Maths Assignment

3 Section 1 The Registered Nurse and Licensed Practical Nurse Workforce An analysis of recent trends in the nursing workforce is important to anticipate future supply growth and identify likely changes in educational and demographic composition.

Information on the size of the U.S. nursing workforce and its distribution across states and in rural and urban areas is presented. Growth in the workforce over time is measured against growth in the general population. Next, key trends in educational attainment, racial/ethnic composition, and gender are highlighted. The section concludes with an analysis of trends in the setting and work hours of the nursing workforce.

Two sources of data from the U.S. Census Bureau were used to examine the current supply of registered nurses (RNs) and licensed practical nurses (LPNs), as well as changes in the workforce that have occurred during the past decade: the American Community Survey (ACS) three-year combined le for 2008 to 2010 and the Census 2000 Long Form 5-percent sample.

(See “About the Data” below.) Owing to the household sampling strategy of these Census surveys, all results presented in this section are for the nursing workforce—those individuals who report their current occupation as nursing and who currently have or are seeking a job. It is not possible to count, with either data source, the number of individuals educated or licensed as nurses who are working in another eld or are out of the workforce entirely. Another important note is that advanced practice registered nurses are included in results for RNs. The Census data sources used here do not separate them.

The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 4 About the Data The ACS 2008 to 2010 three-year le and Census 2000 Long Form 5-percent sample oer nearly identical question wording and an established set of techniques for comparing results over time.

The sources also oer large sample sizes: more than 110,000 RNs and 31,000 LPNs are included within the 2000 5-percent sample, while nearly 90,000 RNs and more than 21,000 LPNs are included in the ACS 2008 to 2010 three-year le. This means that estimates derived from these sources are highly precise and, in most cases, can be made at both state and national levels.

The ACS 2008 to 2010 three-year le was selected over a single- year le in order to improve the precision of state and national estimates. Unlike the Census 2000 data, which represent a point in time, the ACS three-year le represents an average of the three-year time period. It is inappropriate to refer to this estimate as representing 2009. Throughout this section, we refer to this as the “current” nurse supply because it was the most up-to-date three-year le available at the time of our analysis.

For most estimates, relative standard errors (RSEs) are quite small. Because of the large sample size, even small dierences across time (1 or 2 percentage points) are statistically signicant at the 0.05 level. All dierences over time discussed within the text of this section are statistically signicant, though detailed results of signicance testing are not presented. All estimates reported in this section have an RSE of less than 30 percent. More information about the data sources and methods used in this report can be found in “The U.S. Nursing Workforce: Technical Documentation,” available at http://bhpr.hrsa.gov/healthworkforce/index.html .

The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 5 Workforce Size and Distribution There were an estimated 2,824,641 RNs and 690,038 LPNs within the nursing workforce during the 2008 to 2010 time period. Based on the size of the U.S. population during the period, this equates to 921 RNs and 225 LPNs per 100,000 members of the population (per capita).

Tables 1 and 2, below, show the RN and LPN workforces by state, based on the ACS 2008 to 2010 three-year le. Nurses who live in one state but work in another were placed according to the state in which they work. The total population in each state, also derived from the ACS three-year le, was used to calculate the number of RNs per 100,000 population in each state.

Table 1. The RN Workforce, by State, per 100,000 Population State 1 RNs Total Population RNs per 100,000 Alabama 45,666 4,753,812 960.6 Alaska 5,605 700,113 800.6 Arizona 50,841 6,345,751 801.2 Arkansas 27,415 2,897,671 946.1 California 274,722 36,971,641 743.1 Colorado 43,480 4,970,333 874.8 Connecticut 37,555 3,561,486 1,054.5 Delaware 10,380 891,791 1,163.9 District of Columbia 2 9,869 592,306 1,666.2 Florida 167,476 18,674,425 896.8 Georgia 75,976 9,612,759 790.4 Hawaii 9,357 1,347,518 694.4 Idaho 10,527 1,553,404 677.7 Illinois 120,203 12,795,658 939.4 Indiana 63,655 6,458,253 985.6 Iowa 33,378 3,033,163 1,100.4 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 6 Table 1. The RN Workforce, by State, per 100,000 Population (cont’d) State 1 RNs Total Population RNs per 100,000 Kansas 28,556 2,833,318 1,007.9 Kentucky 44,755 4,317,738 1,036.5 Louisiana 42,856 4,490,487 954.4 Maine 16,153 1,329,222 1,215.2 Maryland 55,944 5,733,779 975.7 Massachusetts 80,725 6,514,611 1,239.1 Michigan 89,445 9,908,690 902.7 Minnesota 57,639 5,279,601 1,091.7 Mississippi 29,016 2,958,873 980.6 Missouri 63,756 5,960,413 1,069.7 Montana 11,172 983,763 1,135.6 Nebraska 22,260 1,813,164 1,227.7 Nevada 19,428 2,680,981 724.7 New Hampshire 13,860 1,316,255 1,053.0 New Jersey 75,269 8,756,104 859.6 New M exico 15,701 2,037,799 770.5 New York 196,189 19,303,930 1,016.3 North Carolina 90,663 9,440,195 960.4 North Dakota 7,702 665,681 1,157.0 Ohio 126,582 11,526,823 1,098.2 Oklahoma 29,366 3,716,087 790.2 Oregon 32,113 3,805,432 843.9 Pennsylvania 140,077 12,662,926 1,106.2 Rhode Island 12,744 1,053,846 1,209.3 South Carolina 42,254 4,585,057 921.6 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 7 Table 1. The RN Workforce, by State, per 100,000 Population (cont’d) State 1 RNs Total Population RNs per 100,000 South Dakota 10,076 807,563 1,247.7 Tennessee 67,159 6,303,437 1,065.4 Texas 186,573 24,789,312 752.6 Utah 18,771 2,720,974 689.9 Vermont 6,528 624,976 1,044.5 Virginia 64,268 7,928,022 810.6 Washington 56,607 6,658,052 850.2 West Virginia 19,220 1,847,352 1,040.4 Wisconsin 60,813 5,667,100 1,073.1 Wyoming 4,296 556,787 771.6 U.S. Total 2,824,641 306,738,434 920.9 Data Source: HRSA analysis of the ACS 2008-2010 three-year le 1All state estimates have a relative standard error (RSE) of less than 10%.

2The nursing workforce is likely denser in the District of Columbia (D.C.) in part because of the presence of several academic medical centers, like most cities, that require a large RN workforce. Many nurses and patients commute into D.C. for work and health services.

Since most states include rural and/or suburban areas, it is not instructive to compare D.C. with states in terms of per capita supply.

Table 2. The LPN Workforce, by State, per 100,000 Population State LPNs Total Population LPNs per 100,000 Alabama 12,297 4,753,812 258.7 Alaska 3 782 700,113 111.7 Arizona 7,853 6,345,751 123.8 Arkansas 10,734 2,897,671 370.4 California 54,817 36,971,641 148.3 Colorado 5,843 4,970,333 117.6 Connecticut 8,605 3,561,486 241.6 Delaware 2 1,679 891,791 188.3 District of Columbia 1 1,982 592,306 334.6 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 8 Table 2. The LPN Workforce, by State, per 100,000 Population (cont’d) State LPNs Total Population LPNs per 100,000 Florida 45,686 18,674,425 244.6 Georgia 22,076 9,612,759 229.7 Hawaii 2 2,107 1,347,518 156.4 Idaho 1 2,880 1,553,404 185.4 Illinois 20,949 12,795,658 163.7 Indiana 17,114 6,458,253 265.0 Iowa 7,397 3,033,163 243.9 Kansas 7,056 2,833,318 249.0 Kentucky 9,857 4,317,738 228.3 Louisiana 17,457 4,490,487 388.8 Maine 1 1,952 1,329,222 146.9 Maryland 11,733 5,733,779 204.6 Massachusetts 14,390 6,514,611 220.9 Michigan 19,196 9,908,690 193.7 Minnesota 15,462 5,279,601 292.9 Mississippi 9,719 2,958,873 328.5 Missouri 18,841 5,960,413 316.1 Montana 2 1,737 983,763 176.6 Nebraska 5,882 1,813,164 324.4 Nevada 3,101 2,680,981 115.7 New Hampshire 1 3,526 1,316,255 267.9 New Jersey 16,584 8,756,104 189.4 New Mexico 1 2,555 2,037,799 125.4 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 9 Table 2. The LPN Workforce, by State, per 100,000 Population (cont’d) State LPNs Total Population LPNs per 100,000 New York 46,063 19,303,930 238.6 North Carolina 20,535 9,440,195 217.5 North Dakota 2 2,802 665,681 420.9 Ohio 36,934 11,526,823 320.4 Oklahoma 13,335 3,716,087 358.8 Oregon 1 2,998 3,805,432 78.8 Pennsylvania 38,202 12,662,926 301.7 Rhode Island 1 1,735 1,053,846 164.6 South Carolina 10,149 4,585,057 221.3 South Dakota 2 2,149 807,563 266.1 Tennessee 23,373 6,303,437 370.8 Texas 58,189 24,789,312 234.7 Utah 1 2,728 2,720,974 100.3 Vermont 2 1,229 624,976 196.6 Virginia 22,276 7,928,022 281.0 Washington 8,226 6,658,052 123.5 West Virginia 6,346 1,847,352 343.5 Wisconsin 10,279 5,667,100 181.4 Wyoming 641 556,787 115.1 U.S. Total 690,038 306,738,434 225.0 Data Source: HRSA analysis of the ACS 2008-2010 three-year le Note: The LPN population in small states is more dicult to estimate with precision.

Higher RSEs in these states mean less precise estimates.

1State has an RSE between 10% and 14.9%.

2State has an RSE between 15% and 19.9%.

3State has an RSE between 20% and 25%.

The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education As Table 1 shows, the per capita supply of RNs varies substantially across states, from a high of 1,248 in South Dakota to a low of 678 in Idaho. Per capita RN supply does not take into account dierences in population age, disease prevalence, or the number of hospital beds that must be staed. Still, it is informative because it illustrates that national-level information masks substantial local-level dierences. Figures 1 and 2 present the information graphically, showing that states located in the West and West South Central Census areas tend to have a lower per capita supply of RNs, whereas states in the Midwest and Northeast tend to have a higher per capita supply.

Table 2 and Figures 3 and 4 present the same information for LPNs. Similar to the density of RNs, LPN density is lowest in Western states. In general, areas of the country with a comparatively dense population of RNs also have a comparatively dense population of LPNs.

Figure 1. The RN Workforce per 100,000 Population, by State WashingtonOregon California Nevada Idaho Montana Wyoming Colorado Utah New Mexico Arizona TexasOklahoma Kansas Nebraska South Dakota NorthDakota Minnesota Wisconsin Illinois Iowa MissouriArkansas Louisiana Alabama Tennessee Michigan Pennsylvania New York Vermont Georgia Florida Mississippi Kentucky South Carolina North Carolina Maryland Ohio Delaware Indiana West Virginia New Jersey Conne cticut MassachuseNs Maine Rhode Island Virginia New Hampshire Washington, DC Data Source: HRSA analysis of the ACS 2008-2010 three-year le 10 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education Alaska Hawaii 11 Figure 2. The per Capita RN Workforce, Ranked by State 0 200 400 600 800 1,000 1,200 1,400 South Dakota Massachusetts Nebraska Maine Rhode Island Delaware North Dakota Montana Pennsylvania Iowa Ohio Minnesota Wisconsin Missouri Tennessee Connecticut New Hampshire Vermont West Virginia KentuckyNew York Kansas Indiana MississippiMarylandAlabama North Carolina Louisiana Arkansas Illinois South Carolina U.S. Average MichiganFlorida Colorado New JerseyWashington OregonVirginia Arizona Alaska Georgia Oklahoma Wyoming New Mexico Texas California Nevada Hawaii Utah Idaho Data Source: HRSA analysis of the ACS 2008-2010 three-year le The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 22 Figure 9. Age Distribution of RNs, in Five-Year Increments 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 25 or 2630 3135 3640 4145 4650 5155 5660 6165 6670 7175 76 and younger older Census2000 ACS0810 Data Sources: HRSA analysis of the ACS 2008-2010 three-year file and Census 2000 Long Form 5% sample Another way to view the changing age structure of nurses is through a comparison of absolute numbers in the workforce (see Figure 10). The workforce has grown overall, but this growth is concentrated in the older and younger ends of the age spectrum, and there are actually fewer RNs aged 36 to 45 working today, compared with nine years ago. Although the nursing workforce has aged over the past decade, it is encouraging to see growth in the number aged 35 and younger. This finding suggests that young people continue to see nursing as a viable career and predicts longer-term stability in the age distribution of the nursing workforce.

However, the tremendous growth of RN cohorts nearing retirement age is still a cause for concern. Over the next 10 to 15 years, the nearly 1 million RNs older than 50—about one- third of the current workforce—will reach retirement age. Retirement of large numbers of RNs over the next two decades means a loss of experiential knowledge and leadership brought to the workforce by seasoned RNs. The retirement decisions of this older cohort, which may be influenced by the pace of economic recovery, will affect the nursing workforce going forward.

The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 25 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 25 or 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76 and younger older Census 2000 ACS 08-10 LPN Workforce Demographics Many of the demographic trends observed for RNs hold for LPNs as well. As Figure 12 shows, the LPN age distribution has also flattened and shifted toward older ages. Also consistent with the findings for RNs, the proportion of younger nurses appears to be holding reasonably steady. During the time period covered by this analysis, the average age of LPNs increased by about 1.75 years, from 41.9 in 2000 to 43.6 in the ACS 2008 to 2010.

Figure 12. Age Distribution of LPNs, in Five-Year Increments Data Sources: HRSA analysis of the ACS 2008-2010 three-year file and Census 2000 Long Form 5% sample Similar to RNs, the absolute number of LPNs has grown overall, but this growth has occurred only among those younger than 30 and older than 50 (see Figure 13). The number of LPNs aged 31 to 50 has actually decreased over the past 10 years. More than one-third of the LPN workforce is older than age 50.

The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education 30 Table 7. Estimated Number of RNs, by Setting of Employment Census 2000 Estimate ACS 08-10 Estimate Estimated Growth/ Decline % Change in Growth Hospitals 1,427,497 1,785,304 357,807 25.1% Nursing Care Facilities 189,594 208,051 18,457 9.7% Oces of Physicians 156,559 134,231 -22,328 -14.3% Home Health Care Services 101,895 105,922 4,027 4.0% Outpatient Care Centers 70,224 131,022 60,798 86.6% Other Health Care Services 66,723 153,449 86,726 130.0% Elementary and Secondary Schools 51,495 61,323 9,828 19.1% Employment Services 45,835 58,362 12,527 27.3% Insurance Carriers and Related Activities 22,919 25,155 2,236 9.8% Administration of Human Resource Programs 1 20,509 38,136 17,627 85.9% Justice, Public Order, and Safety Activities 2 14,793 18,137 3,344 22.6% Oces of Other Health Practitioners 13,346 7,596 -5,750 -43.1% Colleges and Universities, Including Junior Colleges 12,637 16,320 3,683 29.1% Residential Care Facilities, Without Nursing 10,853 9,928 -925 -8.5% All Other Settings 3 70,397 71,705 1,308 1.9% Totals 2,275,276 2,824,641 549,365 24.1% Data Sources: HRSA analysis of the ACS 2008-2010 three-year le and Census 2000 Long Form 5% sample 1Category includes RNs whose jobs focus primarily on administration.

2Category includes the majority of nurses working in public health settings.

3For this analysis, all settings holding less than 1% of the RN population have been recoded to “Other.” The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education The average hours worked by LPNs also held quite steady over time, hovering around 37 hours per week across all ages. Similar to RNs, the ACS 2008 to 2010 data suggest that LPNs are working more hours than in 2000 within older age categories (refer to Figure 16).

The dierence is particularly noticeable in the 61 to 70 age category.

Figure 17 shows the average salary of a full-time nurse (36 or more hours per week). Full-time salary has increased by about $20,000 for RNs and about $11,500 for LPNs over the past decade.

An increasing average salary can reect the inuence of many factors, including ination, an older (and more experienced) workforce, and wage hikes to stimulate employment interest in areas facing a nursing shortage. Figure 17 presents the average salary within the ACS 2008 to 2010 adjusted to 2000 constant dollars to remove the impact of ination (darker part of the bar). As the gure also shows, once ination has been accounted for, the salary increase remains notable at nearly 15 percent ($6,600) over 10 years.

Figure 17. Growth in Full-Time Nurse Salaries $7 0, 000 .0 0 $6 0, 000 .0 0 $5 0, 000 .0 0 $4 0, 000 .0 0 $3 0, 000 .0 0 $2 0, 000 .0 0 $1 0, 000 .0 0 $0.00 RNs 2 000 RNs 08 10 LPNs 20 00 LPNs 08 10 $43,906.46 $31,083.31 * $39,360.64 ** $50,497.10 * $63,944.22 ** $27,809.77 Data Sources: HRSA analysis of the ACS 2008-2010 three-year le and Census 2000 Long Form 5% sample *Ination adjusted to 2000 constant dollars.

**Actual salary in the ACS 2008-2010, adjusted to 2010 dollars.

33 The U.S. Nursing Workforce: Trends in Supply and Education The U.S. Nursing Workforce: Trends in Supply and Education