Finding ways to recruit and retain frontline long-term care workers has become a priority for many states. State initiatives have focused primarily on certified nurse assistants, home health aides, and personal care assistants, although some states are implementing legislative agendas for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). For all levels of long-term care workers, such efforts include improving wages and benefits, developing additional training and opportunities for career advancement, and creating additional employee supports.1 The Paraprofessional Health Care Institute and the North Carolina Department of Health and Human Services recently collected information on workforce development activities from all 50 states. In addition, the American Nurses Association and the Health Policy Tracking Service of the National Conference of State Legislatures are documenting state legislative agendas regarding nurse education, data, studies, and staffing.
Between February and April 2002, the Paraprofessional Healthcare Institute (PHI) and the North Carolina Department of Health and Human Services' Office of Long Term Care (NCDHHS) collaborated to conduct a national survey entitled "2002 National Survey of State Initiatives on the Long-Term Direct Care Workforce." The survey has three primary goals: to obtain updated information from states about public policy actions taken or being considered to respond to shortages of direct care workers, to consolidate information previously collected from states,2 and to solicit comment from states on the effects of the slowing economy on direct care worker shortages.3
The survey was mailed to state Medicaid agencies and State Units on Aging. Some surveys were then redirected to the appropriate state entity to respond. Forty-three states responded to the survey (an 86 percent response rate).
The PHI and NCDHHS report summarizes state initiatives taken to address recruitment and retention of nurse aides and other paraprofessionals, categorized as follows:
The following sections describe some of the activities included in these categories and highlight selected examples of state legislative efforts (see Table A.1 for a summary of individual state legislative activity).
Initiatives in this category include wage increases, with and without wage pass-throughs; mandating shift differentials in reimbursement rates; establishing living wage initiatives; helping workers obtain health insurance; and providing job enhancements such as bonuses, childcare assistance, and transportation assistance. Wage pass-throughs refer to an earmarking of a reimbursement increase from a public long-term care funding source to be used to increase wages or benefits for frontline workers.4 As of 2002, 34 states had established some form of a wage pass-through, wage supplement, or related program for nurse aides and other direct care staff.5 California has a wage pass-through in nursing facilities, and Massachusetts approved $35 million in wage pass throughs for CNAs in nursing facilities in fiscal year 2000. Massachusetts also has a separate wage pass through for home care only. In Maryland during the fiscal year 2002, $20 million was added to nursing home reimbursement to improve compensation (wages or benefits) and staffing levels for direct care workers. An additional $20 million increase is planned for FY03. Maryland is also taking on a multi-year effort to bring wages of community workers who serve people with developmental disabilities into parity with their counterparts in state residential centers. Michigan had a nursing facility wage pass through for a number of years; now, nursing facilities must pay a minimum wage of $8.50 per hour for competency-evaluated nurse aides. Wisconsin established a nursing home wage pass through Medicaid rate increase which may be used for wages, benefits or to increase staff hours.
Other state efforts addressing wages and benefits focus on health insurance, other employment enhancements, and establishing "living-wage" payment levels (a term that generally means jobs that provide wages and benefits high enough to keep a family out of poverty). In New York state, a home care worker rate demonstration was created, which provides $203 million for 3.5 years to home care agencies to increase health benefits for aides. In 2000, the Health Care Reform Act authorized a demonstration project between the New York City Human Resources Administration and the Local 1199 National Benefit Fund to improve the process of using Medicaid to pay health insurance premiums for persons who are eligible for continuation of health insurance coverage after leaving a job as established by the Consolidated Omnibus Budget Reconciliation Act (COBRA). New York State enacted the Health Care Workforce Recruitment and Retention Act of 2002, which will provide $707 million for hospitals, $505 million for nursing homes, and $636 million for personal care services and community health centers over the next three years to increase salaries, training and benefits.
Pennsylvania's direct care worker initiative provides grants for the sign-on and longevity bonuses, along with shift differential rates. Pennsylvania also provides benefit enhancements, including educating consumers and providers about health plan eligibility for low-income workers, developing a resource guide for direct care workers, and providing bonuses to cover travel expenses, to reward workers willing to provide care in hard-to-serve areas, and for attending training programs. The AAA Direct Care Worker Initiative Plan in Pennsylvania provides childcare, transportation, profit sharing, uniform subsidies, and other benefits. In Wisconsin, a rate increase from $12 to $15 for personal care workers was established with the intent of the increase benefitting workers. Also in Wisconsin, health insurance for low-income families was made available through the Badger Care program.6
Training and other initiatives identified in the PHI/NCDHHS survey include establishing new job categories, such as medication aides; expanding the scopes of duty for paraprofessionals; improving professional competency and providing continuing education and training; career ladder initiatives; establishing scholarships, grants and loan forgiveness for people to receive training as long-term care workers; and recruiting welfare recipients or participating in Welfare-to-Work initiatives tied to long-term care. In Massachusetts, the extended care career ladder initiative (ECCLI) is a $5 million program funded by the state's legislature as part of the larger nursing home quality initiative to improve nursing home care. The Commonwealth Corporation, which administers the Workforce Investment Act (WIA), oversees ECCLI. The approach of ECCLI is to establish career ladders and training and support systems for incumbent certified nursing assistants and other entry level nursing home workers. The initiative aims to increase the supply and quality of nurse aides as well as address the nursing shortage by "growing the profession from within."7
Professional competency training and continuing education is the most common activity used by states. Massachusetts allocated $1 million for CNA training scholarship funding. The SFY 2002 budget contains $100,000 for supervisory training for nursing home administrators and managers, $1 million for entry level training scholarships for direct care workers (including English as a second language and adult basic education), and $5 million for career ladder development for nursing homes. Michigan provides additional training and testing for nurse aides and $1.7 million (of the allocated $7.4 million Long-Term Care innovation grants) is for staff development and training initiatives. The staffing workgroup in Michigan is collaborating with community colleges regarding long-term care workers career ladder development. In New York, the Health Care Reform Act of 1996 established the workforce retraining initiative, which supports the retraining of eligible heath workers to transition to new jobs within health care ($15 million was available in 1997-1998 and $30 million was added in 2000). Also in New York, hospitals receiving more than $1 million in funding from the community heath care conversion demonstration program are required to spend at least 25 percent of their funds on workforce retraining projects. Facilities receiving less than $1 million must spent at least 10 percent on retraining. This requirement resulted in $60 million being allocated toward training in the first year. Pennsylvania's Area Agency on Aging Direct Care Worker Initiative allocates funding for: specialized training (includes supervisory skills, one day seminars, best practices, etc.), life skills training (includes communication, conflict resolution, appropriate working attire, etc.), mentoring assistance, basic skills at vocational training, and providing tuition assistance. Wisconsin is aiming to increase the minimum training hours (75 hours presently) and develop personal care worker competency testing. The Wisconsin Alzheimer's Institute developed a worker education, training, and assistance program to improve the quality of care in long-term care facilities.8 Wisconsin also established formal guidelines and parameters for training unlicensed workers to work as medication aides and recognized this worker category in nursing homes, community based residential facilities, and hospices.
Thirty-five states have formed at least one task force to address recruitment and retention of direct care workers and half of these states have issued reports on the topic. In 2002, Massachusetts intends to establish both a commission to study the future of long-term care and the long-term care workforce; and an Advisory Council on Quality of Care in nursing homes to address staffing, recruitment, retention, workforce development, budget, policy, and other issues. Maryland established the Statewide Commission on the Crisis in Nursing in 2000, which addresses the state nursing shortage. The state also has a Nursing Home Report Card Steering Committee (1999) and an Oversight Committee on Quality of Care in Nursing Homes (2000). Pennsylvania established its Council on Long-Term Care to highlight workforce problems from the provider/caregiver perspective. The Direct Care Work Group in Pennsylvania is working on apprentice program development and plans to improve recruitment and retention. Pennsylvania's Intra-Governmental Council on Long Term Care issued two reports in 2001 which document the direct care worker shortage.9 In Wisconsin, the Workforce Development Workgroup was formed to identify strategies to meet increasing demands for direct care workers. The group made recommendations and issued a report in 2000.10
In order to improve the quality of care in nursing homes, several states are considering increasing or establishing minimum staffing ratios. These initiatives will increase the demand for certified nursing assistants. Recently adopted state regulations regarding staffing ratios for long-term care facilities are summarized in Table A.1.
| TABLE A.1: Selected State Initiatives on Staffing Ratios in Nursing Homes | |
|---|---|
| State | Staffing Ratios |
| California | (For Nurses) Skilled Nursing Facility
(SNF) -- 3 hr/patient day SNF special -- 2.3 hr/patient day Nursing Facility (NF) -- 1.1 hr/patient day NF developmentally disabled -- 2.7 hr/patient day |
| Florida | CNA -- 2.3 hr/patient day began on
1/1/02 Licensed nursing staff -- 1.0 hr/patient day began on 1/1/02 Increase to 2.6 by 1/1/03 and to 2.9 by 1/1/04. No facility below 1 CNA per 20 residents. Licensed Nurses 1 hour direct care per resident per day with never less than 1 per 40 residents |
| Massachusetts | Level I Care -- 2.6hr/patient day (0.6hr
by licensed personnel) Level II Care -- 2hr/patient day (0.6hr by licensed personnel) Level III Care -- 1.4hr/patient day (0.4hr by licensed personnel) Level IV Care -- 1-20 beds (1:10 day shift), 20+ beds (1 responsible person 24/7) |
| Maryland | Comprehensive Care
Facilities: 1 Full Time (FT) RN (2-99 residents) 2 FT RNs (100-199 residents) 3 FT RNs (200-299 residents) 4 FT RNs (300-399 residents) Ratio no less than 1:25 for nursing personnel |
| New Jersey | 2.5 hr/day (extra staffing required for complex patients) |
| North Carolina | 2.1 hr/patient day All licensed adult care homes/nursing homes must publicly post the number of direct care staff and supervisors on shift |
| Pennsylvania | 2.7 hr/day -- skilled patients 2.3 hr/day -- intermediate care patients1 |
| Wisconsin | Intensive SNF Care -- 3.25 hr/pt day
(0.65 hr RN or LPN) SNF Care -- 2.5 hr/pt day (0.5 hr RN or LPN) Intermediate or Limited Nursing Care -- 2hr/pt day (0.4 hr RN or LPN) |
Source: Paraprofessional Healthcare Institute.
National Survey on State Initiatives to Improve Paraprofessional Healthcare
Employment,
http://www.directcareclearinghouse.org/Documents/National_Survey_on_State_Initiatives.htm.
|
|
Systems Change Grants provide funding for states to design and implement improvements in community long-term support systems in partnership with their disability and aging communities. The 36-month grants, awarded by the Centers for Medicare & Medicaid Services (CMS), will help states enable people with disabilities to reside in their own homes and participate fully in community life.
Grants have been awarded to the following jurisdictions: Alaska, Alabama, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Maryland, Maine, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, Nevada, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Virginia, Vermont, Washington, Wisconsin and West Virginia. Other entities receiving grants include: the Rutgers Center for State Health Policy in New Jersey, the Independent Living Research Utilization program and the Austin Resource Center for Independent Living in Texas, the Mid-Alabama Chapter of the Alabama Coalition of Citizens with Disabilities, the Great Rivers Independent Living Center in Wisconsin, the Making Choices for Independent Living in Maryland, and DisABILITY LINK in Georgia.11
In Maryland, the Systems Change Grant includes $60,000 over three years to fund and promote 'job fairs' to recruit potential home and community-based services (HCBS) waiver personal care providers, to complete paperwork, and to meet training qualifications. These fairs include free CPR/first aid training and reduced cost criminal background checks. In Michigan, a Systems Change grant has a consumer cooperative initiative that proposes to give consumers and families greater control over direct care services. The Texas Planning Council for Developmental Disabilities and the Department of Human Services are using system change grants for recruitment efforts targeting traditionally underemployed workers (i.e., older workers, participants in full-time volunteer programs, people with disabilities, non-English speaking individuals, welfare-to-work participants); the development of college courses offering field work credit for supervised personal assistance experiences; the coordination of efforts to develop and promote a professional association for personal attendants at a local or regional level to increase retention of those currently employed in the field and to recruit and train new attendants; the formation of partnerships with public and/or private workforce agencies or home health organizations to train and place personal assistants; and utilization of marketing strategies for recruitment efforts in a local or regional area. In Wisconsin, a long-term workforce planner is to be hired to provide policy direction and program planning relating to recruitment and retention. The Systems Change grant in Wisconsin also will be used to identify approaches for training and supporting workers and collaborating with the Department of Workforce Development.12
Other initiatives reported by states to address recruitment and retention of direct care workers include improving data collection, establishing worker recognition programs, and funding quality of life initiatives (a general term used to describe services such as daycare, transportation, etc.).13 For example, Georgia is collecting data regarding vacancy rates and average turnover time through the Georgia Division of Health Planning Annual Survey. The first statewide professional association for direct care workers was established in Iowa. The Iowa CareGivers Association's goal is to partner with providers, educators, policy makers, advocates, labor and others to develop a network of support, recognition, education and advocacy. Activities include a series of direct care forums, the CAN Recruitment and Retention Program, leadership training, research, information, and referral. Beginning in 2001, North Carolina is collecting annual data and conducting an analysis of basic turnover data on direct care workers in nursing homes, adult care homes and home care agencies, using a standard set of questions. The Virginia Board of Nursing mandated data collection efforts on aide recruitment and retention.
Massachusetts appropriated $5 million in FY2001 to develop an initiative for recruitment and retention strategies (a part of the overall EECLI quality of care enhancement program). Pennsylvania launched a marketing campaign focusing on the value of direct care workers, a Recognition Day with monetary bonuses for designated workers, an emphasis on public awareness of home care and care giving, and some technical assistance with CareerLink14 networks. The Wisconsin Care Giver Association (WCGA) promotes the well-being of care professionals through advocacy, education, and collaboration with other organizations. The Long Term Care Workforce Alliance in Wisconsin works to enhance the role and status of long term care workers and to raise awareness within the community and with policy makers. The Wisconsin Aging Network sponsors Caregiver of the Year and Cornerstone of the Year awards (for a supervisor or an organization). Finally in Wisconsin, the Care Giver Association sponsors a mentoring program for direct care workers.13
With respect to quality of life issues, Pennsylvania conducted follow-up focus groups with direct care workers, and a report will be forthcoming. Also in Pennsylvania, $1.5 million was allocated for demonstration projects targeting quality of life concerns for direct care workers. The AAA Direct Care Worker Initiative plans in Pennsylvania fund numerous projects related to bonuses, training, benefits, and marketing for the direct care industry.
State activity regarding shortages of registered nurses and licensed practical nurses tends to cut across service providers and not be targeted specifically to long-term care services. Constituent member associations of the American Nurses Association (ANA) are working together to implement a nationwide state legislative agenda on nurse staffing, and progress is being tracked by the ANA. Another source of information on state legislative activity is the Health Policy Tracking Service of the National Conference of State Legislatures, which monitors state government activities aimed at easing the nursing shortage (see Table A.1 for a summary of individual state legislative activity). State legislative priorities include the following:15
Nursing Education Incentives: Approaches include offering student loan forgiveness, grants, and scholarship programs, as well as provisions of funds to schools of nursing to expand nursing programs, staff, and faculty.
Collecting Nursing Supply and Demand Data: Data collection is important for states to accurately assess the nursing shortage and develop comprehensive short and long range state workforce planning strategies.
Nursing Workforce Studies/Task Forces: With concerns about a shortage of nurses, commissions, task forces or councils are being formed to study the nursing and to make recommendations to state officials.
Nurse Staffing Minimums: In order to improve the quality of care, several states are considering increasing or establishing minimum staffing ratios.
Some examples of state legislative activity are described below. The examples are highlights of state activities, and therefore are only select illustrations of efforts aimed at easing the shortage.
Some states have proposed pilot programs to offer high school students special placement in associate degree programs or are extending recruitment efforts to primary and secondary schools. Other legislation would provide money to health care facilities to establish education programs in nursing specialty areas that are in short supply. Further, legislation has also been proposed that would allow tax credits on tuition paid for nursing educational programs, provide nursing education money under the state's welfare to work plan, and maintain eligibility for unemployment benefits for people participating in training programs leading to licensure as a registered nurse.
The following legislation has been enacted in 2002: Arizona established a five year plan to increase the number of nurses who graduate from nursing programs in Arizona.16 In California, the chancellor of community colleges is required to provide grants to community college districts to develop curricula and pilot programs that provide training to licensed nurses in specialty areas.17 The Florida legislation created a grant program for school districts to establish an pilot nursing program in middle schools and a career and technical education program in high schools, to promote a smooth transition to post secondary education or employment.
Kentucky legislation creates the Nursing Workforce Foundation to provide funding and award grants to nursing education programs and nursing employers for the recruitment of students. The Foundation will award nursing scholarships and loan repayment programs for nurses including the training of registered nurses who are pursing advanced degrees to become nursing faculty. Louisiana legislation establishes a commission to address, among other things, the education of future health care workers.16 Massachusetts legislation appropriates funds for higher education scholarships and loans, with eligible programs including schools of nursing.17 Two South Dakota bills revise provisions regarding the state's nurses' education assistance loan program by funding up to $5,000 in tuition reimbursement for nurses who practice for two years and makes an appropriation to expand the nursing programs at South Dakota's public universities. Virginia legislation allows part-time nursing students to be eligible for scholarship and loan repayment programs, while West Virginia legislation creates a scholarship program for persons pursing a master's degree in nursing ($10,000) or a fourth year medical student ($20,000) who agrees to practice at least two years in a medically underserved area in West Virginia or a nurse who agrees to teach for two years at a school of nursing.16
Ten states have enacted legislation directing the collection of data on the nursing labor market and an additional five states have introduced similar legislation. For example, in 2002, legislation was enacted in Georgia that requires health care licensure boards to distribute survey questions to gather data related to work force supply and demographics. The questionnaires will include questions about work place and practice settings, current practice by specialty, geographical location and future practice plans. The Office of the Secretary of State will submit the collected data to the University of Georgia or another recognized agency to project trends and needs for the state's health care workforce. Legislation enacted in South Dakota establishes a nursing workforce center under the direction of the Board of Nursing. The center will be funded by nurse licensure renewal fees. The center may address issues regarding the supply, demand, and need for nurses, including issues of recruitment, retention, educational preparation and utilization of nurses.
Legislation enacted in 2001 in Mississippi directs the Office of Nursing Workforce to ensure an adequate supply of nurses. Legislation passed in North Dakota and Tennessee allows the board of nursing to address issues of supply and demand for nurses including issues of recruitment, retention and utilization of nurses. Florida and Texas laws establish independent Centers for Nursing to carry out goals which include the development of a strategic statewide plan for the nursing workforce in the state. This legislation is based on the North Carolina Center for Nursing, which was established in 1991. The North Carolina Center is the first state-supported agency charged with nurse workforce planning, including issues of nursing supply, demand, recruitment and retention.18
Many states do not have the structure in place to collect and analyze nursing workforce data, but they have commissioned studies or task forces to address specific information needs. California legislation requires the Postsecondary Education Commission to conduct a review and analysis of California community college districts' admission procedures and attendance rates for their two-year associate degree nursing program.19 In 2001, legislation passed in Arkansas that requires the Arkansas Legislative Commission on Nursing to submit a strategic plan for meeting the workforce needs of the state to the Legislative Council. New Hampshire enacted legislation that requires a taskforce to make recommendations on recruitment and retention of health care providers. Legislation enacted in Pennsylvania directs the House Professional Licensure Committee to conduct hearings on the shortage of licensed health care professionals and report its findings and recommendations to the House. Two bills passed in Virginia require the Virginia Partnership for Nursing to conduct a study of the availability and adequacy of nursing education programs. The Virginia bills also establish a 24-member advisory council to assist the Secretaries of Education and Health and Human Services to resolve the nursing shortage and recommend resolutions for issues pertaining to nurse education, recruitment and retention. A bill signed into law in West Virginia requires a commission to study the nursing shortage and make recommendations to the legislature on how to reverse the shortage.18
The "Principles for Nurse Staffing," was developed by an expert panel convened by the American Nurses Association (ANA) and adopted by the ANA Board of Directors in 1998.20 The principles provide recommendations for appropriate staffing to provide a safe environment for nurses and patients, and have encouraged state legislative activity related to nurse staffing. As noted in the discussion of legislative initiatives regarding paraprofessionals, a number of states have adopted regulations regarding staffing for long-term care facilities, and some of these regulations address staffing for RNs and LPNs as well as paraprofessionals.
In 1998, Kentucky and Virginia passed the first legislation aimed at nurse staffing. In 1999, California passed legislation to require nurse-to-patient ratios in acute care hospitals. New Hampshire approved data collection on the rates of RNs per hospital bed. New Mexico agreed to study the education and training mix necessary for personnel to meet state health care demands, and Rhode Island began a study on patient care and nurse staffing in acute care hospitals. Legislation enacted in 2001 in Oregon requires hospitals to create and utilize nurse staffing plans and develop internal review processes.21
U.S. General Accounting Office. Nursing Workforce Recruitment and Retention of Nurses and Nurse Aides is a Growing Concern, May 17, 2001.
NCDHHS has published three reports examining state efforts related to nurse aides and other paraprofessional aide workers:
All three publications are available at the NC Division of Facility Services' website http://facility-services.state.nc.us under "For Providers" link.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
Stone, Robyn I. and Joshua M. Wiener. Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis. The Urban Institute and the American Association of Homes and Services for the Aging. October 2001. [http://aspe.hhs.gov/daltcp/reports/ltcwf.htm]
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
Pindus, Nancy, Jane Tilly and Stephanie Weinstein. Skill Shortages and Mismatches in Nursing Related Health Care Employment. The Urban Institute. April 2002.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
Front Line Workers in Long-Term Care: http://www.abramsoncenter.org/PRI/documents/PA_LTC_workforce_report.pdf, and In Their Own Words - Pennsylvania's Frontline Workers in Long-Term Care: http://www.aging.state.pa.us/aging/LIB/aging/20/363/report_care.pdf.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
U.S. Department of Health and Human Services, HHS News Press Release. HHS Helps People With Disabilities Live in the Community, Awards Major Grants. September 2001.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
Harmuth, Susan and Susan Dyson. Results of the 2002 National Survey Of State Initiatives On the Long-Term Care Direct Care Workforce. The Paraprofessional Health Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. May 2002.
CareerLink is Pennsylvania's term for one-stop career centers authorized under the Workforce Investment Act.
Pindus, Nancy, Jane Tilly and Stephanie Weinstein. Skill Shortages and Mismatches in Nursing Related Health Care Employment. The Urban Institute. April 2002.
American Nurses Association. State Legislative Trends. 2002. (Accessed from http://www.nursingworld.org, on 6/25/02).
Health Policy Tracking Service. Providers: Nursing Shortages. National Conference of State Legislatures. April 5, 2002.
American Nurses Association. State Legislative Trends. 2002. (Accessed from http://www.nursingworld.org, on 6/25/02).
Health Policy Tracking Service. Providers: Nursing Shortages. National Conference of State Legislatures. April 5, 2002.
American Nurses Association. State Legislative Trends. 2002. (Accessed from http://www.nursingworld.org, on 6/25/02).
| Return to: |