Testimony

Before the Committee on Health, Education, Labor and

Pensions, U.S. Senate

United States General Accounting Office

GAO

For Release on Delivery

Expected at 9:30 am

Thursday, May 17, 2001 NURSING WORKFORCE

Recruitment and Retention

of Nurses and Nurse Aides

Is a Growing Concern

Statement of William J. Scanlon

Director, Health Care Issues

GAO-01-750T
Page 1 GAO-01-750T

Chairman Jeffords, Ranking Member Kennedy, and Members of the

Committee:

I am pleased to be here today as you discuss issues related to the current

recruitment and retention of nursing staff, including both nurses and nurse

aides, and concerns about the future supply of these workers. The health

and long-term care systems in the United States rely heavily on the

services of both nurses and nurse aides, the two largest groups of health

care workers. Considerable attention has been given to the nurse

workforce, and several witnesses recently testified before this committee’s

Subcommittee on Aging about nursing shortages throughout the country.

Very little attention, however, has been given to the characteristics and

supply of nurse aides, who provide most of the direct care for persons in

nursing homes and those receiving home health care services.

To assist the Congress as it considers a range of possible federal efforts to

ensure that consumers receive quality health and long-term care services,

you requested that we review current data on the nurse workforce and

examine in more detail the nurse aide workforce in hospitals, nursing

homes, and home health care. Accordingly, my remarks will focus on (1)

factors contributing to the current and anticipated shortage among nurses,

(2) what is known about the current and projected supply of nurse aides

and the factors contributing to the current and anticipated shortage, and

(3) government and private efforts to improve recruitment and retention of

nurse aides. In addition, you requested that we provide a detailed

demographic, employment, wage, and benefit profile of nurse aides in the

different employment settings. This information is presented in appendix I.

To provide information on the nurse workforce, we relied primarily on

published reports and data from the Department of Health and Human

Services’ (HHS) Health Resources and Services Administration (HRSA),

industry and professional associations, researchers, and other experts. To

develop information on the nurse aide workforce, we (1) analyzed recent

data from the Bureau of Labor Statistics’ (BLS) Current Population Survey

(CPS) and Occupational Employment Statistics (OES); (2) interviewed

experts, industry and professional association representatives, and federal

and state agency officials; and (3) conducted a review of the relevant

professional and research literature. We performed our work from January

through May 2001 in accordance with generally accepted government

auditing standards.
Page 2 GAO-01-750T

In summary, recruitment and retention of both nurses and nurse aides are

major concerns for health care providers. Experts and providers are

reporting a current shortage of nurses, partly as a result of patients’

increasingly complex care needs. While comprehensive data are lacking

on the nature and extent of the shortage, it is expected to become more

serious in the future as the aging of the population substantially increases

the demand for nurses. Moreover, several factors are combining to

constrain the current and future supply of nurses. Like the general

population, the nurse workforce is aging, and the average age of a

registered nurse (RN) increased from 37 years in 1983 to 42 in 1998.

Enrollments in nursing programs have declined over the past 5 years,

shrinking the pool of new workers to replace those who are retiring. In

addition, numerous studies report decreased levels of job satisfaction

among nurses, potentially leading to their pursuing other occupations.

Demographic changes over the coming decades may also worsen the

shortage of nurse aides in hospitals, nursing homes, and home health care

settings. With the aging of the population, demand for nurse aides is

expected to grow dramatically, while the supply of workers who have

traditionally filled these jobs will remain virtually unchanged. According to

the Institute of Medicine (IOM), advocacy groups, and provider

associations, a serious shortage of nurse aides already exists. Retention of

nurse aides is a significant problem for many providers, with some studies

reporting annual turnover rates for aides working in nursing homes

approaching 100 percent. Several factors contribute to providers’ difficulty

in both hiring and retaining nurse aides, including relatively low wages and

few benefits. In addition, research has found that the physical demands of

the work and other aspects of the workplace environment lead to

difficulties in retaining nurse aides. In 1999, 30 states indicated that they

were addressing nurse aide recruitment and retention through task forces,

initiatives, and research. The federal government and provider groups also

have begun to address this issue. However, few studies have evaluated the

effectiveness of these efforts.

RNs and licensed practical nurses (LPN) are responsible for a large

portion of the health care provided in this country. RNs make up the

largest group of health care providers, and, historically, have worked

predominantly in hospitals; a smaller number of RNs work in other

settings such as ambulatory care, home health care, and nursing homes.

(See table 1.) Their responsibilities may include providing direct patient

care in a hospital or a home health care setting, managing and directing

complex nursing care in an intensive care unit, or supervising the

Background
Page 3 GAO-01-750T

provision of long-term care in a nursing home. LPNs make up the secondlargest group of licensed health caregivers and primarily provide direct

patient care under the direction of a physician or RN. Nurse aides augment

the care nurses provide by performing routine duties of caring for hospital

patients or long-term care residents under the direction of an RN or LPN.1

Most nurse aides work in nursing homes, where they provide assistance

with activities of daily living such as dressing, feeding, and bathing.

Table 1: Number of RNs, LPNs, and Nurse Aides Working in Three Employment

Settings, 1999

Hospital Nursing home Home health care

RNs 1,280,510 150,230 108,310

LPNs 200,030 208,030 43,460

Nurse aides 388,280 695,570 344,200

Source: 1999 Employment and Wages for Selected Health Care Occupations and Industries, Bureau

of Labor Statistics (BLS), Occupational Employment Statistics (OES).

Both RNs and LPNs are subject to state licensing requirements. Individuals

usually select one of three ways to become an RN—through a 2-year

associate degree, 3-year diploma, or 4-year baccalaureate degree program.

LPN programs are 12 to 18 months in length and generally focus on basic

nursing skills such as monitoring patient or resident condition and

administering treatments and medications. Federal law requires states to

certify nurse aides who provide care in nursing homes and for home

health care agencies that receive Medicare and Medicaid reimbursement.2

This certification can be obtained through either a nurse aide training

program and a competency evaluation—a written or oral test and skills

demonstration—or competency evaluation alone. A state-approved nurse

aide training program must require a minimum of 75 hours of training,

including at least 16 hours of supervised practical training under the direct

supervision of an RN or LPN. Approximately half of the states require the

nursing aide training programs to go beyond the 75-hour minimum, with

several requiring over 120 hours.3

 Federal law also requires states to

 1

We use the term “nurse aide” to refer to all paraprofessional nursing staff working in

hospitals, nursing homes, or home health care.

2

42 U.S.C. Section 1395i-3 (b)(5)(A)(i)(I), 42 U.S.C. Section 1396r(b)(5)(A)(i)(I), and

Section 1395bbb(a)(3)(A)(i).

3

This information was obtained through interviews with state officials and a survey

conducted in Oct. 2000 by the Paraprofessional Healthcare Institute and the National

Citizens’ Coalition for Nursing Home Reform.
Page 4 GAO-01-750T

maintain a registry of nurse aides working in nursing homes who have

passed their competency evaluations; no such requirement exists for aides

working in home health care.4 For nurse aides working in hospitals, there

are no federal requirements related to certification, training, competency

evaluations, or a registry.

The nation’s health care providers are reporting a shortage of nurses in a

range of settings. Although comprehensive data are lacking to describe the

nature and extent of the current shortage, there is evidence of a growing

demand for nurses with skills to treat patients with complex care needs.

Furthermore, shortages can affect the quality of care. The shortage is

expected to worsen as the aging population increases demand and fewer

people enter the nurse workforce. Job dissatisfaction among nurses may

further reduce the strength of the nursing supply.

Providers and experts around the country have reported that the nation is

currently facing a shortage of nurses. There is a lack of comprehensive

national data to describe the full nature and extent of the shortage, but

several types of information point to an existing shortage. For example,

California reported an RN vacancy rate of 8.5 percent for all employers in

1997, with hospitals reporting a rate of 9.6 percent, nursing homes 6.9

percent, and home health care 6.4 percent. The Dallas-Fort Worth Hospital

Council reported vacancy rates for 2000 of 9.3 percent for RNs in

emergency departments and 16.9 percent for RNs in critical care units. A

recent survey of providers in Vermont found that nursing homes and home

health care agencies had RN vacancy rates of 15.9 percent and 9.8 percent,

respectively, while hospitals had an RN vacancy rate of 4.8 percent (up

from 1.2 percent in 1996).

An important factor in the current shortage is the higher proportion of

patients having more complex care needs, which increases the demand for

nurses with training for specialty areas such as critical care and

emergency departments. In addition, the increased use of technology in

care settings has increased the demand for a higher skill mix of RNs.

Furthermore, the expansion of care delivery settings—such as home

health care and community-based health care delivery systems—has

increased the job opportunities available and demand for these workers.

 4

42 U.S.C. Section 1395i-3 (e)(2)(A) and 42 U.S.C. Section 1396r(e)(2)(A).

Demographic and Job

Satisfaction Factors

Could Worsen

Shortage of Nurses

Current Nurse Shortage Is

Due to Several Factors
Page 5 GAO-01-750T

A nursing shortage may have serious implications for the quality of patient

care. A recent HRSA study found a relationship between higher RN

staffing levels and the reduction of certain negative hospital inpatient

outcomes, such as urinary tract infection and pneumonia.5

 Furthermore, a

recent Health Care Financing Administration (HCFA) report to Congress

found a direct relationship between nurse staffing levels in nursing homes

and the quality of resident care. HCFA’s analysis of three states’ data

demonstrated that, after controlling for case mix, there is a minimum

nurse staffing threshold below which quality of care may be seriously

impaired.6

 However, 23 percent of the facilities in the three states were not

staffing at the combined RN and LPN minimum staffing threshold level,

and 31 percent of the facilities were not staffing at the RN minimum

staffing threshold level.7

The nursing shortage is expected to worsen in the future, with pressures

expected on both demand and supply. The future demand for nurses is

expected to increase dramatically when the baby boomers reach their 60s,

70s, and beyond. The population aged 65 years and older will double from

2000 to 2030. Moreover, the population aged 85 and older is the fastest

growing age group in the U.S. At the same time, the number of persons

who have traditionally worked in the nursing workforce—women between

25 and 54 years of age—is expected to remain relatively unchanged over

the period from 2000 to 2030.8

 Over the past decade, the nurse workforce’s

average age has climbed steadily, while fewer young persons are choosing

to enter the nursing profession. The average age of the RN population in

2000 was 45, almost 1 year older than the average in 1996. While over half

(52 percent) of all RNs were reported to be under the age of 40 in 1980,

 5

Harvard School of Public Health, Vanderbilt University School of Nursing, and Abt

Associates, Nurse Staffing and Patient Outcomes in Hospitals, contract No. 230-99-0021,

HRSA (Washington, D.C.: HHS, 2001).

6

The states included in the analysis were New York, Ohio, and Texas for calendar years

1996 and 1997. The minimum staffing threshold for RNs and LPNs combined was 0.75

hours per resident day. For RNs alone, the minimum staffing threshold level was 0.20 hours

per resident day.

7

Phase II of the HCFA Study is currently under way to analyze additional states’ data to

identify alternative minimum thresholds and optimal case-mix adjusters and to assess

relative costs and benefits of such thresholds. According to HCFA officials, more research

will be required to assess the feasibility of implementing minimum ratio requirements.

8

Few men currently work in nursing. As of 2000, only 5.9 percent of RNs employed in

nursing were men.

The Nursing Shortage Is

Likely to Worsen
Page 6 GAO-01-750T

fewer than one in three were younger than 40 in 2000. During the same

period, the percentage of nurses under age 30 dropped from 25 to 9

percent. As shown in figure 1, the age distribution of RNs has shifted

dramatically upward. The number of nurses aged 25 to 29 decreased from

about 296,000 in 1980 to about 177,000 in 2000, while the number aged 45

to 49 grew from about 153,000 to about 465,000.

Figure 1: Age Distribution of the Registered Nurse Population, 1980 and 2000

Source: HRSA, The Registered Nurse Population: National Sample Survey of Registered Nurses,

March 2000.

The total number of licensed RNs increased 5.4 percent between 1996 and

2000—the lowest increase ever reported in HRSA’s periodic survey of

RNs.9

 Nursing program enrollments further indicate a narrowing of the

 9

HRSA, The Registered Nurse Population: National Sample Survey of Registered Nurses,

Mar. 2000.

0

100

200

300

400

500

<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 >=65

Age

Number of nurses (in thousands)

1980

2000
Page 7 GAO-01-750T

pipeline. According to a 1999 Nursing Executive Center Report, between

1993 and 1996, enrollment in diploma programs dropped 42 percent and

enrollment in associate degree programs declined 11 percent.10

Furthermore, between 1995 and 1998, enrollment in baccalaureate

programs declined 19 percent, and enrollment in master’s programs

decreased 4 percent. Over the past 25 years, career opportunities available

to women have expanded significantly, while there has been a

corresponding decline of interest by women in nursing as a career. A

recent study reported that women graduating from high school in the

1990s were 35 percent less likely to become RNs than women who

graduated in the 1970s.11

In addition to the lack of students entering and graduating from nursing

programs, there is concern about a pending shortage of nurse educators.

The average age of professors in nursing programs is 52 years old, and 49

years old for associate professors. The average age of new doctoral

recipients in nursing is 45, compared with 34 in all fields. From 1995 to

1999, enrollments in doctoral nursing programs were relatively stagnant.

Job dissatisfaction may play a crucial role in determining the extent of

future nurse shortages. Recent surveys of nurses have found decreased job

satisfaction, and a high portion of respondents have reported increased

pressure to accomplish work, the need to work overtime, and stressrelated illness. A recent Federation of Nurses and Health Professionals

survey found that half of the currently employed nurses who were

surveyed had considered leaving the patient-care field for reasons other

than retirement over the past 2 years.12 Of this group, 56 percent indicated

that they wanted a less stressful and physically demanding job, 22 percent

said they were concerned about schedules and hours, and 18 percent

wanted more money. Over one-fourth (28 percent) of nurses in a 1999

study by the Nursing Executive Center described themselves as somewhat

 10The Nursing Executive Center, A Misplaced Focus: Reexamining the Recruiting/Retention

Trade-Off (Washington, D.C.: The Advisory Board Company, Feb. 11, 1999).

11Buerhaus, Peter I. et al., “Policy Responses to an Aging Registered Nurse Workforce,”

Nursing Economics Vol. 18, No. 6 (Nov.-Dec. 2000).

12Federation of Nurses and Health Professionals, The Nurse Shortage: Perspectives from

Current Direct Care Nurses and Former Direct Care Nurses (opinion research study

conducted by Peter D. Hart Research Associates)(Washington, D.C.: 2001).

Job Dissatisfaction May Be

a Major Factor in Future

Nurse Shortages
Page 8 GAO-01-750T

or very dissatisfied with their job, and about half (51 percent) were much

less satisfied with their job than they were 2 years ago.13

Job dissatisfaction is a primary reason cited for nurse retention problems.

As of March 2000, 18.3 percent of RNs reported not being employed in

nursing, up slightly from 17.3 percent in 1992. A recent survey reported

that the national turnover rate among hospital staff nurses was 15 percent,

up from 12 percent in 1996.14 Nursing home and home health care industry

surveys indicate that nurse turnover is an issue for them as well. In 1997, a

survey sponsored by the American Health Care Association (AHCA) of 13

nursing home chains identified a 51-percent turnover rate for RNs and

LPNs.15 A 2000 national survey of home health care agencies reported a 21-

percent turnover rate for RNs and 24-percent turnover rate for LPNs.16

Demographic changes over the coming decades may also worsen the

shortage of nurse aides. With the aging of the population, demand for

nurse aides is expected to grow dramatically, while the number of persons

who have traditionally filled these jobs will change very little. Retention of

nurse aides is currently a significant problem for many hospitals, nursing

homes, and home health care agencies, with some studies reporting

annual turnover rates for aides working in nursing homes approaching 100

percent. Low wages, few benefits, and difficult working conditions

contribute to recruitment and retention problems for nurse aides. High

turnover can contribute to both increased costs to the facility and

problems with quality of care.

Several factors have contributed to growing demand for nurse aides to

provide health and long-term care services. In the decade between 1988

and 1998, the number of employed nurse aides increased 40 percent.

Medical advances that have allowed people with chronic illnesses and

 13The Nursing Executive Center, The Nurse Perspective: Drivers of Nurse Job Satisfaction

and Turnover (Washington, D.C.: The Advisory Board Company, 2000).

14The Nurse Perspective: Drivers of Nurse Job Satisfaction and Turnover.

15American Health Care Association, Facts and Trends 1999, The Nursing Facility

Sourcebook (Washington, D.C.: AHCA, 1999).

16Hospital & Healthcare Compensation Service, Homecare Salary & Benefits Report, 2000-

2001 (Oakland, N.J.: Hospital & Healthcare Compensation Service, 2000).

Demographic

Changes, Low

Compensation, and

Difficult Working

Conditions Contribute

to Shortage of Nurse

Aides

Demographic Trends Will

Continue to Increase

Demand for Nurse Aides
Page 9 GAO-01-750T

disabilities to live longer, advances in technology that have allowed people

with significant care needs to receive care in their homes or other

community-based settings, and increased funding for in-home services,

particularly from the Medicare and Medicaid programs, are factors

increasing demand for nurse aide services. In addition, the growing

number of elderly will have a significant effect on demand in the future.

The number of persons over age 85, those most in need of health and long

term care services, will more than double from 4.3 million in 2000 to 8.9

million in 2030, when the baby boomers first begin to reach age 85.

At the same time, the supply of workers to fill these jobs will remain

virtually unchanged. Between 2000 and 2030, the total working-age

population—persons aged 18 to 64—is expected to grow by only 16

percent. The number of women aged 20 to 54—the traditional pool of

nurse aides—will increase by only 9 percent from 2000 to 2030. The

potential mismatch between future supply and demand for caregivers is

illustrated by the change in the expected ratio of potential care providers

to potential care recipients. As shown in figure 2, the ratio of the workingaged population, aged 18 to 64, to the population over age 85 will decline

from 39.5 workers for each person 85 and older in 2000 to 22.1 in 2030 and

14.8 in 2040. The ratio of women aged 20 to 54 to the population age 85

and older will decline even more dramatically, from 16.1 in 2000 to 8.5 in

2030 and 5.7 in 2040.
Page 10 GAO-01-750T

Figure 2: Decline in Elderly Support Ratio Expected, 2000 to 2040

Source: GAO analysis of U.S. Census Bureau Projections of Total Resident Population, Middle

Series, December 1999.

Over the next several years, even before the baby boomers begin retiring,

nurse aide jobs are expected to be among the fastest growing in the

workforce. The 40-percent increase in nurse aide employment from 1988

to 1998 is in contrast to the 19-percent increase in the number of persons

employed in the overall labor market. From 1998 to 2008, the overall

number of nurse aide jobs is projected to grow an additional 36 percent—

from 2.1 million to 2.9 million jobs—compared to the 14-percent projected

growth in all jobs. Jobs for nurse aides working in home health care are

projected to increase even faster, namely by 58 percent, from 746,000 in

1998 to 1.2 million in 2008.

Numerous reports and media accounts in recent years have described the

inability of a range of providers to hire and retain adequate numbers of

nurse aides. However, little analytical work has been conducted to assess

the nature or overall magnitude of the paraprofessional nursing staff

Recruitment and Retention

of Nurse Aides Is Widely

Reported To Be a Problem

0

5

10

15

20

25

30

35

40

45

2000 2010 2020 2030 2040

Year

Workers per person 85 and older

Women aged 20-54 to each persons 85 and older

Working-aged population 18-64 to each person 85 and older
Page 11 GAO-01-750T

shortage.17 Nonetheless, the IOM and other experts agree that we are

facing a shortage of nurse aides throughout the country.18 The current lowunemployment economy has increased competition for workers and

exacerbated the shortage of nurse aides. With a low national

unemployment rate, higher paying jobs with better working conditions

have opened up for women who have traditionally held nurse aide jobs.

Recent national analyses demonstrate the growing concern over the

supply of these workers. In a 1999 survey of state long-term care

ombudsmen, the respondents from more than 40 states reported “critical”

shortages of direct care staff.19 In another recent survey of states, officials

from 42 of the 48 states responding reported that nurse aide recruitment

and retention were currently major workforce issues in their states.20 More

than two-thirds of these states (30 of 42) reported that they were actively

engaged in efforts to address these issues.

Several state or local level studies cite nurse aide recruitment as a problem

for many providers. In a 2000 study of the nurse aide workforce in

Pennsylvania, staff shortages were reported by three-fourths of nursing

homes and more than half of all home health care agencies.21 Over half (53

percent) of private nursing homes and 46 percent of certified home health

care agencies reported staff vacancy rates higher than 10 percent.

Nineteen percent of nursing homes and 25 percent of home health care

agencies reported vacancy rates exceeding 20 percent. The Dallas-Ft.

Worth Hospital Council reported a hospital vacancy rate for nurse aides of

 17Some policymakers and planners have expressed concerns about the quality and

timeliness of data currently available on these workers. HRSA is currently funding a project

to assess trends, issues, and projections of supply and demand for nurse aides. It is

expected that this work will be completed by late 2001 and will include identifying,

comparing, and assessing the adequacy of existing data sources for assessing the scope and

scale of current workforce shortages.

18Institute of Medicine, Improving the Quality of Long-Term Care (Washington, D.C.:

National Academy Press, 2000).

19Submitted to the Domestic Strategy Group of the Aspen Institute by the Paraprofessional

Healthcare Institute, Direct-Care Health Workers: The Unnecessary Crisis in Long-Term

Care (Bronx, N.Y.: Paraprofessional Healthcare Institute, Sept. 2000).

20North Carolina Division of Facility Services, Comparing State Efforts to Address the

Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers

(Raleigh, N.C.: Sept. 1999).

21Leon, Joel et al., Pennsylvania’s Frontline Workers in Long Term Care (Jenkintown, Pa.:

Polisher Research Institute at the Philadelphia Geriatric Center, 2001).
Page 12 GAO-01-750T

17 percent in 2000, up from 11 percent in 1999. A recent survey of

providers in Vermont found high vacancy rates for nurse aides,

particularly in hospitals and nursing homes; as of June 2000, the vacancy

rate for nurse aides in nursing homes was 16 percent, in hospitals 15

percent, and in home health care 8 percent.

Providers also face problems with retention of nurse aide staff. Available

data indicate nurse aide turnover in nursing homes and home health care

agencies is much higher than the labor force in general (13 to 18 percent)

or the service workforce (20 percent).22 Annual turnover rates among aides

working in nursing homes are reported to be from about 40 percent to

more than 100 percent. In 1998, a survey sponsored by AHCA of 12 nursing

home chains found 94-percent turnover of nurse aide positions.23 A recent

national study of home health care agencies identified a 28-percent

turnover rate among aides in 2000, up from 19 percent in 1994.24

Studies have cited low wages and few benefits as factors contributing to

nurse aide turnover. Our analysis of national wage and employment data

from BLS indicates that, on average, nurse aides receive lower wages and

have fewer benefits than workers generally; this is particularly true for

those working in nursing homes and home health care.25 In 1999, the

national average hourly wage for aides working in nursing homes was

$8.29, compared to $9.22 for service workers and $15.29 for all workers.

For aides working in home health care agencies, the average hourly wage

was $8.67, and for aides working in hospitals, $8.94. Aides working in

 22Comprehensive national data on nurse aide turnover are not available, and caution must

be used when comparing turnover rates from different studies. While nurse aide turnover

rates are typically the number of nurse aides that have left a facility divided by the total

number of nurse aide positions, there is no standard method for calculating turnover and

methods used in different studies vary. It is generally agreed that staff who leave after a

very short tenure on the job contribute most to high turnover rates. Some nurse aide

positions may turn over several times during a given year, while others may not turn over

for several years.

23AHCA, Staffing of Nursing Services in Long Term Care: Present Issues and Prospects for

the Future (Washington, D.C.: AHCA, 2001).

24Hospital & Healthcare Compensation Service, Homecare Salary & Benefits Report 2000-

2001 (Oakland, N.J.: Hospital & Healthcare Compensation Service, 2000) and Hospital &

Healthcare Compensation Service, Homecare Salary & Benefits Report 1994-1995 (Oakland,

N.J.: Hospital & Healthcare Compensation Service, 1994).

25Detailed demographic, employment, and wage data on nurse aides in hospitals, nursing

homes, and home health care are presented in app. I.

Lower Wages, Fewer

Benefits, and Difficult

Work Conditions Linked to

Nurse Aide Turnover
Page 13 GAO-01-750T

hospitals are much more likely than aides in nursing homes and home

health care to have employer-provided health and retirement benefits.

Aides in nursing homes and home health care are similar to other service

workers in that they are less likely to have employer-provided health

insurance or pension coverage than workers in general. Most nursing

homes and home health care agencies do not offer pension coverage, and

only 21 to 25 percent of aides in these settings are covered.

Our analysis of CPS data indicates that many nurse aides have sufficiently

low earnings and family incomes to qualify for public benefits such as food

stamps and Medicaid. While 11 percent of all workers had family incomes

below poverty, 18 percent of aides working in nursing homes and 19

percent of aides working in home health care had incomes below that

level. One in three aides working in nursing homes earned less than

$10,000 per year, and 36 percent reported family incomes below $20,000.

In addition, aides working in nursing homes and home health care are

more than twice as likely as other workers to be receiving food stamps

and Medicaid, and they are much more likely to lack health insurance.

One-fourth of aides in nursing homes and one-third of aides in home

health care are uninsured compared to 16 percent of all workers.

Studies have also identified the physical demands of nurse aide work and

other aspects of the workplace environment as contributing to retention

problems. Nurse aide jobs are physically demanding, often requiring

moving patients in and out of bed, long hours of standing and walking, and

dealing with patients or residents who may be disoriented or

uncooperative. Nursing homes have one of the highest rates of workplace

injury, 13 per 100 employees in 1999, compared to the construction

industry with 8 per 100 employees.

The 2000 IOM study of quality in long-term care identified several

environmental and job design factors that directly affect nurse aide

turnover, including

• adequacy of training;

• methods for managing workload and schedules;

• opportunities for career advancement;

• respect from administrators;

• organizational recognition;

• workloads and staffing levels;

• clarity of roles; and

• participation in decisionmaking.
Page 14 GAO-01-750T

In another study, the degree of nurse aide involvement in resident care

planning was superseded only by the condition of the local economy as a

factor affecting turnover.26 For example, in facilities where nursing staff

were perceived to accept aides’ advice and suggestions or simply

discussed care plans with aides, the turnover was lower than in those

facilities where aides were not involved in care planning.

Negative effects—related to both costs for the facility and quality of

patient care—have been associated with high turnover. Direct provider

costs of turnover include recruitment, selection, and training of new staff,

overtime, and use of temporary agency staff to fill gaps. Indirect costs

associated with turnover include an initial reduction in the efficiency of

new staff and a decrease in nurse aide morale and group productivity.

High turnover can disrupt the continuity of patient care—that is, aides may

lack experience and knowledge of individual residents or clients.

Furthermore, when turnover leads to staff shortages, nursing home

residents may suffer harm because of the increased number of residents

the remaining staff must care for, resulting in less time to care for each

resident. The recent HCFA report to Congress that found a direct

relationship between nurse staffing levels in nursing homes and quality

also found a direct relationship between nurse aide staffing levels and the

quality of resident care. HCFA’s analysis of the three states’ data

demonstrated that, after controlling for case mix, there is a minimum

nurse aide staffing threshold below which quality of care may be seriously

impaired.27 Moreover, 54 percent of the facilities in the three states were

not staffing at that minimum threshold level.28

 26Banaszak-Holl, Jane and Marilyn A. Hines, “Factors Associated with Nursing Home Staff

Turnover”, The Gerontologist, Vol. 36, No. 4 (1996), pp. 512-17.

27The states included in the analysis were New York, Ohio, and Texas for calendar years

1996 and 1997.

28Nurse aides had a minimum staffing level of 2.00 hours per resident day.

High Nurse Aide Turnover

May Lead to Higher

Provider Costs and Quality

of Care Problems
Page 15 GAO-01-750T

Most initiatives and research efforts to address nurse aide recruitment and

retention have been undertaken by states and provider groups. In 1999, 30

states indicated that they were addressing nurse aide recruitment and

retention, primarily in nursing homes and home health care agencies,

through task forces, initiatives, and research. HHS has also recently begun

to focus on the supply and demand of this workforce through research and

planning efforts. (See appendix II.)

Initiatives intended to improve nurse aide recruitment and retention can

be categorized under three major themes: (1) improved wages and

benefits; (2) the development of additional training and opportunities for

career advancement; and (3) additional employee supports, including

improved work environments, job skills, and social supports. In addition,

many initiatives are multifaceted, addressing two or more of these areas.

The programs discussed below illustrate the types of initiatives under way.

Appendix II provides additional information on selected initiatives.

States have taken steps to improve the wages or benefits of nurse aides by

increasing reimbursement rates, primarily for aides working in nursing

homes and home health care. As of 2000, 26 states had established some

form of a wage pass-through, wage supplement, or related program for

nurse aides and other direct care staff.29 Methods of wage pass-throughs

vary from state to state; participation by providers can be voluntary or

mandatory, and states use different formulas to calculate the amount of

money provided. According to the 2000 North Carolina Division of Facility

Services survey, 4 out of 12 states that had implemented a wage passthrough reported that it had had some positive effect on recruitment and

retention of nurse aides, although little data exist to substantiate this view.

While some states have reported that they are satisfied with their

accountability procedures to ensure that pass-through dollars are reaching

 29North Carolina Division of Facility Services, Results of a Follow-Up Survey to States on

Wage Supplements for Medicaid and Other Public Funding To Address Aide Recruitment

and Retention In Long-term Care Settings (Raleigh, N.C.: Nov. 4, 2000) and Nursing Homes:

Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives

(GAO/HEHS-00-197, 2000). Wage pass-throughs provide a specific amount or percentage

increase in reimbursement, earmarked typically for nurse aides’ salaries and/or benefits.

Government and

Private Initiatives

Seek to Address

Nurse Aide Retention

and Recruitment, but

Few Have Been

Evaluated
Page 16 GAO-01-750T

aides, concerns have been raised that funds may not always be used as

intended. Few states have addressed the issue of benefits for nurse aides.

According to a 1999 study, only three states had considered or taken

action to require any form of benefits for nurse aides and other workers.30

Initiatives to improve training and opportunities for career advancement

have been undertaken by states as well as providers. States and providers

are experimenting with specialized training for nurse aides in targeted

patient care areas, such as treatment of persons with dementia, and are

developing career ladders that offer aides a chance to improve their skills

while also advancing their careers. For example, according to

Massachusetts officials, the Massachusetts’ Nursing Home Quality

Initiative provides $5 million in fiscal year 2001 specifically to develop

competitive nurse aide career ladder grants and to encourage the

development of partnerships of concerned groups, including community

colleges and workforce investment boards.31

Initiatives that focus on workplace and social supports for nurse aides fall

into two categories. The first type of support targets the structure of the

aides’ work environment, focusing on issues such as nurse aide

participation in care planning and the empowerment of nurse aides to act

on their special knowledge of their clients. For example, the Wellspring

Program in Wisconsin is an alliance of 11 providers whose approach is

based on the idea that management should foster quality of care with

appropriate policies, but decisions on policy implementation should be left

to the front-line workers who are most familiar with residents’ needs.

The second type of support focuses on general work skills and social

supports for nurse aides. For example, the Iowa Caregivers Association, a

nonprofit organization representing nurse aides, received state funding to

develop a pilot project to determine the effect on nurse aide recruitment

and retention of employee supports such as workshops on teamwork and

 30The states identified in the study were Hawaii, Idaho, and Maine. See North Carolina

Division of Facility Services, Comparing State Efforts to Address the Recruitment and

Retention of Nurse Aide and Other Paraprofessional Aide Workers (Raleigh, N.C.: Sept.

1999).

31The federal Workforce Investment Act of 1998 required states and localities to develop

workforce investment boards. The state board works with the governor to develop a

statewide workforce development plan and helps develop statewide workforce investment

systems and labor market information systems. Local boards are responsible for

implementing the system in their local area.
Page 17 GAO-01-750T

communication and an aide-mentoring program. Additionally, the

California Caregivers Training Initiative is a state-funded effort to improve

nurse aide recruitment and retention and includes providing supportive

services such as childcare and transportation. Other state and provider

initiatives have addressed general work skills through programs such as

general educational development diploma preparation or courses in

English as a Second Language.

HRSA’s Division of Nursing is charged with providing national leadership

to ensure an adequate supply and distribution of qualified nursing

professionals. HRSA has generally focused on licensed nursing

professionals, rather than nurse aides, but has recently undertaken a study

of the supply of and demand for aides. Along with HRSA, HCFA and the

Office of the Assistant Secretary for Planning and Evaluation (ASPE) are

also focusing attention on the nurse aide workforce. HCFA plans to

address issues that affect nurse aide recruitment and retention in Phase II

of the Report to Congress on Appropriateness of Minimum Nurse Staffing

Ratios in Nursing Homes, while ASPE’s research is designed to identify

successful recruitment and retention programs for nurse aides.

To date, most research on initiatives to address the nurse aide shortage

has been largely nonevaluative. Providers cite reduced turnover rates as

evidence of effectiveness. Some efforts are now under way to determine

the effectiveness of various interventions. Two states, Kansas and

Michigan, have gathered longitudinal data on the impact of their wage

pass-throughs on turnover. Michigan’s data indicate that since the

implementation of the nursing home wage pass-through in 1990, turnover

rates have decreased from 75 percent to 68 percent, while in Kansas

turnover has declined slightly, from 120 percent to 116 percent, since

implementation in 1998, but these measures may not account for other

factors that affect the aide workforce. Some states and providers have also

begun to realize the importance of formal evaluations and have

implemented evaluation efforts as a component of their initiatives. Further

information on these and other evaluations is included in appendix II.

Recruitment and retention of nursing staff—both nurses and nurse aides—

pose a problem today that will likely worsen as demand for these workers

increases in the future. Demographic forces are widening the gap between

the numbers of people needing care and the nursing staff available to

provide care. As a result, the nation will face a shortage of different

dimensions than those of the past. The private sector and state

governments have taken the lead in trying to address recruitment and

Concluding

Observations
Page 18 GAO-01-750T

retention issues for nurse aides. Additional evaluation is needed to

determine which initiatives are most effective. More detailed data are also

needed to delineate the extent and nature of nurse and nurse aide

shortages to assist in planning and targeting corrective efforts. As the

federal government focuses more on the nursing workforce in hospitals,

nursing homes, and home health care, support for the evaluation of efforts

to increase the supply of nurses and nurse aides may also help identify

more effective steps to ameliorate the shortage.

Chairman Jeffords and Ranking Member Kennedy, this concludes my

statement. I would be happy to answer any questions that you or Members

of the Committee may have.

For more information regarding this testimony, please contact me or Janet

Heinrich at (202) 512-7118, or Helene Toiv at (202) 512-7162. Eric

Anderson, Connie Peebles Barrow, Paula Bonin, Emily Gamble Gardiner,

and Nila Garces-Osorio also made key contributions to this statement

GAO Contacts and

Staff

Acknowledgments
Page 19 GAO-01-750T

Nurse aides work for a variety of employer types and in a variety of

settings. Of the approximately 2.2 million nurse aides employed in 1999,

most work either in nursing homes, hospitals, or home health care. (See

fig. 3.) Nurse aides compose a much smaller percentage of total employees

in hospitals than they do in either nursing homes or home health care.

(See fig. 4.) In contrast, nurses make up the largest portion of hospital

employees, and a smaller share of workers in nursing homes and home

health care.

Figure 3: Nurse Aide Employment by Setting, 1999

Note: “Other” includes a range of employment settings such as residential care, social services, and

temporary staffing agencies.

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational Employment Statistics data.

Appendix I: Demographic and Employment

Characteristics of Nurse Aides

Home health

Hospital

Nursing home

Other

35%

16%

18%

32%
Page 20 GAO-01-750T

Figure 4: Nurses and Nurse Aides as a Percentage of all Employees in Hospitals,

Home health care, and Nursing homes, 1999

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational Employment Statistics data.

The number of nurse aides in the workforce increased by 40 percent

between 1988 and 1998 (see fig. 5), more than twice the rate of growth of

the overall workforce. The greatest growth was among aides working in

home care, with their numbers more than doubling from 1988 to 1998.

According to BLS projections, these trends are expected to continue into

the next decade. While total employment in the workforce is projected to

grow by 14 percent from 1998 to 2008, projections for nurse aide

employment call for a 36-percent increase over the period, and a 58-

percent increase in the numbers working in home care.

8

0

10

20

30

40

50

60

70

80

90

Hospital Home health Nursing home

Percentage of total employees

Nurse aides

Nurses

54

38

30

24

20
Page 21 GAO-01-750T

Figure 5: Growth in Nurse Aide Employment, 1988-1998 and Projected to 2008

Source: Bureau of Labor Statistics, Monthly Labor Review.

Compared to the workforce in general, nurse aides are more likely to be

female, non-white, unmarried, and with children at home. (See table 2.)

While half of all workers and about two-thirds of service workers are

women, 80 to 90 percent of nurse aides are women. In addition, nurse

aides tend to be somewhat younger than the overall workforce, and a high

proportion are minorities. About half of nurse aides are non-white,

compared to only one-quarter of all workers. Aides in hospitals have

slightly higher rates of employer-provided health and pension benefits

than the general workforce. However, aides in nursing homes and home

health care are less likely than other workers to have employer-provided

health insurance and much less likely to be covered by a pension.

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

1988 1990 1992 1994 1996 1998 2008 proj.

Year

Number of nurse aides (in millions)
Page 22 GAO-01-750T

Table 2: Characteristics of Nurse Aides and Other Workers

Nurse Aides working in

Nursing homes Home health care Hospitals Service workers All workers

Mean age 37.0 41.3 38.7 37.3 44.8

Age ranges (percent)

 <25 21.3 11.8 13.4 23.7 13.0

 25-34 26.8 20.4 27.2 22.7 19.3

 35-44 24.7 29.0 27.9 24.0 22.4

 45-54 15.1 21.2 17.4 16.2 17.7

 55+ 12.2 17.8 14.1 13.3 27.6

Gender (percent)

 Male 9.1 10.8 20.4 32.5 48.0

 Female 90.9 89.2 79.6 67.5 52.0

Race/Ethnicity (percent)

 White, non-Hispanic 56.6 48.5 53.5 60.3 73.8

 Black, non-Hispanic 31.8 33.8 33.0 18.1 11.5

 Hispanic and other 11.5 17.6 13.5 21.6 14.7

Immigration (percent)

 Native born 88.9 79.6 86.9 80.9 87.8

 Immigrant 11.1 20.4 13.1 19.1 12.3

Education

 Less than high school 22.6 21.4 10.1 24.8 17.4

 High school 50.0 40.7 43.8 42.3 33.1

 Some college 27.3 37.9 46.2 32.8 49.5

Marital Status (percent)

 Married 39.4 43.5 43.7 43.7 57.2

 Never married 36.8 26.9 32.6 37.3 23.8

 Widowed, divorced

 or separated

23.8 29.5 23.7 19.0 19.0

Children (percent)

 None 43.7 49.9 54.8 53.9 61.8

 Any under 18 years 56.3 51.1 45.2 46.1 38.2

Unmarried with children (percent) 32.4 24.6 20.2 20.8 11.0

Source: GAO analysis of combined 1998, 1999, and 2000 Current Population Survey, March

Supplements.

Many nurse aides are among the working poor. Aides working in nursing

homes and home care are much more likely than other workers to be

uninsured, living below the poverty level, and receiving public benefits

such as food stamps and Medicaid. (See table 3.) Nursing home and home

health care aides are also two to three times more likely as other workers

to be unmarried and have children at home. Among single parent nursing

home and home health care aides, 35 to 40 percent are below poverty, and

30 to 35 percent receive food stamps.
Page 23 GAO-01-750T

Table 3: Income, Earnings, and Poverty Status of Nurse Aides and Other Workers

Nurse Aides working in

Nursing homes Home health care Hospitals Service workers All workers

Family income (percent)

 Under $10,000 12.4 16.1 6.8 13.0 9.3

 $10,000-19,999 23.8 21.6 16.7 19.7 13.3

 $20,000-29,999 18.2 19.6 16.9 15.9 12.9

 $30,000-39,000 14.6 13.2 14.9 12.7 11.7

 $40,000-49,999 11.3 9.5 11.6 10.1 10.0

 $50,000 + 19.7 20.0 33.2 28.5 42.8

Family income

 Mean $33,982 $33,653 $43,832 $40,712 $56,020

 Median 26,970 25,908 36,080 30,769 42,400

Individual earnings

 Mean $14,723 $13,501 $17,834 $13,412 $22,313

 Median 13,287 12,265 16,608 10,795 13,500

Individual earnings (full-time, full-year

workers)

 Mean $19,416 $19,216 $21,432 $19,515 $39,672

 Median 17,000 17,002 20,000 16,608 30,663

Poverty status (percent)

 Below poverty 17.8 18.8 8.1 16.1 10.5

 100 –149 13.2 15.9 10.4 12.8 8.4

 150 –199 15.0 11.4 11.9 12.6 8.9

 Above 200 54.1 53.9 69.6 58.4 72.3

Health insurance (percent)

 Uninsured 25.2 32.1 14.2 31.2 16.4

 Employer coverage 57.5 47.3 77.9 51.7 61.6

 Medicaid 9.9 11.1 2.1 6.9 3.9

Pension coverage

 Percent covered 25.2 21.2 51.3 21.3 44.4

Food stamps

 Percent receiving 13.5 14.8 5.3 9.3 5.5

Note: All reported income and earnings have been adjusted to constant 1999 dollars using the

Consumer Price Index, U.S. city average, for all urban consumers.

Source: GAO analysis of combined 1998, 1999, and 2000 Current Population Survey, March

Supplements.
Page 24 GAO-01-750T

Nationally, the mean hourly wage for a nurse aide in all settings was $8.59

in 1999, yet wages vary widely across states. (See table 4.) The

competitiveness of nurse aide wages with those of other service or

production jobs where they might be likely to find employment also varies

widely across states, as does the relative economic standing of nurse aides

compared to other workers. As a percentage of state per capita income,

the mean annual earnings of a nurse aide in 1999 ranged from a high of 85

percent in Alaska to a low of 48 percent in the District of Columbia. (See

table 5.)

Table 4: Nurse Aide Wages Compared to Other Occupations, by State, 1999

Mean hourly wage, 1999

Nurse aideaFactory workerbFast food cook Housekeeper

Alabama $7.24 $10.45 $5.90 $6.35

Alaska 11.63 11.12 9.05 9.09

Arizona 8.26 9.85 6.39 6.66

Arkansas 6.78 8.98 6.09 6.30

California 8.93 10.18 6.86 7.82

Colorado 8.56 9.67 6.40 7.42

Connecticut 11.32 12.36 7.14 8.69

Delaware 9.01 9.37 6.81 7.45

District of Columbia 9.29 c7.54 10.33

Florida 8.25 8.82 6.90 7.07

Georgia 7.40 10.03 6.56 6.80

Hawaii 9.57 9.94 7.60 10.96

Idaho 7.71 9.61 6.40 6.67

Illinois 8.16 12.64 6.74 7.29

Indiana 8.22 11.06 6.59 7.01

Iowa 8.17 11.71 6.65 7.07

Kansas 7.86 10.51 6.70 6.82

Kentucky 7.77 11.40 6.25 6.80

Louisiana 6.53 10.40 5.96 6.32

Maine 8.01 9.43 6.78 7.61

Maryland 8.98 11.60 6.50 7.85

Massachusetts 9.96 11.13 7.71 8.45

Michigan 8.76 12.43 6.55 7.59

Minnesota 9.27 11.21 6.82 8.05

Mississippi 7.19 9.20 6.32 6.46

Missouri 7.45 12.08 6.35 6.88

Montana 7.47 10.18 5.93 6.45

Nebraska 8.37 10.24 7.02 6.96

Nevada 9.66 10.07 6.62 8.66

New Hampshire 9.32 10.43 7.21 7.71
Page 25 GAO-01-750T

Mean hourly wage, 1999

Nurse aideaFactory workerbFast food cook Housekeeper

New Jersey 9.85 11.17 6.83 7.98

New Mexico 7.35 9.57 6.09 6.69

New York 9.27 10.26 6.69 9.71

North Carolina 7.77 10.45 6.38 7.06

North Dakota 7.48 9.38 6.40 6.56

Ohio 8.34 11.11 6.52 7.27

Oklahoma 7.17 11.91 6.08 6.53

Oregon 8.58 10.44 7.23 7.68

Pennsylvania 8.82 10.82 6.34 7.66

Rhode Island 9.51 8.78 6.84 8.28

South Carolina 7.54 11.66 6.39 6.93

South Dakota 7.66 8.74 6.42 6.60

Tennessee 7.77 10.18 6.53 6.79

Texas 8.63 9.19 6.24 6.40

Utah 8.10 9.11 6.70 7.08

Vermont 8.30 10.24 7.52 7.42

Virginia 7.67 10.19 6.26 7.05

Washington 8.59 11.13 6.74 7.87

West Virginia 6.83 8.60 5.99 6.57

Wisconsin 8.66 10.56 6.59 7.37

Wyoming 7.74 8.95 6.34 7.09

U.S. 8.59 10.67 6.54 7.46

a

Wage data for nurse aides represent the combined total of workers in three OES occupational

categories: (1) nursing aides, orderlies, and attendants; (2) home health care aides; and (3) personal

and home care aides.

b

Factory workers consist of the occupational category “team assemblers,” persons who work as part

of a team having responsibility for assembling an entire product or component of a product. Team

assemblers compose the largest single category of production worker, accounting for just over 10

percent of all production employees.

c

Wage data for factory workers in the District of Columbia were not available.

Source: GAO analysis of Bureau of Labor Statistics, 1999 Occupational Employment Statistics data.
Page 26 GAO-01-750T

Table 5: Nurse Aide Earnings as a Percentage of State Per Capita Income, 1999

State Mean annual earningsaPer capita income

Aide earnings as percentage of

state per capita income

Alabama $15,068 $22,987 66

Alaska 24,199 28,577 85

Arizona 17,185 25,189 68

Arkansas 14,101 22,244 63

California 18,569 29,910 62

Colorado 17,811 31,546 56

Connecticut 23,544 39,300 60

Delaware 18,750 30,778 61

District of Columbia 19,323 39,858 48

Florida 17,154 27,780 62

Georgia 15,383 27,340 56

Hawaii 19,898 27,544 72

Idaho 16,028 22,835 70

Illinois 16,967 31,145 54

Indiana 17,105 26,143 65

Iowa 16,986 25,615 66

Kansas 16,355 26,824 61

Kentucky 16,164 23,237 70

Louisiana 13,592 22,847 59

Maine 16,655 24,603 68

Maryland 18,685 32,465 58

Massachusetts 20,715 35,551 58

Michigan 18,216 28,113 65

Minnesota 19,286 30,793 63

Mississippi 14,945 20,688 72

Missouri 15,501 26,376 59

Montana 15,537 22,019 71

Nebraska 17,401 27,049 64

Nevada 20,094 31,022 65

New Hampshire 19,377 31,114 62

New Jersey 20,481 35,551 58

New Mexico 15,289 21,853 70

New York 19,279 33,890 57

North Carolina 16,172 26,003 62

North Dakota 15,553 23,313 67

Ohio 17,348 27,152 64

Oklahoma 14,921 22,953 65

Oregon 17,850 27,023 66

Pennsylvania 18,339 28,605 64

Rhode Island 19,788 29,377 67

South Carolina 15,681 23,545 67
Page 27 GAO-01-750T

State Mean annual earningsa Per capita income

Aide earnings as percentage of

state per capita income

South Dakota 15,923 25,045 64

Tennessee 16,153 25,574 63

Texas 17,961 26,858 67

Utah 16,852 23,288 72

Vermont 17,260 25,889 67

Virginia 15,954 29,789 54

Washington 17,877 30,392 59

West Virginia 14,204 20,966 68

Wisconsin 18,022 27,390 66

Wyoming 16,105 26,396 61

U.S. 17,866 28,542 63

a

Mean annual earnings are for a full-time, full-year worker (2,080 hours) earning the mean hourly

wage. Sixty-seven percent of all workers are employed full-time for the full year compared to 68

percent of hospital aides, 60 percent of aides in nursing homes, and 53 percent of aides in home

health care.

Source: GAO analysis based on earnings data from Bureau of Labor Statistics, 1999 Occupational

Employment Statistics data and per capita income data from the Bureau of Economic Analysis, U.S.

Department of Commerce.

Two primary sources of data were used to describe the demographic and

employment characteristics of nurse aides—the Current Population

Survey (CPS) conducted by the Census Bureau for the Bureau of Labor

Statistics (BLS) and the Occupational Employment Statistics (OES) survey

conducted by BLS and State Employment Security Agencies.

The CPS is a monthly survey of approximately 47,000 households and is

the source of official government statistics on employment and

unemployment. The monthly CPS contains basic demographic and labor

force data, while the March CPS survey contains additional data on work

experience, income, benefits, and migration. For our analysis, we used the

March CPS files. Although the overall sample size of the monthly CPS is

large, nurse aides represent a relatively small portion of the overall

workforce. In order to obtain a sample of aides large enough to support

our statistical analysis, we combined the 3 most recent years of data from

the March CPS in 1998, 1999, and 2000. We ended with a weighted sample

of 766 hospital aides, 1,230 nursing home aides, and 1,073 home health

care aides.

Paraprofessional nursing aide workers may be classified under several

occupational and industry categories in the CPS. We selected two

occupational categories: health aides, except nursing (occupational code

446) and nursing aides, orderlies, and attendants (code 447). We crossTechnical Notes on

Analysis
Page 28 GAO-01-750T

tabulated these two occupational codes (446, 447) by industry codes to

identify the settings where these workers are employed. We included

hospitals (industry code 831) and nursing and personal care facilities

(code 832). We identified nurse aides working in home health care as

those employed in private households (code 761), social services (code

871), and health services, not elsewhere classified (code 840). We

considered service workers to be those classified in private household

occupations (codes 403-407) and service occupations (codes 433-469)

regardless of industry.

The OES program surveys approximately 400,000 establishments per year,

taking 3 years to fully collect the sample of 1.2 million establishments. The

OES collects data on wage and salary workers in nonfarm establishments

and produces employment and wage estimates for over 700 occupations

by geographic area and by industry. Employment and wage data for nurse

aides were based on three occupational categories in the OES: (1) nursing

aides, orderlies, and attendants (standard occupational code 31-1012), (2)

home health care aides (31-1011), and (3) personal and home care aides

(39-9021). We compared data across three employment settings: hospitals

(standard industry code 806), nursing and personal care facilities (805),

and home health care services (808). For comparison purposes we chose

three other occupational categories: team assemblers (51-2092), fast food

cooks (35-2011), and maids and housekeeping cleaners (37-2012).
Page 29 GAO-01-750T

Initiatives and research efforts to address nurse aide recruitment and

retention focus primarily on improved wages and benefits (table 6),

opportunities for additional training and career advancement (table 7),

and additional employee supports, including improved work

environments, job skills, and social supports (table 8). Many initiatives are

also multifaceted, addressing two or more of these areas (table 9). While

states and providers have undertaken most initiatives and research efforts,

the federal government has recently begun to focus on the supply and

demand of this workforce. The Department of Health and Human Services,

through HRSA, HCFA, and ASPE, has undertaken research and planning

efforts focused on nurse aide issues (table 10). The tables describe

selected examples of initiatives and research efforts, and are not meant to

be comprehensive.

Table 6: Wages and Benefits

State wage pass-throughs

Affected provider type Nursing homes and home health care agencies

Description States with wage pass-throughs require that some portion of a long-term care

reimbursement increase from a public funding source be used specifically to increase

wages and/or benefits for nurse aides. In some states, only facilities that apply may

participate in the pass-through programs. As of September 2000, 26 states have

established a wage pass-through, wage supplement, or related program to provide

supplemental wages or benefits.

Funding source Varies (funds are usually from Medicaid, but may also include Older Americans Act funds,

state appropriations, and other sources)

Start date Varies from state to state. Some states have had pass-throughs in place since the early

1980s to deal with episodic worker shortages; most pass-throughs are relatively recent.

Evaluation findings Data collected in Michigan indicate that between 1990 and 1998, the aide turnover rate

dropped from 74.5 percent to 67.45 percent, which the state attributes to a pass-through

that has been in place since 1990.Kansas’ aide turnover rate in facilities participating in

the 1999 pass-through went from 120 percent in 1998 to 116 percent in 1999.

There have been no evaluations examining short- or long-term effects of the wage passthrough strategy and differences in outcomes based on state variations in methodology.

Appendix II: Examples of Government and

Private Initiatives to Address Nurse Aide

Recruitment and Retention
Page 30 GAO-01-750T

Table 7: Training and Career Ladders

Massachusetts Nursing Home Quality Initiative

Affected provider type Nursing homes (other provider types may be included in one component of the

initiative, provided a nursing home is the primary applicant)

Description The initiative grants state funds to providers, and includes $35 million for a

wage pass-through for nurse aides, $1 million for a scholarship program to

attract new aides, $5 million for a career ladder grant program for aides, and

$1.1 million in education and job supports for current or former welfare

recipients interested in a career as a nurse aide. The career ladder grant

program includes a component targeting the culture of nursing homes; this

component also requires applicants to collaborate with other providers, the

workforce development community, community colleges, and other interested

groups to increase program impact.

Funding source Funded by a $42 million appropriation from the state.

Start date Implemented in 2000.

Evaluation findings No evaluation has been conducted to date.

Grantees in the career ladder program are required to participate in an

evaluation that will be conducted by The Commonwealth Corporation. The

scheduled deadline for this evaluation is June 30, 2002.

Virginia Nursing Assistant Institute Initiative

Affected provider type Nursing homes, home health care agencies, hospitals

Description The Institute was developed by local officials, associations, and providers to

offer comprehensive free or low-cost aide training; conduct workforce needs

assessments; provide technical assistance to providers interested in promoting

best practices management; facilitate aide recruitment; provide networking and

peer support; and increase community awareness of the aide shortage. The

initiative is a joint effort of seven agencies in the western Virginia area.a

Funding source Private funds, private and public grants

Start date 1999

Evaluation findings No overall evaluation conducted to date.

a

The agencies are Charlottesville Albemarle Technical Education Center, the Jefferson Area Board

for the Aging, Monticello Area Community Action Agency, Martha Jefferson Hospital, Piedmont

Virginia Community College, University of Virginia Health Systems, and Williamson’s Health Care

Network.
Page 31 GAO-01-750T

Table 8: Employee Supports

The Wellspring Program

Affected provider type Nursing homes

Description The Wellspring Program is a collaborative of 11 providers and is based on the idea

that while top levels of management should create quality of care through appropriate

policy, decisions on how to implement the policy should be made by the front-line

workers who are most familiar with the needs of the residents. To implement this

policy, the facilities who compose the Wellspring Program have created “care

resource teams” which receive specialized job training and are empowered to train

other workers and develop, implement, and evaluate facility level care and structural

changes. Nurse aides play a prominent role in these interdisciplinary teams.

Additionally, clinical experts, including a geriatric nurse consultant, are available to the

teams, and the geriatric nurse consultants regularly visit each facility to provide

assistance and support.

Funding source Private

Start date 1994

Evaluation findings The Institute for the Future of Aging Services, with funding from The Commonwealth

Fund, is conducting an evaluation of the Wellspring Program. However, turnover rates

for aides across the 11 facilities have dropped from 110 percent (1994) before the

implementation of the Wellspring Program to a current rate of 23 percent (2001).

California Caregivers Training Initiative

Affected provider type Nursing homes, home health care agencies, hospitals

Description The state of California’s Caregiver Training Initiative (CTI) is designed to develop and

implement proposals to recruit, train, and retain caregivers, including nurse aides and

other entry level staff. Initiatives undertaken with funds from CTI must be regional in

scope and may include supportive services such as childcare, transportation, and

personal growth workshops. Participants in the regional initiatives must meet the

eligibility requirements of the two funding sources, the federal Workforce Investment

Act and Welfare to Work Grant Program state matching funds. In order to receive

money from CTI, applicants must develop collaborations with representatives of the

health care industry, public agencies, labor organizations, and public education. As of

January 31, 2001, 12 grants, ranging in size from $400,000 to just over $2.5 million,

were awarded.

Funding source $25 million ($15 million from Workforce Investment Act funds, and $10 million from

State General Fund match dollars)

Start date 2000

Evaluation findings No evaluation has been conducted to date. However, an evaluation is required . The

evaluation will address the implementation, process, and outcomes of each funded

program. Programs are required to collect and maintain data on an ongoing basis,

and to provide regular progress reports to the evaluation staff.
Page 32 GAO-01-750T

Iowa Caregivers Association CNA Recruitment and Retention Pilot Project

Affected provider type Nursing homes

Description The goal of the CNA Recruitment and Retention Pilot Project was to assess and

address the needs of direct care workers in order to reduce staff turnover in nursing

facilities. After conducting a needs assessment of nurse aides in the state, the Iowa

Caregivers Association recruited three facilities to participate in the pilot as tracking

facilities and three to act as control facilities (with two additional urban facilities

recruited during the second year of the pilot). They then implemented a series of

interventions, including training on conflict resolution, workshops in communication

and team building, and a nurse aide mentoring training program.

Funding source Funded through the Iowa Department of Human Services

Start date 1998

Evaluation findings An evaluation by the National Resource Center for Family Centered Practices at the

University of Iowa School of Social Work found that the average length of service over

the 2-year pilot period was 18.96 months in the intervention facilities versus 10.01

months in the control facilities. Significantly lower turnover rates occurred in the

treatment facilities than in the control facilities (34 percent vs. 82 percent) in the first

year. Additionally, treatment facilities scored significantly better than control facilities

on several indicators of job satisfaction.
Page 33 GAO-01-750T

Table 9: Multifaceted

Cooperative Home Care Associates

Affected provider type Home health care agencies

Description Cooperative Home Care Associates (CHCA) is a worker-owned home health care

provider in the Bronx, New York. It currently employs 550 minority women, and was

developed on the premise that home health care clients would receive higher quality

of care if home health care workers were offered higher quality jobs. Over 75 percent

of women who work for CHCA were previously dependent on public assistance.

Wages at CHCA are among the area’s highest, and the provider offers a full range of

benefits, including health care and a retirement plan. CHCA provides 4 weeks of

classroom training plus 90-days of on-the-job training, and offers continuing

development to staff. Employees are given the opportunity to become owners of the

company, and senior staff are also guaranteed a minimum of 30 hours per week.

Funding source Private

Start date 1985

Evaluation findings No formal evaluation has been conducted. However, CHCA reports that its annual

turnover of aides is less than 25 percent, and within the last 2 years 82 percent of

aides remained with CHCA at least 180 days.

Providence Mount Saint Vincent

Affected provider type Nursing home

Description Providence Mount Saint Vincent (PMSV) is a long-term care facility in Seattle,

Washington that offers a range of services, including a nursing center and adult day

services. In 1991, PMSV restructured itself to provide “resident directed care.” The

organization defines resident directed care as care directed by residents, including

choosing the daily routines and services the resident wishes to receive. Front-line

staff were given the power to make decisions related to patient care, and certain

middle management positions were eliminated to provide resources for more directcare staff. All employees received cross-training in multiple tasks, which, according

to PMSV, gave them greater opportunity for advancement. Aides also received pay

increases with each year of service, bonuses for staying with PMSV, and a full

benefit plan, including health care and a pension.

Funding source Private

Start date 1991

Evaluation findings No formal evaluation has been conducted. However, since the implementation of the

changes, turnover at PMSV is lower than the industry standard. In 1994, PMSV’s

turnover rate was 54 percent, in 1995 it was 39 percent, and in 1996 it was 37

percent.
Page 34 GAO-01-750T

Wisconsin’s Community Links Workforce Project

Affected provider type Nursing homes, home health care agencies (and other long-term care providers)

Description The state Bureau of Aging and Long Term Care Resources allowed counties to

apply for funds to support local initiatives designed to strengthen or expand the

community long-term care workforce. Thirty-two grants from 28 counties were

funded, and included multidisciplinary collaborations to address the issue of aide

recruitment and retention, efforts to tap nontraditional sources of workers, and

programs to provide wrap-around services for aides, such as the establishment of

emergency funds for unexpected car repairs and assistance with children’s school

supplies.

Funding source Community Options Program and Community Options Program-waiver funds

Start date 1999

Evaluation findings No evaluation conducted to date.
Page 35 GAO-01-750T

Table 10: Federal Research and Data Collection Initiatives

Report to Congress on Appropriateness of the Minimum Nurse Staffing Ratios in

Nursing Homes, Phase II—Health Care Financing Administration, HHS

Affected provider type Nursing homes

Description Phase II of the Staffing Ratio study will examine the costs and benefits associated with

establishment of staffing minimums and further explore the findings of Phase I.

Additionally, Phase II will examine issues that affect the recruitment and retention of

nurse aides, including turnover rates, amount of staff training, and management of staff

resources.

Funding source Federal

Start date 2000, with an expected completion date of late 2001

Evaluation findings No evaluation has been completed.

National Study of Nursing Home Nurse Aides and Home Health Workers—Health

Resources and Services Administration, HHS

Affected provider type Nursing homes and home health care agencies

Description The Health Resources and Services Administration recently began a national study of the

current and future supply of and demand for front-line long-term care workers. The study

will include analysis of existing databases and interviews of long-term care workers,

providers, associations, and interested state agencies. The interviews will be conducted

by the Center for Health Workforce Studies at State University of New York, University at

Albany’s School of Public Health, and other health workforce centers around the country.

A report is expected in late 2001.

Funding source Federal

Start date 2000

Evaluation findings No evaluation has been completed.

Frontline Workers in Long-Term Care—Office of Disability, Aging, and Long-Term

Policy, Office of the Assistant Secretary for Planning and Evaluation, HHS

Affected provider type All long-term care workers

Description This project is designed to heighten the awareness of federal, state, and local

policymakers about issues related to the development of a quality long-term care

workforce. The project will identify successful recruitment and retention models for frontline long-term care workers and will suggest policy and research activities to promote a

quality paraprofessional long-term care workforce. ASPE is collaborating with the Robert

Wood Johnson Foundation. HCFA, HRSA, Administration on Aging, the Department of

Education, Agency for Healthcare Research and Quality, and the Department of Labor

are also involved.

Funding source Federal and private

Start date 2000

Evaluation findings No evaluation has been completed.

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