it take for the RN workforce respond in kind, and what are the implications for workforce planning? Viewing the future RN workforce through the lens of health reform would significantly recharacterize the supply shortage and thus redirect policy actions to build, skill, and distribute an RN workforce that can meet the demands of a reformed health care delivery system (Bovbjerg et al., 2009).

Increasing the presence of RNs in settings and positions that will assist the development of care management initiatives will require preparing RNs to direct team-based care management strategies and transitional care from ambulatory care practices, and reassessing the need for a growing share of the nurses to fill staffing vacancies in hospitals. Hospital vacancy rates derive from staffing levels that vary significantly across regions (Figure F-2), and across hospitals within regions, and are largely determined locally based on an estimate of the number of nurses needed to meet some predetermined ideal threshold (Goldfarb et al., 2008). Grumbach and colleagues (2001) remark on the absence of widely accepted standard for what constitutes adequate RN staffing levels in hospitals. A review of the evidence on the outcomes of RN staffing levels in hospitals does not produce a staffing rate or configuration that consistently yields positive outcomes, in spite of substantial cross-sectional associations between the number of RNs and hospital patient outcomes (Kane et al., 2007; Lankshear et al., 2005). Nonetheless, vacancy rates—which are widely accepted as evidence of supply shortages of RNs—continue to be used in workforce planning efforts to estimate the shortfall in hospital RNs and drive policy action and educational system re-

FIGURE F-2 Geographic variation in rates of hospital-based RNs per 1,000 population (2006).

FIGURE F-2 Geographic variation in rates of hospital-based RNs per 1,000 population (2006).

SOURCE: Goodman et al., 2009. Reprinted with permission from the Dartmouth Atlas Project, 2009. Copyright 2009 by the Trustees of Dartmouth College.



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