Distinct workforce activation states among licensed US nurses outside nursing employment

Background Licensed registered nurses (RNs) who are not employed in nursing are often counted as reserve capacity. A license, however, does not indicate readiness to enter the workforce. We examined whether this population contains distinct workforce activation states and how reported reasons for not working in nursing correspond to those states. Methods We analyzed the 2022 National Sample Survey of Registered Nurses, a nationally representative cross-sectional survey of licensed US nurses. The study population comprised RNs and RN advanced practice registered nurses who were actively licensed but not working for pay in nursing on 31 December 2021. The outcome distinguished five states reported at survey response: no future intention, actively looking, plans future entry or return, undecided, and already entered or returned. Ten prespecified reasons with adequate cell sizes were examined in separate survey-weighted multinomial models. Variance estimation used the main survey weight and 80 successive difference replicate weights. Models adjusted for age, sex, race and ethnicity, nursing education and license type; the family caregiving model also adjusted for marital status and dependents. Results The model-eligible sample included 7,744 respondents, representing 869,236 licensed RNs. An estimated 44.4% had no future intention to work in nursing, 25.6% were undecided, 14.6% had entered or returned, 10.7% planned future entry or return, and 4.7% were actively looking. Retirement was associated with a 27.0 percentage point higher adjusted probability of no future intention (95% CI 21.1 to 32.9). Family caregiving was associated with a 14.6 point higher probability of planned entry or return (95% CI 10.9 to 18.3) and a 13.3-point lower probability of no future intention (95% CI -18.0 to -8.5). Burnout, stressful work, inadequate staffing, scheduling problems and poor management were each concentrated in the undecided state, with adjusted probability differences from 6.1 to 14.6 points. These patterns remained in analyses restricted by retirement, prior nursing work, license type and official imputation status. Conclusions The licensed nonworking RN population is a stratified labor reserve. Family caregiving identifies a planned reserve, workplace barriers identify a conditional reserve, and retirement identifies a largely nonmobilizable group. Workforce planning should measure activation state before treating licensed capacity as available supply.