Disparities Found in States' RNs per Capita

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By Debra Wood, RN, contributor

January 14, 2014 - Some states have twice as many registered nurses per capita than others, creating possible issues with access to care and quality.

Mary Lou Brunell: More RNs per capita improve access to care.
Mary Lou Brunell, RN, MSN, said more registered nurses improve the quality and access to care.

“There has always been a bit of a disparity,” said Mary Lou Brunell, RN, MSN, executive director of the Florida Center for Nursing in Orlando. “The reason for the variance is in the culture of the state and staffing patterns and care delivery models.”

Brunell explained that facilities in some states may depend more on support staff than registered nurses. Also, the health of the state’s population may become a factor, with healthier states needing fewer nurses. At 865 nurses per 100,000 population, Florida falls just below the national average of 874 nurses per 100,000.

Linda Tieman, RN, MN, FACHE, executive director of the Washington Center for Nursing in Tukwila, Wash., agreed that the state’s culture is a factor, and added that utilization can also affect the number of nurses per capita.

“You may have a different demand due to the model of care, how the care is delivered,” Tieman said.

There are fewer nurses in Washington State, with 798 nurses per 100,000 population, than the national average.

Sheila Burke: Even states with high RNs per capita could still use more.
Sheila Burke, RN, MSN, MBA, DNP, said there aren’t any states that have a glut of registered nurses.

“There isn’t any state that has a glut of RNs. What did happen is that market and health care changes drastically affected the local demand for RNs,” added Sheila Burke, RN, MSN, MBA, DNP, dean of Kaplan University School of Nursing. She offered as an example Michigan, which was hard hit during the economic decline. The number of people entering hospitals fell, as people delayed elective procedures. This caused nurses to be laid off or let go, and those RNs that may have been considering retirement chose to retain their positions for as long as possible. 

Additionally, Burke said, many medical centers chose to reduce the budget for RNs in an attempt to reduce or limit staff costs. Michigan falls slightly higher than average per capita at 908 nurses per 100,000 people.

The data 

The U.S. Census Bureau reports in 2011 that the District of Columbia had the most employed RNs per capita at 1,728 per 100,000, and Nevada the least per capita, 605 per 100,000. The District of Columbia also had the most nurses per capita in 2009, at 1,483, and Nevada the lowest at 609. The numbers include advanced practice nurses. Several states, including California, Oregon and Washington, fall below the national rate.

“Historically, the West Coast has had managed care for more than 50 years, has had lower average daily census, lower lengths of stay, and a greater emphasis on prevention and out-patient care, and this has resulted partially in fewer RNs per 100,000 working as nurses in those states,” Tieman said. “In addition, other parts of the United States are more heavily saturated with nursing schools, particularly pre-licensure baccalaureate programs. I think there’s some relationship to production and employment.”

Other states with the most number of registered nurses per capita in 2011 included South Dakota at 1,349, Massachusetts at 1,321, North Dakota at 1,310 and Rhode Island at 1,174.

At the other end of the spectrum is California with 664 RNs per 100,000 people, Georgia at 665, Utah at 678 and Arizona at 690.

Brunell expressed surprise at California being so low, since it has established nurse-to-patient ratios.

Diane Vines: Low nurses per capita rate in California is a concern.
Diane Vines, RN, PhD, expressed concern at the low number of nurses per capita in California, with some nurses leaving the state just when demand is likely to increase.

Diane Vines, RN, PhD, dean of nursing at Mount St. Mary’s College in Los Angeles, reported serious cuts in funding for publicly funded baccalaureate and associate degree programs, which has resulted in programs turning away students. Then many graduates leave the state for better employment opportunities.

“It is very alarming, and especially alarming in the non-urban areas,” Vines said.

Why are low concentrations of RNs a concern? 

“Not having a sufficient number of RNs can affect access to patient care, access to emergency departments and operating rooms sometimes, and the quality and safety of care,” Tieman said. “The evidence is compelling.”

Studies have shown that higher nursing hours per patient day improve outcomes, Brunell added. 

“The ratio of RNs in a hospital per patients affects the errors and number of falls and things that happen,” Vines said. “The quality of care is affected by the ratio of nurses to patients.”

Employment opportunities 

Lower concentration of nurses does not necessarily equate with more job opportunities.

Linda Tieman: Low nurses per capita rates can affect patient outcomes.
Linda Tieman, RN, MN, FACHE, said studies have shown that a low concentration of RNs can affect access to care and patient outcomes.

“It depends on the care delivery models in those states,” Tieman said, adding that where there are low numbers of RNs and RN positions, it could be harder to find a job.

Tieman reports new graduates in Washington are experiencing difficulty finding employment. That’s concerning, she said, because it leads to people not applying for nursing school, when the industry is going to need more nurses.

Vines also reported a decrease in the number of new graduate nurses being hired, as more employers seek experienced RNs. However, many opportunities exist, she said, in rural areas of California and in new roles, such as nurse navigators and care coordinators.

Each market has its set of characteristics and influencing factors, added Burke. Urban settings, with a number of facilities serving complex and difficult populations, may result in higher turnover, making it easier to get a position. Employers may be content with a higher nurse-to-patient ratio, she said.

“If the market has a fairly stable set of providers and the communities it serves are not seeking care for elective treatments or care of an illness, the reduced number of admissions may result in fewer RN openings,” Burke said.

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