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

III. Factors Influencing RN Supply and Demand

a. An Aging Population: The New Variable

Hawai‘i’s population is projected to grow 33 percent between 2000 and 2020—one of the top 5 fastest growing in the nation.²⁰ This unprecedented demographic shift is the overarching factor fueling today’s nursing shortage. Largely attributable to a spike in post-World War II births, known as the “baby boom,” this unprecedented increase in older adults can be seen in most developed and many developing countries throughout the world.²¹ In 2011, the first baby boomers will turn 65 and by 2030 all baby boomers will have aged into the 65 years and 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. Moreover, the so-called oldest old in Hawai‘i, people age 85 and older, will increase even more dramatically by 121 percent (Figure 12). By 2020, 1 out of every 4 people living in Hawai‘i will be 60 years or older and 1 out of every 35 people will be age 85 years or older.²²

Five phenomena, with implications for the nursing workforce, are expected to emerge from this unprecedented demographic shift: (1) demand for health care and long-term care services will increase, (2) the nursing workforce itself will rapidly age into retirement, (3) health care will face greater competition as it recruits future nurses from a smaller workforce pie, (4) informal caregiver support may diminish, giving way to increased demand for formal (paid) long-term care services, and (5) a smaller tax base may force health care financing changes that reduce demand for RNs.

Figure 12
Hawai‘i Population 60 years Old and Older as a Percentage of Total Population, Selected Years, 1980–2020.

Source: Executive Office on Aging, State of Hawai‘i, “Profile of Hawai‘i’s older adults,” May 2003, http://www2.state.hi.us/eoa/information/stats/profile2003.pdf (16 January 2004).

(1) Increased demand for health care and long-term care services: Use of healthcare services increases with age due to greater incidence of chronic disease and disability. Persons age 65 and older currently use 23 percent of the nation’s ambulatory care visits, 48 percent of hospital days, 69 percent of home health visits, and 83 percent of nursing home visits.²³ As Hawai‘i ages, demand for health and long-term care services is expected to increase, triggering heightened demand for RNs.

(2) Mass retirements among current nurses: A 2001 Hawai‘i survey shows that nearly 80 percent of the current nursing workforce plans to retire within the next 20 years, at a time when their experience and knowledge will be most needed.²⁴ The workforce gap left by retiring nurses is exacerbated by a trend towards older nursing graduates, limiting new nurses’ “work life.” Currently, the average nursing graduate is about 31 years old.²⁵ These trends can be explained, in part, by a dramatic decline in the number of young women interested in nursing as a career over the last two decades, likely due to expanding career options for women.²⁶ However, these trends appear to be changing. Nursing school enrollments in 2003 were up 16.6 percent over the previous year according to a national survey, indicating renewed interest in nursing as a career.²⁷

(3) Greater competition for a smaller workforce: America as a whole is expected to see a downturn in labor growth over the next 20 years as baby boomers reach retirement age and a smaller cohort of workers is available to replace them. Between 2000 and 2020, the labor force in America is expected to grow by only 16 percent, a marked decrease from the 50 percent growth experienced between 1980 and 2000. Furthermore, this small margin of growth is expected to rely solely on people aged 55 or over and immigrants, with no new labor growth expected among American born persons age 25 to 54.²⁸ Health care providers can expect increased competition from all industries as they recruit future nurses from a shrinking workforce pie.

(4) Reduced reliance on informal caregiving: Long-term care is predominantly provided not by nursing homes and home care services but by unpaid family members, also known as informal caregivers. Fourteen-percent of all adults in Hawai‘i are informal caregivers.²⁹ Informal caregivers help with bathing, eating, dressing, using the toilet, transportation, and other every day activities that persons with chronic illness and disability cannot manage by themselves.³⁰ As society ages, demand for long-term care, and thus informal caregivers, is expected to rise. At the same time, fewer family members may be available to provide care because: (1) baby boomers had fewer children than their parents (3.7 children in the mid-1950s compared to 1.7 in the mid-1970s), (2) baby boomers have higher divorce rates than their parents and children of divorced parents are less likely to provide care for their parents, and (3) women, who provide the bulk of informal care, are more likely to be working than they were 20 years ago and have less time to provide care. Compared to the nation as a whole, Hawai‘i baby boomers have fewer children, higher rates of divorce and remarriage, and women are more likely to work.³¹ Nationally, with over 78 percent of long-term care recipients relying exclusively on informal care, even a modest downturn in family caregiving is likely to result in a surge in demand for paid long-term care services and an increase in demand for RNs to help provide these services.³²

(5) Changes in healthcare financing: Medicare and Medicaid are the primary payors of health and long-term care services for older adults. As society ages, these public programs are expected to face increased demand and subsequently increased cost. At the same time, increasing costs will rely on the contributions of a smaller tax base. It is projected that by 2005, the ratio of workers to retirees will be 5:1, falling to 2.75:1 by 2050. Some observers believe that these lower “dependency ratios” will not sustain current health service reimbursement rates and consequently will result in reduced benefits, narrowed eligibility for services, increased out-of-pocket costs for beneficiaries, and reduced reimbursement to health care providers.³³ In response, consumers may limit health care consumption if it becomes cost prohibitive and providers may ration or discontinue some services because they cannot afford to operate at lower reimbursement. The implication is that demand for RNs may be diminished, however there is no evidence that such changes would end the nursing shortage.

b. Nursing School Capacity

Nursing educators are the gateway to the “nursing pipeline.” Imagine if future nurses apply to a nursing program, but are turned away because the program does not have sufficient capacity to enroll them. Now, imagine this scenario during a nursing shortage and the danger of inadequate nursing education capacity is clear. This scenario is playing out in Hawai‘i today, with 293 qualified nursing applicants turned away in 2003 because schools did not have the capacity to enroll them.³⁴ Notably, the number of applicants turned away is equal to 90 percent of the number of nursing students graduated in 2003. Key factors to consider when assessing nursing education capacity include: (1) supply of qualified faculty willing to work as educators, (2) adequacy of clinical sites to provide meaningful practice opportunities for students, and (3) curricula and pedagogies needed to prepare future nurses to meet the population’s dynamic health needs.

(1) Too few faculty: A recent survey shows that Hawai‘i nursing schools are turning away future nurses primarily because they do not have enough faculty. All of Hawai‘i’s public nursing schools reported needing more faculty to meet demand, but lacked the funds to add these positions. Hawai‘i’s two private schools did not report these needs, indicating greater flexibility to add faculty because they are privately funded. Furthermore, over the past 2 years, all of Hawai‘i’s nursing schools reported difficulty filling vacant faculty positions, primarily because salaries were too low, not because there was a shortage of qualified applicants. Nationally, a master’s prepared nurse can make an average of $80,697 working in a hospital, compared to $60,357 as nurse faculty.³⁵

Most nursing educators today, like clinical nurses, are nearing retirement age. Nationally, the average nursing educator is about 53 years of age and is expected to retire in 10 years. Low enrollment in graduate programs that prepare nurses to become educators, indicates that these faculty retirements may not be easily replaced. Without sufficient numbers of new nursing faculty to replace them, mass retirements will severely limit efforts to expand student enrollment and increase overall nursing supply.³⁶

(2) Shortage of clinical practice sites: According to the same survey, a shortage of clinical practice sites is the second leading barrier to enrolling qualified nursing school applicants in Hawai‘i, especially on O‘ahu and Hawai‘i.³⁷ Nursing students must have clinical experiences to hone their nursing skills, familiarize themselves with new technologies, and apply critical thinking skills. Anecdotal evidence suggests that health care providers, already experiencing the nursing shortage’s effects, are finding it difficult to provide clinical opportunities for students because staffing is too strained.

(3) Competency Mismatch: While a shortage of RNs is commonly defined by numbers of nurses, it can also be assessed by the ability of nurses to meet the population’s health care needs. Health care needs change and nursing schools respond by updating curricula and training methods to ensure education is current with practice. When education and practice do not correspond, a competency mismatch occurs. For example, changes in technology across all settings, especially hospitals and home health, require nurses to have new competencies to stay current. In Hawai‘i, new technologies are enabling children to be cared for at home, instead of institutions. However, providers report difficulty in recruiting nurses qualified to use these new technologies, creating a shortage of nurses for this specialty practice.

Unlike new technologies, which typically have consequences for a specific practice setting, a rapidly aging population represents an overarching shift in the population’s health care needs and has implications for nearly all health care settings. As Hawai‘i’s population ages, health care providers will care for an increasing number of older adults, requiring nurses to have basic competency in geriatrics. Geriatrics is a cross-cutting competency, important for nearly every nursing specialty from intensive care units to psychiatric wards to home health to public health, not just nursing homes.

Health care needs of older adults are significantly different than younger adults. “The average 75-year-old person has three chronic medical conditions and regularly uses about 5 prescription drugs, as well as multiple over-the-counter drugs.” Memory loss, depression, incontinence, disability, differences in the way symptoms of disease present, changes in the body’s absorption of medications, all can add layers of complexity to caring for older adults.³⁸ Research is beginning to confirm the importance of geriatric training for quality of care. One study finds that patients cared for by nurses trained in geriatrics are less likely to be restrained, have fewer hospital admissions, and are less likely to be inappropriately transferred to a hospital.³⁹

Yet, while the need to develop nursing competency in geriatrics is clear, what remains to be defined is how best to get there from here. For example, while all US nursing schools require a pediatrics rotation, similar consensus has not been reached for geriatrics. In Hawai‘i, a stand-alone geriatrics course is offered in only two of eight nursing schools, while others integrate geriatrics into adult health curricula.⁴⁰ These low numbers are not surprising, given that in 2000 only 23 percent of the country’s baccalaureate nursing programs required students to take a nursing geriatrics course. In 1999, only 4 percent of nursing programs met the gold-standard for geriatric nursing education which includes a stand-alone geriatric nursing course, multiple clinical practice opportunities in geriatrics, and at least one full-time faculty member certified in geriatrics.⁴¹

c. Work Environment for Nurses

According to a 2002 report by the American Hospital Association, “most health care workers entered their professions to ‘make a difference’ through personal interaction with people in need. Today, many in direct patient care feel tired and burned out from a stressful, often understaffed environment, with little or no time to experience one-on-one caring.”⁴² A recent national survey of RNs confirms this observation reporting that just 69.5 percent of all RNs are satisfied with their job and that male nurses are less satisfied than female nurses. According to the report, nurses working in hospitals and nursing homes are the least satisfied with only 67 and 65 percent reporting satisfaction, respectively. Nurse satisfaction levels are low compared with 85 percent of all workers and 90 percent of professional workers who express satisfaction with their job.⁴³

Concerns commonly associated with nursing dissatisfaction include: (1) inadequate staffing to perform work, (2) heavy workloads, (3) increased overtime, and (4) lack of sufficient support staff.44 In a large survey of RNs working in acute hospitals in Pennsylvania, only 33 percent of nurses reported there were enough RNs to provide quality care and enough staff to get the work done, only 29 percent reported that their administration listened and responded to nurses’ concerns, and only 43 percent reported they had enough support staff. Twenty-two percent reported they planned to leave their job in the next year while 33 percent of nurses age 30 or younger planned to leave.⁴⁵ A 2000 national survey of RNs found 45 percent of RNs who left nursing for another occupation did so, in part, because they find their current position more professionally rewarding.⁴⁶

Efforts to improve working conditions for nurses may not only help retain employed nurses but also encourage nurses not working in nursing to re-enter the workforce and build interest in nursing as a career choice.⁴⁷

d. Foreign Nurse Migration

Easing the nursing shortage is not only a factor of how many new nurses can be introduced into the workforce, but also how fast they can be introduced. Nursing’s response to increased demand is less elastic than other occupations because it usually takes 3 to 4 years to complete basic nursing education. Over the past 50 years, providers have weathered this lag effect by recruiting foreign nurses (nurses who received their basic nurse training outside of the US) to bolster the workforce while it is adjusting to market forces. However, recent evidence suggests that providers are now relying on this foreign pool even in times of nursing surplus. During 1988, the last major nursing shortage, the US licensed 3.7 foreign nurses per every 100 US-trained nurses. By 1996, a time of relative nursing surplus, this ratio increased to 5.1 foreign-trained nurses per every 100 US-trained.⁴⁸ Hawai‘i depends heavily on foreign nurses who comprise an estimated 25 percent of the nursing workforce,⁴⁹ compared with only 5.1 percent nationally.⁵⁰

The US affords foreign nurses better pay, educational opportunities, and practice environments. For example, in the Philippines a nurse makes about $2,400 annually, far less than what could be earned in America. Filipinos continue to dominate the foreign nurse population at 52 percent, followed by nurses from Canada and Korea. Recruitment also targets nurses in sub-Saharan Africa, Southeast Asia, and the Caribbean.⁵¹

It is not clear how sustainable foreign RN importation will be in the midst of a global nursing shortage. US recruiters will face increased competition from other countries with nursing shortages, such as the United Kingdom and Ireland. Furthermore, host countries themselves are forecasting nursing shortages. Many host countries have fragile health care systems that could be dismantled by nurse exportation. For example, the Philippines, which is the primary exporter to the US, reportedly has 30,000 unfilled nursing positions.⁵² Recruiting foreign nurses therefore 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.

e. Wages and Market Dynamics

Past nursing shortages have generally relied on market dynamics alone to bring the workforce back into balance. Employers raised wages, and without other systematic interventions, the nursing shortage abated. Today, most observers believe that wage increases alone will not resolve the current shortage because the expected magnitude and duration of the shortage is too great.⁵³ These observers argue that instead of focusing on wages alone, concomitant measures are needed. Others, while agreeing with this point contend that the shortage cannot be resolved without at least some attention to wages.

Wage enhancements have typically been used to increase supply by luring part-time workers into full-time work, and to a lesser degree by increasing nursing school enrollments. However, it is not clear to what extent wage enhancements prevent nurses from leaving for more lucrative occupations. For example, a recent national survey found that only 18 percent of nurses who were considering leaving nursing wanted more money.⁵⁴ However, a 2000 national sample survey of nurses found that wages played a more important role with 35 percent of RNs leaving nursing, in part, because of wages.⁵⁵

Today, there is already some evidence that employers are responding to the shortage by increasing wages. Nationally, growth in median RN earnings (adjusting for inflation) remained flat throughout the 1990s, but increased by 13 percent between 1997 and 2001. Likewise, entry wages for RNs increased 5.7 percent between 2000 and 2002. As employers consider the efficacy of economic interventions, it is interesting to assess the feasibility of this option by examining just how high wages would have to go to ease the shortage. 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 2020.⁵⁶ This would more than double RN labor costs. In Hawai‘i, this would mean an increase in average annual RN salary from $58,490⁵⁷ today to between $90,000 and almost $99,000 by 2020. It is unlikely that salary increases would be sustainable at these levels.

f. Direct Care Worker Shortage

There is no substitute for a RN. However, RNs routinely delegate nursing tasks to direct care workers.⁵⁸ Direct care workers, also known as paraprofessionals, are those nursing aides, home care aides, orderlies, personal care aides, and attendants that provide direct care in hospitals, nursing homes, private homes, and out-patient settings. They take vital signs such as blood pressure, help people with physical disabilities carry out activities of daily living like bathing, and provide emotional support to millions of older adults and younger persons with chronic illness and disability. Across all health care settings, direct care workers support RNs, especially in long-term care settings where direct care workers provide 8 out of every 10 nursing home hours of care and every hour of non-skilled nursing service in home care.⁵⁹

Evidence suggests that the direct care workforce is in crisis. Long plagued by limited training, physical and emotionally taxing work, low pay, and flat career growth, direct care workers have high turnover and vacancies rates. Nationally, nursing homes report nursing assistant turnover rates ranging from 45 percent to 105 percent, while home health rates are significantly lower at 10 percent.⁶⁰ In 2002, turnover rates for nursing assistants were an estimated 21 percent in Hawai‘i nursing homes.⁶¹ In a 2003 survey of state Medicaid agencies, Hawai‘i reported that the shortage of direct care workers is a “serious workforce issue.”⁶² Without enough direct care workers, RNs have to absorb these tasks as part of their workload, increasing overall demand for RNs.

g. The Role of State Policymakers

State policymakers play an integral role in shaping nursing in Hawai‘i. Supply and demand for nurses is greatly influenced by policymakers’ role in: (1) supporting higher education, (2) reimbursing health care services, (3) regulating health care services, and (4) establishing workforce development programs and policies.⁶³ Furthermore, policymakers are responsible for the health and welfare of citizens and are interested in the impact a nursing shortage has on the public’s health.

There are numerous ways in which states influence RN supply and demand and are not limited to the following examples. First, higher education relies on state support. Thus, inaction on the part of states to increase funding so nursing schools can expand student enrollment would limit nursing supply growth. In Hawai‘i such inaction would severely limit growth. Second, states control Medicaid reimbursement. Reducing Medicaid reimbursement rates may reduce demand for RNs. Third, states regulate private insurance. Mandating that health plans provide a new health service may increase demand for RNs.⁶⁴ Lastly, federal labor programs, such as the Workforce Investment Act, provide funds to states to address workforce shortages through training and development initiatives. Targeting these funds for nursing workforce development may bolster supply.⁶⁵

Increasingly, states are supporting the infrastructure needed to collect and analyze nursing workforce data and develop statewide nursing workforce development strategies. In 2003, state legislation established such an infrastructure with the Hawai‘i State Center for Nursing, housed within the University of Hawai‘i at Manoa School of Nursing and Dental Hygiene, heralding an important milestone for nursing’s future in Hawai‘i.

²⁰Bureau 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).
²¹US Census Bureau, Economics and Statistics Administration, US Department of Commerce and US National Institute on Aging, National Institutes of Health, US Department of Health and Humans Services, “An Aging World: 2001,” November 2001, http://www.census.gov/prod/2001pubs/p95-01-1.pdf (16 January 2004).
²²Executive Office on Aging, State of Hawai‘i, “Profile of Hawai‘i’s older adults,” May 2003, http://www2.state.hi.us/eoa/information/stats/profile2003.pdf (16 January 2004).
²³C.T. Kovner, M. Mezey, and C. Harrington, “Who Cares for Older Adults? Workforce Implications of an Aging Society,” Health Affairs 21, no.5 (2002): 78–89.
²⁴B.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.
²⁵Bureau 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).
²⁶P.I. Buerhaus, D.O. Staiger, and D.I. Auerbach, “Implications of an Aging Registered Nurse Workforce,” Journal of the American Medical Association 283, no.22 (2000): 2948–2954.
²⁷American Association of Colleges of Nursing, “Nursing Shortage Fact Sheet,” March 2004, http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm (16 January 2004).
²⁸D. Ellwood, Grow Faster Together or Grow Slowly Apart: How will America Work in the 21st Century? (New York, NY: The Aspen Institute Domestic Strategy Group, 2003).
²⁹Executive Office on Aging, State of Hawai‘i, “2002 Statewide Survey on Caregiving,” March 2003, http://www2.state.hi.us/eoa/pdf/Caregiving_Survey.pdf (16 January 2004)
³⁰Ibid.
³¹H.S. Karel, K. Braun, and V. Tanji, Baby Boomer Data: Hawai‘i 2000 (Honolulu, HI: State of Hawai‘i, Executive Office on Aging, 2000).
³²L. Thompson, Long-term Care: Support for Family Caregivers (Washington, DC: Georgetown University, Long-Term Care Financing Project, March 2004).
³³Bureau 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).
³⁴Hawaii Center for Nursing, 2004 Hawai‘i Nursing Education Survey (Honolulu, HI: University of Hawai‘i at Manoa School of Nursing and Dental Hygiene, unpublished).
³⁵American Association of Colleges of Nursing, Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding Supply,” May 2003, http://www.aacn.nche.edu/Publications/WhitePapers/TFFFWP.pdf (16 January 2004).
³⁶Ibid.
³⁷Hawai‘i Center for Nursing, 2004 Hawai‘i Nursing Education Survey (Honolulu, HI: University of Hawai‘i at Manoa School of Nursing and Dental Hygiene, unpublished).
³⁸Alliance for Aging Research. Medical Never-never Land: Ten Reasons Why America is Not Ready for the Coming Age Boom,” 2002, link (16 January 2004).
³⁹C.T. Kovner, M. Mezey, and C. Harrington, “Who Cares for Older Adults? Workforce Implications of an Aging Society,” Health Affairs 21, no.5 (2002): 78–89.
⁴⁰Personal communication with Hawai‘i nursing schools, June 2004.
⁴¹C.T. Kovner, M. Mezey, and C. Harrington, “Who Cares for Older Adults? Workforce Implications of an Aging Society,” Health Affairs 21, no.5 (2002): 78–89.
⁴²R. Steinbrook, “Nursing in the Crossfire,” New England Journal of Medicine 346, no. 22 (2002):1757–1766.
⁴³Page, A. Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington, DC: The National Academies Press, 2003).
⁴⁴Ibid.
⁴⁵R. Steinbrook, “Nursing in the Crossfire,” New England Journal of Medicine 346, no.22 (2002): 1757–1766.
⁴⁶Bureau 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).
⁴⁷A. Page, Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington, DC: The National Academies Press, 2003).
⁴⁸B.L. Brush, J. Sochalski, and A.M. Berger, “Imported Care: Recruiting Foreign Nurses to US Health Care Facilities,” Health Affairs 23, no. 3 (2004): 78–87.
⁴⁹Personal communication with the State of Hawai‘i, Board of Nursing, June 2004.
⁵⁰B.L. Brush, J. Sochalski, and A.M. Berger, “Imported Care: Recruiting Foreign Nurses to US Health Care Facilities,” Health Affairs 23, no. 3 (2004): 78–87.
⁵¹Ibid.
⁵²L.H. Aiken, J. Buchan, J. Sochalski, et al. “Trends in International Nurse Migration,” Health Affairs 23, no.33 (2004): 69–77.
⁵³C.S. Brewer, “The Roller Coaster Supply of Registered Nurses: Lessons From the Eighties,” Research in Nursing and Health 19 (1996): 345–357.
⁵⁴A. Page, Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington, DC: The National Academies Press, 2003).
⁵⁵J. Spetz, and R. Given, “The Future of the Nurse Shortage: Will Wage Increases Close the Gap?,” Health Affairs 22, no.6 (2003): 199–206.
⁵⁶Ibid.
⁵⁷Bureau of Labor Statistics, US Department of Labor. “Occupational Employment and Wages, 29-1111 Registered Nurses,” May 2003, http://www.bls.gov/news.release/pdf/ocwage.pdf (16 January 2004).
⁵⁸ P. Prescott, “The Enigmatic Nursing Workforce,” Journal of Nursing Administration 30, no.2 (2000): 59–65.
⁵⁹R.I. Stone, S.L. Dawson, and M. Harahan, Why Workforce Development Should be Part of the Long-term Care Quality Debate (Washington, DC: Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, October 2003).
⁶⁰R. Stone, and J. Wiener, Who Will Care for Us: Addressing the Long-Term Care Workforce Crisis (Washington, DC: Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, 2001).
⁶¹ American 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).
⁶²Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services, Office of Long-term Care, Results of the 2003 National Survey of State Initiatives on the Long-term Care Direct Care Workforce (Raleigh, NC: North Carolina Office of Long-term Care, March 2004).
⁶³E. Salsberg, Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Care (New York, NY: Milbank Memorial Fund, 2003).
⁶⁴Ibid.
⁶⁵C. Raynor, Federal Workforce Development Programs: A New Opportunity for Long-term Care Workers (Washington, DC: Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, 2003).