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

II. Snapshot of Nursing Supply and Demand
Hawai‘i currently has a shortage of RNs, which is expected to quadruple in size by 2020.

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. (Figure 1 and Figure 2). Herein lies the basic premise for asserting that Hawai‘i has a shortage of RNs—demand that outstrips supply. During this period, demand for RNs is expected to increase by 4,554 new full-time equivalent¹ (FTE) positions.² Concurrently, nearly 80 percent of the current nursing workforce, or 8,397 RNs, is expected to retire, peaking between 2005 and 2010 (Figure 3).³ Thus, as demand for RNs increases, supply will remain relatively stagnant. In 2003, Hawai‘i nursing schools graduated a total of 330 students (Figure 4).⁴ If graduation rates do not increase dramatically, there will not be enough new graduates to replace retiring nurses and meet new demand.

Figure 1
Projected Supply and Demand for Registered Nurse Full-Time Equivalents in Hawai‘i, Selected Years 2000–2020

Source: Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Projected Supply, Demand, and Shortages of Registered Nurses: 2000–2020. Hawai‘i Revisited,” April 2003, http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/ (16 January 2004).

Figure 2
Projected Shortfall of Registered Nurse Full-Time Equivalents in Hawai‘i, Selected Years 2000–2020

Source: Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Projected Supply, Demand, and Shortages of Registered Nurses: 2000–2020. Hawai‘i Revisited,” April 2003, http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/ (16 January 2004).

Figure 3
Hawai‘i RNs in 2000 by Expected Year of Retirement, Selected Years 2000–2020.

Source: B.M. Kooker, C. Winters-Moorhead, M. Acosta, and S. Hobbs, “Nursing Workforce Supply Data Trends in Hawai‘i,” Hawai‘i Medical Journal 62 (2003): 193–197.

Figure 4
Hawai‘i Nursing School Graduates, 1996–2003.

Source: 1996–2001 data source is B.M. Kooker, C. Winters-Moorhead, M. Acosta, and S. Hobbs, “Nursing Workforce Supply Data Trends in Hawai‘i,” Hawai‘i Medical Journal 62 (2003): 193–197. 2001–2003 data source is Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.

Increasingly, nurses are working in non-nursing positions.

In Hawai‘i, about 1 out of every 6 RNs does not work in nursing, slightly less than the national average. Nationally, some 27 percent of these nurses are working, just not in nursing and the trend appears to be growing.⁵ Between 1992 and 2000, the number of nurses working in non-nursing positions increased by almost 36 percent nationwide. Even more striking is the increase in the number of new nurses who are not working in nursing. During the same period, the percentage of new male nurses not employed in nursing increased nearly three fold, while new female nurses increased by more than half.⁶

Nationally, 65 percent of nurses not working in nursing are unemployed and are not looking for nursing employment. About 70 percent of these nurses are age 50 years old or older, while a smaller percentage are younger nurses who are married and have preschool age children at home.⁷

RN supply has increased over the last 20 years, but Hawai‘i has fewer employed RNs per 100,000 residents than the national average.

Hawai‘i’s nursing supply increased by nearly 7,000 RNs between 1980 and 2003. A significant dip in supply can be seen in the late eighties during the nation’s last major nursing shortage (Figure 5). Currently, 14,676 RNs are licensed to practice in Hawai‘i. Of these, 10,533 live in Hawai‘i.⁸ Further breakdown shows that Hawai‘i has 703 employed RNs per capita, lower than the national average of 782 per capita. Per capita ratios vary widely, for example, Massachusetts has a 1,194 per capita whereas California only has 544. The western region of the country as a whole tends to have fewer RNs for their population than the rest of the country.⁹

County level data comparing number of RNs employed per capita are not available. However, county comparisons can be made by looking at the number of RNs living in each county per 50,000 residents. This comparison ranks O‘ahu as having the highest ratio of RNs per capita followed by Kaua‘i, Maui, and Hawai‘i respectively (Figure 6).¹⁰ These figures overstate supply because they do not account for nurses not working in nursing and nurses working part-time, among other variables. County and island level data are especially important for Hawai‘i because as an island state, nurses cannot easily commute from county to county or state to state, as they can on the mainland.

The average RN in Hawai‘i is female and white.

Females have long dominated the nursing profession. In Hawai‘i, females make up 94 percent of the nursing workforce despite the fact that they make up only 49 percent of the population. However, new nursing school enrollments show a trend toward recruiting more males. Males comprised 12 percent of Hawai‘i Pacific University’s recent enrollment and 20 percent of the University of Hawai‘i at Ma¯noa’s enrollment. Ethnicity also presents a workforce disparity with 48 percent of Hawai‘i’s nurses identified as caucasian although caucasians make up only 25 percent of Hawai‘i’s population (Figure 7).¹¹

Figure 5
Supply of Registered Nurses Licensed in Hawai‘i, 1980–2003.

Source: Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.

Figure 6
Ratio of Registered Nurses per 50,000 Residents by Hawai‘i County, 2004.

Source: RN supply source is personal communication with the State of Hawai‘i, Board of Nursing, June 2004. County population source is US Census Bureau, “Hawai‘i Quick Facts,” 2003, http://quickfacts.census.gov/qfd/states/15000.html (16 January 2004).

Between 2002-2012, RNs will experience the largest job growth of any occupation.

Between 2002 and 2012, RNs for the first time are expected to have the largest job growth of any occupation, according to the US Bureau of Labor Statistics. This demonstrates the magnitude of RN growth relative to other occupations considered to be in high demand (Figure 8). Furthermore, among health care providers in Hawai‘i, RN job growth between 2000–2010 is more than three times greater than any other health occupation including physicians and nursing aides (Figure 9).¹²

RN rate of job growth will be greatest in home health and nursing homes, however demand will remain greatest in hospitals. Between 2000–2020, home health will have the greatest rate of RN job growth, followed by nursing homes (Figure 10). These increases can be directly attributed to an aging society and a trend toward earlier hospital discharges.¹³ During the same period, hospitals will continue to be the primary work setting for RNs, employing about 60 percent of all RNs, followed by nursing homes and home health respectively (Figure 11).¹⁴

Figure 7
Ethnic Distribution of Registered Nurses in Hawai‘i, 2001.

Source: B.M. Kooker, C. Winters-Moorhead, M. Acosta, and S. Hobbs, “Nursing Workforce Supply Data Trends in Hawai‘i,” Hawai‘i Medical Journal 62 (2003): 193–197.

Figure 8
Top Five Job Occupations in the US by Projected Job Growth, 2002–2012.

Source: Bureau of Labor Statistics, US Department of Labor, “Occupational Employment Projections to 2012,” February 2004, http://www.bls.gov/opub/mlr/2004/02/art5full.pdf (16 January 2004).

Figure 9
Average Annual Job Openings for Health Professions in Hawai‘i, 2000–2010.

Source: State of Hawai‘i, Department of Labor and Industrial Relations, Average Annual and Total Job Openings, 2000–2010 (Honolulu, HI: State of Hawai‘i Department of Labor and Industrial Relations).

Figure 10
Percent Increase in FTE Nurse Demand Nationally by Employment Setting, 2000–2020

Source: Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Changing Demographics: Implications for Physicians, Nurses, and Other Health Workers,” 2003, http://bhpr.hrsa.gov/healthworkforce/reports/changedemo/default.htm (16 January 2004).

Figure 11
Percentage Distribution of RNs by Employment Setting Nationally, 2000, 2010, 2020

Source: Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Projected Supply, Demand, and Shortages of Registered Nurses: 2000–2020. Hawai‘i Revisited,” April 2003, http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/ (16 January 2004).

Hawai‘i’s hospitals and nursing homes are experiencing high vacancy and turnover rates.

Vacancy rates are commonly used to indicate the presence and severity of a nursing shortage. Economists consider a shortage to be present when vacancy rates exceed 5–6 percent over an extended period of time.¹⁵ In 2002, RN vacancy rates in Hawai‘i’s nursing homes were an estimated 8 percent. This is low compared to nearly 47 states reporting rates exceeding 10 percent, 25 of which report rates 15 percent and higher.¹⁶ While vacancy rates for hospitals in Hawai‘i are not available, the rate for the Western region of the country averaged 12 percent in 2000, the highest in the country. Critical care nurse vacancies were highest followed by medical/surgical and emergency room nurses.¹⁷

Nurses in hospitals and nursing homes often cope with high vacancy rates and high turnover rates simultaneously. In 2002, Hawai‘i’s nursing homes reported an estimated RN turnover rate of 39 percent. Ten states reported turnover rates in excess of 60 percent.¹⁸ Nationally, RN turnover in hospitals was 21 percent in 2000.¹⁹

¹Full-time equivalent (FTE) is a measure of the number of RNs demanded or supplied assuming everyone worked full-time, therefore it understates the number of RNs because some RNs do not work full-time.
²Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Projected Supply, Demand, and Shortages of Registered Nurses: 2000–2020. Hawai‘i Revisited,” April 2003, http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/ (16 January 2004).
³B.M. Kooker, C. Winters-Moorhead, M. Acosta, and S. Hobbs, “Nursing Workforce Supply Data Trends in Hawai‘i,” Hawai‘i Medical Journal 62 (2003): 193–197.
⁴Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.
⁵Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses,” March 2000, http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/default.htm (16 January 2004).
⁶J. Sochalski, “Nursing Shortage Redux: Turning the Corner on an Enduring Problem,” Health Affairs 221, no.5 (2002): 157–164.
⁷ 7Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses,” March 2000, http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/default.htm (16 January 2004).
⁸Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.
⁹Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses,” March 2000, http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/default.htm (16 January 2004).
¹⁰Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.
¹¹B.M. Kooker, C. Winters-Moorhead, M. Acosta, and S. Hobbs, “Nursing Workforce Supply Data Trends in Hawai‘i,” Hawai‘i Medical Journal 62 (2003): 193–197.
¹²Bureau of Labor Statistics, US Department of Labor, “Occupational Employment Projections to 2012,” 2004 February, http://www.bls.gov/opub/mlr/2004/02/art5full.pdf (16 January 2004).
¹³Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Changing Demographics: Implications for physicians, nurses, and other health workers,” 2003, http://bhpr.hrsa.gov/healthworkforce/reports/changedemo/default.htm (16 January 2004).
¹⁴Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, “Projected Supply, Demand, and Shortages of Registered Nurses: 2000–2020. Hawai‘i Revisited,” April 2003, http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/ (16 January 2004).
¹⁵P. Prescott, “The Enigmatic Nursing Workforce,” Journal of Nursing Administration 30, no.2 (2000): 59–65.
¹⁶American Health Care Association, Health Services Research and Evaluation, “Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes,” February 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf (16 January 2004).
¹⁷American Organization of Nurse Executives, “Acute Care Hospital Survey of RN Vacancy and Turnover Rates in 2000,” 2002, http://www.wha.org/workForce/pdf/aone-surveyrnvacancy.pdf (16 January 2004).
¹⁸American Health Care Association, Health Services Research and Evaluation, “Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes,” February 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf (16 January 2004).
¹⁹American Organization of Nurse Executives, “Acute Care Hospital Survey of RN Vacancy and Turnover Rates in 2000,” 2002, http://www.wha.org/workForce/pdf/aone-surveyrnvacancy.pdf (16 January 2004).