An overview and policy implications of national nurse identifier systems: A call for unity and integration.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country.

BACKGROUND: After an unprecedented increase in nursing school enrollment and graduates in the past 10 years, projected shortages of nurses have been erased at a national level. However, nursing markets are local, and an uneven distribution of health care providers of all types is a longstanding feature of health care in the United States. PURPOSE: The purpose of this study was to understand how the outlook for future registered nurse (RN) supply varies regionally across the United States. METHODS: We apply our nursing supply model to the nine U.S. Census Divisions to produce separate supply forecasts for each region. DISCUSSION: We find dramatic differences in expected future growth of the nursing workforce across U.S. regions. These range from zero expected growth in the number of RNs per capita in New England and in the Pacific regions between 2015 and 2030 to 40% growth in the East South Central region (Mississippi, Alabama, Tennessee, Kentucky) and in the West South Central region (Texas, Oklahoma, Arkansas, Louisiana). CONCLUSION: Assuming growth in the demand for RNs per population, some regions of the United States are expected to face shortfalls in their nursing workforce if recent trends do not change.

Recent Changes in the Number of Nurses Graduating from Undergraduate and Graduate Programs.

Since the 1970s, a number of initiatives have attempted to increase the proportion of nursing graduates with a baccalaureate degree, but with little national effect. Now market forces, health reforms, and an Institute of Medicine report (2011) have combined to transform the educational composition of the nursing workforce. Today, there are considerably more graduates of baccalaureate nursing programs than associate degree programs. The educational transformation of the nursing workforce is not limited to baccalaureate education but includes the rapidly increasing numbers of registered nurses who have earned graduate degrees. These changes in nursing education are increasing the readiness of nursing professionals to capitalize on new opportunities, overcome challenges, and take on new roles and responsibilities as the nation's health care delivery and payments systems evolve in coming years.

Will the RN Workforce Weather the Retirement of the Baby Boomers?

IMPORTANCE: After forecasts made more than a decade ago suggested dire nursing shortages, enrollment in nursing schools doubled. The implications of this unprecedented change for the nursing workforce have not yet been fully explored. OBJECTIVE: To forecast the size and age distribution of the nursing workforce to the year 2030 and to compare to demand recently projected by the Health Resources and Services Agency. DESIGN: A retrospective cohort analysis of employment trends by birth year and age were used to project age and employment of registered nurses (RNs) through 2030. SETTING: Data on employed RNs from the United States Bureau of the Census Current Population Survey (1979-2000, N=72,222) and American Community Survey (2001-2013, N=342,712). PARTICIPANTS: RNs between the ages of 23 and 69 years. MAIN OUTCOME MEASURE: Annual full-time equivalent (FTE) employment of RNs in total and by single year of age. RESULTS: Annual retirements from the nursing workforce will accelerate from 20,000 a decade ago to near 80,000 in the next decade as baby boomer RNs continue to age. We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce. Overall, we project that the registered nursing workforce will increase from roughly 2.7 million FTE RNs in 2013 to 3.3 million in 2030. We also find that the workforce will reach its peak average age in 2015 at 44.4. This increase in workforce size, which was not expected in forecasts made a decade ago, is contingent on new entry into nursing continuing at its current rate. Even then, supply would still fall short of demand as recently projected by the Health Resources and Services Agency in the year 2025 by 128,000 RNs (4%). CONCLUSIONS: The unexpected surge of entry of new RNs into the workforce will lead to continued net growth of the nursing workforce, both in absolute FTE and FTE per capita. While this growth may not be sufficient to meet demand, such projections are uncertain in the face of a rapidly evolving health care delivery system.

Doctor of nursing practice by 2015: an examination of nursing schools' decisions to offer a doctor of nursing practice degree.

OBJECTIVES: The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP. METHODS: Key informant interviews and an online survey of nursing school deans and program directors were performed. DISCUSSION: The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints. CONCLUSION: Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

Do Associate Degree Registered Nurses Fare Differently in the Nurse Labor Market Compared to Baccalaureate-Prepared RNs?

Roughly 40% of the nearly 3 million registered nurses (RNs) in the United States have an associate's degree (ADN) as their highest level of nursing education. Yet even before the recent Institute of Medicine report on The Future of Nursing, employers of RNs have increasingly preferred baccalaureate-prepared RNs (BSNs), at least anecdotally. Data from the American Community Survey (2003-2013) were analyzed with respect to employment setting, earnings, and employment outcomes of ADN and BSN-prepared RNs. The data reveal a divergence in employment setting: the percentage of ADN-prepared RNs employed in hospitals dropped from 65% to 60% while the percentage of BSN-prepared RNs employed in hospitals grew from 67% to 72% over this period. Many ADNs who would have otherwise been employed in hospitals seem to have shifted to long-term care settings.

Health care reform and the health care workforce--the Massachusetts experience.

Massachusetts' experience with health care reform may be predictive of the effects of national health care reform. Data on employment in the health care industry were examined to determine the impact of the Massachusetts reform on the state's health care workforce.

Response: effectiveness in primary care is paramount, but need not come at the expense of efficiency.

Effective primary care is vital to sustainable provision of primary care for the US population. However, efficiency and effectiveness go hand-in-hand. Effective care is that which enables a health system to optimize the performance of all care providers while eliminating wasteful practices. If high-quality patient care and strengthened patient-provider relationships are to occur outside of isolated pockets of innovation and spread to the populace as a whole, each primary care physician must work within a system that affords the tools, opportunity, and support needed to optimally manage a growing number of patients with mounting health care needs. The expectation that primary care physicians must come into direct contact with each and every patient, no matter the acuity or chief complaint, no longer meets the expectations of patients or those whom we would attract to enter the field of primary care. We can no longer repair the faults in our primary care workforce by simply increasing the number of providers working in exactly the same way primary care physicians have always worked. A modern workforce will require efficient practices to produce the most effective health care for the population.

Do we really need more physicians? Responses to predicted primary care physician shortages.

Predicted primary care shortages have spurred action to increase the number of primary care physicians. However, simply increasing the number of primary care providers is not the only solution to resolving the imbalance between the supply of primary care physicians and the demand for primary care services. In this point-counterpoint, we highlight the limitations of existing primary care shortage predictions and discuss strategies to deliver primary care services without necessarily increasing the number of primary care physicians for a given population. Innovative solutions can be used to reduce or even eliminate projected primary care shortages while changing the prevailing paradigm of primary care.

The Rapid Growth of Graduates From Associate, Baccalaureate, And Graduate Programs in Nursing.

Growth in the number of RN graduates from 2002-2012 has been dramatic and broad based, occurring between both associate and baccalaureate programs, and has included people from all racial and eth- nic backgrounds. This growth has occurred in all types of public, private not-for- profit, and proprietary institu- tions. The growth of RNs with gradu- ate degrees has also increased, particularly since 2004. Given the rapid production of nursing graduates, leaders in academic nursing education are urged to focus on the quality of nursing graduates, take steps to assure that graduates are well prepared for growth in nonhospital settings, ensure graduates are aware of the many challenges they will confront, and are well prepared to seize opportunities that will unfold during an era of health reform.

Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic.

Importance: Health care delivery systems rely on a well-prepared and adequately sized registered nurse (RN) workforce. The US RN workforce decreased by more than 100 000 in 2021 during the COVID-19 pandemic-a far greater single-year drop than observed over the past 4 decades. The implication for the longer-term growth of the RN workforce is unknown. Objective: To describe recent trends in RN employment through 2023 and forecast the growth of the RN workforce through 2035. Design, Setting, and Participants: Descriptive analysis of recent trends since the start of the COVID-19 pandemic in RN employment using data from the US Bureau of the Census Current Population Survey and including employed RNs aged 23 to 69 years from 1982 through 2023, and retrospective cohort analysis of employment trends by birth year and age to project the age distribution and employment of RNs through 2035. Main Outcome and Measures: Annual full-time equivalent (FTE) employment of RNs by age, demographics, and sector of employment; forecast of RN workforce by age through 2035. Results: The final sample included 455 085 RN respondents aged 23 to 69 years. After a sharp decline in 2021, RN employment recovered, and the total number of FTE RNs in 2022 and 2023 was 6% higher than in 2019 (3.35 million vs 3.16 million, respectively). Using data on employment, education, and population through 2022, the size of the RN workforce was projected to increase by roughly 1.2 million FTEs to 4.56 million by 2035, close to prepandemic forecasts. Growth will be driven primarily by RNs aged 35 to 49 years, who are projected to compose nearly half (47%) of the RN workforce in 2035, up from 38% in 2022. Conclusions and Relevance: In this study, the rebound in the total size of the US RN workforce during 2022 and 2023 indicates that the earlier drop in RN employment during the first 2 years of the COVID-19 pandemic was likely transitory. Updated forecasts of the future RN workforce are very close to those made before the pandemic.

Projections of the long-term growth of the registered nurse workforce: a regional analysis.

Providing regional projections of the RN workforce will allow underlying differences in the age structure of the RN workforce to become more visible. By providing regional-level projections, it will also be possible to identify those regions whose RN workforce is expected to grow at a slower rate relative to other regions. States in the South and Midwest have a greater supply of younger-aged RNs available to replace fewer numbers of older-age RNs compared to other regions. In contrast, the Northeast and West have fewer younger RNs currently in their workforce yet a relatively larger number of older age RNs to replace. These differences in age structure may be partly due to differences in nursing school enrollment and expansion in nursing education capacity across regions. This information can help guide national and state health workforce planners, employers, educators, and others in developing policies and initiatives that may impact nursing supply in their states.

Characteristics of rural registered nurses and the implications for workforce policy.

PURPOSE: Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future. METHODS: We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States. FINDINGS: While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019. CONCLUSIONS: The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

Marriage, Children, and Sex-Based Differences in Physician Hours and Income.

Importance: A better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities. Objective: To investigate differences in earnings and hours worked for male and female physicians at various ages and family status. Design, Setting, and Participants: This retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019. Exposures: Earned income and work hours. Main Outcomes and Measures: Outcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022. Results: The sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children. Conclusions and Relevance: In this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019.

OBJECTIVE: To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING: Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN: Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS: We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS: Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS: States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery.

BACKGROUND: The nurse practitioner (NP) workforce has been a focus of considerable policy interest recently, particularly as the Patient Protection and Affordable Care Act may place additional demands on the healthcare professional workforce. The NP workforce has been growing rapidly in recent years, but fluctuation in enrollments in the past decades has resulted in a wide range of forecasts. OBJECTIVES: To forecast the future NP workforce using a novel method that has been applied to the registered nurse and physician workforces and is robust to fluctuating enrollment trends. RESEARCH DESIGN: An age-cohort regression-based model was applied to the current and historical workforce, which was then forecasted to future years assuming stable age effects and a continuation of recent cohort trends. SUBJECTS: A total of 6798 NPs who were identified as having completed NP training in the National Sample Survey of Registered Nurses between 1992 and 2008. RESULTS: The future workforce is projected to grow to 244,000 in 2025, an increase of 94% from 128,000 in 2008. If NPs are defined more restrictively as those who self-identify their position title as "NP," supply is projected to grow from 86,000 to 198,000 (130%) over this period. CONCLUSIONS: The large projected increase in NP supply is higher and more grounded than other forecasts and has several implications: NPs will likely fulfill a substantial amount of future demand for care. Furthermore, as the ratio of NPs to Nurse Practitioners to physicians will surely grow, there could be implications for quality of care and for the configuration of future care delivery systems.

The nursing workforce: a comparison of three national surveys.

The termination of the National Sample Survey of Registered Nurses (NSSRN) represents a loss of a key source of information on the nursing workforce that has been available for more than 30 years. At the same time, this loss presents new opportunities to address some of the biases associated with using licensing data to construct lists of RNs to construct a sampling frame. Given the loss of this key national data source on the nursing workforce, the NSSRN is compared to existing alternatives for nursing workforce data in two U.S. Census Bureaus surveys: the Current Population Survey and the American Communities Survey. The endeavor of workforce planning and a deeper understanding of whether we are equipped to meet the nation's changing health care landscape will benefit from a thoughtful consideration of how best to obtain accurate and comparable data from future surveys.