Strategies to Increase the Number of Initial Licensure Registered Nurses and Nursing Faculty

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1 Strategies to Increase the Number of Initial Licensure Registered Nurses and Nursing Faculty A Report to the 81 st Texas Legislature January 2009 Texas Higher Education Coordinating Board Accountability

2 Texas Higher Education Coordinating Board A.W. Whit Riter III, CHAIR Fred W. Heldenfels IV, VICE CHAIR Elaine Mendoza, SECRETARY OF THE BOARD Charles Trey Lewis III, STUDENT REPRESENTATIVE Laurie Bricker Joe B. Hinton Brenda Pejovich Lyn Bracewell Phillips Robert W. Shepard Robert V. Wingo Tyler Austin San Antonio Houston Houston Crawford Dallas Bastrop Harlingen El Paso Raymund A. Paredes, COMMISSIONER OF HIGHER EDUCATION Mission of the Coordinating Board The Texas Higher Education Coordinating Board s mission is to work with the Legislature, Governor, governing boards, higher education institutions and other entities to help Texas meet the goals of the state s higher education plan, Closing the Gaps by 2015, and thereby provide the people of Texas the widest access to higher education of the highest quality in the most efficient manner. Philosophy of the Coordinating Board The Texas Higher Education Coordinating Board will promote access to quality higher education across the state with the conviction that access without quality is mediocrity and that quality without access is unacceptable. The Board will be open, ethical, responsive, and committed to public service. The Board will approach its work with a sense of purpose and responsibility to the people of Texas and is committed to the best use of public monies. The Coordinating Board will engage in actions that add value to Texas and to higher education. The agency will avoid efforts that do not add value or that are duplicated by other entities. The Texas Higher Education Coordinating Board does not discriminate on the basis of race, color, national origin, gender, religion, age, or disability in employment or the provision of services.

3 Executive Summary This report summarizes the state s efforts to prepare students for initial licensure as registered nurses. It offers strategies for increasing both enrollments and graduation rates in initial licensure programs and the number of nursing faculty to teach in these programs. The primary goal of these efforts is to reach the statewide projections for new initial licensure graduates set by the Texas Center for Nursing Workforce Studies. In discussing strategies for increasing the number of initial licensure graduates and nursing faculty, this report also complements two other reports prepared for the 81st Texas Legislature. A New Curriculum Model for Initial RN Licensure Program (October 2008) and The Feasibility of Sharing Basic Health Science Courses in Health Education Programs (July 2008) presents strategies for promoting efficiencies in the state s nursing programs and improving the quality of initial licensure education. The executive summaries for both reports are included as Appendices B and C. The data and analyses in this report are divided into six sections: Initial Licensure Education, Graduate Education and Potential Nursing Faculty, Initial Licensure Nursing Faculty, Practitioner and Practice Trends, Strategies for Increasing the Number of Graduates in Nursing Education, and Summary of Key Findings and Recommendations. Key Findings Initial Licensure Education Since 1998, initial licensure programs have increased significantly in applications (124 percent), first-year enrollments (133 percent), and total enrollments (52 percent). Since 2001, initial licensure graduates have increased by 55 percent. To keep up with the demand for new registered nurses, the state s nursing programs will need to double the number of initial licensure graduates (approximately 14,600) by 2012 and nearly double that number again (approximately 24,900) by From 2001 to 2007, only two of the state s initial licensure programs increased the number of graduates in each of those six years, and only 13 programs had net increases of 50 graduates or more during this six-year period. Due to these variations across programs, institutions may benefit from having established graduation targets. In 2007, the statewide graduation rate for one-year and two-year initial licensure programs was 69 percent. The statewide rate varied widely by institution from 22 percent to 98 percent. Programs at health-related institutions had the highest overall graduation rates (86 percent), followed by those at universities (72 percent) and community colleges (66 percent). i

4 Graduate Education and Potential Nursing Faculty Since 2003, the total enrollment of graduate nursing students has increased by 56 percent, peaking in 2007 at 3,837. From , the number of graduates from Master of Science in Nursing (MSN) programs increased by 96 percent. Doctoral graduates increased by 76 percent during the same time period. Despite the increased enrollment in graduate nursing programs, the shortage of nursing faculty remains a significant concern for the state. Master s Programs Since 2003, there has been a steady increase in the total enrollment of master s students (51 percent) with the most significant increase occurring with nursing educator program enrollment (141 percent). Graduates from master s nursing programs have increased significantly with nursing educator having the highest increase (493 percent) of all master s nursing programs. However, for 2007, less than 10 percent of all master s level graduates were from nursing educator programs. There are currently 18 MSN degree programs that prepare nursing educators. Post-master s nursing educator certificate program options are offered at seven institutions. These certificate programs offer courses in curricular and instructional design for master s-prepared nurses whose graduate preparation is in another specialization area, such as advanced practice nursing. Doctoral Programs In 2008, the first-year entering enrollment in Doctor of Philosophy in Nursing (Ph.D.) programs was the lowest in the last six years. This decrease may be attributed to the Doctor of Nursing Practice (DNP), the new professional doctoral program for advanced practice nurses. Since 2006, seven DNP programs have been established in Texas, in addition to the seven Ph.D. programs. From 2007 to 2008, DNP total student enrollment increased by 625 percent. Initial Licensure Faculty The average age of all nursing faculty is 53 years. Approximately 66 percent of nursing faculty are eligible to retire within the next 12 years. With nursing faculty salaries well below those for master s-prepared nurses in practice, recruiting new faculty from practice will be difficult. To expand on the success of the existing Professional Nursing Shortage Reduction Program, Texas Higher Education Coordinating Board (THECB) requested an additional $10 million for the ii

5 biennium. The request also proposed an amendment to the appropriation rider to allow funds to be used for stipends for future nurse educators. Practitioner and Practice Trends Only a small portion of nurses are qualified to be faculty in initial licensure programs. Less than 12 percent of all Texas nurses have graduate degrees. The state has fewer nurses per 100,000 population than eight of the 10 most populous states and the 2004 national average. The Upper Rio Grande and South Texas regions (excluding Bexar county) have the fewest nurses per 100,000 population. Recommendations The THECB recommends the following strategies or actions to increase the number of nursing graduates from Texas institutions: The THECB should establish institution-specific graduation targets for initial licensure programs in the state s Higher Education Accountability Systems for community colleges, universities, and health-related institutions. To improve graduation rates, the Texas Legislature could provide incentive funding for those nursing programs that achieve an 85 percent or higher graduation rate or that have made significant progress toward the 85 percent graduation rate. The Texas Legislature could provide funding for the existing Graduate Nurses Loan Repayment Program. The funds would repay the student loans of graduates from MSN in nursing educator programs and Ph.D. in nursing programs at a cost of $7,000 per year for each student. The Texas Legislature should increase funding for the Professional Nursing Shortage Reduction Program by $10 million and amend the Program s appropriation rider to allow eligible institutions to use the funds to pay stipends to graduate students who enroll in nurse educator degree or certificate programs. Acknowledgements The THECB gratefully acknowledges the contributions of the staffs of the Texas Board of Nursing and Texas Center for Nursing Workforce Studies in the production of this report. We would also like to thank our consultants on this report: Andrea Lindell, Ph.D., RN, ANEF, dean of the College of Nursing and associate senior vice president for academic health affairs at the University of Cincinnati, and Nancy Spector, Ph.D., RN, director of education at the National Council of State Boards of Nursing. We are also grateful to Elizabeth Mayer, a research associate, and Alfredo Obregón, a higher education intern, for their work on this report. iii

6 iv

7 Table of Contents Introduction... 1 I. Initial Licensure Education... 6 A. Schools with Initial Licensure Programs... 7 B. Student Data for Initial Licensure Programs... 8 II. Graduate Education and Potential Faculty A. Student Data for All Graduate Programs B. Master of Science in Nursing Programs C. Doctoral Programs III. Initial Licensure Nursing Faculty IV. Practitioner and Practice Trends V. Strategies for Increasing Capacity and Student Success in Nursing Education A. Initial Licensure Education B. Graduate Education and Potential Nursing Faculty C. Initial Licensure Nursing Faculty VI. Summary of Key Findings and Recommendations Data Sources Appendices v

8 Appendices A B C Status of Key Recommendations from Previous THECB Reports on Initial Licensure Nursing Programs and Nursing Faculty Executive Summary of A New Curriculum Model for Initial RN Licensure Programs (October 2008) Executive Summary of The Feasibility of Sharing Basic Health Science Courses in Health Education Programs (July 2008) D Institutions Offering Initial Licensure Programs (As of October 2008) E F G H I J Additional Maps Showing the Location of Specific Types of Initial Licensure Programs 2007 Graduation Rates by Initial Licensure Program Six-Year Graduation Trend Analysis By Initial Licensure Program Detailed Educational Pipeline by Degree Level Institutions Offering Master of Science in Nursing by Program Type Institutions That Submitted Incomplete or No Data for Graduate Programs K Practice Salary Data by Job Title and Texas Location (2008) L Projects Funded under the Nursing, Allied Heath, and Other Health Education Grant Program vi

9 Introduction Background Nurses are often referred to as the backbone of health care in the United States. They are frequently the most visible practitioners in a hospital, school, home, or long-term care facility, focusing not only on a particular health problem but also on the whole patient and the needs of her or his family. Registered nurses (hereafter referred to as nurses or Texas nurses ), those individuals who have earned at least a three-year diploma, two-year associate s degree, or a four-year baccalaureate degree in nursing, constitute the largest health care occupation, holding 2.5 million jobs in the United States. 1 As of May 2007, Texas had 155,858 nurses (approximately 6 percent of the national total) residing and practicing in the state. In recent years, Texas, like many states, has experienced a well-publicized nursing shortage that is different from shortages of the past and, therefore, may have a more long-term impact on the availability and quality of health care delivery. In the past, nursing shortages have been caused primarily by market factors such as levels of health care reimbursement. The current shortage is driven primarily by demographic changes. General population growth, the rising proportion of people over age 65, and advances in medical technology are expected to greatly accelerate the future demand for patient care services and, thus, the need for new nurses. As a result of these factors, the U.S. Department of Labor has identified nursing as the top occupation in the country for an increase in employment through the year This means that more new jobs are expected to be created for nurses than for any other occupation. And while other health care occupations, particularly those in allied health fields, show higher rates of job growth in Texas, the sheer number of nurses needed to fill new and replacement positions in Texas makes nursing education an important issue for the state. The THECB has determined that increasing the number of nurses is of sufficient importance to make it a specific target for success in Closing The Gaps by 2015, The Texas Higher Education Plan. The Projected Need for New Initial Licensure Graduates in Texas In recent years, the Texas Center for Nursing Workforce Studies, a unit of the Texas Department of State Health Services, has built a sophisticated data collection system to document the current and future need for graduates from initial RN licensure programs (hereafter referred to as initial licensure programs). In 2006, the Center made its first projections of the number of new initial licensure graduates needed in the state, using a supply-demand model developed by the U.S. Health Resources and Services Administration. This original table has been recently updated by the THECB to reflect new projections of graduates based on the number of initial licensure graduates reported from 2002 through 2007: 1 Source: U.S. Department of Labor,

10 Year Projected Need for New Initial Licensure Graduates in Texas Baseline Supply of Graduates* ( ) Total Supply of RN Graduates Needed** Additional Number of Graduates Needed ,031 N/A N/A ,553 N/A N/A ,031 N/A N/A ,510 9,717 1, ,989 12,065 3, ,468 14,593 5, ,946 15,199 5, ,425 17,117 6, ,904 17,777 6, ,382 19,383 8, ,861 20,073 8, ,340 23,302 10, ,819 24,085 11, ,297 24,870 11,573 Sources: Texas Center for Nursing Workforce Studies and Coordinating Board. *Numbers are based on a simple regression formula of actual graduation data reported from 2002 to Graduation numbers do not include those from programs that have not yet produced graduates as of **U.S. Health Resources and Services Administration, Supply Model. The data show that from 2007 to 2012, the state will need to double the number of initial licensure nursing graduates to begin to meet the need for new nurses. By 2020, that 2012 number will need to almost double again. Initial and Future Responses to Projections To achieve short-term projections, Texas has concentrated much of its efforts on building enrollment capacity and improving student graduation rates in the state s 94 initial licensure programs. To increase capacity and improve graduation rates in these programs, the state must also produce more nursing faculty from its master s and doctoral programs or recruit master s or doctorally prepared nurses from practice. A chart showing the progression of nursing education from initial licensure graduate to doctoral graduate appears on pages 4 and 5. In an effort to achieve long term projections, key supporters of nursing, such as the Robert Wood Johnson Foundation and the U.S. Department of Labor, are encouraging nursing programs to increase enrollments and improve graduation rates through greater efficiencies in nursing education. Those efficiencies would change how students are taught and how instruction is delivered by leveraging scarce resources, such as faculty and instructional technology, among existing nursing programs. 2

11 Focus and Organization of this Report This report summarizes the progress of the state s initial licensure programs to relieve the state s nearterm nursing shortage and to offer other strategies for increasing enrollments and graduates from those programs. It also updates selected information presented in the THECB s previous legislative reports: Increasing Capacity and Efficiency in Programs Leading to Initial RN Licensure in Texas (2004); and Strategies to Increase the Number of Graduates from Initial RN Licensure Programs (2006). The status of key recommendations from those two reports is included in Appendix A. The report also supplements two recent reports prepared for the 81st Texas Legislature that present long-term strategies that promote a new curriculum model for nursing education and other efficiencies in the state s initial licensure programs. The executive summaries for those reports, A New Curriculum Model for Initial RN Licensure Program (October 2008) and The Feasibility of Sharing Basic Health Science Courses in Health Education Programs (July 2008) are included as Appendices B and C. The data and analyses in this report are divided into six sections: Initial Licensure Education, Graduate Education and Potential Faculty, Initial Licensure Nursing Faculty, Practitioner and Practice Trends, Strategies for Increasing the Number of Graduates in Nursing Education, and Summary of Key Findings and Recommendations. 3

12 COMMON EDUCATION PATHWAYS FOR TEXAS REGISTERED NURSES (RNs) High School Graduates take the Recommended High School Curriculum Hospital-Based Community Colleges University or Health-Related Institution Diploma 3 years Transition Program (LVN to ADN) 1 year Associate Degree (ADN) 2 years Bachelor s Degree (BSN) 4 years Accelerated & Alternate Entry Program 1-2 years RN Licensure Exam Practice as Registered Nurse LVN: Licensed Vocational Nursing Program ADN: Associate Degree Nursing Program BSN: Bachelor of Science Degree Nursing Program 4

13 COMMON PATHWAYS FOR GRADUATE NURSING EDUCATION IN TEXAS Master of Science in Nursing (MSN) 2-3 years Advanced Practice Nursing - Nurse Midwife - Nurse Practitioner - Nurse Anesthetist - Clinical Nurse Specialist - Nurse Educator - Nurse Administrator - Public Health Nurse *Doctor of Nursing Practice 2-3 additional years Doctor of Philosophy in Nursing (Ph.D.) 3+ additional years *Currently Texas Tech University Health Sciences Center has the only Doctor of Nursing Practice program that admits students who are not Advanced Practice Nurses. 5

14 I. Initial Licensure Education This section presents specific data and issues related to initial licensure programs, defined as education programs that prepare students for initial licensure as registered nurses. Texas has five major types of initial licensure programs: Diploma programs are traditionally hospital-based and require three years of study. Licensed vocational nursing to registered nurse programs (LVN-RN) traditionally requires one year of study after a student has completed a certificate program and is licensed as vocational nurse (LVN). The LVN then completes a curriculum leading to licensure as a registered nurse. Most of the LVN-RN programs are offered as LVN-ADN programs at community colleges, and program completers are reported as ADN graduates. Associate degree programs (ADN) traditionally require prerequisites (i.e., anatomy and physiology) plus two years of study at a community college. Baccalaureate degree programs (BSN) traditionally require four years of study with nursing curricula usually occurring during the last two years at a university or healthrelated institution. Alternate entry degree programs are normally accelerated, second-degree programs and are usually offered at a university or health-related institution. Graduates from these different programs take the same national licensure exam and often earn the same starting salary at health care facilities. The following table shows the distribution of these types of programs as of September 2008 and the percentage of degrees conferred in 2007: Initial Licensure Programs In Texas (2007, 2008) Type of Program Number of Programs * Percentage of 2007 Graduates ** Diploma 2 2.5% Associate Degree (ADN) 62 59% Baccalaureate Degree (BSN) 29 38% Alternate Entry Master s Degree 1 0.5% Total Programs % Sources: Texas Center for Nursing Workforce Studies and the Texas Board of Nursing. * Number of Programs represents the most current number of initial licensure programs approved by the Texas Board of Nursing as of September Not all of the new programs produced graduates in ** Percentage of 2007 Graduates represents the percentage of students who graduated from each type of the state s 86 initial licensure programs in The 86 programs reported a total of 7,031 graduates. 6

15 A. Schools with Initial Licensure Programs Regions Initial Licensure Programs by Region (2008) Total Programs Diploma Associate Degree Nursing Programs Baccalaureate Degree Nursing Programs* High Plains Northwest Metroplex Upper East Texas Southeast Texas Gulf Coast Central Texas South Texas West Texas Upper Rio Grande Total Source: Texas Board of Nursing and Coordinating Board. *Texas Woman's University is counted twice to include separate programs in Houston and in Dallas. For a list of the institutions with initial licensure programs, see Appendix D. For additional maps by specific type of degree program, see Appendix E. 7

16 B. Student Data for Initial Licensure Programs 1. Applications From 1998 to 2007, the number of applications increased by 124 percent. In 2007, applications declined for the first time during this period, although offers of admission continued to increase (see next page). Total Qualified Applications (Duplicated) to Initial Licensure Programs in Texas ( ) 25,000 22,325 22,393 22,885 20,000 19,035 15,000 11,021 11,646 15,166 12,253 13,961 13,861 14,090 11,419 10,000 5,000 8,510 8,004 5,654 5,324 2,856 2,680 7,027 7,322 7,571 4,324 4,682 3,994 9,504 5,662 8,364 8,532 8,795 7, * 1999* 2000* All RN Programs Diploma & ADN Programs BSN Programs Source: Texas Center for Nursing Workforce Studies (TCNWS). *1998, 1999, 2000 data from the Texas Board of Nursing. 8

17 2. Offers of Admission From 1998 to 2007, offers of admission increased by 125 percent. In 2007, the application and admission data show that 7,765 qualified applicants (duplicated) were not admitted to initial licensure programs. Based on a 2003 study of qualified applicants, the THECB estimates that approximately 10 percent of qualified applicants submit more than one application during an academic year. Total Offers of Admission to Initial Licensure Programs in Texas ( ) 12,000 10,802 10,593 10,766 11,270 10,000 8,672 9,457 9,147 8,000 7,446 6,733 6,496 6,649 7,169 6,000 4,000 4,998 4,991 3,227 3,099 4,680 2,766 5,117 3,555 5,643 5,737 3,814 3,410 4,069 4,097 4,117 4,101 2,000 1,771 1, * 1999* 2000* All RN Programs Diploma & ADN Programs BSN Programs Source: Texas Center for Nursing Workforce Studies (TCNWS). *1998, 1999, 2000 data from the Texas Board of Nursing. 9

18 Based on a survey conducted by the Texas Center for Nursing Workforce Studies, lack of budgeted faculty positions is the most frequently stated reason that nursing programs gave for not admitting additional qualified applicants. However, space restrictions also limit enrollment capacity. Stated Reasons Why Qualified Applicants Are Not Admitted to ADN and BSN Programs in Texas (2007) Other 8% Lack of Clinical Space 22% Lack of Qualified Faculty Applicants 21% 43% Space Limits 49% Faculty Limits Limited Classroom Space 21% Lack of Budgeted Faculty Positions 28% Source: Texas Center for Nursing Workforce Studies (TCNWS). 10

19 3. First-year Entering Enrollments From 1998 to 2007, first-year entering enrollments increased by 133 percent. Enrollment in BSN programs increased at a faster rate than Diploma and ADN programs. Total First-Year Entering Enrollment in Initial Licensure Programs in Texas ( ) 12,000 10,000 9,043 8,992 9,567 10,066 8,000 6,000 4,000 4,323 2,911 4,087 2,653 6,110 3,868 2,242 6,967 4,333 2,634 7,891 8,012 4,884 5,181 3,007 2,831 5,812 5,629 3,231 3,363 6,028 6,491 3,539 3,575 2,000 1,412 1, * 1999* 2000* All RN Programs Diploma & ADN Programs BSN Programs Source: Texas Center for Nursing Workforce Studies (TCNWS). *1998, 1999, 2000 data from the Texas Board of Nursing. 11

20 4. Total Enrollment From 1998 to 2007, enrollments in initial licensure programs increased by 52 percent. BSN enrollments increased at a faster rate than in Diploma and ADN programs. Total Enrollment in Intial Licensure Programs in Texas ( ) 20,000 18,000 16,000 14,845 15,318 16,350 16,711 17,841 14,000 12,000 10,000 8,000 6,000 11,701 11,455 11,589 7,058 6,833 6,617 4,643 4,622 12,172 7,170 4,972 5,002 13,540 8,133 5,407 8,621 8,930 6,224 6,388 9,288 9,794 7,062 6,917 10,548 7,293 4,000 2, * 1999* 2000* All Initial RN Programs Diploma & ADN Programs BSN Programs Source: Texas Center for Nursing Workforce Studies (TCNWS). *1998, 1999, 2000 data from the Texas Board of Nursing. 12

21 5. Graduation Rates In 2007, the statewide graduation rate was 69 percent. Programs at health-related institutions had the highest rate (86 percent), followed by universities (72 percent) and community colleges (66 percent). Statewide Graduation Rates for Initial Licensure Programs (2007) Number of Enrollees Graduated 100 %* Graduated 150 %** Total Graduates Percent Graduated^ By Region High Plains % Northwest % Metroplex 1, , % Upper East Texas % Southeast Texas % Gulf Coast 1, % Central Texas % South Texas 1, , % West Texas % Upper Rio Grande % Total 7,772 3,884 1,486 5, % By Type of Program 1-year (LVN-ADN) % 2-year ADN and BSN 6,873 3,459 1,349 4,808 70% Total 7,772 3,884 1,486 5, % By Type of Institution Delivering Program Community College 4,864 2, , % University 2, , % Health-related Institution % Total 7,772 3,884 1,486 5, % Sources: Texas public and independent institutions with initial licensure programs, Coordinating Board. The following institutions are not included in the rate calculations: Cisco Junior College, St. Phillips College, University of Mary Hardin-Baylor, Houston Baptist University, Covenant School of Nursing, Baptist Health System *Graduated 100 % - represents the number of students who graduated "on-time" in programs that normally can be completed in one year (LVN-ADN programs) or two years (general ADN or BSN programs). **Graduated 150 % - represents the number of students who graduated from a one-year program in 18 months or from a two-year program in 36 months. ^Methodology: Final percentages were based on 150 percent time to graduation. Two-year program cohorts who were admitted in either spring, summer, or fall of 2004, were tracked for 36 months, graduating no later than December 2006, May 2007, or August 2007, respectively. One-year program cohorts who were admitted in either spring, summer, or fall of 2005, were tracked for 18 months, graduating no later than June 2006, December 2006 or February 2007, respectively. Graduation rates by individual program for 2007 are included as Appendix F. 13

22 6. Graduates Since 2001, the number of initial licensure program graduates has increased by 55 percent. 8,000 Graduates from Initial Licensure Programs in Texas ( ) 7,000 6,674 7,031 6,000 5,000 4,000 3,000 2,000 5,156 3,243 1,913 5,042 5,243 4,615 4,531 4,609 3,371 3,368 2,896 2,832 2,833 1,671 1,719 1,699 1,776 1,875 5,677 3,632 2,045 6,029 3,760 2,269 4,173 2,501 4,352 2,679 1, * 1999* 2000* All Initial RN Programs Diploma & ADN Programs BSN Programs Source: Texas Center for Nursing Workforce Studies (TCNWS). *1998, 1999, 2000 data from the Texas Board of Nursing. A six-year trend analysis of the number of graduates by individual nursing programs is included as Appendix G. The data from that analysis show: The graduating classes of most of these programs are relatively small. In 2007, 71 percent of initial licensure programs had fewer than 100 graduates. Nursing programs have difficulty sustaining increases in graduates from year to year. Of the 78 programs reporting graduates for each year from , only 2 institutions (2.5 percent) reported increases in graduates for each of the six years. Another 10 institutions (13 percent) showed increases in five of the six years. Thirteen institutions (17 percent) had a net increase of 50 graduates or more over the six-year period. 14

23 The Gulf Coast, Metroplex, and South Texas (excluding Bexar County) regions have the fewest initial licensure graduates per 100,000 population. Despite these discrepancies, the Gulf Coast and Metroplex have more practicing nurses per 100,000 population than other regions. (See also page 38.) Initial Licensure Graduates per 100,000 Population by Region (2007) 72 Statewide Average: Excluding Bexar County: Sources: Texas Center for Nursing Workforce Studies and Coordinating Board. When the number of initial licensure graduates within a region is compared to the total population of a region, the High Plains region has the highest ratio of graduates to 100,000 population, and the Metroplex region has the lowest ratio of graduates to 100,000 population. Comparison of the Regional Population and Initial Licensure Graduates (2007) Regions Percent of Texas Initial Licensure Graduates Texas Population 15 Percent of Texas Population Percent Difference High Plains 8.5% 833, % 4.9% Northwest 3.7% 567, % 1.2% Metroplex 17.8% 6,226, % -8.9% Upper East Texas 8.9% 1,069, % 4.3% Southeast Texas 4.8% 777, % 1.4% Gulf Coast 18.9% 5,436, % -4.4% Central Texas 11.3% 2,621, % 0.1% South Texas 20.1% 4,380, % 1.3% West Texas 2.7% 552, % 0.3% Upper Rio Grande 3.2% 792, % -0.2% Population 100% 23,259, %

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