Geographic Variations in Health Care Workforce Training in the US The Case of Registered Nurses

Background: In the United States, registered nurses (RNs) are trained through 1 of 3 educational pathways: a diploma course, an associate's degree, or a baccalaureate degree in nursing. A national consensus has emerged that the proportion of RNs who are baccalaureate trained should be substantially increased. Yet, achieving that goal may be difficult in areas where college graduates are unlikely to reside. Objectives: To determine whether the level of training of the hospital RN workforce varies geographically, along with the education of the local general workforce. Research Design: Cross sectional, ecological study. Subjects: Hospital nurses who participated in the National Sample Survey of Registered Nurses in 2004 (N = 16,567). Measures: RN training was measured as Diploma, Associates degree, or Baccalaureate degree or above. County-level general workforce quality was assessed as the adult college graduation rate. Counties were divided into US population quartiles, with the highest quartile (Q4) having >29.3% college graduates, and the lowest quartile (Q1) having <16.93% college graduates. Results: Hospital RNs have a higher level of training in counties where the general population is better educated. For example, in Q4, 55.2% of hospital RNs are baccalaureate trained; in Q3, 50.2%; in Q2, 45.2%; and in Q1, 34.9% (P < 0.001 for all pairwise comparisons). The association between RN training and general workforce education is found in cities, towns, and rural areas. Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a baccalaureate degree in nursing-rich nursing workforce in some areas of the United States. Further work is needed to assess whether educational segregation similarly influences the distribution of other health-care professionals, and whether it leads to variations in the local quality of care.