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State and national data on the Georgia nursing workforce

Published:October 04, 2021DOI:https://doi.org/10.1016/j.outlook.2021.07.005

      Abstract

      Background

      The enduring absence of robust nursing workforce data creates gaps to support evidence-based workforce planning and policy development.

      Purpose

      The purpose of this study was to examine Georgia nursing workforce data available through state and national agencies to determine if significance differences exist among data sources.

      Methods

      A cross-sectional, descriptive analysis of 2017 Georgia nursing workforce data was used to examine and compare workforce characteristics available from five data sources. The advantages and limitations of each data source were reviewed.

      Findings

      Significant differences were noted in the quality and quantity of data collected on the Georgia nursing workforce as reported by state and national agencies. None of the datasets include in our analysis had comprehensive and timely data on the Georgia nursing workforce.

      Discussion

      Nursing workforce stakeholders must work collaboratively to require and implement a comprehensive re-licensure survey. It is only though a standardized national minimum dataset that we can ensure an adequate nursing workforce.

      Keywords

      Introduction

      Since the Institute of Medicine (IOM) released its report on the Future of Nursing in 2011, the demand for accurate and robust nursing workforce data has rapidly increased to improve healthcare assessment and planning (
      • Institute of Medicine
      Institute of Medicine
      The future of nursing: Leading change, advancing health.
      ;
      • Spetz J.
      • Cimiotti J.P.
      • Brunell M.L.
      Improving collection and use of interprofessional health workforce data: Progress and peril.
      ). Unfortunately, according to the Committee for Assessing Progress on Implementing the Future of Nursing recommendations, “little progress has been made on building a national infrastructure that could integrate the diverse sources of health workforce data, identify gaps, and improve and expand usable data not just on the nursing workforce but also on the entire health care workforce.” (

      Institute of Medicine. (2015). Assessing progress on the Institute of Medicine report. The Future of Nursing. Washington, D.C.: National Academies of Sciences, Engineering, Medicine.

      ; p.S-12). The enduring absence of robust nursing workforce data jeopardizes policies that determine the RN pipeline at both levels of states and nationwide. The absence of data is acutely more evident when the nationwide pipeline of RNs is threatened.
      Although several agencies, such as the National Council of State Boards of Nursing (NCSBN), the Health Resources and Services Administration (HRSA), and the United States (U.S.) Census Bureau, have collected national data on registered nurses (RNs), we know of no other national agencies that publish publicly available data annually with overviews of the RN workforce that provide timely information for workforce planning. Moreover, the findings from all these national RN surveys make it challenging to inform state-level policy-making due to the small samples of RNs surveyed from each state. At the state level, boards of nursing typically use required data from initial licensure as well as re-licensure and various re-licensure surveys to collect additional information beyond the RN contact information. Unfortunately, these surveys vary widely in quality and consistency, and some are voluntary, making the comparison with national-level reports difficult. Furthermore, few studies have assessed data collected at the state level and how those state data compare with national data.
      This study aimed to compare the quality of five state and national data sources for the Georgia RN workforce. It highlights the significant differences among the estimates generated from these data sources and the gaps in data collected, emphasizing the need for improved and nationwide standardization of data collection efforts.

      Background

      State-Level Data Sources

      At the state level, there are generally two available data sources that describe the RN workforce. One is the state licensure data which includes a roster of all RNs licensed to practice in each state and territory. These rosters typically require RNs’ limited information such as name, address, year of the first license, and current license expiration date, if applicable.
      The second source of state-level data that describes the RN workforce with more depth and breadth is the survey that is typically part of the nurse re-licensure process - a survey that is often voluntary. However, these surveys are inconsistent across states, and their content and quality vary widely (
      • Spetz J.
      The research and policy importance of nursing sample surveys and minimum data sets.
      ;
      • Spetz J.
      • Kovner C.T.
      How should we collect data on the nursing workforce?.
      ). To improve the uniformity of the RN workforce data, the National Forum of State Nursing Workforce Centers (Forum) developed a standard set of survey items referred to as the Nursing Minimum Dataset. These survey items include the Nurse Demand Dataset, the Nurse Supply Dataset, and the Nursing Education Dataset. In whole or in part, these surveys are currently used by many State workforce centers and boards of nursing. The National Forum Nurse Supply Dataset includes a minimum of 20 questions developed in 2008 and revised in 2015 by the Forum. Questions query nurses on demographic characteristics, educational attainment, license type, and employment. The Forum recommends collecting all 20 items to have a nationally standard data source to describe the RN workforce. Currently, 38 out of 50 states are using the National Forum Nurse Supply Dataset items as part of their process to collect data on the RN workforce (

      National Forum of State Nursing Workforce Centers. (2020). Nursing workforce centers location. Retrieved from https://www.nursingworkforcecenters.org/location-map/. (Accessed on November 7, 2020)

      ). For example, in Georgia, the Board of Nursing (GBON) administers a voluntary online survey with the National Forum Nurse Supply Dataset items and additional workforce items during the re-licensure process. Beyond the information included in the National Forum Nurse Supply Dataset, this re-licensure survey in Georgia includes additional items that query nurses on their educational attainment and state(s) of licensure.

      National-Level Data Sources

      Nationally, several agencies routinely collect data on the RN workforce. Funded by the federal government, the National Center for Health Workforce Analysis within HRSA has been conducting the National Sample Survey of Registered Nurses, which was initiated in 1979 and was conducted every four years from 1980 to 2008. After a hiatus of 10 years, the National Sample Survey of Registered Nurses was reinstated in 2018 with an updated questionnaire. The survey now includes items that apply to RNs and advanced practice registered nurses (APRNs) such as the nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, and certified nursing midwife. In addition, the survey queries nurses on demographic characteristics, educational attainment, employment, and practice characteristics. These data provide a basis for estimating the RN workforce, assessing trends, and projecting the future supply of RNs.
      NCSBN compiles data on the RN workforce through the National Nursing Workforce Study. In addition, through a partnership with the Forum, NCSBN surveys a random sample of actively licensed RNs stratified by state and territory. This survey has been conducted every two years since 2013. It contains survey items similar to HRSA's National Sample Survey of Registered Nurses, such as demographic characteristics, educational attainment, employment, and practice characteristics.
      The U.S. Census Bureau collects data on the RN workforce via the American Community Survey, the largest ongoing household survey. Since 2001, the American Community Survey has been used to survey 3.5 million households annually. With its impressive response rate of over 90%, the American Community Survey provides individual and household-level data on demographic characteristics, jobs and occupations, education level, veteran status, housing, and other socioeconomic characteristics. It also includes an exceptionally large sample of RNs that allows investigators to analyze nurse workforce trends with a high degree of accuracy. With its annual sample of roughly 30,000 RNs nationwide, the sample of the American Community Survey is similar in size to both the HRSA's National Sample Survey of Registered Nurses and the NCSBN's National Nursing Workforce Study.
      Over the years, investigators have reviewed the advantages and limitations of state and national-level data sources in their efforts to estimate the supply and demand for RNs and to evaluate educational programs (
      • Nooney J.G.
      • Cleary B.L.
      • Moulton P.
      • Wiebusch P.L.
      • Murray J.L.
      • Yore M.
      • Brunell M.L.
      Toward standardization (part 1): assessment of state and national nursing workforce data sources.
      ;
      • Spetz J.
      The research and policy importance of nursing sample surveys and minimum data sets.
      ;
      • Spetz J.
      • Kovner C.T.
      How should we collect data on the nursing workforce?.
      ). Others have estimated RN workforce characteristics using national-level data, such as the National Sample Survey of Registered Nurses and the American Community Survey (
      • Auerbach D.I.
      • Fau S.D.
      • Muench U.
      • Buerhaus P.I.
      The nursing workforce: a comparison of three national surveys.
      ). However, few studies have comprehensively compared RN workforce estimates using different data sources at the state and national levels.
      Georgia ranks 41 in the number of RNs per capita (790.4 vs. 920.9 of the U.S. average), among the lowest in the U.S. (

      U.S. Department of Health and Human Services. (2013). The U.S. Nursing Workforce: Trends in Supply and Education. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nursingworkforcetrendsoct2013.pdf. (Accessed 8 May 2016).

      ). Georgia is also in the South Atlantic region, where a report has estimated minimal growth (2.9%) of RNs per capita through 2030 (
      • Auerbach D.I.
      • Buerhaus P.I.
      • Staiger D.O.
      How fast will the registered nurse workforce grow through 2030?.
      ). Thus, evidence-based and data-driven RN workforce planning is critical for sustaining a sufficient RN supply and meeting the demand of care. In this current study, we used 2017 data from four agencies to review the data collected by each, examine the advantages and limitations of each dataset, and compare estimates of the supply of RNs and the overall characteristics of the RN workforce in the State of Georgia. The information gained from this study will inform future efforts to ensure consistent and comprehensive data collection efforts of the RN workforce, evidence that could provide the data necessary to sustain the RN workforce in Georgia.

      Methods

      Designand Data Source

      This study was a cross-sectional analysis of five available data sources on the Georgia RN workforce in 2017. Data sources included the GBON state license roster, the GBON voluntary Licensure Renewal Survey, the National Sample Survey of Registered Nurses from HRSA, the National Nursing Workforce Survey from the NCSBN, and the American Community Survey from the U.S. Census Bureau.
      • GBON State License Roster. The GBON has a roster of all RNs that includes required publicly available information such as name, mailing address, license type, license number, license status, original license date, and license expiration date. As of June 30, 2017, 116,924 RNs and 11,545 APRNs were listed as actively licensed with the GBON (GBON, 2018).
      • GBON Voluntary Licensure Renewal Survey. Since Georgia renews half of its RN licenses each year between September and February, we merged survey data from 2017 with survey data from 2018 to obtain a complete dataset. Of the 107,743 actively licensed RNs who renewed their license, only 52,574 RNs and 7,309 APRNs (55.5%) indicated they were employed in Georgia and answered one or more of the renewal survey items.
      • HRSA-National Sample Survey of Registered Nurses. Data from this survey included survey responses from a national sample of 50,273 actively licensed RNs. The survey response rate was 50.1% (

        U.S. Department of Health and Human Services. (2019). Technical Report for the National Sample Survey of Registered Nurses. Retrieved from Rockville, Maryland:

        ). The 940 Georgia nurses who responded to the survey and were employed in Georgia were included in our analysis.
      • NCSBN-National Nurse Workforce Study. Data from the 2017 survey included responses from a national sample of 48,704 RNs. The overall response rate to the survey was 32.8% (
        • Smiley R.A.
        • Lauer P.
        • Bienemy C.
        • Berg J.G.
        • Shireman E.
        • Reneau K.A.
        • Alexander M.
        The 2017 National Nursing Workforce Survey.
        ). Data on the 1,338 RNs who were actively licensed and employed in Georgia were included in our analysis.
      • American Community Survey. The 2017 survey provided 1-year data estimates from Georgia households that allowed us to estimate the number of actively employed nurses in Georgia. The overall survey response rate was 92.7% for households, but the response rate specific to RNs is not known (
        • U.S. Census Bureau
        American Community Survey Response Rates and Reasons for Noninterviews.
        ). For this study, data were retrieved from the Public Use Microdata Sample for the 1,137 individuals residing in Georgia who were currently employed as an RN or APRN.

      Analysis

      Quantitative analyses were conducted to compare the RN workforce estimates using data from the five sources mentioned above. Except for those data from the GBON, all data were weighted for analyses to provide statewide estimates of the Georgia RN workforce. Descriptive statistics were presented as means and standard deviations for continuous data and as numbers and percentages for categorical data. All analyses were computed using STATA/MP version 15.1 (College Station, TX; StataCorp LLC. 2017).

      Findings

      Comparison of Survey Questions

      A summary of RN characteristics collected by each agency is presented in Table 1. HRSA and the U.S. Census Bureau included more data on RN demographic characteristics than the other agencies. The GBON (re-licensure survey), HRSA, and NCSBN collected more data on education, license, and certification. HRSA and NCSBN included more data on RN employment characteristics. Compared with all other agencies, HRSA included more data on RN geographic characteristics, job satisfaction, and intention to leave their position or the nursing and/or health care profession.
      Table 1RN Characteristics Collected by Different Agencies
      GBON
      State License Roster (required).
      GBON
      Re-licensure survey (voluntary).
      HRSANCSBNU.S. Census Bureau
      Demographics
      Age/date of birthXXXX
      Race/EthnicityXXXX
      GenderXXXX
      Marital StatusXX
      Children StatusXX
      Secondary Languages SpokenXX
      Education, License, and Certification
      Entry-level educationXXX
      Year of Finished Entry-Level EducationXX
      Highest educationXXXX
      Year of Finished Highest EducationXX
      Receive entry-level nursing education or license from other countriesXXX
      Non-Nursing DegreeXXX
      State of LicensureXXX
      License TypeXXXX
      Date of original licensureXXX
      Activity status of licenseXXXX
      Additional states of licensureXXX
      License numberXX
      Employment
      Employment statusXXXX
      Reason for unemploymentXXX
      How many positions heldXX
      Primary employment settingXXXX
      Primary employment positionXXX
      Primary employment specialtyXXX
      Primary employment Full-time statusXXXX
      Primary employment status (e.g., nursing, non-nursing)XXX
      Hours worked per wk in primary nursing positionXXXX
      Provide direct patient careX
      Activities of primary employment positionX
      Salary of primary employment positionXXX
      Secondary employment settingXXX
      Secondary employment positionXX
      Secondary employment specialtyXX
      Secondary employment status (e.g., nursing, non-nursing)XX
      Hours worked per wk in secondary nursing positionXX
      Provide direct patient care
      Activities of secondary employment position
      Salary of secondary employment positionX
      Geographic Characteristics
      Employment Address/ZipcodeXXX
      Mailing Address/ZipcodeXXX
      Workforce Outcomes
      Job satisfactionX
      Intention to leaveX
      Reasons for leavingX
      Intention to retireX
      Notes: GBON, Georgia Board of Nursing; HRSA, Health Resources and Services Agency; NCSBN, National Council of State Boards of Nursing.
      low asterisk State License Roster (required).
      Re-licensure survey (voluntary).

      Comparison of Estimates of RN Workforce

      Using data collected by the GBON, HRSA, NCSBN, and the U.S. Census Bureau, we examined how the estimates of RN characteristics differed by source (Table 2). The State License Roster of GBON was excluded from this analysis because it does not provide employment status or include any data on demographic and employment characteristics available from other sources. The GBON voluntary re-licensure survey included data from 59,883 employed RNs, a much smaller number than the estimated numbers reported by other national agencies. HRSA, NCSBN, and the U.S. Census Bureau reported the weighted number of employed Georgia RNs at 92,436, 108,378, and 95,030, respectively. The estimated percentage of APRNs employed in Georgia ranged from 6.2% to 13.6%, percentages similar across data sources, except for U.S. Census Bureau's estimates, which reported a lower percentage of 6.2%.
      Table 2Estimates of Employed RN workforce in GA in 2017
      GBON
      Re-licensure survey (voluntary).
      (N = 59,883)
      HRSA(N = 92,436)NCSBN(N = 108,378)U.S. Census Bureau(N = 95,030)
      Types of License
      RN52,574 (87.8%)83,002 (89.8%)92,421 (86.4%)85,190 (93.8%)
      APRNs7,309 (12.2%)9,434 (10.2%)14,580 (13.6%)5,880 (6.2%)
      Age47.547.249.044.7
      Gender
      Female54,714 (92.2%)85,032 (92.0%)100,116 (92.8%)87,122 (91.7%)
      Male4,647 (7.8%)7,404 (8.0%)7,776 (7.2%)7,908 (8.3%)
      Race
      White-65,943 (71.3%)82,863 (76.4%)61,059 (64.3%)
      Black/African American-21,554 (23.3%)16,848 (15.6%)24,375 (25.7%)
      Other-4,939 (5.3%)8,667 (8.0%)6,678 (10.0%)
      Ethnicity
      Hispanic478 (0.8%)5,631 (6.1%)4,698 (4.3%)2,718 (2.9%)
      Non-Hispanic59,405 (99.2%)86,805 (93.9%)103,680 (95.7%)92,312 (97.1%)
      Level of Education
      Associate or less18,072 (30.2%)31,751 (34.3%)38,475 (35.5%)31,711 (33.4%)
      Bachelor24,218 (40.4%)41,230 (44.6%)47,466 (43.6%)45,963 (48.4%)
      Master8,535 (14.3%)17,847 (19.3%)19,197 (17.7%)16,492 (17.4%)
      Doctorate732 (1.2%)1,608 (1.7%)2,835 (2.6%)864 (0.9%)
      Setting
      Hospital and inpatient36,092 (60.3%)63,342 (68.5%)51,759 (47.8%)63,852 (67.2%)
      Community-based care12,631 (21.1%)15,886 (17.2%)8,991 (8.3%)17,327 (18.2%)
      Other10,002 (16.8%)13,208 (14.3%)45,927 (42.4%)14,175 (15%)
      Hours per week37.336.638.538.9
      Notes: GBON, Georgia Board of Nursing; HRSA, Health Resources and Services Agency; NCSBN, National Council of State Boards of Nursing.
      low asterisk Re-licensure survey (voluntary).
      The reported mean age of RNs was similar across data sources with a range of 44.7 to 49 years. Gender estimates were similar across data sources, with roughly 92% of employed RNs being female. HRSA, NCSBN, and the U.S. Census Bureau reported that the RN workforce was predominately white, with percentages that ranged from 64% to 76%. Because the GBON re-licensure survey is voluntary, the numbers on race were not reported due to a low response rate. All agencies reported that non-Hispanic RNs represented more than 90% of the entire population, although the percentages varied from 93.9% to 99.2%.
      The data on educational attainment showed that the plurality of RNs licensed in Georgia were educated at the baccalaureate level, where the percentage ranged from 40.4% to 48.4%. Similarly, the percentage of RNs educated at the masters level ranged from 14.3% to 19.3%, and 0.9% to 3.4% of RNs were educated at the doctoral level.
      The majority of RNs reported that they worked in a hospital or an inpatient setting. Yet, differences in the estimates were noted where the percentage of hospital-based RNs reported by NCSBN was much lower than the other data sources (47.8% vs. 60.3% to 68.5%). Conversely, the estimates from NCSBN showed wide variation in the percentages of RNs working in other settings when compared to other sources (42.4% vs. 14.3% to 16.8%). On average, across data sources, RNs reported they worked 37.8 hours per week.

      Advantages and Limitations of Each Data Source

      The advantages and limitations of each data source are summarized in Table 3. For the state-level data sources, the GBON collects data annually, which is beneficial when examining RN workforce trends. However, neither of these two data sources provides comprehensive data on the RN workforce. The GBON re-licensure survey is voluntary and has a low response rate.
      Table 3The Advantages and Limitations of the Datasets Used for This Study
      AdvantagesLimitations
      GBON
      State License Roster (required).


      • Required

      • Dynamic system of licensees
      • Only collects license information on licensees
      GBON
      Re-licensure survey (voluntary).


      • Annual data collection

      • Voluntary survey

      • Collects limited information of licensees

      • Only collect data of the half of the RN population every year
      HRSA• Comprehensive data on RN workforce.• Conducts every four years

      • Small sample of RNs at the state level can result in sampling error

      • Sampling issue with race
      NCSBN• Comprehensive data on RN workforce.• Conducts every two years

      • Small sample of RNs at the state level can result in sampling error
      U.S. Census Bureau

      • Annual data collection• Not specific to the RN workforce and collects limited information of RNs

      • Small sample of RNs at the state level can result in sampling error
      Notes: GBON, Georgia Board of Nursing; HRSA, Health Resources and Services Agency; NCSBN, National Council of State Boards of Nursing.
      low asterisk State License Roster (required).
      Re-licensure survey (voluntary).
      Among the three national-level agencies, the U.S. Census Bureau is the only one that collects data annually. These data provide recent information on changes in the RN workforce, data that can be used for workforce planning. However, since the U.S. Census Bureau does not collect data specific to the RN workforce, it provides limited data on RN characteristics compared to the GBON re-licensure survey and other national-level data sets. As a result, HRSA and NCSBN collect more comprehensive information on the RN workforce when compared with all other agencies, which can provide better overall estimates of the nursing workforce. However, due to their design, all three national-level agencies collect data from a small sample of RNs compared to the GBON.

      Discussion

      In this study, we examined data from four agencies that provide data on the employed RN workforce in the State of Georgia. Specifically, we reviewed the data that each agency collects, compared their estimated parameters on the RN workforce in Georgia, and discussed the advantages and limitations of each. Among these agencies, only the GBON and the U.S. Census collect data on the RN workforce annually, but those data are limited. Although the GBON re-licensure survey collects more comprehensive information, it is a voluntary survey with a historically low response rate, and thus, it is not possible to capture the characteristics of the Georgia RN population. HRSA and NCSBN collect more comprehensive data compared to the GBON and the U.S. Census Bureau. Because these data are collected less frequently, we do not have timely estimates on the RN workforce, which is necessary to make timely policy recommendations. In addition to limited data collection on the supply of RNs in Georgia, we also noted stark differences in data reported from the state and national agencies. We reported inconsistent estimates on most of the RN characteristics provided by all agencies, such as age, race and ethnicity, level of education, employment setting, and working hours. These findings are consistent with previous studies that reported different estimates on RN characteristics using the HRSA's National Sample Survey of Registered Nurses and the American Community Survey (
      • Auerbach D.I.
      • Fau S.D.
      • Muench U.
      • Buerhaus P.I.
      The nursing workforce: a comparison of three national surveys.
      ).
      Our study findings serve as a call for action to improve data and data collection on the RN workforce in both Georgia and nationwide. A comprehensive RN workforce data collection effort is important for all workforce stakeholders, which includes state licensing bodies, professional and provider associations, educational institutions and associations, employers, and policymakers (

      Gaul, K., Moore, J., & Fraher, E. (2016). Collaborating with licensing bodies in support of health workforce data collection: issues and strategies. [Press release]. Retrieved from http://www.healthworkforceta.org/wp-content/uploads/2016/05/HWTAC_TA-to-States_Brief.pdf

      ). These stakeholders need robust data to understand the ever-evolving RN workforce pipeline, which is imperative due to the nationwide shortage of RNs, patient complexity, and increased demand for nursing care (
      • Spetz J.
      • Cimiotti J.P.
      • Brunell M.L.
      Improving collection and use of interprofessional health workforce data: Progress and peril.
      ).
      The collection of RN workforce data needs to be longitudinal, comprehensive, and mandated. Because it is voluntary, the GBON re-licensure survey has not been demonstrated as an effective method for collecting data about the RN workforce in Georgia. Therefore, legislative actions are necessary and currently being pursued to require the completion of workforce data surveys as a part of obtaining and maintaining an active nursing license. Moreover, RN workforce data must be collected periodically and in a timely manner. This is critical for workforce stakeholders to capture and track any change in the RN workforce.
      The selection of RN workforce items that form the data sets also needs to include a broad scope of the workforce characteristics. The IOM Committee on the Future of Nursing identified three core areas of data that need to be collected – supply, demand, and education programs (
      • Institute of Medicine
      Institute of Medicine
      The future of nursing: Leading change, advancing health.
      ). Although the Forum developed the minimum datasets of supply, demand, and education programs, not every state is represented in the Forum, not every member of the Forum collects these three components, and not all of these components are collected to the same extent (
      • Moulton P.L.
      • Wiebusch P.L.
      • Cleary B.L.
      • Brunell M.L.
      • Napier D.F.
      • Bienemy C.
      • Cimiotti J.P.
      Toward standardization (Part 2): National nursing minimum data sets consensus building and implementation status.
      ;
      • Spetz J.
      • Cimiotti J.P.
      • Brunell M.L.
      Improving collection and use of interprofessional health workforce data: Progress and peril.
      ). Comprehensive data of RN supply should include their demographic characteristics, educational attainment, license type, and employment characteristics. Based on our study and previous studies in Georgia, the Georgia RN workforce supply data are inadequate due to the limited information collected (

      Li, Y., Cimiotti, J. P., Yoshihara, M., Hertzberg, V. S., & McCauley, L. A. (2020). Georgia Nurse Workforce 2009-2018. Retrieved from Atlanta, GA: http://www.nursing.emory.edu/_includes/documents/ACS-Report-04-13-2020.pdf. (Accessed on 20 April, 2020).

      ;

      Wheeler, R. (2016). Report of the registered nurse population in Georgia. Retrieved from Atlanta, GA: https://issuu.com/gnlc/docs/gnlc_nursing_workforce_report_ 2014. (Accessed 19 September 2018).

      ). For example, race and ethnicity are not required data, making it a challenge for diverse workforce planning.
      Moreover, RN demand data and nursing education program data are not available for analysis in Georgia. Highly relevant RN demand data are critical for workforce planning because they provide information on unmet demand regarding vacancies and the projected new positions to be created and filled (
      • Nooney J.G.
      • Cleary B.L.
      • Moulton P.
      • Wiebusch P.L.
      • Murray J.L.
      • Yore M.
      • Brunell M.L.
      Toward standardization (part 1): assessment of state and national nursing workforce data sources.
      ). Data that include current staffing, vacancies, turnover, recruitment, and budgets need to be available to analyze the demand for RNs in Georgia. Nursing education program data should also be synthesized from each school to understand program capacity, student characteristics, faculty characteristics, and other factors necessary to sustain the Georgia RN workforce and prepare the next generation of nurses. Without these data, it is impossible to determine if we are preparing a sufficient pipeline of RNs to address the racial and geographic distribution of the nursing workforce.
      A longitudinal and comprehensive RN workforce data collection system requires a collaborative effort among workforce stakeholders at both the state and national levels (

      Gaul, K., Moore, J., & Fraher, E. (2016). Collaborating with licensing bodies in support of health workforce data collection: issues and strategies. [Press release]. Retrieved from http://www.healthworkforceta.org/wp-content/uploads/2016/05/HWTAC_TA-to-States_Brief.pdf

      ). To achieve a timely and comprehensive collection of RN workforce data in Georgia, stakeholders must consult or work with experts in survey development and workforce centers in other states. More research is needed to determine the best data collection methods that can be executed at a minimal cost yet provide the most comprehensive data on the supply, demand, and education of RNs. It is only through these efforts that Georgia and other states can gain confidence that their RN workforce is adequately prepared to encounter any situation that might require additional resources or burden our healthcare systems, such as public health emergencies (e.g., coronavirus-19) and natural disasters.
      This study clearly demonstrates the need for immediate and deliberate actions leading to comprehensive and consistent state and national nursing workforce datasets. Because the problem continues to persist and consequences have been dire, more urgent action is required. In Georgia, nursing workforce stakeholders must work collaboratively to require the re-licensure survey and implement an accurate, comprehensive, and timely collection of RN workforce data. At the national level, a collaborative steering committee of nursing workforce data stakeholders must address the following four imperatives: (a) review and update the current Nursing Minimum Dataset Surveys as indicated and standardize the implementation of these surveys nationwide; (b) develop a nursing metadata file to be used nationwide that includes the RN workforce's supply, demand, and education; (c) advocate for state licensure boards nationwide to mandate comprehensive survey data collection; and (d) disseminate best practices on moving toward a mandatory survey system.
      This study had a few limitations. First, it is possible that we did not include all data sources on the RN workforce; however, we chose those sources with the most extensively validated data collection methods. We note that we could have included the Current Population Survey from the U.S. Census, a nationwide survey of 100,000 individual households; however, the sample of RNs included in that source is typically smaller than that of the American Community Survey. Second, our finding that data collection on the RN workforce needs to be improved at the state level is limited to Georgia, which might not be generalizable to other states. We acknowledge that several states have workforce research centers with solid funding sources that support regular collection and comprehensive RN workforce data analysis, such as North Carolina, California, New York, and Texas. Lastly, because of a low response rate of the GBON re-licensure survey, our results may not fully represent the statewide estimates of RN characteristics in Georgia. Despite these limitations, the study's findings serve as a stimulus to improve the collection of RN workforce data in Georgia and other states as needed with focused and dedicated national nursing collaboration toward common data standards.
      In conclusion, our work reviewed five available data sources from which we conducted a comparative analysis of the nursing workforce in Georgia. As mentioned above, this study's findings demand actions to advance nursing workforce data collection and analysis in Georgia and other states while emphasizing having high quality workforce data readily available and accessible.

      Author Contribution

      Credit author statement: Yin Li: Conceptualization, Methodology, Formal analysis, Writing (original draft, review, and editing); Leanna Greenwood: Methodology, Formal Analysis, Writing (review, and editing); Lisa Eichelberger: Writing (review, and editing); Lucy Marion: Writing (review, and editing); Jim Cleghorn: Data acquisition, Writing (review, and editing); Rebecca Wheeler: Writing (review, and editing); Jeannie P. Cimiotti: Conceptualization, Methodology, Writing (review, and editing).

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