Nursing Supply and Demand Study 2008

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1 Nursing Supply and Demand Study Sherman Avenue, Suite 100 Cincinnati, OH Phone: (513)

2 2 Table of Contents I. Introduction... 3 II. Hospital Survey (Demand)... 4 A. Registered Nurse (RN) Staff Turnover ( ) Changing Full time / Part time Employment Status within the Organization Reasons for Leaving Position Registered Nurses Hired by Level of Experience Registered Nurses Hired by Specialty Area... 6 B. Registered Nurse Staff ( comparison) RN Staff Positions: Total RN Staff Positions: Filled / Unfilled and Full / Part time RN Staff Positions: Specialty Areas Staff Positions: Advanced Practice Certification Staff Positions: Role... 9 C. Registered Nurse Staff Demographics ( comparison) Age distribution for Registered Nurses Race and Ethnicity for Registered Nurses Gender Hospital RN Educational Level...11 III. Schools of Nursing Survey (Supply)...12 A. Students Program Admissions Student Demographics (Age / Race & Ethnicity) Student Retention Pass Rates for the NCLEX Examination Placement of Graduates...15 B. Concerns limiting program capacity C. Faculty Positions Demographics (Age / Race/ Gender) Faculty Compensation Faculty Changes & Expected Retirements...17 IV. Estimates of RN Supply and Demand A. Model B. Model References

3 I. Introduction GREATER CINCINNATI HEALTH COUNCIL NURSING SUPPLY AND DEMAND STUDY 2008 The purposes of the 2008 Supply and Demand Study were: Greater Cincinnati Health Council 3 1. To gather regional data on nursing faculty, student admission and retention, current nursing workforce and workforce needs. 2. Compare 2008 results to the 2006 Supply/Demand study results. 3. Project the future supply and demand of the nursing workforce, focusing on needs, challenges and a common vision. Hospital survey data were collected between September and December Surveys were sent to 14 organizations, representing 17 hospitals, and there was a 70% return rate. To improve estimates of supply and demand, data was supplemented from other sources. Participating organizations were: Clinton Memorial Hospital, Deaconess Hospital of Cincinnati, Dearborn County Hospital, Health Alliance, Highland District Hospital, Margaret Mary Community Hospital, Mercy Health Partners, North Key Community Care, St. Elizabeth Medical Center, and TriHealth. Ten nursing school surveys were distributed and nine were returned for a 90% return rate. The nine schools represented five associate degree (AD), five baccalaureate (BS) and three alternative entry programs. Participating schools and universities were: The Christ College of Nursing and Health Sciences; Cincinnati State Technical and Community College; College of Mount St. Joseph; Galen College of Nursing; Good Samaritan College of Nursing and Health Science; Miami University; Northern Kentucky University; University of Cincinnati; and Xavier University. This survey considered only hospital demand for nurses and did not include other community needs for registered nurses. It is estimated that nationally 56% of registered nurses (RNs) in the United States are employed in a hospital setting 1. In Ohio, 52% of RNs are employed in a hospital setting 2. On the supply side, 90% of newly licensed nurses in the Cincinnati area are hired by hospitals. It is important to note that a significant number of these RNs will, at a later time, leave the hospital to work in community settings. Survey results are reported and compared to the 2006 Greater Cincinnati Health Council Supply/Demand Survey. The nursing workforce (Demand) findings will be presented first, followed by the schools of nursing (Supply) findings, and lastly, estimates of supply and demand will be presented.

4 II. Hospital Survey (Demand) A. Registered Nurse (RN) Staff Turnover ( ) Greater Cincinnati Health Council 4 1. Changing Full-time / Part-time Employment Status within the Organization. Since 2006 more RNs are changing to full-time (FT) status (57% in 2006 & 64% in 2007) and decreasing their part-time status (42% in 2006 & 35% in 2007). This trend is shown in Figure 1. The reason for this change is unknown, but may be a reflection of the economic times and more nurses are finding it necessary to work full-time. The percentages and trend are shown in Figure 1. Figure 1. Percentage of registered nurses who changed from part-time to full-time or full-time to part-time and the linear trend for part-time to full-time employment status. 2. Reasons for Leaving Position. The largest percentage of nurses in 2006 (62%) and 2007 (62%) left for Other reasons such as motherhood, personal or family illness, or relocation. There is an upward trend for this category, likely due to nurses choosing positions outside the hospital setting. For nurses who are leaving, retirements or leaving the profession accounted for 3% in 2004 and 2005, 5% in 2006, and 6% in The reasons for leaving the hospital for the years are shown in Figure 2.

5 5 Figure 2. Reasons for leaving the hospital position are compared for years In comparison to the 2006 Survey responses, there were no remarkable changes in percentages for the categories of Staff Reduction, Fired/Terminated, or Leaving the Profession. The proportion of Retirements increased slightly, and the proportion nurses taking a different position decreased dramatically, from 27% in 2004 to 4.5% in Caution should be taken in concluding that nurses are staying in their positions, since this could be a reporting difference resulting from the changing hospital alliances that occurred between 2006 and Registered Nurses Hired by Level of Experience. In 2006, 16% of RNs hired were new graduates; and in 2007, 26% of hired nurses were new graduates. Figure 3. Percent of new RN hires by type of new hire: New Graduate, Experienced RN for the years Fewer newly licensed graduates were hired in 2006 compared to other years. This dip is likely the result of reporting differences resulting from hospital re-alliances (Figure 3). As with the previous survey, Registered Nurses are predominately hired from local and regional markets

6 6 (96%) and only 4% (all years) came from other countries or regions. This indicates an adequate supply of RNs for the Cincinnati region. However, the supply stream from the region s schools of nursing may have reached its capacity for graduating new nurses (see the Nursing Schools section). 4. Registered Nurses Hired by Specialty Area The percentages of RNs hired for a specialty area were similar for 2006 and What is interesting is that the percent of nurses hired in medical/surgical areas is only 19% for 2006 and 18% in In the previous survey respondents projected an increase of 204 medical surgical beds and 83 critical care beds for Paradoxically, there was a 9% increase in hiring critical care nurses and a 13% drop in hiring of RNs for medical/surgical areas. Medical surgical and critical care RNs will likely continue to be the most difficult positions to fill, because of the continued demand. Quality of care, patient safety, and productivity are issues in areas of higher turnover due to the learning essential for both new and experienced RNs 3, 4. The Registered Nurses hired by specialty area are shown in Figure 4. Figure 4. Percentage of Registered Nurses hired by specialty area. M/S (Medical/Surgical; CC (Critical Care); OR (Operating Room); Ob/Gyn (Obstetrics/Gynecology); Psych (Psychiatric) Reporting differences between the 2006 Survey and the 2008 Survey may account for some of the inconsistencies between the two surveys. In the 2006 survey, respondents indicated that 2303 RNs were hired, but in this survey only 1094 nurses were reported hired, almost half of the previously reported number, and turnover rate is only 1% lower than previously reported. B. Registered Nurse Staff ( comparison) 1. RN Staff Positions: Total Ten of the 14 organizations reported a total of 10,896 filled (full and part-time) positions, and 731 unfilled (full and part time) positions for a total of 11,627 available positions. The 2006 survey accounted for a total of 11,927 (full and part-time) positions with an additional 839 FTE positions projected to be added between 2006 and Thus the anticipated number of positions should have been higher; however, with the decrease in number of part-time positions,

7 7 some of the deficit of 1,139 positions would be accounted for by the change to full-time positions, as well as a smaller number of additional RNs actually hired. The reported number for 2008 positions are likely an under estimation of the real number. Some organizations were unable to respond to the 2008 survey and total positions were estimated from other documents, reports, and personal communication from the organization. 2. RN Staff Positions: Filled / Unfilled and Full / Part-time Overall, the percentages of filled to unfilled positions were consistent from 2006 to 2008 (Figure 5). In 2006 there was a 7% vacancy and in 2008 there was a 6% vacancy rate for registered nurses. The vacancy rate for Ohio in 2007 was 4.8% 5. A vacancy rate greater than 5% is often reflective of a shortage of nurses 6. Although the Cincinnati region is slightly above 5%, this does not mean that a shortage exists. If positions are filled by temporary agencies, this would be considered a substitution, not a shortage, and substitutions may have benefits in helping to manage acute variances in staffing demands 7. It is also important to note that data were collected between September and December of 2008, just as an economic downturn was in progress. In February 2009, a neighboring region was experiencing vacancy rates of 1% 8. This mobilization of the existing pool of RNs is a short term response to future needs for hospital nurses 9, 10, but as demand continues to grow in response to aging of the population, there will be a continued trend for additional nurses to replace those leaving the workforce and to meet the increasing demand over time 11. A greater percentage of positions are full-time compared to Full-time positions went from 54% in 2006 to 78% in 2008 (Figure 6). This changing trend toward full-time employment was also shown by the increase in hiring of full-time RNs (See section IIA1). Figure 5. Percentage of filled and unfilled positions for years 2006 and 2008.

8 8 Figure 6. Percentage of full-time versus part-time positions for years 2006 and 2008 Figure 7. Vacancy rates based on GCHC annual vacancy survey 3. RN Staff Positions: Specialty Areas Seven organizations representing ten hospitals reported the number of RN positions by specialty area. As forecasted in the 2006 survey, there was an increase in the percent of nurses in critical care positions, operating room and obstetrics/gynecology. Medical/surgical positions remained the same; psychiatric and other positions decreased. These changes are shown in Figure 8.

9 9 Figure 8. Percent of specialty RN staff for years 2006 and Staff Positions: Advanced Practice Certification Only two organizations reported the number of registered nurses with advance practice certification. No comparisons are presented. 5. Staff Positions: Role The proportions of RN staff by role are consistent from 2006 to 2008 (Figure 9). Approximately 90% of hospital RNs are in direct care roles for both surveys. In comparison, 69% of Ohio RNs identify direct care as their primary role 2. The ideal ratio of administration, staff education, and direct care providers depends on organizational structure and staff characteristics. However, the high ratio of direct care providers indicates a strong value for the importance of bedside care, as well as a high level of acuity demanding well-educated nurses. Figure 9. Percent of RN positions by role.

10 10 C. Registered Nurse Staff Demographics ( comparison) 1. Age distribution for Registered Nurses. There is a noticeable flattening of the RN age distribution from 2006 to 2008, indicating an aging of the RN population. There are 4% more nurses in the 55 to 64 year old age group, with a decrease in 35 to 44 year old and the 45 to 55 year old groups. There is only a 1% increase in the year old age group and a 2% increase in the year old age group. The regional aging of the RN workforce will likely continue as more RNs from the baby boomer generation retire. The demographic cohort available to replace these nurses is smaller, but a larger proportion are entering nursing in their late twenties than previous cohorts who entered at an earlier age. Those who are entering nursing are more mature, more educated and less likely to leave nursing early in their career. Overall, the long-term projection of a severe nursing shortage by 2020 has lessened and will take a longer and longer time to develop 12. Figure 10. Percent of RN age distribution for years 2006 and Race and Ethnicity for Registered Nurses. There was no change in race/ethnicity distribution from 2006 to 2008, with Non-Hispanic White RNs representing 90% of the of the distribution, Non-Hispanic Black 7%, and all other minorities 3%. In Ohio, 5.6% of RNs are in ethnic minorities, and 3.1% of RNs are Non- Hispanic Black. Nationally 81.8% of RNs are Non-Hispanic White and 4.2% are Non-Hispanic Black. Except for Hamilton County which has a 27% minority population and 25% Non- Hispanic Black population, the remaining regional counties range from 90% to 95% Non- Hispanic White populations 13. As the region becomes more diverse in race/ethnicity, efforts to attract minorities into nursing must continue.

11 11 Figure 11. Percentage of Registered Nurses by Race/Ethnicity for 2006 and Gender The percentage of males employed in local hospitals remains at 6% for 2008 which is higher than Ohio (4.4%) and the U.S (5.8%). Just as with minorities, more men need to be actively recruited into nursing Hospital RN Educational Level Level of education for registered nurses was not collected in the 2006 survey. The level of education is shown in Figure 6. Nurses with an Associate degree make up 38% of hospital RN staff, 33% have a baccalaureate degree, followed by 25% with Diplomas. Approximately 3% of RNs were reported as prepared at either the masters or doctoral level. The numbers for masters and doctoral prepared nurses are under-reported two returned surveys indicated the organization was unable to provide the data. Also, numbers for advanced practice positions were not reported; therefore, extrapolation from these numbers was not possible. In Ohio, 31% of RNs have a Diploma, 29% an AD, 31% a baccalaureate, and 9% a masters or doctoral degree. Compared to the U.S., 17% of RNs report having a diploma, 33.7% an AD, and 34.2% a BS. Approximately 13% have a masters or doctoral degree 14. Figure 12. Percentage for educational levels of hospital Registered Nurses in 2008.

12 12 III Schools of Nursing Survey (Supply) A. Students 1. Program Admissions The numbers of student admissions were up in both 2007 (1610 students) and 2008 (1825). The distribution of student admissions for is shown in Figure 13. Additionally, most of the programs show a waiting list, indicating that the programs have reached capacity. A total of 474 applicants in 2007 and 490 applicants in 2008 were placed on a wait list, resulting in an average of 23% of qualified applicants denied admission each year. The number of qualified applicants and admitted students for is shown in Figure 13. Figure 13. The number of qualified applicants and the number of admitted students to schools of nursing for the years Student Demographics (Age / Race & Ethnicity) The age and race/ethnicity of admitted students remains consistent from 2005 through These results are shown in Figure 14 and Figure 15. The greatest number of student admissions is in the youngest age group (ages 17-24).

13 13 Figure 14. Percent of age groups for nursing students admitted for academic years The distribution of admissions by race is similar to that reported for hospital RN staff. Twelve percent of the admissions in 2008 are male compared to 11% in A 1% increase is not significant, but as nursing salaries rise, more men may be attracted into the profession. Figure 15. Percent of nursing student admission by race/ethnicity for Academic Years Student Retention Retention rates for the academic school years of 2006 and 2008 are shown in Figure 16.

14 14 Figure 16. Percent retention for nursing students in Academic Years 2006 and The first and second years primarily reflect attrition in alternative nursing programs (BS non-nursing to Master s degree) and associate degree programs. The first year shows a 20% drop in retention, but the remaining years show a consistent pattern of retention for the years 2006 and Reasons for attrition from highest to lowest are: unable to meet academic expectations, demands of family and work, financial need, and change in major. The decrease in retention for 2008 may be the result of increased admissions and limited resources for assisting students to remain in the program. 4. Pass Rates for the NCLEX Examination In 2006, 89% percent of the graduates passed the NCLEX Examination on the first attempt. In 2008, 87% passed on the first attempt. Not enough programs in 2008 reported on second and third attempts to take the examination to make a comparison to the 2006 responses. The number of graduates educated in Ohio and passing the NCLEX Examination on the first try is shown below for the years Kentucky does not report actual numbers. Figure 14. Number of nursing graduates Passing NCLEX Examination on the first try for the years

15 15 The number passing the NCLEX on the first attempt (Ohio only) has gone from 461 in 2003 to 780, in 2008, a 40% increase in the number of newly licensed RNs produced in 2008 compared to Placement of Graduates In 2006, 87% of nursing graduates were hired by hospitals in the Cincinnati MSA, and in 2008, 90% were hired by Cincinnati MSA hospitals. Only 10% of graduates in 2006 and 9% in 2008 took positions outside the Cincinnati MSA. Based on previously reported demand data, 96% of RN s (both new graduates and experienced nurses) are hired from the Tristate region, which supports a home grown stable nursing workforce. B. Concerns limiting program capacity Factors limiting program capacity were rated as: 4 (critical), 3 (major), 2 (moderate), 1 (minor) and 0 (none). The comparison of concerns for 2006 and 2008 are shown in Figure 17. Financial factors were the greatest concern in 2008, but availability of faculty was the greatest concern in Classroom space is also rated higher in 2008 than These findings indicate that programs are at a maximum for physical space and are feeling financial pressures. Availability of faculty continues to be a concern. The pressures for increasing enrollment and the limited availability of qualified faculty indicate that schools of nursing are struggling to meet the demand for graduates. However, with the lower vacancy rate, the demand for graduates may lessen. It is important to remember that it takes one (accelerated programs) to four years (baccalaureate programs) to educate a nurse, and a balance between the supply and long-term demand is critical. Figure 17. Average rating (0 4) for concerns limiting program capacity for Academic Years 2006 and 2008.

16 C. Faculty Greater Cincinnati Health Council Positions In 2006, there were 312 faculty positions available (full and part-time) with a 12% vacancy rate. Sixty percent of the positions were full-time. In 2008, there are 284 faculty positions available (full and part-time) with a 6% vacancy rate, with an increase of 60% to 80% in full-time positions (Figure 18). The increase in full-time faculty could have been due to a number of internal and external factors including a more stable faculty, increased salaries, availability of preceptors, and increased class size. Figure 18. Percent full-time and part-time faculty status for 2006 and Demographics (Age / Race/ Gender) The age distributions for 2006 and 2008 indicate an aging of the population (Figure 19). There is a 7% increase in the number of faculty in the year old age group, and a slight increase in the age group and age group. Within 10 years over 40% of current nursing faculty will be at retirement age. Figure 19. Percent of faculty in age categories for years 2006 and 2008.

17 17 Even with an adequate supply of master s and doctoral prepared nurses, there will be a significant loss of experienced educators. Survey data about enrollments in master s degree and doctoral programs was insufficient to make projections about the supply of future nursing educators; however, several schools have started nurse educator programs, and this may be one reason for the 7% increase in younger faculty. The race/ethnicity distribution for nursing faculty is similar to the distribution for registered nurses. However, with only 6% male faculty, there are few role models for males coming into nursing. 3. Faculty Compensation The average starting salary for full-time faculty in 2008 was $55,019 compared to $48,968 in The average hourly rate for part-time faculty in 2008 was $33.75 compared to $31.50 in Low salaries are considered as one of the primary reasons nurses with masters 16, 17 and doctorates were not attracted into nursing education. 4. Faculty Changes & Expected Retirements Fewer faculty members retired in 2008 than 2006, but a greater percentage left for other reasons (Figure 20). Faculty retention is a growing issue as numbers of students increase. Although work hours are more flexible than hospital nursing, the hours in preparing, evaluating, and revising courses; evaluating student performance; attending to curricular changes; publishing; remaining current with practice changes; and interfacing with community and clinical placement sites, makes the work highly complex and demanding. The work demands combined with the low salaries are an issue in maintaining adequate numbers of nursing educators. Figure 20. Percent of educators who left the position or retired for Academic Years 2006 and IV. Estimates of RN Supply/Demand Two models were used to estimate the balance of RN supply and demand. Each model was based on assumptions derived from either national reports or inferred from the 2006 and 2008 surveys. External forces (changing economic climate) and the lack of necessary data, resulted in assuming constant rates for retirement, workforce migration and leaving the RN workforce.

18 18 A. Model I Assumptions: 1. Demand for RNs increases annually at 2%. The rate is based on national estimates of a 2-3% annual increase in demand; Model I uses the lower rate of 2%. The baseline number of RNs is 11,116, the estimated number of full and part-time positions. 2. RN supply 5% for first 5 years then at 2% annually. The supply includes new graduate RNs who pass the NCLEX examination the first time, and 50% of the new graduates who pass on the second attempt. The migration into the region is considered a constant and is a part of the estimate for supply. The baseline supply of 1,032 new nurses was based on estimates obtained from survey data, with 84% new graduates and 16% migration into the local region. The increased rates were selected as a conservative estimate of growth, since the growth in the number of local graduates has increased an average of 10% a year since Combined with the large number of qualified applicants denied admission, it is likely that the numbers of students admitted will not decrease in the near future. 3. Nine percent leaving profession remains constant and is not anticipated to change in the near future. Leaving the workforce includes retirements, taking nursing positions out of the hospital, and the other categories reported in the survey. Nurses changing or taking other hospital positions was not included in the leaving the workforce estimate. 4. Staffing acuity patterns remain constant. Nurse staffing intensity impacts the demand for RNs, but the survey was not constructed to elicit estimates of intensity. 5. The RN vacancy rate continues at 5%. Recent hospital labor force reports suggest this rate is decreasing. Model I Projected changes in RN supply and demand using assumptions of 2% increase in demand; 9% leaving profession; 5% increase in students graduating. Year Demand (N) (2% annual increase) Total RNs in workforce (N) Leaving Workforce (9% annual rate) Demand plus leaving workforce (N) RNs entering the local workforce (N) Supply /Demand Percent shortage % 12.8% % 10.2% % 7.6% % 4.9% % 2.1% % 2.1% % 2.1% % 2.1% % 2.1% % 2.1%

19 19 In 2006 two projection models were used. The first model gave a projection of an 18% shortage of RNs for , 8% for and 2% for The projections were based on number of anticipated RN positions rather than a constant increase in demand, as we used in the current model. The projections for the 2008 Model One are 13% in 2009, and an average of 5% for , and 2% for the last five years of projection. These projections are remarkably close to the 2006 projections, giving some degree of confidence that our local region is dealing well with the projected nursing shortage. These projections may be overly optimistic as more nurses reach retirement age. The actual percentage of nurses leaving the workforce due to retirements could increase incrementally in the last 10 years of the Model I projection table. Also, as more experienced nurses retire, the knowledge gap may widen as new graduates develop confidence and competence. Competencies are essential for safe patient care, and it is reasonable to assume that new graduates will not have the level of productivity as experienced nurses, and will take up to 5 years or more to reach the level of an expert nurse. 4 Lastly, nursing programs are reaching a critical level of capacity and find it necessary to deny admission to about 26% of qualified applicants. Although the assumptions of Model One are reasonable, there are external conditions that can influence the future supply and demand of nurses. With this in mind, a second more conservative model for projections is also proposed. B. Model II Assumptions: The rationale for assumptions of Model II are the same as Model I, but include higher rates for demand and the same rate for supply. 1. Demand for RNs increases annually at 3%. 2. The RN supply will increase 5% annually. No increase in the projected rate of growth of nursing schools is anticipated since qualified applicants are currently being denied admission. 3. The supply estimate includes new graduates (84%) and nurses from the regional market (16%) as new hires. 4. Nine percent leaving the profession remains constant. Leaving includes retirements, taking non-hospital RN positions and other reasons for leaving. The calculations do not include taking another hospital position. 5. Staffing intensity remains constant. 6. Vacancy rate remains at 5%.

20 20 Model II. Projected changes in RN supply and demand using assumptions of 3% increase in demand; 9% leaving profession; and 5% increase in graduate nurses. Year Demand (N) (2% annual increase) Total RNs in workforce (N) Leaving Workforce (9% annual rate) Demand plus leaving workforce (N) RNs entering the local workforce (N) Supply /Demand Percent shortage % 20.6% % 19.0% % 17.4% % 15.8% % 14.2% % 12.5% % 10.8% % 9.1% % 7.3% % 5.5% The second model projected in 2006 gave a projection of a 25% shortage of RNs for , 17% for and 9% for Again, the projections were based on number of anticipated RN positions rather than a constant increase in demand, as we used in the current Model II. The shortage projections in 2008 Model II are 20% for 2009, an average of 16% for , and an average of 9% for the last five years of projection. These projections are close to the 2006 projections using a conservative model. Although external factors are influencing our current supply and demand balance in favor of supply, it is imperative to remain aware of the trends that influence the balance. A small increase in demand as was made in Model II shows the impact on available supplies of RNs. In the the National Survey of Registered Nurses 1 report projected a 12% shortage of RNs in This is quite close to the shortage projected using local data. However, in both Model I and Model II the shortage is significantly less severe than projected in the National Survey due to the continued growth of Tristate new graduates. Instead of a projected 30% national shortage, the local region will likely experience a shortage between 5 and 11%. Study Participants The Greater Cincinnati Health Council would like to thank Dr. Linda. S. Davis, PhD, RN, University of Cincinnati, for the analysis of the survey data and the following organizations for their participation: Clinton Memorial Hospital, Deaconess Hospital of Cincinnati, Dearborn County Hospital, Health Alliance, Highland District Hospital, Margaret Mary Community Hospital, Mercy Health Partners, North Key Community Care, St. Elizabeth Medical Center, and TriHealth. The Christ College of Nursing and Health Sciences; Cincinnati State Technical and Community College; College of Mount St. Joseph; Galen College of Nursing; Good Samaritan College of Nursing and Health Science; Miami University; Northern Kentucky University; University of Cincinnati; and Xavier University.

21 References Greater Cincinnati Health Council U.S. Department of Health and Human Services, HRSA (2005).Preliminary findings 2004 National Sample survey of Registered Nurses. Retrieved October 1, 2006 from ftp://ftp.hrsa.gov/bhpr/nursing/rnpopulation/theregisterednursepopulation.pdf. 2. State of Ohio Board of Nursing. (2004). Workforce Survey Summary. Retrieved October 1, 2008 from 3. Jones, C. (2005). The costs of nurse turnover, part 2: Application of the nursing turnover cost calculation methodology. Journal of Nursing Administration, 35; Orsolini-Hain, L. & Malone, R.E. (2007). Examining the impending gap in clinical nursing expertise. Policy, Politics, & Nursing Practice, 8; NEONI. (2007) Nursing workforce facts. Retrieved October 1, 2008 from D6D75D83C374/342/nursingfacts.pdf 6. Buerhaus, P. I. (2008). The potential imposition of wage controls on nurses: A threat to nurses, patients, and hospitals. Nursing Ecomonics$, 26; Goldfarb, M.G.; Boldfard, R.S. & Long, M.C. (2008). Making sense of competing nursing shortage concepts. Policy, Politics, & Nursing Practice; 9; Sutherly, B. (February 18, 2009). Nursing vacancies drop as recession persists; regional turnover rates are lower, but. Dayton Daily News. Retrieved February 24, 2009 from 9. Buerhaus, P.I.; Donelan, K.; Ulrich, B.T.; DesRoches, C.; & Dittus, R. (2007). Trends in the experiences of hospital-employed registered nurses: Results from three national surveys. Nursing Economic$, 25; Buerhaus, P.I.; Auerbach, D.I. & Staiger, D.O. (2007). Recent trends in the registered nurse labor market in the U.S.: Short-run swings on top of long-term trends. Nursing Economic$; 25, Buerhaus, P.I. (2008). Current and future state of the US nursing workforce. JAMA, 3000; Auerbach, D.I.; Buerhaus, P.I. & Staiger, D.O. (2007). Better late than never: Workforce supply implications of later entry into nursing. Health affairs, 26; U.S. Census Bureau. "Ohio American Community Survey Demographic and Housing Estimates: 2006". United States Census Bureau Retrieved on

22 U.S. Department of Health and Human Services, Health Resources and Services Administration. The registered nurse population: findings from the 2004 national sample survey of registered nurses. Retrieved on February 20, 2009 from National Council Licensure Examination for Registered Nurses (2009) RN NCLEX Statistics: G4 Rolling quarters Jurisdiction Program Summary of All First Time Candidates Educated in Ohio Board of Nursing. Retrieved on February 20, 2009 from U.S. Department of Health and Human Services, HRSA (2005). Projected supply, demand and shortages of registered nurses: Retrieved October 1, 2008 from Institute for Women s Policy Research. (2006). Solving the Nursing Shortage through Higher Wages. Retrieved December 30, 2008 from

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