Abstract
Introduction
Registered nurse (RN) workforce planning relies on a robust understanding of trends in nursing job dynamics. Relevant, current data on RNs' education, training, and job outcomes are critical to implementing solutions to mitigate high job vacancy rates or workforce shortages.
Methods
This study used data from the 2018 and 2022 National Sample Survey of Registered Nurses to describe the sociodemographic characteristics and job dynamics of the nursing workforce before and after the pandemic, including nurses entering and leaving the workforce, and examined factors associated with leaving a primary job.
Results
Despite concerns about 2018 weights, results suggest signs of increasing representation of Black RNs and potential declines in representation of Hispanic RNs over time respective to the US population. We found high rates of job turnover related to well-being and safety in the workplace in 2022.
Conclusion
These findings suggest that strategies to increase workforce diversity have been successful among select groups, and ongoing policy should continue to focus on groups that are underrepresented. While the future of federal workforce diversity programs is unclear, states and organizations can implement strategies to support recruitment and retention of diverse groups of RNs.
Keywords: nursing workforce, diversity, workforce policy, turnover, retention
Key Points.
Findings show a higher percentage of racially and ethnically diverse RN entrants than exists in the overall RN workforce, suggesting trends toward increased representation of at least some groups of RNs.
Targeted policy toward improving diversity among RN workforce entrants has been somewhat effective and should be continued and tailored to the specific needs of states and communities.
Racially and ethnically diverse RNs have higher rates of job turnover, indicating a need for enhanced workforce supports and policies to retain RNs that represent the diversity of the US population.
Introduction
Registered nurses (RNs) make up the largest part of the health workforce and play critical roles in maintaining access to care and optimizing outcomes for patients and communities across the United States. Mapping workforce trends is a critical component of workforce research and planning and includes assessment of the sociodemographic representativeness of the nursing workforce compared to the US population. Relevant data on demographics, education, training, and job outcomes among RNs are critical to identifying workforce issues and implementing solutions to mitigate high job vacancies, shortages, or inadequate distribution of RNs to communities needing care.
Along with advocating for measures to grow and support the workforce, the National Academies' Future of Nursing 2020 report advances the national goal of improving sociodemographic concordance between RNs and the communities they serve to ensure high-quality care that meets population needs.1,2 Concordance in race, ethnicity, sex, and/or life experience between patients and clinicians has been found to enhance access and quality of care.1,3-7 In particular, racial and ethnic concordance between patients and nurses is associated with improved maternal outcomes.8,9 Improving diversity also supports the ability of the workforce to respond to challenges and change with creativity and innovation.7,10
Work toward improving nursing workforce diversity to reflect the population has been a focus for several decades. Public and private entities have developed grant programs to help academic institutions recruit, retain, and graduate nurses of diverse backgrounds as well as attracting and retaining faculty from underrepresented groups.2,11 For example, in 2014, the Health Resources and Services Administration (HRSA) initiated the Nursing Workforce Diversity program, which provided funding, resources, and targeted goals for student and faculty recruitment to academic institutions offering prelicensure nursing programs.12 A systematic review spanning publications from 2010 to 2023 examined efforts to promote representation among academic institutions and healthcare organizations; the review noted a variety of strategies such as career advancement programs, pipeline programs, and academic support initiatives with varied levels of impact on improving workforce diversity among groups underrepresented in healthcare, such as Black or Latino workers.13 These programs represent work at multiple levels to improve workforce diversity, yet none provide data about how the diversity of the nursing workforce has changed over time. In addition, previous data have suggested that initiatives focused on diversity benefit some racial or ethnic groups more than others,14 so examining any changes in the diversity of those entering the nursing workforce is necessary.
Understanding the characteristics of RNs leaving jobs and how that affects the diversity of the nursing workforce is also warranted. During and after the pandemic, heightened attention to issues such as burnout and intent to leave jobs has marked nursing workforce research, but most studies focus on intention to leave a job15,16 which is not perfectly correlated with job departure17 and does not provide sufficient information about actual job shifts. US labor data show little evidence of RNs leaving in substantially increased numbers following the pandemic.18 While data show ongoing high rates of job vacancies, they do not provide insight as to whether new jobs are being opened or RNs are leaving their jobs.19 In addition, RNs from underrepresented racial and ethnic groups disproportionately experienced high rates of burnout and intent to leave nursing in the pandemic era, so it is important to understand the impact of these phenomena on the nursing workforce.20-22
Assessing how well the RN workforce represents the US population requires appropriate data. National nursing workforce surveys are one approach that can be used to track changes in RN workforce characteristics over time. While there are several national nursing workforce surveys, they offer limited data to track turnover of nurses and the sociodemographic characteristics of those entering or leaving nursing. This study utilizes the National Sample Survey of RNs (NSSRN), which provides more robust information related to job shifts and work experiences than other national surveys. We aim to describe shifts in the sociodemographic characteristics and job dynamics of the nursing workforce before and after the pandemic and to examine factors associated with leaving a primary job. We also explore how concerns about the use of 2018 NSSRN data in characterizing the racial and ethnic representation may affect our ability to understand the changing representation of the RN workforce. The findings from this study will inform policymakers and workforce planners looking to increase the diversity of the RN workforce.
Methods
This study was a retrospective secondary analysis of public use file data from the 2018 and 2022 NSSRN. The NSSRN is a national survey conducted by the HRSA's National Center for Health Workforce Analysis.23 The NSSRN collects data on actively licensed RNs across the United States every 4 years and typically includes a sample of approximately 50 000 RNs. Our study sample included RNs who were not advanced practice RNs (APRNs) and who indicated that they held a primary nursing job on December 31 of the year prior to the survey. We used the weighted NSSRN data to explore RN sociodemographic characteristics (eg, race, ethnicity, sex, age, education), job characteristics, and selected job outcomes. This study was exempted from human subjects review by an Institutional Review Board as the dataset is deidentified and publicly available.
Outcome
Job status
The primary outcome of the study was the RN's job status. We identified RNs as “entrants” if they indicated that they had obtained their initial nursing license in the 2 calendar years prior to the survey (ie, 2016 or 2017 for 2018 respondents and 2020 or 2021 for 2022 respondents). We defined “leavers” as RNs who indicated whether they had left the primary job held in the prior year. We further divided leavers into 3 groups: (1) retirees, (2) those who left for a different nursing job, or (3) those who left the nursing profession altogether (the survey did not ask about subsequent employment status). Note that RNs included in the “leaver” category may have left their job for positive reasons such as promotion or pursuit of education, which is reflected in the “reasons for leaving” variable defined below.
Variables
Sociodemographic characteristics
The survey included each respondent's age in years, age categories, a binary male/female sex variable, race, and ethnicity. There are 6 racial categories in the NSSRN public use data: American Indian/Alaska Native (AIAN), Asian, Black, Native Hawaiian/Pacific Islander (NHPI), White, and Multiracial. For this study, we collapsed the AIAN and NHPI due to a limited number of observations. Ethnicity was collapsed into Hispanic or non-Hispanic. We collapsed the level of prelicensure nursing education to an associate degree or lower vs a baccalaureate or higher. We included a variable identifying if prelicensure nursing education occurred in or out of the United States. The 2022 dataset included a variable for an RN to indicate whether they worked in a rural or non-rural area; this variable was not available in the 2018 data.
Job characteristics
Respondents answered questions about their primary job, and we used a secondary job variable to indicate if an RN worked more than 1 job. Work settings were collapsed into the following: consultant or indirect care; inpatient medical hospital; ambulatory settings (including primary care and specialty clinics and public and community health settings); long-term care (LTC), behavioral health, and home health (referred to as LTC/behavioral/home); and remote or telehealth settings. Respondents indicated if they worked full- or part-time.
Reasons for leaving jobs
RNs who indicated that they left their primary job were asked to select all that applied from an extensive list of factors that may have contributed to their decision to leave. From this list, we sorted factors into seven categories (see Supplement 1): work environment, safety, life factors, well-being, career, education, pay, and other.
Analysis
Using sample weights provided with the survey data, we performed descriptive analyses of RNs' sociodemographic and work characteristics between years, using χ2 testing to assess any significant differences between the years overall and among specific groups of entrants or leavers (reporting significance at α = 0.05). We performed a multivariate logistic regression analysis of factors associated with an RN leaving their job (excluding retirement) vs staying in a job. Because the survey changed its variance methodology from jackknife in 2018 to successive difference replication in 2022, we were unable to pool the years together in a single regression analysis to identify changes between years. Instead, we performed separate analyses and looked for differences or similarities in the odds of leaving by specific characteristics between the 2 years.
Sensitivity analysis
Workforce researchers have raised concerns that the survey weights in the 2018 NSSRN inaccurately characterize the size of the RN workforce by race and ethnicity with an overestimation of Hispanic RNs and an underestimation of Asian and Black RNs.24 To understand the extent to which the 2018 survey weights affected overall conclusions about the changing racial/ethnic distribution of the RN workforce, we examined data extracted from the 2018 and 2022 American Community Survey (ACS), a nationally representative sample of over 3 million households conducted annually by the US Census Bureau. Specifically, we followed recommendations to describe the racial and ethnic distribution of adults 18 years and older who self-identified as employed RNs (excluding APRNs) in ACS compared to NSSRN using ACS survey weights for analysis.25 The weighting concerns of NSSRN did not affect our ability to examine the characteristics of RNs within racial and ethnic groups, as done in other papers using this data.25
Findings
The 2018 and 2022 NSSRNs included 50 273 and 49 114 observations, respectively, representing an estimated 3.96 million (2018) and 4.35 million (2022) RNs and APRNs in total (weighted estimates used from this point forward). The study sample of employed RNs who were not APRNs was 2 899 043 for 2018 and 3 065 868 for 2022. The mean age of the workforce in the study sample decreased from 46.4 years to 45.6 years with significant changes in the distribution among age categories (Supplement 2). There was a significant increase in representation of men from 9.9% in 2018 to 12.3% in 2022 (Table 1). While the data show significant changes in the racial distribution of RNs between 2018 and 2022 and a nonsignificant decrease in the percentage of Hispanic RNs (10.8%-9.5%), these findings are limited by weighting issues in 2018. The proportion of RNs in the workforce who completed a baccalaureate or higher as their initial nursing degree increased from 39.1% to 47.3%, and the percentage of RNs educated outside the United States increased by 1.5 percentage points (pp) to 6.7%. Table 1 shows detailed demographic and work characteristics for the entire RN workforce as well as entrants and leavers.
Table 1.
Demographic characteristics of registered nurse workforce and entrants, 2018 and 2022.
| RN workforce (percent of all RNs) | RN entrants (percent of all entrants) | RN leavers (percent of all leavers) | ||||
|---|---|---|---|---|---|---|
| 2018 | 2022 | 2018 | 2022 | 2018 | 2022 | |
| N | 2 899 043 | 3 065 868 | 207 045 | 226 028 | 372 784 | 811 881 |
| % of workforce | 7.1 | 7.4 | 12.9 | 26.5 | ||
| Mean age (SD) | 46.4 (0.1) | 45.6 (0.1) | 32.7 (0.4) | 31.8 (0.4) | 45.8 (0.4) | 43.1 (1.2) |
| Sex | ||||||
| Female | 90.1 | 87.7 | 87.1 | 82.7 | 88.3 | 87.9 |
| Male | 9.9 | 12.3 | 12.9 | 17.3 | 11.7 | 12.1 |
| Racea | ||||||
| AIAN/NHPI | 1.2 | 0.9 | 0.5 | 1.4 | 1.5 | 1.1 |
| Asian | 5.6 | 10.0 | 5.8 | 10.7 | 4.1 | 7.2 |
| Black | 8.2 | 11.7 | 8.1 | 16.5 | 8.8 | 11.7 |
| Multiracial | 5.0 | 4.9 | 10.3 | 9.6 | 4.5 | 5.1 |
| White | 80.1 | 72.5 | 75.3 | 61.7 | 81.1 | 74.9 |
| Ethnicitya | ||||||
| Hispanic | 10.8 | 9.5 | 17.4 | 11.7 | 11.5 | 11.5 |
| Not Hispanic | 89.2 | 90.5 | 82.6 | 88.3 | 88.5 | 88.5 |
| Education | ||||||
| Associate degree or less | 61.0 | 52.7 | 50.7 | 45.6 | 66.7 | 54.0 |
| Bachelor's degree or more | 39.1 | 47.3 | 49.3 | 54.4 | 33.3 | 46.0 |
| RN education location | ||||||
| United States | 94.8 | 93.3 | 96.3 | 93.7 | 96.6 | 95.9 |
| Outside United States | 5.2 | 6.7 | 3.7 | 6.3 | 3.4 | 4.1 |
| Number of jobs worked | ||||||
| More than 1 job | 10.3 | 9.0 | 9.1 | 7.1 | 11.7 | 11.9 |
| 1 job | 89.7 | 91.0 | 90.9 | 92.9 | 88.3 | 88.1 |
| Work status | ||||||
| Full time | 79.7 | 82.3 | 90.9 | 92.1 | 78.7 | 83.8 |
| Part time | 20.3 | 17.7 | 9.2 | 7.9 | 21.3 | 16.2 |
| Work settings | ||||||
| Indirect care | 5.5 | 5.9 | 0.5 | 0.5 | 5.7 | 3.7 |
| Inpatient care | 51.8 | 52.8 | 74.3 | 72.1 | 52.3 | 57.0 |
| Ambulatory care | 26.7 | 27.8 | 11.8 | 16.7 | 21.3 | 25.7 |
| LTC/behavioral/home | 15.4 | 12.6 | 13.3 | 10.6 | 20.2 | 13.1 |
| Remote/telehealth | 0.6 | 0.9 | 0.1 | 0.1 | 0.4 | 0.5 |
| Work rurality | ||||||
| Works in rural area | 12.4 | 10.5 | 12.3 | |||
| Works in non-rural area | 87.6 | 89.5 | 87.7 | |||
For the RN workforce and entrant columns, numbers indicate the percentages of the entire workforce or entrants in each category. Bolded numbers indicate a significant difference (P < .05) in χ2 analysis of the distribution of characteristics within the category from 2018 to 2022. Rurality is not available in 2018 data.
Abbreviations: AIAN/NHPI, American Indian, Alaska Native, Native Hawaiian, and Pacific Islander; LTC, long-term care; RN, registered nurse.
aData for race and ethnicity should be interpreted with caution due to underweighting for Black RNs and overweighting for Hispanic RNs in the 2018 NSSRN.24
Work characteristics
The proportion of RNs working full-time increased significantly from 79.7% in 2018 to 82.3% in 2022, while the number working more than 1 job dropped significantly from 10.3% to 9.0% (Table 1). Just over half of RNs in both years reported working in an inpatient medical setting, with over a quarter working in ambulatory care, 12%-16% in LTC/behavioral/home settings, 5%-6% in roles without direct patient care, and less than 1% in remote or telehealth settings (Table 1). While the distribution of RNs across work settings was generally similar from 2018 to 2022, we found significant differences with a notable 2.8 pp decrease of RNs working in the LTC/behavioral/home category, with small increases in the other settings. In 2022, 12.4% of RNs reported working in a rural area.
Entrants
The percentage of entrants in the workforce grew from 7.1 in 2018 to 7.4 in 2022 (Table 1). There were no statistically significant differences in sociodemographic characteristics between entrants in 2018 and 2022, with the exception of race, although there were nonsignificant increases in the percentage of entrants who were male (4.4 pp), who had a bachelor's degree or higher (5.1 pp), and who received their nursing education outside of the United States (2.6 pp).
The racial composition of entrants appears to have changed significantly from 2018 to 2022, with increased percentages of AIAN/NHPI, Asian, and Black entrants; given that the weighting concerns in 2018 suggested underrepresentation of Asian and Black RNs, the increase may be understated. Though the decrease in Hispanic entrants was not statistically significant, the lack of significance and direction of change should be interpreted with caution given the overrepresentation of Hispanic RNs in 2018. Looking at the 2022 findings only, the entering RN workforce is more racially and ethnically diverse than the overall RN workforce.
In an alternative view of the changing racial and ethnic composition of the RN entrants that is not subject to the 2018 weighting issue, Table 2 presents the percentage of entrants within each racial and ethnic group in 2018 and 2022 and indicates improved representation among several groups. In 2022, 10.4% of Black RNs were entrants compared to 7.1% of Black RNs being entrants in 2018, with similar increases among AIAN/NHPI and Asian RNs. A smaller percentage of Multiracial, White, and Hispanic RNs were entrants in 2022 compared to 2018.
Table 2.
Registered nurse entrants and leavers within race and ethnicity groups, 2018 and 2022.
| RN entrants (percent within group) | RN leavers (percent within group) | |||
|---|---|---|---|---|
| 2018 | 2022 | 2018 | 2022 | |
| Race | ||||
| AIAN/NHPI | 3.1 | 11.3 | 15.7 | 30.9 |
| Asian | 7.4 | 8.0 | 9.5 | 19.1 |
| Black | 7.1 | 10.4 | 14.0 | 26.5 |
| Multiracial | 14.8 | 14.4 | 11.6 | 27.6 |
| White | 6.7 | 6.3 | 13.0 | 27.4 |
| Ethnicity | ||||
| Hispanic | 11.5 | 9.1 | 13.7 | 32.1 |
| Not Hispanic | 6.6 | 7.2 | 12.8 | 25.9 |
Entrants are respondents who indicated they had received their first RN license in the 2 years preceding the survey (ie, 2016 or 2017 for 2018 survey and 2020 or 2021 for 2022 survey). Leavers are respondents who indicated that they were working in a primary job as of December 31 in the year prior to the survey (ie, 2017 or 2021) but had left that job at the time of the survey (including retirees). Numbers represent the percent of workers within a specific race/ethnic category who entered a job or left a job for any reason. For example, among the group of Asian RNs, there was an increase in the percentage of entrants between years, going from 7.4% entrants (93.6% who were not entrants) to 8.0% entrants (92.0% were not entrants). Bolded numbers indicate a significant difference (P < .05) in the category from 2018 to 2022.
Abbreviations: AIAN/NHPI, American Indian, Alaska Native, Native Hawaiian, and Pacific Islander; RN, registered nurse.
Leavers
Overall, the percentage of RN leavers increased significantly from 2018 to 2022 (12.9%-26.5%; Table 3), likely influenced by the timing of the survey in early 2022 as RNs were experiencing ongoing pandemic impacts. The sociodemographic characteristics of RN leavers, including those who changed jobs, left the profession, or retired, did not significantly change from 2018 to 2022, although the decreased proportion of White leavers in 2018 compared to 2022 indicates a potential loss of diversity among experienced RNs. Within each specific racial and ethnic group, the percentage of RN leavers increased significantly, either approaching or exceeding the doubling seen in the overall workforce (Table 2). Groups with the highest increases in the percentage of leavers were AIAN/NHPI RNs (15.2 pp), Multiracial RNs (16.0 pp), and Hispanic RNs (18.4 pp).
Table 3.
Job status of registered nurse workforce and entrants, 2018 and 2022.
| Percent of total workforce | Percent of entrants | |||
|---|---|---|---|---|
| 2018 | 2022 | 2018 | 2022 | |
| N | 2 899 043 | 3 065 868 | 207 045 | 226 028 |
| Stayed in primary job | 87.1 | 73.5 | 83.0 | 63.6 |
| Left primary job | 12.9 | 26.5 | 17.0 | 36.7 |
| Changed primary job | 10.2 | 22.6 | 16.5 | 34.9 |
| Left nursing profession | 1.4 | 2.1 | 0.6 | 1.5 |
| Retired | 1.3 | 1.8 | 0 | 0 |
Entrants are respondents who indicated they had received their first registered nursing license in the 2 years preceding the survey (ie, 2016 or 2017 for 2018 survey and 2020 or 2021 for 2022 survey). Leavers indicated that they were working in a primary job as of December 31 in the year prior to the survey (ie, 2017 or 2021) but had left that job at the time of the survey. Bolded numbers indicate a significant difference (P < .05) in the percent within the category from 2018 to 2022.
Among RN leavers, the rates of RNs retiring or leaving the profession were largely unchanged between 2018 and 2022 (Table 3). Among RN entrants, rates of leaving for any reason significantly increased from 17.0% in 2018 to 36.7% in 2022, with a 0.9 pp increase in job entrants who left the nursing profession altogether.
Reasons for leaving
Registered nurse leavers commonly cited well-being, safety, work environment, pay, life issues, and career decisions as reasons for leaving. Among RNs who switched jobs, frequently cited reasons included work environment (60.0%), well-being (54.4%), and safety (53.2%) as the top 3 reasons for leaving their job in 2022, with notable increases in the percentage citing well-being and safety as compared to 2018 (Supplement 3). The top 3 rationales among leavers who left the profession of nursing (excluding retirees) were well-being (58.1%), life reasons (50.1%), and work environment (46.0%). Other frequently cited reasons in both years included pay and career moves.
Factors associated with leaving
In a logistic regression analysis of respondents from 2022 (Table 4; Supplement 4), the odds of leaving a job for any reason were significantly higher among Hispanic RNs compared to non-Hispanic RNs (OR 1.38, 95% CI: 1.10, 1.74), RNs with an associate degree or lower vs those with a bachelor's degree or higher (OR 1.16, 95% CI 1.02, 1.32), and new RN entrants (2 years or less) compared to those in the profession for more than 2 years (OR 1.30, 95% CI: 1.05, 1.62). There were significantly decreased odds of leaving a job among RNs aged less than 35 years compared to 35 or more years old (OR 0.50, 95% CI: 0.44, 0.56), RNs educated outside the United States vs in the United States (OR 0.62, 95% CI: 0.44, 0.88), RNs working full time vs part time (OR 0.83, 95% CI: 0.72, 0.97), and those working in indirect care (OR 0.49, 95% CI: 0.36, 0.65) or ambulatory care (OR 0.80, 95% CI: 0.71, 0.91) vs inpatient medical care. These trends were similar to those in 2018, when there were also significantly higher odds of leaving for RNs working in LTC/behavioral/home settings vs inpatient medical care (OR 1.47, 95% CI: 1.21, 1.79) and lower odds of leaving for female RNs vs male RNs (OR 0.77, 95% CI: 0.61, 0.97).
Table 4.
Factors associated with registered nurses leaving a job, 2018 and 2022.
| 2018 | 2022 | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Category (reference) | OR | SE | t | P > t | 95% CI | OR | SE | z | P > z | 95% CI | ||
| Age group (<35) | ||||||||||||
| 35+ | 0.60 | 0.06 | −5.03 | 0.00 | 0.49 | 0.73 | 0.50 | 0.03 | −10.80 | 0.00 | 0.44 | 0.56 |
| Sex (male) | ||||||||||||
| Female | 0.77 | 0.09 | −2.22 | 0.03 | 0.61 | 0.97 | 1.01 | 0.10 | 0.11 | 0.91 | 0.83 | 1.23 |
| Race (White) | ||||||||||||
| AIAN/NHPI | 1.68 | 0.63 | 1.39 | 0.17 | 0.80 | 3.55 | 1.25 | 0.36 | 0.79 | 0.43 | 0.72 | 2.19 |
| Asian | 0.96 | 0.21 | −0.19 | 0.85 | 0.62 | 1.49 | 0.82 | 0.12 | −1.31 | 0.19 | 0.61 | 1.10 |
| Black | 1.14 | 0.16 | 0.94 | 0.35 | 0.86 | 1.51 | 1.16 | 0.14 | 1.27 | 0.20 | 0.92 | 1.46 |
| Multiracial | 0.84 | 0.19 | −0.80 | 0.42 | 0.54 | 1.30 | 0.96 | 0.20 | −0.18 | 0.86 | 0.64 | 1.45 |
| Ethnicity (non-Hispanic) | ||||||||||||
| Hispanic | 1.22 | 0.21 | 1.12 | 0.27 | 0.86 | 1.72 | 1.38 | 0.16 | 2.77 | 0.01 | 1.10 | 1.74 |
| RN education (bachelor's degree or higher) | ||||||||||||
| Associate degree or lower | 1.31 | 0.10 | 3.55 | 0.00 | 1.13 | 1.52 | 1.16 | 0.08 | 2.22 | 0.03 | 1.02 | 1.32 |
| Education location (US) | ||||||||||||
| Not in US | 0.65 | 0.24 | −1.19 | 0.24 | 0.32 | 1.33 | 0.62 | 0.11 | −2.68 | 0.01 | 0.44 | 0.88 |
| Workforce entrant (not entrant) | ||||||||||||
| Entrant within 2 yrs | 1.24 | 0.17 | 1.57 | 0.12 | 0.95 | 1.63 | 1.30 | 0.14 | 2.42 | 0.02 | 1.05 | 1.62 |
| Work status (full time) | ||||||||||||
| Part time | 0.95 | 0.09 | −0.51 | 0.61 | 0.78 | 1.16 | 0.83 | 0.06 | −2.38 | 0.02 | 0.72 | 0.97 |
| Work setting (inpatient care) | ||||||||||||
| Indirect care | 1.13 | 0.24 | 0.58 | 0.57 | 0.74 | 1.74 | 0.49 | 0.07 | −4.91 | 0.00 | 0.36 | 0.65 |
| Ambulatory care | 0.73 | 0.06 | −3.98 | 0.00 | 0.62 | 0.85 | 0.80 | 0.05 | −3.39 | 0.00 | 0.71 | 0.91 |
| Long-term care/behavioral health/home health | 1.47 | 0.15 | 3.86 | 0.00 | 1.21 | 1.79 | 1.09 | 0.10 | 0.96 | 0.34 | 0.91 | 1.31 |
| Remote/telehealth | 0.66 | 0.37 | −0.74 | 0.46 | 0.22 | 1.99 | 0.53 | 0.19 | −1.76 | 0.08 | 0.26 | 1.08 |
| Rurality (in rural area) | ||||||||||||
| Not in rural area | 0.98 | 0.09 | −0.20 | 0.84 | 0.82 | 1.17 | ||||||
| _cons | 0.19 | 0.03 | −11.01 | 0.00 | 0.14 | 0.26 | 0.51 | 0.07 | −5.17 | 0.00 | 0.40 | 0.66 |
Bold number indicate significance at P < .05. Rurality is not available in 2018 data.
Abbreviations: AIAN/NHPI, American Indian, Alaska Native, Native Hawaiian, Pacific Islander; US, United States.
Sensitivity analysis
As identified by other researchers, NSSRN reports a notably lower percentage of Asian (5.6% vs 9.3%) and Black RNs (8.2% vs 12.0%) and a higher percentage of AIAN/NHPI (1.2% vs 0.5%), Multiracial (5.0% vs 3.9%), White (80.1% vs 74.5%), and Hispanic RNs (10.8% vs 7.4%), compared to ACS in 2018 (Supplement 5). The gap between ACS and NSSRN in 2022 is notably smaller across all racial and ethnic categories except Multiracial RNs, where NSSRN reports a lower percentage compared to ACS (4.9% vs 10.7%), likely due to differences in the survey and whether respondents can write in a race not listed in the question. According to ACS data, the percentage of RNs identifying as White decreased from 74.5% to 67.0% (7.5 pp decrease) between 2018 and 2022, a statistically significant difference. While there were slight increases in percentages across all other racial groups, most of the change between 2018 and 2022 was due to an increase in the percentage of Multiracial RNs (6.8 pp increase). The percentage of Hispanic RNs significantly increased by 1.8 pp (Supplement 5). Altogether, the race distribution in the weighted 2022 NSSRN data compared to the 2022 ACS data does not indicate ongoing significant concern with weighting issues.
Discussion
As of 2022, the RN population is not yet racially and ethnically representative of the US population26 such that AIAN/NHPI (0.9% vs 2.2%) and Black RNs were underrepresented compared to the population (11.7% vs 13.4%), while Asian RNs were overrepresented compared to the population (10.0% vs 6.2%), although the absence of detailed racial categories may obscure larger disparities in representation. The percentage of White RNs in 2022 reasonably represents the population (72.5% vs 73.8%). The share of RNs who were Hispanic in 2022 was around half of the Hispanic US population (9.5% vs 18.7%).
Although the race and ethnicity data in the 2018 NSSRN have been noted as problematic, our study suggests that progress has been made toward increased representation among Black RNs over the 2 survey periods, particularly among RN entrants, and echoes other national nursing studies showing improved representation over the study time period.15 The magnitude of the change is hard to discern since NSSRN data suggest a several percentage point increase, a change that may be overestimated due to weighting issues, while ACS data suggest less only a 0.1 pp increase between years. There continues to be growth in the representation of Asian nurses among RNs. This growth may be tempered by recent immigration policies in the United States that may decrease the future flow of nurses from abroad including the Philippines, a significant source of immigrant nurses in the United States.
While NSSRN data suggest no significant changes, and possibly a decrease, in representation of Hispanic RNs, including when considering the rates of entry and leaving, ACS data suggest an increase in Hispanic representation. In other national surveys, the proportion of Hispanic RNs has been steadily increasing since at least 2015,15 although it does not approach representation proportionate to the share of the US population.26 These findings echo those of health professions more broadly, where Hispanic workers continue to be underrepresented compared to the population in multiple professions, including nursing.27,28 While we cannot reliably interpret our findings as suggesting that representation of Hispanic RNs in the workforce is growing or declining, the representation of the 2022 RN population as well as entrants is concerningly low compared to the general US population.29 More importantly, the significantly higher odds of turnover among Hispanic RNs puts further emphasis on this point. Other research shows disproportionate levels of burnout, depression, intent to leave a job, and lingering stress related to COVID-19 among Hispanic RNs, with the highest rates among younger RNs and those rating their work environment less favorably.30 Together with our findings, these data suggest that programs aiming to increase the representation of Hispanic RNs in the US nursing workforce must be paired with targeted policies that support their well-being, transitions from academia to nursing practice, and recruitment and integration into well-resourced work environments.
Registered nurse turnover rates increased dramatically from 2018 to 2022. The timing of the questionnaire, which asks RNs about jobs held in December of 2021, coincides with a period of turmoil in the nursing workforce. The initial impacts of the pandemic—including illness, burnout, concerns for safety, and high work demands—were exacerbated by ongoing pandemic surges, inadequate staffing and other resources, and an influx of patients whose chronic conditions and preventive care needs had been delayed.31-33 With staffing shortages throughout the nation, RNs had high job mobility and increasing incentives to join different organizations.32 Interestingly, while turnover rates considerably increased between 2018 and 2022, the percentage of RNs leaving the nursing profession altogether did not signal significant workforce attrition. Rather, this pattern reflected a high-level of churn whereby RNs were switching jobs more frequently than in prior years, particularly when examining the rate of switching among entrants alone, which deserves more attention. The level of churn was similar across racial and ethnic groups, with Asian RNs experiencing the least amount of movement. Registered nurses who switched jobs frequently cited work environment, well-being, or safety at work as their reasons for leaving, with well-being and safety increasing between years, likely due to the impacts of the pandemic on job demands and burnout.32,34 Previous data indicate that RNs from diverse racial and ethnic backgrounds more often experience discrimination in the workplace, so efforts to enhance retention need to address work environments and policies that negatively impact underrepresented RNs.35-37 Future research should seek to unpack specific issues in work environments contributing to concerns with well-being and safety, factoring in sociodemographic characteristics where possible, and differentiating between causes of turnover and attrition.
Implications for research and policy
There are positive signs that there is improving diversity of RNs in the workforce, particularly among entrants, which follows several decades of work focused on improving access to a nursing career for individuals from racially and ethnically diverse backgrounds, and suggests that policies and programs have been effective in recruiting and retaining some groups of underrepresented RNs.37-39 At the state level, multifaceted mechanisms such as funding, reimbursement, and encouragement lead to more substantial and lasting gains in improving representation in the workforce.13,40 In the current political milieu, the future of federal programs such as HRSA's Nursing Workforce Diversity grant program has an uncertain future, so additional funding of programs and progress toward improved representation of the nursing workforce requires innovative investments by states or organizations and focused advocacy by healthcare organizations that support workforce diversity in alignment with current federal law.41 In addition to federal and state programs that support increased representation among nurses, organizations should offer mentorship, career development opportunities, and other supports to improve retention of nurses from underrepresented groups.
Effective policy advocacy and programming need research that examines links between workforce representation and improved outcomes for patients. Despite national and statewide efforts toward ensuring that the RN workforce represents the population,42,43 there are limited available data on the concordance of RN and patient race and ethnicity at the county or community level. Future research should aim to better understand the racial and ethnic diversity of RNs within smaller geographic regions and how the extent to which they mirror the population may impact access, care delivery, and outcomes for those communities. In addition, other individual characteristics such as different gender identities and disabilities should be examined in the workforce, as racial and ethnic concordance is only a single component of ensuring that the RN workforce represents the communities it serves.
Limitations
There are several limitations to using the NSSRN data. As previously noted, there were some noted weighting issues with the 2018 dataset which led to concern about underrepresented Black RNs and overrepresented Hispanic RNs;25,29 these irregularities could lead to inaccurate identification of workforce trends for those groups when comparing 2018 data to other years. Comparing NSSRN data with ACS suggests that the 2022 weights may not be as much of a problem as in 2018, though more attention is needed as to how Multiracial individuals are measured in NSSRN. In this study, providing data from both 2018 and 2022 lays the groundwork for future analysis tracking sociodemographic shifts, where reliance on the 2022 data as a baseline mitigates concerns about the 2018 weighting issues. In general, NSSRN sample sizes are limited for some racial groups, necessitating that groups are combined and potentially obscuring important shifts or differences in smaller groups, which may be compounded by the use of a “Multiracial” response in lieu of participants selecting a primary racial identity. However, the collapsed categories used in this NSSRN (AIAN, Asian, Black, NHPI, Multiracial, and White) are the same as those in the Census data,27 so it is reasonable to make general comparisons about representativeness. Because the NSSRN data are based on a survey, they are also subject to nonresponse bias; survey weighting has accounted for sampling and response bias in multiple steps.44
Conclusion
The RN workforce better represented the racial diversity of the US population in 2022 than in 2018, suggesting improved opportunities and support for obtaining nursing education for RNs in those groups. However, the high rates of turnover in the overall RN workforce and particularly among entrants signal a need for ongoing efforts focused on improving work environments and initiatives to retain RNs and protect their safety and well-being. Continued improvement in nursing workforce representation requires ongoing investment in policies and programs that support recruitment and retention of RNs from all identities and backgrounds. Strategies for improving representation will diversify the voices and experiences that shape the RN workforce, promoting collaboration to identify priorities for the profession and offer different solutions and innovations for issues within healthcare.
Supplementary Material
Contributor Information
Kyla F Woodward, Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA 98195, USA; Department of Family Medicine, Center for Health Workforce Studies, University of Washington, Seattle, WA 98195, USA.
Sue Skillman, Department of Family Medicine, Center for Health Workforce Studies, University of Washington, Seattle, WA 98195, USA.
Bianca K Frogner, Department of Family Medicine, Center for Health Workforce Studies, University of Washington, Seattle, WA 98195, USA.
Supplementary material
Supplementary material is available at Health Affairs Scholar online.
Funding
This manuscript was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $511 451 with zero percentage financed with nongovernmental sources. The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US government. For more information, please visit HRSA.gov (https://www.hrsa.gov/grants/manage/acknowledge-hrsa-funding).
Data availability
NSSRN data are publicly available from https://data.hrsa.gov/topics/health-workforce/nchwa/nursing-workforce-survey-data.
Notes
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
NSSRN data are publicly available from https://data.hrsa.gov/topics/health-workforce/nchwa/nursing-workforce-survey-data.