNs and LPNs.  The situation is more severe in State-operated facilities.  Correctional facilities reported 28 percent and 23 percent vacancy rates for RNs and LPNs, respectively, while vacancy rates for registered nurses soared to 38 percent in Georgia Department of Human Resources’ mental health inpatient facilities. ^[42]  

Despite adversity, there are positive elements.  A 2002 Georgia Health Care Workforce Policy Advisory Committee report identified rising numbers of applications and enrollment levels.  However, the State has a lengthy process in order to meet the growing demand for nurses.  The committee found that “ … it will take a number of years of steady enrollment increases and matriculation stability to bring the graduation numbers up to a credible level.”

According to the AACN, nursing programs in Georgia are experiencing significant enrollment gains, particularly in entry-level RN programs, where enrollment in 2003 was 18 percent higher than the previous year. Student enrollment in master’s and doctoral programs also was up between 2002 and 2003, by 7 percent and 8 percent, respectively. 

Although this upward trend promises a future wave of nurses from the pipeline, the system is still not producing enough graduates to fill a rapidly growing number of nursing jobs.  Georgia relies significantly on other States to educate its nurses.  According to Georgia’s Statewide Area Health Education Center, nearly 40 percent of registered nurses received their education in another State.  Among LPNs, 82 percent went to school in Georgia, and 18 percent received their education elsewhere.  Expanding the State’s capacity to produce more nursing graduates is critical.  To meet the growing demand for nurses, the Workforce Policy Advisory Committee wrote in its 2002 report, “Georgia’s educational systems, both public and private, must aggressively expand their capacity to produce health care graduates.” ^[43]

Although Georgia schools have to deny qualified applicants, the numbers are not as high as in other States, including those in the region.  According to the SREB, schools in the 16-State region reported declining qualified applicants in significant quantities.  More than half of associate degree programs and 36 percent of bachelor’s degree programs reported denying qualified candidates. ^[44]

In comparison, entry-level baccalaureate programs in Georgia reported turning away 15 percent of qualified candidates to entry-level baccalaureate programs in 2000—a marked reduction from 1995, when they rejected nearly 27 percent of qualified candidates, amounting to 779 potential nursing students.  The main reasons schools turned away qualified individuals included insufficient faculty and filled admission seats. ^[45]  

Indiana

Indiana’s demand for RNs is expected to grow more slowly than the other 4 States; however, a shortage of nearly 18,000 nurses is expected by 2020 due to the expected drop in supply of nurses. According to the BHPr, the shortfall of nurses will double between 2010 and 2020, from more than 8,000 to almost 18,000 (figure 21).

[D]

Source: Health Resources and Services Administration, Bureau of Health Professions, 2002.

According to the 2001 Indiana Health Care Professional Development Commission report, the number of new LPNs and RNs dropped between 1994 and 2001, with new LPNs dropping by nearly 30 percent (figure 22). 

[D]

Despite declining numbers of new graduates in the late 1990s, it appears that the trends may be slowly reversing.  According to the 2002 Indiana Nursing Workforce Development Steering Group, enrollments increased by 5 percent between 2000 and 2002.  Moreover, the AACN reports that student enrollment in nursing programs is increasing, with gains in both entry-level and RN-to-Baccalaureate programs (11 percent and 7 percent, respectively). The gains are most significant in master’s degree programs, where 2003 enrollment was 19 percent higher than in 2002.  This marks a reversal in a negative growth rate of minus 12 percent between 1999 and 2000.  Similarly, enrollment in doctoral level programs increased between 2002 and 2003 by 4 percent, a reversal of negative enrollment growth between 1999 and 2000.

Between 2000 and 2002, nursing programs reported an increase of 600 applications—or 64 percent more applications in 2002 than two years before—for entry-level baccalaureate programs.  Along with this increase in applications, however, was a simultaneous increase in the number of rejected applicants.  Schools reported turning away more than twice as many qualified applicants in 2002 than in 2000—13 versus 6 percent, respectively.  At the Indiana University School of Nursing—which enrolls 1,400 students and graduates 40 percent of the State’s nurses—the dean reported having to deny 1 in 4 students because of faculty shortages.  The program was short four faculty members in 2004. ^[46]  

Non-BSN programs also are turning away qualified candidates, according to the NLN.  In 2002, LPN and associate degree programs turned away 14 percent of qualified applicants, with LPN programs reporting that they turned away nearly one-quarter of all qualified applicants. 

As in all five States, Indiana faces a critical shortage of faculty.  According to the Indiana 2001 Registered Nurse Survey, the number of RNs who reported teaching as their principal position dropped from 692 in 1997 to 665 in 2001—a decrease of 4 percent.  Not surprisingly, nursing faculty in 2001 were older on average than they were in 1997.  The percent of nursing faculty between the ages of 31 and 44 dropped from 31 percent in 1997 to 18 percent in 2001.  During that period, the proportion of nurses over age 55 increased. ^[47]

Although the faculty workforce is becoming smaller, it is increasingly moving toward holding higher degrees.  The percentage of faculty with master’s or doctorate degrees increased between 1997 and 2001.  Faculty with doctoral degrees comprised 19 percent in 2001, up from 10 percent in 1997.  The numbers and proportion of faculty with a bachelor’s degree or lower declined from 1997 to 2001.  Faculty who held bachelor’s degrees comprised 20 percent in 2001, down from 28 percent in 1997. ^[48]

Similarly, the workforce as a whole is increasing its highest educational attainment.  According to the 2001 Indiana Registered Nurse Survey, the number and percentage of nurses with diplomas is dropping, and it is increasing for nurses with baccalaureate degrees.  Diploma nurses comprised 15 percent of the RN workforce in 2001, down from 21 percent in 1997.  At the same time, nurses with baccalaureate degrees increased by 35 percent.  Associate degree nurses increased in number over that time period, but fell slightly in terms of their share of the overall workforce.  Master’s level nurses increased from 1,690 in 1997 to 2,828 in 2001—an increase of 67 percent. Nurses with doctoral degrees increased from 97 in 1997 to 172 in 2001, for an increase of 83 percent. ^[49]  

Moreover, there are some signs of recent growth and diversification in the nursing supply.  According to the 2001 Indiana Registered Nurse Survey, the number of RNs practicing in Indiana increased by 18 percent between 1997 and 2001, from 38,721 to 45,615.  During the same period, the workforce also became more diverse, with the number of African-American RNs and RNs of Hispanic origin growing by 33 percent. ^[50]

Texas

Although the supply of nurses is expected to grow steadily in Texas—by about 25 percent between 2000 and 2020, according to the BHPr—it is not expected to be enough to outpace demand, which is expected to rise even faster.  As a result, by 2020, Texas is expected to be short by 52,000 nurses, as shown in figure 23.

[D]

In 2003, the shortage already had impacted hospitals, which reported an average vacancy level of 11 percent, according to a survey by the Texas Hospital Association.  To address the problem, schools of nursing need to double the number of graduates each year from 5,000 to 10,000. ^[51]  Moreover, another survey completed by the University of Texas Health Science Center at San Antonio found that 26 percent of registered nurses no longer were working in direct care nursing in 2002; nearly one-third of them cited job conditions—such as stress, long hours and lack of decision-making power—as reasons they had left direct care. ^[52]  As a result, the State, along with the private and academic sectors, is taking steps to expand the pipeline of incoming nurses and, at the same time, improve working conditions. 

The educational pipeline is showing signs of recovery, particularly in the number of students entering and graduating from Texas schools of nursing.  In 2003, the State’s 75 basic RN programs produced approximately 5,200 graduates; nearly 60 percent held associate degrees. ^[53]

According to the Texas Higher Education Coordinating Board (THECB), Texas has experienced the following milestones: ^[54]

• Qualified applicants to RN programs—including diploma and associate degree in nursing and BSN programs—increased 67 percent between 1997 and 2003. 
• First-year entering enrollees in all RN programs increased by 87 percent between 1997 and 2003, with increases in BSN programs and associate degree and diploma programs.
• The number of all RNs graduating in Texas reached 5,242 in 2003—returning to 1997 levels.  The number of graduates from diploma and associate degree programs jumped from 2,832 to 3,368 between 2001 and 2003, while BSN programs—increasing from 1,699 to 1,874—grew at a slower rate.

Also reporting gains in applications, the AACN reported that applications to entry-level baccalaureate programs jumped by nearly 30 percent between 2000 and 2002.  In both years, schools reported turning away about one-fifth of qualified applicants; the most-cited reason was insufficient faculty.  The faculty shortage is an increasing problem for the Lone Star State; the THECB reported that faculty numbers have not increased at the same rate as class sizes.  Between 1999 and 2003, the average entering RN class size increased 108 percent, while average full-time faculty increased by 13 percent.  According to the board, schools’ inability to hire more faculty “ … appears to be the greatest impediment to increasing enrollment in initial RN licensure programs.”  At the heart of the problem: disparities in salaries between faculty and clinical nurses.  The disparity is especially pronounced in community colleges. 

The problem does not appear to be diminishing in the near future.  The number of graduates from graduate nursing programs is at a 10-year low, according to the THECB, and more graduate students appear to be preparing for clinical practice than for an academic career.

Utah

Utah ranks third in the nation in the severity of its nurse shortage, behind California and Nevada, and the picture is even more bleak for long-term care, where the RN vacancy rate for nursing homes is the highest in the country at 24.3 percent. Hospitals use overtime and temporary nurses to fill the void, but the shortage persists. ^[55]  These stopgap measures are costing hospitals $15 million to $20 million annually, according to the Utah Hospitals and Health Systems Association. As a result of the shortage, hospitals are turning away patients and postponing surgeries. ^[56] Moreover, the situation is expected to worsen as new facilities open.

According to BHPr, the gap between supply and demand is widening in the Beehive State, where the supply of RNs is expected to remain relatively unchanged at a time when demand is growing steadily. The result: by 2020, Utah is expected to be short by nearly 7,000 RNs (figure 24).

[D]

Of the five States, Utah has the largest number of non-BSN students enrolled compared to BSN students enrolled in 2002, according to the NLN.   For every student enrolled in a BSN program, 2.33 were enrolled in non-BSN programs (including LPN and associate-level programs). 

In 2002, the State’s 9 basic RN programs graduated approximately 883 RNs, and 70 percent held associate degrees. ^[57] Utah had the highest ratio of non-BSN students graduating from nursing schools compared with BSN students. In 2002, for every BSN graduate, there were 4.62 graduates from non-BSN programs.

Utah nursing programs saw a 53 percent gain in applications to RN programs between 2000 and 2002—the largest gain of the 5 studied States.  Utah’s nursing programs also have reported an increase in admissions: 2003 admissions were greater than any other year and were nearly 70 percent greater than admissions in 1995 (figure 25). ^[58]

[D]

About 1,700 people applied to non-BSN programs in 2002; of those, about two-thirds, or 1,099 people, applied to associate programs; the remainder applied to LPN programs.^[59]  According to the AACN, nursing programs in Utah—particularly those at the master’s degree and doctoral levels—are enrolling more students.  In 2003, enrollment in master’s degree programs was up by 11 percent from the prior year, and enrollment in doctoral programs was up by 62 percent. 

In baccalaureate programs, Utah schools reported that they denied a large proportion of qualified candidates, mainly due to insufficient faculty.  In 2000, the University of Utah and Brigham Young University reported turning away nearly 50 percent of qualified candidates to their generic baccalaureate programs.

Non-BSN programs also are turning away qualified candidates, according to the NLN.  About 250 applicants to non-BSN programs—or 15 percent of all applicants—were not accepted in 2002. In LPN programs, nearly 34 percent of qualified applicants were turned away and placed on wait lists, while 4 percent of applicants to associate programs were placed on a waiting list.

Conclusion

Although each State differs in terms of its supply and demand, certain overall trends can be seen in each of the five focus States.  Demand—driven by population growth and an aging baby boomer cohort—is forecasted to intensify during the next decade and beyond.  Each State has made improvements in reversing certain trends, including boosting applications, enrollments and graduation rates.  Also in their favor, the five focus States seem to be following the National trend of diversifying their nursing student and faculty populations.

That said, States are struggling with faculty shortages—worsened by aging faculty and sluggish enrollments in the educational track—and therefore are unable to accept the larger number of nursing students necessary to meet current and future demand.  If States cannot resolve this problem, they will continue to experience a widening gap between supply and demand as too many nurses leave the field and too few nurses are available to replace them. 

Chapter Two examines current State strategies aimed to expand the capacity of each State’s nursing programs.  As the chapter shows, States are taking multiple approaches and are using limited resources for only the most critical needs. 

[1].  U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions (BHPr), Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 (Rockville, Md.: HRSA, July 2002).

[2].  Ibid. 

[3].  Ibid.

[4].  Marilyn Biviano, “Supply, Demand and Projected Shortages of Registered Nurses,” slide presentation prepared by the National Center for Health Workforce Analysis (NCHWA), 2002.

[5].  American Association of Colleges of Nursing, Enrollment Increases at U.S. Nursing Schools Are Moderating While Thousands of Qualified Students Are Turned Away, Press Release, December 15, 2004.

[6].  Alexander, Wegner & Associates, Health Care Industry: Identifying and Addressing Workforce Challenges (Washington D.C.: U.S. Department of Labor, Employment and Training Administration, February 2004).

[7].  Southwest Georgia Area Health Education Center, Health Careers in Georgia: 2002-2004 (Albany, Ga.: SGAHEC, 2002).

[8].  Ibid.

[9].  National League for Nursing, Supply Data: Number of Programs 1995 through 2000 (unpublished data, 2003).

[10].  National League for Nursing, Nursing Data Review, Academic Year 2003: Volume 1 Contemporary RN Nursing Education, (New York, N.Y.: NLN, 2003).

[11].  Ibid.

[12].  L.E. Berlin, J. Stennett and G.D. Bednash, 2003-2004 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing (Washington D.C.: American Association of Colleges of Nursing, 2004).

[13].  American Association of Colleges of Nursing, “Fact Sheet: Accelerated Baccalaureate and Master’s Degrees in Nursing,” October 2004, http://www.aacn.nche.edu/Media/FactSheets/AcceleratedProg.htm.

[14].  L.E. Berlin et al., 2003-2004 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing.

[15].  Ibid. 

[16].  American Association of Colleges of Nursing, “Fact Sheet: Accelerated Baccalaureate and Master’s Degrees in Nursing.”

[17].  L.E. Berlin et al., 2003-2004 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing.

[18].  National League for Nursing, Nursing Data Review, Academic Year 2003: Volume 1 Contemporary RN Nursing Education.

[19].  American Association of Colleges of Nursing, Enrollment Increases at U.S. Nursing Schools Are Moderating While Thousands of Qualified Students Are Turned Away, Press Release.

[20].  L.E. Berlin et al., 2003-2004 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing.

[21].  California Board of Registered Nursing, NCLEX-RN Task Force Report: The Problem and the Plan, December 2000,  http://www.rn.ca.gov/forms/pdf/taskforce00.pdf.

[22].  National Advisory Council on Nurse Education and Practice, A National Agenda for Nursing Workforce Racial/Ethnic Diversity, Executive Summary (Washington, D.C.: HRSA, Bureau of Health Professions, 1999); http://bhpr.hrsa.gov/nursing/nacnep/divrepex.htm.

[23] Jennifer Larson, “Diverse Nurse Workforce Needed for a Diverse Nation,” NurseZone, March 29, 2002, http://www.nursezone.com/stories/SpotlightOnNurses.asp?articleID=8532.

[24].  These data should be interpreted with caution because, in many cases, a different number of schools reported in 1997 and in 2001.  Therefore, the data could be skewed by a program that did not report in one year but did in another.  In some cases, schools have been added between 1997 and 2001; for example, 12 of 13 Georgia schools reported race and ethnicity data in 1997, while 15 of 15 reported in 2001.  Thus, the comparisons—although flawed—are included to show general State trends.

[25].  National League for Nursing, Nurse Educators, 2002: Report of the Faculty Census Survey of RN and Graduate Programs” (New York, N.Y.: NLN, 2002).

[26].  Georgia Department of Community Health, Health Workforce Policy Advisory Committee, What’s Ailing Georgia’s Health Care Workforce? Serious Symptoms, Complex Cures (Atlanta, Ga.: GDCH, August 2002).

[27].  Teresa M. Valiga, The Nursing Faculty Shortage: A National Perspective, testimony at a Congressional Briefing, Washington, D.C., September 8, 2004.

[28].  HRSA, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses (Rockville, Md.: HRSA, March 2000); http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/rnss1.htm.

[29].  HRSA, The Registered Nurse Population, 1992, 1996 and 2000 sample surveys (Washington, D.C.: HRSA, various years). 

[30].  Karen Sechrist et al., Planning for California’s Nursing Work Force: Phase III Final Report (Sacramento, Calif.: Association of California Nurse Leaders, 2002), http://www.ucihs.uci.edu/cspcn/TheFinalReport2002.pdf.

[31].  Ibid.

[32].  California Strategic Planning Committee for Nursing, “Additional RN Pre-Licensure Nursing Education Slots Needed” (Sacramento, March 2000, news release) http://www.ucihs.uci.edu/cspcn/slots2001.pdf

[33].  National League for Nursing, Nursing Data Review, Academic Year 2003: Volume 1 Contemporary RN Nursing Education, (New York, N.Y.: NLN, 2003).

[34].  Janet Coffman, “States’ Options for Addressing Nursing Workforce Challenges” (presentation at annual meeting of the National Conference of State Legislatures, August 2001).

[35].  California Department of Consumer Affairs, Board of Registered Nursing, Sample Survey Data File: 1990, 1993, and 1997 (Sacramento, Calif.: BRN, 1999).

[36].  Ibid.

[37].  Ibid.

[38].  Ibid.

[39].  Ibid.

[40].  California Strategic Planning Committee for Nursing, “Additional RN Pre-Licensure Nursing Education Slots Needed” (Sacramento, March 2000, news release), http://www.ucihs.uci.edu/cspcn/slots2001.pdf

[41].  Karen Sechrist et al., Planning for California’s Nursing Work Force: Phase III Final Report (Sacramento, Calif.: Association of California Nurse Leaders, 2002), http://www.ucihs.uci.edu/cspcn/TheFinalReport2002.pdf.

[42].  Georgia Department of Community Health, Healthcare Workforce Policy Advisory Committee, What’s Ailing Georgia’s Health Care Workforce?  Serious Symptoms. Complex Cures (Atlanta: GDCH, August, 2002).

[43].  Ibid. 

[44].  Southern Regional Education Board, “2002 SREB Survey Highlights” (Atlanta: SREB, November 2002), http://www.sreb.org/programs/Nursing/publications/2002Survey/2002_Survey2.pdf

[45].  American Association of Colleges of Nursing, unpublished data 2002.

[46].  Gina Czark, “Applications Increase, But More Students Denied Admission,” NWITimes.com, November 24, 2004.

[47].  Indiana State Department of Health, “Indiana Registered Nurse Survey, 2001” (Indianapolis, Ind.: IDH, 2001), http://www.in.gov/isdh/publications/01nurse/toc.htm

[48].  Ibid.

[49].  Ibid.

[50].  Indiana State Department of Health, “Indiana Registered Nurse Survey, 2001” (Indianapolis, IN: IDH, 2001) http://www.in.gov/isdh/publications/01nurse/toc.htm

[51].  Alexia Green et al., “Addressing the Nursing Shortage: A Legislative Approach to Bolstering the Nursing Education Pipeline,” Policy, Politics & Nursing Practice 5, no. 1 (February 2004): 41-48.

[52].  Texas Higher Education Coordinating Board, Increasing Capacity and Efficiency in Programs Leading to Initial RN Licensure in Texas (Austin, Texas: THECB, July 2004), http://www.thecb.State.tx.us/UHRI/reports.cfm

[53].  National League for Nursing, Nursing Data Review, Academic Year 2003: Volume 1 Contemporary RN Nursing Education (New York, N.Y.: NLN, 2003).

[54].  Ibid.

[55].  [Presenter Not Ascertainable], “Utah Nursing Education Initiative: Solutions to Utah’s Nursing Shortage” (presentation at a National Conference of State Legislatures meeting, November 2002.)

[56].  Utah Legislature, Higher Education Appropriations Subcommittee, “Nursing Initiative,” (Salt Lake City, February 3, 2003,) http://le.utah.gov/~2003/minutes/ahed0203.htm

[57].  National League for Nursing, Nursing Data Review, Academic Year 2003: Volume 1 Contemporary RN Nursing Education (New York, N.Y.: NLN, 2003).

[58].  Ibid.

[59].  National League for Nursing, unpublished data, 2002