BACKGROUND

The problems facing registered nurses are longstanding. 7, 8 Registered nurses represent the largest single health care profession in the United States. People usually become registered nurses by completing an associate’s-degree program at a community college, a diploma program administered at a hospital, or a baccalaureate degree program at a college or university and then obtaining a state license. During the past 25 years, the number of diploma programs has sharply declined. A 2000 survey of registered nurses who had recently completed their initial nursing education showed that more than half had graduated from an associate’s-degree program and about two fifths from a baccalaureate program. 9 Licensed practical nurses account for about one quarter of the nurse work force. They typically have a high-school diploma and are trained in a one-year program at a technical or vocational school or a community or junior college. Every four years, the National Sample Survey of Registered Nurses provides a statistical snapshot of the profession. 9 In 2000, there were an estimated 2,694,540 persons with a license to practice as registered nurses in the United States. An estimated 82 percent were employed in nursing, and of these, 28 percent were working on a part-time basis. Of the registered nurses employed in nursing, 1,300,323 (59 percent) worked in hospitals. The unemployment rate for registered nurses was about 1 percent. 10 An estimated 95 percent of the nurses were women, 72 percent were married, and 87 percent were white. Their average age was 45 years. Thirty-four percent reported their highest level of education as an associate’s degree, 22 percent as graduation from a nursing diploma program, 33 percent as a bachelor’s degree, and 10 percent as a master’s or doctoral degree. Seven percent were practicing or prepared to practice in an advanced practice role, such as clinical nurse specialist, nurse anesthetist, nurse midwife, or nurse practitioner. Between 1983 and 2000, the staffing levels of registered nurses in hospitals increased by 37 percent (Fig. 1). The staffing levels of licensed practical nurses decreased by 46 percent. The average daily census of hospitalized patients fluctuated but decreased overall. Through 1993, the ratio of registered nurses to patients increased, but it may merely have kept pace with increases in the severity of patients’ conditions. 11 Although the ratio of registered nurses to hospitalized