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2005 - 2006
Nursing Education & Practice
Hawaii's Health in the
Balance: A Report on the
State of the Nursing Workforce

Hawaii State Center for Nursing

2528 McCarthy Mall
Webster Hall 432
Honolulu, Hawaii 96822 - Map -

Ph: (808) 956-5211
Fax: (808) 956-3257


Nursing Education and Practice:
Building Partnerships to Ensure a Stable Nursing Workforce in Hawai’i

(download pdf file)

Introduction | Nursing Workforce Shortage | Opportunities & Challenge

Strategies | Partnership | Summary & References | Summit Planning Group

Spotlight on UH System


A Nursing Shortage in an Increasingly Complex Healthcare Environment Significant advances in biomedical science and in the complexity of health care, coupled with a worsening nursing shortage and numerous reports of unsafe and inadequate patient care, are challenging both nursing education and nursing practice to look for innovative approaches to increase and maintain a qualified and competent nursing workforce (Health Care’s Human Crisis:The American Nursing Shortage, Kimball, 2002; Cultural Transformation in Healthcare, Kimball, 2005; Long, 2004; Designing the 21st Century Hospital, Robert Wood Johnson Foundation, 2005).


A number of nursing shortages have occurred in the past. However, as Berliner and Ginzberg (2002) point out previous nursing shortages resulted from a mismatch between the demands of the market and the difficulties healthcare organizations encountered in raising wages and the willingness of new graduates to work for those wages. Today’s nursing workforce problems are more complex and driven by fundamental demographic changes. Of these, there are three separate, but related, demographic changes occurring; a decline in the number of new nurses entering the workforce, high turnover (55% to 61%) rates of new nurses changing jobs, and an aging nursing workforce that is retiring or leaving the workforce early (Casey et al., 2004; Roche et al., 2004).


These shifts are happening at a time when the population is aging and the demand in all sectors of healthcare is increasing. The 76 million strong baby-boom generation now ranges in age from 40 to 59, and already shows signs of stressing the resources of our healthcare system. Over the next thirty years, this generation will require significant amounts of healthcare for chronic diseases (such as cardiovascular diseases and stroke; diabetes; respiratory diseases; cancer), acute illnesses (heart attack), and end-oflife care. In addition, the chronic disease burden, and need for care, is increasing for people of all ages. Changes in the approach to the delivery of healthcare are impacting nursing demand. Many conditions that required hospitalization in the past are treated in the ambulatory care setting. Consequently, people admitted to hospitals today are much sicker than people in hospitals fifteen years ago; their care is technology intensive, complex and demanding. People are discharged from hospitals when they are still very ill, with recovery occurring in nursing homes or at home.


Nationally, registered nurses (RNs) are the largest licensed healthcare professional group with 83.2 percent (an estimated 2,421,461 RNs) employed in 2004 (Health Resources and Services Administration, 2004). The number of RNs with an associate degree increased from 19 percent (308,616 nurses) in 1980 to 42.2 percent (1,227,256) of the workforce in 2004. For RNs who completed their initial education in a baccalaureate degree program, the estimated figures indicate an increase from 17.3 percent (287,993) in 1980 to 30.5 percent (887,223) in 2004. In addition, an estimated 0.5 percent of RNs in 2004 (15,511) had received their initial nursing education through a master’s or doctoral degree program (Health Resources and Services Administration, 2004).


The supply of nurses is dependent upon the number of new nursing graduates entering the profession, and the number of existing nurses remaining in the profession. While over 92% of registered nurses are women the increase in occupations open to women has resulted in both fewer young women entering nursing than in the past, and many nurses leaving the profession for career opportunities that are less physically / emotionally demanding and provide better salaries. The result is a declining supply of nurses in the United States. In March 2004, the National Sample Survey of Registered Nurses (NSSRN) identifies that the national average age of the registered nurse population was estimated to be 46.8 years, more than 4 years greater than in 1996 when the average age was 42.3 years (Health Resources and Services Administration, 2004). Those who educate new nurses, nursing faculty, have an average age of 46.8, but more concerning is that the highest educated nurses, those with doctorates in nursing or related fields average 55.7 years (Health Resources and Services Administration, 2004) Even if there is an increase in the number of young people seeking to become nurses, we cannot increase current production without increasing nursing faculty.


The Association of American Colleges of Nursing (AACN) 2003 white paper “Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Supply” reports that according to projections from the Bureau of Labor Statistics (BLS), there will be more than one million vacant positions for RNs by 2010 due to growth in demand for nursing care and net replacements due to retirement (Hecker, 2001). Data from the 2000 National Sample Survey of Registered Nurses (NSSRN) estimated that 39 percent of RNs employed in nursing held baccalaureate or master's degrees in nursing (Spratley, Johnson, Sochalski, et al., 2001). The 2004 NSSRN Survey indicates these estimates have risen slightly to 41 percent. Therefore, one can postulate that at least 410,000 of the vacancies projected by the BLS will be for RNs with baccalaureate or master's nursing degrees, which translates into the need for large numbers of well-prepared faculty to educate these new nurses. In addition, US high schools will graduate the largest class in history in 2007-2008 a projected 3.2 million graduates (Western Interstate Commission for Higher Education, 1998). Even if enrollment demand in nursing increases only modestly, will sufficient numbers of nursing faculty be available to teach these students?


Hawaii’s Healthcare Industry & Nursing Workforce Shortage


Hawaii’s healthcare industry is the second largest private industry and the health services sector (i.e., providers, clinics, hospitals, and nursing facilities) provided more than $3 billion toward the state gross product in 2003 (Healthcare Association of Hawaii, 2005). Healthcare Association of Hawaii (HAH) identifies that Hawaii's healthcare industry employed more than 40,000 individuals in 2003 and paid out more than $1.6 billion in wages. Out of those employed, registered nurses (RNs) make up the largest licensed healthcare professional group. ‘Hawaii’s Health in the Balance: A Report on the State of the Nursing Workforce’ identifies there is currently an estimated shortfall of 1,518 RNs in Hawaii (Raynor et al. 2004). This shortfall is projected to rise to 2,267 RNs by 2010. Employer demand for RNs between 2002 and 2012 is expected to increase by 24 percent. However, the supply of RNs is expected to grow only by about 10 percent and by 2012, 3,500 registered nurses will be required to fill new positions (53% of job openings) and replace those RNs retiring (47% of job openings) (Hawaii Department of Labor and Industrial Relations, 2006). In 2003, nursing programs graduated a total of 330 students and forecasts indicate if graduation rates do not increase dramatically there will not be enough new graduates to replace retiring nurses and meet the growing employer demand.


As the gap widens between supply and demand of RNs, employers will find it increasingly difficult to fill vacant positions and some positions will remain vacant for extended periods. As seen in other healthcare delivery settings across the country where positions remain vacant the employer response may be to continue to provide services with fewer RNs threatening the quality of care and/or reducing access to care by delaying or discontinuing services. Thus, the growing nursing shortage is expected to have a significant negative impact not only on our local population requiring healthcare services but also on people from Asian and Pacific Rim countries coming to Hawaii expecting to receive the most contemporary medical treatments, restorative and rehabilitative care, procedures and services.


Hawaii’s Efforts to Address the Nursing Workforce Shortage: A Catalyst Bringing Together Education & Practice


In 2003, the Hawaii State Legislature established the Hawaii State Center for Nursing (HCSFN) (Act 198, HB 422) in an effort to address the nursing shortage. The Center is one of a number of State Nursing Workforce Centers (Michigan Center for Nursing, New Jersey Collaborating Center for Nursing, North Carolina Center for Nursing, Oregon Center for Nursing, Tennessee Center for Nursing, Inc., Washington Center for Nursing, New Mexico Center for Nursing Excellence, and Mississippi Office of Nursing Workforce) that serves as a catalyst for the implementation of innovative education and practice models by bringing together individuals at the state and local levels, nursing leaders, educators and healthcare organizations to strategically address nursing workforce issues at the grass roots level (see Robert Wood Johnson Foundation Charting Nursing’s Future, Nov. 2005).


The Center’s efforts build upon previous work begun in 1996 when Hawaii was one of 20 sites nationwide to receive funding from the Robert Wood Johnson Foundation for the initiative, ‘Community Initiative on Nursing in Hawaii’ (CINH) and has resulted in ongoing work to forecast the supply of nurses for our state. The efforts of the many individuals involved in the work of CINH have resulted in a solid foundation for the Center which is positioned to become a powerful catalyst for change. The functions of the Center include collect, analyze data, prepare, and disseminate written reports and recommendations regarding the current and future status and trends of the nursing workforce; conduct research on best practices and quality outcomes; develop plans for implementing strategies to recruit and retain nurses; and research, analyze, and report data related to the retention of the nursing workforce.


As the hub of statewide strategic planning and data collection, the Center supports proactive workforce planning; fosters recruitment initiatives; and evaluates and disseminates strategies that will lead to higher levels of job satisfaction and improved retention among nurses. The Center will build coalitions across the broad spectrum of stakeholders in our state and will facilitate the efforts of the many individuals and groups already involved.


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