health professions (2002) however, emergency and acute care nurses are in great demand, and this temporary reduction of the shortage is not expected to last as the economy improves. in 2009, it was reported that in places like des moines, iowa newly graduated nurses were having more difficulty finding jobs and older nurses were delaying retirement due to economic conditions. this hiring situation was mostly found in hospitals; nursing homes continued to hire and recruit nurses in strong numbers. some states have a surplus of nurses while other states face a shortage. this is due to factors such as the number of new graduates and the total demand for nurses in each area. some states face a severe shortage (such as the northwestern states, as well as texas and oklahoma), while other states have a surplus of registered nurses. year supply demand shortage percent 2000 1,890,700 2,001,500 -110,800 -6% 2005 1,942,500 2,161,300 -218,800 -10% 2010 1,941,200 2,347,000 -405,800 -17% 2015 1,886,100 2,569,800 -683,700 -27% 2020 1,808,000 2,824,900 -1,016,900 -36% us: supply versus demand projections for fte registered nurses source: data from the bureau of health professions. (2004). patching up the shortage nursing shortages can be consistent or intermittent depending on the number of patients needing medical attention. these patients are often keenly aware of staffing issues due to the communication issues and missed care that they experience and report, too. retention and recruitment are important methods to achieve a long-term solution to the nursing shortage. recruitment is promoted through making nursing attractive as a profession, especially to younger workers, to counteract the high average age of rns and future waves of retirement. refining the work environment can improve the overall perception of nursing as an occupation. this can be achieved by ensuring job satisfaction. a few ways the academic nursing administrators can make a change in illustrated from the writers lori candela, antonio gutierrez, and sarah keating in their journal, nurse education today. "individual support to attend workshops or conferences, participation in on-campus teaching/learning faculty sessions, the use of consultants with expertise in particular areas around teaching and evaluation, and mentoring networks that include senior faculty with teaching expertise" can all create a strong relationship between staff members therefore developing a better environment. additionally, financial opportunities such as signing bonuses can attract nurses individuals are more likely to participate in activities when there is an advantage in it for them. to assist the health sector, congress approved the nurse reinvestment act in 2002 to provide funding to advance nursing education, scholarships, grants, diversity programs, loan repayment programs, nursing faculty programs, and comprehensive geriatric education. currently, mandatory overtime for nurses is prohibited in nine states, hospital accountability to implement valid staffing plans in seven states, and only one state implements the minimum staffing ratio. individuals from groups such as ona worked with oha to test the impact that rn staffing had on patient health care. after uncovering crucial information nurses from across the states joined these group members to find ways to be able to assign responsibility where it was needed which resulted in the impact of staffing shortages. this acts resulted in the "nursing 2015 initiative which built personal relationships and new-found trust". other ways of assisting to fill the shortage in the united states would include giving nurses the opportunity to pick their own overtime and schedules. also, it would be a great incentive to young nurses to enter a hospital if they knew there were bonuses for continued excellence. in addition, maintaining a staff with an experienced skill mix provides opportunities for educating younger nurses and improving patient outcomes. to respond to fluctuating needs in the short term, health care industries have used float pool nurses and travel agency nurses. float pool nurses are staff employed by the hospital to work in any unit. agency nurses are employed by an independent staffing organization and have the opportunity to work in any hospitals on a daily, weekly or contractual basis. similar to other professionals, both types of nurses can only work within their licensed scope of practice, training, and certification. travel nurses do often move between very different hospital systems, but they tend to remain within similar units (such as emergency departments or intensive care units). float pool nurses have experience with the same systems and management. float pool nurses and agency nurses, as mentioned by first consulting group, are used in response to the current shortage. use of the said services increases the cost of health care, decreases specialty, and decreases the interest in long-term solutions to the shortage. when float pool nurses are held for longer terms within their units, it is suggested that hand-offs are completed more safely. giving more power to nursing managers in controlling patient ratios or acceptable unit numbers can assist these changes. health care industries have the opportunity to reduce nursing workloads and improve patient outcomes through the addition of nursing support staff (such as nursing assistants or licensed practical nurses). international recruitment is often used to fill the nursing gap but gives rise to concern now that the u.s. homeland security has stopped the issuance of the h-1c visa, which was deemed specifically for nurses. because of the affordable care act, which will result in an increased number of insured americans, it is estimated that there will be an even greater need for nurses in the near future. u.s. trained nurses are concerned, however, that this recruitment initiative impedes on their ability to obtain positions in the field after completing their training. a nursing shortage does not translate to new nursing jobs. a growing response to the nursing shortage is the advent of travel nursing a specialized sub-set of the staffing agency industry that has evolved to serve the needs of hospitals affected. according to the professional association of nurse travelers, there are an estimated 25,500 working in the u.s. the number of lvn/lpn nurse travelers is not known. there is a nursing recruitment initiative and nursing workforce development program for residents of the united states originally from foreign countries, who were professional nurses in their countries but are no longer in that profession in the united states. this initiative helps them get back into the nursing profession, especially getting through credentialing and the nursing board exams. the original model was developed in 2001 at san francisco state university in cooperation with city college of san francisco ("the san francisco welcome back center"). there are centers in many cities, such as los angeles, san diego, and boston—where it is called a "boston welcome back center for internationally educated nurses". it is a program meant for residents of the united states only. the boston welcome back center was opened in october 2005 with a $50,000 seed grant from the board of higher education's nursing initiative. the invention of information technology systems has significantly helped with the nursing shortage in america. it solutions such as hospital operations dashboards and acuity-based staffing solutions. the acuity based solutions strategically manages staffing and patient impact outcomes through the use of data analytics to determine data productivity trends. hospital operations dashboards use real time solutions, predictive analytics and engineered algorithms, this tool analyzes clinical data and transforms data into actionable items to help with management. these systems anticipate demand and then balance resources and demand in real time to ensure safe staffing. these systems are also effective in managing the float pool nurses and systemwide bonus offerings during times of low staffing and high patient intake. the rafaela measurement system of daily workload per nurse is used in finland to assess staffing needs throughout a hospital and fill needed gaps in patient care. avoiding fixed staffing ratios through these patient-workload management systems ensures nurses are able to provide whole patient care. legislation in 2004, california became the first state to legally mandate minimum nurse-to-patient staffing ratios in acute care hospitals. a subsequent study evaluated the effect on outcomes for nurses and patients by comparing outcomes in california in the subsequent two years with those of new jersey and pennsylvania — two similar states without such mandates. there was substantial compliance with the mandate in california, with over 80% compliance rates reported across several different units of surveyed hospitals; equivalent levels of non-mandated compliance in the comparator states were considerably lower, at 19%, 52%, and 63% compliance in medical/surgical, pediatric, and intensive care units (icus) in new jersey and 33%, 66%, and 71% in pennsylvania. after extensive adjustment for patient and hospital characteristics, the study revealed statistically significant relationships between the nurse-to-patient ratio and 30-day mortality and failure to rescue (ftr — that is, failure to prevent a clinically important deterioration, such as death or permanent disability, from a complication of an underlying illness or of medical care) in all three states. across all three states, facilities with nurse-to-patient ratios consistent with those mandated in california were associated with lower rates of nursing burnout, and nurses reported consistently better quality of care. in september 2007, in the 110th congress, senator richard durbin of illinois introduced s.2064: nurse training and retention act of 2007 on the floor of the senate. it was a bill to fund comprehensive programs to ensure an adequate supply of nurses. it was referred to committee for study but was never reported on by the committee. in april 2008, in the 110th congress, h.r. 5924: emergency nursing supply relief act was introduced as a bill to the house of representatives by robert wexler of florida. if it had passed, it would have amended the american competitiveness in the twenty-first century act of 2000 and would have given up to 20,000 visas per year to nurses and physical therapists until september 2011. immediate family members of visa beneficiaries would not be counted against the 20,000 yearly cap. the bill was referred to committees for study in congress but was never reported on by the committees. on february 11, 2009, legislation was introduced by representatives john shadegg (r-az), jeff flake (r-az), and ed pastor (d-az) in the 111th congress to the house of representatives, hr 1001 ("the nursing relief act of 2009": to create a new non-immigrant visa category for registered nurses, and for other purposes) making a new non-immigrant "w" visa category for nurses to be able to work in the united states. this was to relieve the nursing shortage still considered to be a crisis despite the economic problems in the country. the proposed bill was referred to the committee on the judiciary but was never reported on by committee. the 2010 patient protection and affordable care act includes more strategies for funding and retention. the act provides funding for advanced education nursing grants, diversity grants, and offers a nurse education loan repayment program. the program repays over half of the student loans if the nursing student signs a contract stating that they will work for two years at a medical facility that has a nursing shortage. the nurse reinvestment act of 2002 had many strategies. the law authorized and had provisions that included topics such as loan repayment programs and scholarships, providing more grants to the nursing students, making more public service announcements about nursing and educating the public on what a great profession it is and making nursing school more flexible by creating options for the people who already have a degree but would like to go into nursing. in assistance to the shortage of staff when it comes to nursing, pearce (2018) declared in the study conducted that the federal registered nurse staffing act that has been put into congress since 1998 came out with a current updated version called the safe staffing for nurse and patient safety act, which looks to "create a unique staffing plan for each unit; and consider nurse experience, patient intensity of need, staff skill mix, and other resource availability, such as availability of technology". immigration process to u.s. nurses seeking to immigrate to the u.s. can apply as direct hires or through a recruitment agency. for entry to the u.s. a foreign nurse must pass a visa screen which includes three parts of the process. first they must pass a creditable review, followed by a test of nursing knowledge called the commission on graduates of foreign nursing schools examination (cgfns), and finally a test