Is a Nursing Shortage on the Way in California?...Libatique 4. What is going on in our RN labor market?!Newspaper&stories&of&newgraduates&who&are&unemployed!Hospital&reports&of&inability&to&fill&key&nursing&positions!Anecdotesabout&using&more&contract&nurses!What&will&happen&next?

Is a Nursing Shortage on the Way in California?

April 20, 2017

Today’s presenters

§ Joanne Spetz

• Professor, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco

§Teri Hollingsworth

• Vice President, Human Resources Services, Hospital Association of Southern California

§ Judee Berg

• Chief Executive Officer, HealthImpact (formerly the California Institute for Nursing and Health Care)

2

Goals for this webinar

§ Learn how Chief Nursing Officers perceive the current RN labor market

§Track the latest hospital vacancy and turnover data

§Understand how recently-graduated nurses are faring

§Answer the question: Is there an RN shortage in California?

• Will there be one in the future?

§Assess next steps for ensuring an adequate nurse supply

3

The work presented today is supported by…§Funders

• Betty Irene Moore Nursing Initiative (legacy funding)

• Kaiser Permanente Northern California

• California Board of Registered Nursing

§Acknowledgements & thanks to…

• FutureSense LLC

• UCSF Staff & Interns: Lela Chu, Tim Bates, Amy Shinoki, Lena Libatique

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What is going on in our RN labor market?

§Newspaper stories of new graduates who are unemployed

§Hospital reports of inability to fill key nursing positions

§Anecdotes about using more contract nurses

§What will happen next?

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6

Survey of Chief Nursing Officers

§Fielded by UCSF

§Web-based survey with option to return paper survey via fax or email

§ 8 surveys conducted

• Fall 2010, Spring 2011, Fall 2011, Spring 2012, Fall 2012, Fall 2013, Fall 2014, Fall 2015

• Fall 2016 survey: 104 facilities represented

7

Perceptions of employers: Overall labor market

34.3%

40.1%

18.4%

8.6%

5.5%

4.7%

5.3%

55.2%

46.9%

49.0%

32.3%

45.2%

43.9%

30.9%

7.6%

6.8%

13.1%

18.7%

19.8%

6.8%

11.8%

2.9%

5.6%

12.6%

26.8%

17.1%

23.6%

27.0%

0.6%

6.8%

13.6%

12.4%

20.9%

25.0%

0% 20% 40% 60% 80% 100%

2016

2015

2014

2013

2012

2011

2010High demand: difficult to fill open positionsModerate demand: some difficulty filling open positionsDemand is in balance with supplyDemand is less than supply availableDemand is much less than supply available

8

Differences across regions: Overall RN labor market

9

4.1

4.3

4.5

3.9

4.2

5.0

1.0 2.0 3.0 4.0 5.0

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2016201520142013201220112010

Differences across regions: Experienced RNs

10

4.3

4.1

4.6

4.1

4.6

5.0

1.00 2.00 3.00 4.00 5.00

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2016201520142013

Differences across regions: New Grad RNs

11

2.6

2.0

3.2

2.2

2.1

1.5

1.0 2.0 3.0 4.0 5.0

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2016201520142013

Rural vs. urban perceptions

4.8

4.2

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Rural Non-Rural

2010201120122013201420152016

12

Average ranking of the RN market by position

4.34.0 3.9 3.8

2.6 2.4 2.3

1.01.52.02.53.03.54.04.55.0

13

Change in employment in the past year (2015 - 2016)

66.3%

60.0%

35.3%

35.0%

38.2%

26.7%

30.0%

27.6%

40.0%

53.9%

63.0%

56.9%

53.3%

66.0%

6.1%

0.0%

10.8%

2.0%

4.9%

20.0%

4.0%

0% 20% 40% 60% 80% 100%

New RN graduate

NP

Experienced RN

Aide/assistant

Other RN

LVN

CNS

Increased employment No change Decreased employment

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Hiring requirements and preferences

52.3%

4.6%

69.5%

21.2%

51.9%

3.8%

53.8%

31.7%

0% 20% 40% 60% 80% 100%

Minimum experience requirement

Baccalaureate degree required

Baccalaureate degree preferred

No specific requirements

2016 2015 2014 2013 2012 2011

15

Plans regarding BSN-educated nurses, 2015

§ 67% plan to increase the share with BSN (75% in 2015;; 71% in 2014;; 66% in 2013)

§ 9.9% require that hired RNs obtain a BSN within a certain time (8.7% in 2015)

§ 56.3% require a BSN for promotion beyond staff nurse

§ 39% differentiate RN salary by education degree (32% in 2014 & 2015)

16

Challenges to increasing the share of BSN-educated RNs

§Most common barriers to increasing share with BSN:

• Lack of interest among incumbent RNs

• Lack of tuition reimbursement funds

• Lack of funds for financial incentives

• Scheduling / staffing barriers

• Lack of BSN nurses in community

• Lack of BSN programs in community

17

Overall hiring expectations for the next year

31.4%23.5%

31.2% 35.1%47.7%

65.4% 60.2%

50.0% 67.8% 51.6% 50.0%

48.1%

33.2% 37.9%

18.6%8.7%

17.2% 14.9% 4.2% 1.5% 1.9%

0%

25%

50%

75%

100%

Hire fewer than last year

No change

Hire more than last year

18

Expected RN hiring by care setting for next year (2016 - 2017)

67.3%

32.4%

30.8%

16.7%

44.0%

29.7%

64.9%

69.2%

80.6%

54.9%

3.0%

1.1%

0% 20% 40% 60% 80% 100%

Inpatient care

Ambulatory care

Home health

Long-term care

Case management

Increased hiring No change Decreased hiring

19

Percent of new hires that were new graduates

34%

6%

26%

32%

15%

31%29%

7%

24%

33%

20%

31%32%

8%

28%

0%5%10%15%20%25%30%35%40%

Full-time Part-time Overall

Fall 2012 Fall 2013 Fall 2014 Fall 2015 Fall 2016

20

Residency programs for non-employee new graduates, Fall 2016

§About 1/5 of hospitals reported a residency program• Similar rate as last survey• 64% paid program

§77% of hospitals said 75-100% of residency completers were hired in last year• 23% said they hired less than 25%

21

Residency programs for non-employee new graduates, Fall 2016

0% 20% 40% 60% 80% 100%

Medical-surgical

Emergency

Critical care

OR/Peri-op

Obstetrics/newborn

Pediatrics/neonatal

Ambulatory care

Psychiatry

Rehabilitation

22

Hiring expectations for new graduates

21.6% 22.3% 24.1%35.1%

47.3% 48.5%

59.7% 55.4%61.1%

57.2%49.2% 48.5%

18.7% 22.3% 14.8% 7.7% 3.5% 2.9%

0%

25%

50%

75%

100%

2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017

Increase hiring No change Decrease hiring

23

Reasons for expected increase in new graduate hiring• Lack of available experienced RNs

• Expected retirement of incumbent RNs

• Recently developed relationships with RN education programs to prepare new graduates for needed roles

• Recently developed mentoring programs for new graduates

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25

Quarterly hiring of full-time personnel, HASC Survey, Fall 2013 - Fall 2016

3.5%

2.5% 2.5%

3.9%

4.5%

2.3%2.7%

3.6%4.0%

2.6%2.2%

5.6%

3.7%

5.2%

4.4%

3.6%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Staff RNs Other RNs LVNs Aides

2013201420152016

26

RN Vacancies, HASC Survey, 2010 - 2016

3.4%4.0%

3.2%

4.2%4.8%

6.9%

5.9%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

All RNs

Fall 2010Fall 2011Fall 2012Fall 2013Fall 2014Fall 2015Fall 2016

27

Quarterly turnover of full-time personnel, HASC Survey, Fall 2013 - Fall 2016

2.3%

3.4%3.1%

2.8%2.6%2.9%

3.7%

2.5%

3.2% 3.3% 3.3% 3.3%

2.5%

5.9%5.4%

4.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Staff RNs Other RNs LVNs Aides

2013201420152016

28

Per Diem, Contract, and Agency RN Staff as Percent of Current Staff

0%

2%

4%

6%

8%

10%

12%

14%

16%

2010 2011 2012 2013 2014 2015 2016

Per DiemContractAgency

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2015 – 2016 Study TeamNew Graduate Nurse Employment

§HealthImpact

§California Board of Registered Nursing

§Association of California Nurse Leaders

§California Student Nurses Association

§Funder: Kaiser Permanente Northern CA

31

2015-2016 New Graduate Nurse Survey

§Sample Size: Random 50% of 8,280

§RNs newly licensed between September 2015 and August 2016

§Response Rate: 28%

§Response Rate Year Before: 12%

32

New Graduate Nurse Profile

47.7

45.8

5.8

0%10%20%30%40%50%60%70%80%90%100%

Degree

MSNBSNADN

33

New Graduate Nurse Profile

25.7

18.7

15.7

10.6

9.6

6.7

5.03.9 2.5 1.7

LAOrange/Inland SF Bay AreaNorthern CASan DiegoCentral ValleySacramentoCentral CoastOut of StateN Sac Valley

34

New Graduate Employment

57% 57% 54%59%

65%74%

85%

0%10%20%30%40%50%60%70%80%90%

2010 2011 2012 2013 2014 2015 2016

% Employment

35

Some Regional Differences

0%10%20%30%40%50%60%70%80%90%100%

2015 2016

LA County

SF Bay

Orange/Inland

N CA

San Diego/ImperialCentral Valley

Sacramento

36

Employment rate varies by education

37

53% 55%59%

55%

63%67%

62%

70%

58%

76% 78%

50%

83%89%

64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AD BSN ELM*

20122013201420152016

*Small ELM response rate in the 2015 New RN Graduate Hiring Survey

Importance of BSN Degree

2012 2013 2014 2015 2016

Hospitalemployers who prefer/require a BSN degree upon hire

74.1% 75.2% 80.4% 80.5% 85.3%

No job offer dueto lack of BSN degree

35.0% 37.8% 38.5% 30.1% 39.5%

38

Where are New Graduates Working?

Hospital Inpatient67.6%

Hospital Outpatient15%

Community Settings6%

LTC/Rehab6.7%

Behaviorial Health2%

Home Health1.5%

Other1%

Corrections0.3%

39

Participation in a Transition to Practice/Residency Program

§Employer Provided Participation– 42.4%

§School of Nursing Provided Participation– 5.2%

Total Participation = 47.6%

of New Graduates Participated in a

Transition to Practice Program

40

Length of Transition toPractice/Residency Programs

0%5%10%15%20%25%30%35%

41

Reasons for Hiring Difficulty

§No Experience

§BSN Preferred Degree

§No Positions Available

42








43

What is happening now?

§There is current and anticipated job growth

• Inpatient care growth in census and higher acuity

• Ambulatory care growth

§Shortage of experienced RNs

• Operating Room

• Labor & Delivery

• Emergency Department

• Intensive care

§Expected retirements of RNs

44

California RN graduations per year

6,158

11,512 11,191

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

45

Best supply and demand forecasts for RNs, 2015-2035

46

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Best Supply ForecastNational 25th percentile FTE RNs/populationOSHPD hours per patient day-based forecastLow Supply Forecast (low count & employment)National average FTE RNs/population








47

Concerns for workforce policy

§What education changes are needed to ensure new graduates have the right skills?

§As care models evolve and shift where and how health care is delivered, what is the impact on nursing education?

§How do we foster opportunities to gain on-the-job skills and pursue additional education?

§There is a stabilization in the number of new graduates per year in the state

• Will there be enough nurses in the right place with the right skills in the future?

§Employers prefer to hire nurses with a baccalaureate or higher degree. How do we increase capacity in RN to BSN programs and maintain quality?

48

Solutions

§Employers: Partner with schools

• Invest in new graduate hiring

‒ Less expensive than a shortage

§ Recruitment costs

§ Costs of patient care lapses

§ Costs of rapid wage increases

• Invest in transition to practice/residency programs

• Invest in transition in practice programs

• Provide clinical faculty

• Flexible scheduling for RNs pursuing advanced degrees

49

Solutions

§Educators: Partner with employers

• Offer electives in the clinical areas of shortage

• Ensure streamlined education progression

• Expand partnerships beyond acute care settings

• Include employers in education program content discussions

§Policymakers: Maintain education capacity

• Do not let enrollments drop

• Support scholarship programs such as the HPEF programs

• Explore non-traditional clinical placement settings and use of simulation

50

Check out the UCSF website!http://rnworkforce.ucsf.edu

57

Interactive data displays

57

Also go to the BRN websiteForms & Publications

53

Questions?

Thoughts?

Ideas?

Perspectives?

54

Documents

Is a Nursing Shortage on the Way in California?...Libatique 4. What is going on in our RN labor market?!Newspaper&stories&of&newgraduates&who&are&unemployed!Hospital&reports&of&inability&to&fill&key&nursing&positions!Anecdotesabout&using&more&contract&nurses!What&will&happen&next?