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Nursing Education & Practice

Hawaii's Health in the
Balance: A Report on the State
of the Nursing Workforce

Executive Summary
Snapshot of Nursing Supply
and Demand
Factors Influencing RN
Supply and Demand
Public Health Stakes
Hawaii's Efforts
Call to Action & Conclusion
Taskforce Members

Hawaii State Center for Nursing

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Webster Hall 432
Honolulu, Hawaii 96822 - Map -

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Hawai'i's Health in the Balance:
A Report on the State of the Nursing Workforce, October 2004
(download pdf file)


Executive Summary


This report was commissioned by the Hawai‘i Nursing Shortage Taskforce to (1) provide an overview of the nursing workforce, (2) describe the scope and magnitude of the nursing shortage including factors that underlie a shortage, (3) identify the impact the shortage has on the state’s ability to provide health care services, and (4) recommend actions that can be taken to lessen the effects of the shortage and help avert future shortages.


What is the problem?

Hawai‘i, along with most of the country, is experiencing a shortage of Registered Nurses (RNs) that is expected to quadruple in size by 2020. RNs are the largest group of health care providers and work across all health care settings providing hands-on care.


Between 2000 and 2020, demand for RNs in Hawai‘i is expected to grow by 55 percent, while supply of RNs is expected to grow by only 13.8 percent.

During this period, demand for RNs is expected to increase by 4,554 new full-time equivalent (FTE) positions. At the same time, nearly 80 percent of today’s nursing workforce, or 8,397, nurses are expected to retire. Thus, as demand increases dramatically, supply will remain relatively stagnant.

In 2003, Hawai‘i nursing schools graduated a total of 330 students. If graduation rates do not increase dramatically, there will not be enough new graduates to replace retiring nurses and meet new demand. In 2003, Hawai‘i’s nursing schools turned away 293 qualified nursing applicants because they did not have enough faculty positions to meet student demand.

RN vacancy rates were 8 percent in Hawai‘i’s nursing homes in 2002 and 12 percent in hospitals in the Western region of the country in 2000. Economists consider a shortage to be present when vacancy rates exceed 5–6 percent over an extended period of time.


Factors Leading to a Nursing Shortage

Today’s nursing shortage is widely considered to be “different” than all previous shortages because it is the result not of market dynamics, but an unprecedented demographic shift towards an older population. Hawai‘i is on the cusp of this “senior boom,” aging twice as fast as the rest of the country. Between 2000 and 2020, the number of people age 60 and over living in Hawai‘i will increase by almost 75 percent and people age 85 and older will increase by 121 percent. A rapidly aging society has two primary consequences for the nursing workforce: (1) health care demand will increase and (2) the current nursing workforce will contract dramatically as nurses age into retirement. In response, efforts to address the shortage should focus on increasing nursing supply. The following key factors should be addressed to bolster nursing supply and lessen the effects of the nursing shortage:

Nursing school capacity: In 2003, Hawai‘i’s nursing schools turned away 293 qualified nursing applicants because they did not have enough faculty to enroll them. All of Hawai‘i’s public nursing schools report they need more faculty to meet student demand but lack the funds to add positions. Without expanded student enrollment, nursing supply growth in Hawai‘i will be severely limited. In addition, nursing schools report difficulty in finding clinical sites for students, a necessary part of nursing education. Lastly, there is a need to ensure that nursing education is current with practice, especially in geriatrics and technology dependent specialties, so that Hawai‘i not only has enough nurses but enough nurses qualified to meet Hawai‘i’s health care needs.

Work environment for nurses: A recent national survey finds just 69.5 percent of all RNs are satisfied with their job. These satisfaction levels are low compared with 85 percent of all workers and 90 percent of professional workers who express satisfaction with their job. Concerns commonly associated with RN job dissatisfaction include: (1) inadequate staffing to perform work, (2) heavy workloads, (3) increased overtime, and (4) lack of sufficient support staff. Job dissatisfaction contributes to the increasing number of RNs who are leaving the profession.

Foreign nurse migration: Hawai‘i depends heavily on foreign nurses who comprise an estimated 25 percent of the state’s nursing workforce compared with only 5 percent nationally. During today’s global nursing shortage, recruiting foreign nurses raises not only ethical questions about “stealing away” nurses from countries that desperately need them, but also how sustainable such exports will be amidst increasing global demand for nurses.

Direct care workers shortage: There is no substitute for a RN. However, RNs routinely delegate nursing tasks to direct care workers, such as nursing aides. Hawai‘i, as with most of the country, has a shortage of direct care workers. Without enough direct care workers, RNs have to absorb these workers’ tasks as part of their own workload, increasing overall demand for RNs.

Wages and market dynamics: Past nursing shortages have generally relied on market dynamics alone to bring the workforce back into balance. Nationally, growth in median RN earnings (adjusting for inflation) remained flat throughout the 1990s, but increased by 13 percent between 1997 and 2001. Recent research shows that RN wages would have to rise 55–69 percent between 2005 and 2016 to increase nursing enrollments and end the nursing shortage by 2020.

The role of state policy makers: Supply and demand for nurses is greatly influenced by policy makers’ role in: (1) supporting higher education, (2) reimbursing health services, (3) regulating health services, and (4) establishing workforce development programs and policies. For example, higher education relies on state support. Inaction on the part of the Hawai‘i legislature to increase funding to nursing schools so they can expand student enrollment would severely limit nursing supply growth.


Impact on Public Health

It is important to recognize that at risk is more than a shortage of workers. A shortage of RNs means a shortage of quality health care for the people of Hawai‘i. Research consistently shows what patients have long understood, RNs equal quality care. As the shortage of RNs grows, so too will the threat to public health.

With a statewide shortage, it follows that health care providers will find filling vacancies more difficult and some positions may remain vacant for extended periods. In turn, providers may respond by: (1) continuing to provide services with fewer RNs, potentially reducing quality of care and/or (2) delaying or discontinuing services, reducing access to care.

Research consistently finds a positive relationship between higher RN staffing levels and quality of care. A recent federal study of acute care hospitals concluded that a higher proportion of RN hours and a greater number of hours of care by RNs are associated with better care. Likewise, RN staffing in nursing homes is directly correlated with better resident outcomes, according to a landmark federal study in 2001.

According to a 2001 national survey of acute care hospitals, the nursing shortage has “substantially” impacted providers’ ability to deliver quality care. Fifty-one percent of providers reported emergency room overcrowding, 26 percent closed the emergency department for four hours a week, 25 percent closed beds, 23 percent restricted admissions, 11 percent increased waiting time for surgery, and 6 percent reduced or eliminated services.



Hawai‘i has a shortage of RNs, which is expected to quadruple in size by 2020. Increasing numbers of RN vacancies, and vacancies that remain unfilled for extended periods, can be expected to leave fewer RNs available to provide care —potentially undermining quality of care and access to care. The consequences for public health and safety will be significant. While no single intervention can fully address the shortage, it is clear that no combination of interventions will be successful without first addressing the shortage of nursing faculty. Without funding for additional faculty positions, nursing schools will continue to turn away qualified applicants, severely limiting Hawai‘i’s ability to increase nursing supply. Efforts on the part of providers, educators, policy makers, consumers, and labor should be collaborative and strategic, recognizing the complexity of bringing the workforce back into equilibrium and the risk of inaction. Investments made today will not only benefit Hawai‘i over the next 20 years, but begin to develop a proactive culture that will sustain a robust, qualified nursing workforce to meet Hawai‘i’s health care needs into the future.


Call to Action

The recommendations listed below were developed and approved by the Hawai‘i Nursing Shortage Taskforce.

Priority Recommendation
1. Provide funds to add more nursing school faculty positions so that nursing schools can expand student enrollment. (Legislature)

Other Recommendations
2. Establish a consortium between providers and nursing educators to ensure that Hawai‘i not only has a sufficient supply of nurses, but a supply of nurses with the skills and competencies to meet Hawai‘i’s health care needs. (Affiliate Group, Providers, Educators, Hawai‘i State Center for Nursing)
3. Develop a statewide nursing workforce data collection system to support proactive workforce planning, including areas such as turnover, retention, and vacancy rates, temporary nurse usage, county-level and military nursing supply, foreign nurse recruitment, nursing education capacity, and direct care worker supply. (Providers, Educators, Hawai‘i State Center for Nursing)
4. Foster recruitment initiatives with special focus on groups underrepresented in nursing such as people of color and men. (Providers, Nursing Educators, Secondary Schools, Workforce Investment Board, Area Health Education Center, Private Business, and the Hawai‘i State Center for Nursing)
5. Implement, evaluate, and disseminate strategies that will lead to higher levels of job satisfaction and improved retention among nurses, including strategies for career progression in nursing. (Providers, Nursing Educators, Labor, Hawai‘i State Center for Nursing)


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