This document provides an overview of the nursing labor market in the United States. It discusses the development of nursing as a profession in the 1800s. It describes the types of nurses and their education levels. It examines trends in the age, gender, and racial/ethnic distribution of registered nurses from 1980 to 2008. It analyzes factors that determine nurse supply and demand such as wages, education pipelines, and policy changes. The document also discusses historical cycles of nursing shortages and surpluses in the US and how the Affordable Care Act may impact nursing demand going forward.

1. Nursing labor markets
An introduction
Joanne Spetz, Ph.D.
University of California, San Francisco
April 20, 2012 1

2. Nursing in a nutshell
• Focus on helping people and
communities attain, maintain, and
recover optimal health
• Science and art
• Care, not cure
• Modern nursing developed as a
profession in the 1800s
– Military and religious roots
– Florence Nightingale and the Crimean War
• 3 million US nurses today
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3. What do nurses do?
• Nursing process
– Assess and diagnose needs of patients
– Plan and implement interventions
– Evaluate the outcomes of care
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4. Types of nurses
• Registered nurses (RNs) (associate degree or
higher)
• Licensed practical / vocational nurses (1-2 years
of education)
• Unlicensed assistants, certified nursing
assistants
• Advanced practice RNs (master’s degrees)
– Nurse practitioners (NPs)
– Certified Nurse Midwives (CNMs)
– Clinical Nurse Specialists (CNSs)
– Certified Registered Nurse Anesthetists (CRNAs)
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5. Basic RN education, 2008
Source: 2008 National Sample Survey of RNs
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6. Highest education of U.S. RNs, 2008
After receiving an RN license, many nurses continue their education.
Source: 2008 National Sample Survey of Registered Nurses
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7. Age distribution of RNs,
1980-2008
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Source: 2008 National Sample Survey of RNs

8. Gender distribution of RNs
6.6%
Male
Female
93.4%
Source: 2008 National Sample Survey of RNs
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9. Racial/ethnic distribution of RNs
0% 20% 40% 60% 80% 100%
83.2%
White, non-Hispanic
65.6%
3.6%
Hispanic/Latino
15.4%
5.4% RN population
Black/African-American
12.2% US population
5.8%
Asian or Pacific Islander
4.5%
0.3%
American Indian/Alaska Native
0.8%
1.7%
Two or more races
1.5%
Source: 2008 National Sample Survey of RNs
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10. Geographic variation in RN supply
Employed RNs per 100,000
Pacific
Mountain
West North Central
East North Central
West South Central
East South Central
South Atlantic
Middle Atlantic
New England
0 200 400 600 800 1,000 1,200
Source: 2008 National Sample Survey of RNs
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11. Where do nurses work in the US?
Hospital
62.3%
Other
3.9%
Home health
6.4%
Ambulatory care
10.5%
Community/
public health Education Nursing home
7.8% 3.8% 5.3%
Source: 2008 National Sample Survey of Registered Nurses
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12. What determines nurse supply?
• Number of licensed nurses able to work
• Flow of nurses into labor force
(graduations & immigration)
• Flow of nurses out of labor force
(retirements & emigration)
• Decisions of licensed nurses to work
– Wages that can be earned
– Family economic situation
– Marital status, children, other dependents
– Burnout, stress, schedules, interests
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13. Percent of RNs Working in
Nursing, by some of 2008
We might collapse Age,
these groups by decade to Nurses under 60 years
simplify the chart. old work at high
100% rates, but at older
90% ages, their employment
80% rates drop substantially.
70%
60%
50%
40%
30%
20%
10%
0%
25 5
30 9
35 4
40 9
45 4
50 9
55 4
60 9
65 4
70 9
4
+
2
-2
-3
-3
-4
-4
-5
-5
-6
-6
-7
75
er
nd
U
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Source: 2008 National Sample Survey of RNs

14. What determines RN demand?
• Demand for health care services
– Mix of services
• Licensure regulations
– RN scope of practice limits what non-RNs can do
– Technology can substitute
• Policy
– Minimum staffing regulations
– Reimbursement levels from insurance
– Pay for performance
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15. Nursing Labor Markets: Cycles of
Shortage and Surplus
• Since WW2, there have been near-constant
nursing shortages
• Cycles of surplus and shortage have been
studied by policymakers and economists
• Most recent “surplus” was mid-1990s
• We have had a “shortage” since the late
1990s, although this might be changing

16. Why do we see shortages or
surpluses?
• Delays in wage increases
• Delays in increasing or decreasing the number
of new nurses
• Licensing regulations
• Minimum staffing requirements
• Limited number of employers
– Some workplaces are more desirable than others

17. Predictors of Shortage of Hospital
Nursing Workforce in US
• Higher probability of shortage for in Hospitals
that are :
– Public
– In Southern states
– That serve a high share of Medicare and Medicaid
patients
– That serve patients that are sicker or have more
complex health needs
– Use of “team” nursing staffing structure
(Seago, Ash, et al., 2001)
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18. Leading Reasons for not working in
nursing
(% important or very important)
Stress on the job
Other dissatisfaction (job)
Childcare
Dissatisfaction w/ nursing profession
Other family
Salary
Inconvenient schedules
Try another occupation
Benefits
Job-related illness/injury
0% 20% 40% 60%
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Source: Board of Registered Nursing 2006 Survey

19. There are few ways to increase
nurse supply
• Short-term supply
– Increase work hours of those now working
– Recruit nurses who are licensed but not working
• Long-term supply
– Attract more people to the profession
• Improve working conditions, salaries
• Marketing – men, underrepresented minorities
– Expand nursing education pipeline
– Increase efficiency of nursing programs
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20. Was the shortage of the 2000s
different from prior shortages?
• Severity of shortage was greater than in
the past
• Demand did not adjust even when wages
rose
– Focus on staffing due to recent research
– Minimum nurse-to-patient ratios
• Delays in generating new graduates
– Projected retirements of aging nurses are large
– Difficult to generate enough new graduates to
keep up
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21. Has the shortage ended?
• Newly graduated RNs are having trouble finding
jobs in some markets
• Demand has dropped due to less health care
demand
– More people are uninsured
• Supply of current RNs has risen
– Working RNs taking extra shifts and overtime
– Experienced nonworking RNs seeking jobs
• Is this a temporary situation?
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22. The Affordable Care Act and
Nursing: Changes in Care
• Health insurance expansions  higher demand
for all health services
– RN demand will rise
• Programs to emphasize preventive care 
higher demand for primary care providers
– Higher demand for Nurse Practitioners
– RN demand could rise because they can provide
many of these services
• Incentives for more home and community care
– Greater need for RNs who work in home health and
public settings
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23. The Affordable Care Act and
Nursing: Changes in Payment and
Training
• Performance-based payment  more emphasis
on quality
– RNs contribute to better quality  demand will rise
• Bundled payments  efforts to increase
continuity of care
– RN case managers will become more important
– RNs in home and transitional settings needed
• Health workforce investments
– Funding increases for advanced nursing education
– Grants to increase diversity
– Loan repayment and scholarships to work in
underserved areas
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24. Some final thoughts…
• Nursing is one small piece of health care in the
US…
• But it reflects all the problems of health policy
– Quality of care
– Cost of care
– Access to care
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25. To learn more
• Robert Wood Johnson Foundation Future of
Nursing http://www.thefutureofnursing.org/
• U.S. Health Resources and Services
Administration reports
http://bhpr.hrsa.gov/healthworkforce/allreports.
html
• American Nurses Association
http://www.nursingworld.org/
• Johnson and Johnson’s Discover Nursing
http://www.discovernursing.com/
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