Economic Recovery and the Nursing Labor Market in California

Economic Recovery and the Nursing Labor Market in

California

August 2014

2

Today’s presenters

• Joanne Spetz– Professor at the 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– Executive Director of the California Institute for

Nursing & Health Care

3

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

• Measure the impact of enrollment trends on forecasts of future supply

• Examine new estimates of future demand

• Identify next steps for ensuring an adequate nurse supply

4

The collaboration

• Betty Irene Moore Nursing Initiative

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

• California Institute for Nursing & Health Care

• Hospital Association of Southern California

• Acknowledgements & thanks to…– California Hospital Association

– Hospital Council of Northern & Central California

– FutureSense Inc.

– Hospital Association of San Diego & Imperial Counties

– UCSF Staff & Interns: Tim Bates, Lela Chu, Jessica Lin, Dennis Keane, Anne Reid

5

What is going on in our RN labor market?

• Reports of nurse surplus 2009-now– Newspaper stories of new graduates who are

unemployed

• Demand for RNs dropped due to the recession– Decline in health insurance coverage

– Lower use of services

• Supply of RNs has increased over the past 10 years– Growth in RN education programs

• Is the economic recovery changing the situation?

6






• Examine new estimates of future demand

• Identify next steps for ensuring an adequate nurse supply

Survey of Chief Nursing Officers

• Fielded by UCSF

• Funded by Gordon & Betty Moore Foundation

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

• Questions based on previous CINHC survey and National Forum of State Nursing Centers “Minimum Demand Data Set” recommendations

• Six surveys conducted– Fall 2010, Spring 2011, Fall 2011, Spring 2012, Fall

2012, Fall 2013

7

Perceptions of employers: Overall labor market

2013

2012

2011

2010

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

8.6%

5.5%

4.6%

5.0%

32.3%

45.0%

43.0%

29.4%

18.7%

19.7%

6.6%

11.3%

26.8%

17.0%

23.2%

25.6%

13.6%

12.4%

20.5%

23.8%

0.0%

0.5%

2.0%

5.0%

High 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

9Higher number = more shortage

Sacramento & Northern CA

San Francisco Bay Area

Central California

Los Angeles

Inland Empire

Southern Border

California

0 1 2 3 4 5

3.14

2.09

2.93

2.82

2.72

2.36

2.68

2.81

2.27

3.34

2.95

3.00

2.93

2.88

2.96

2.76

3.41

3.20

3.78

3.00

3.14

3.22

1.89

3.18

3.17

3.47

2.76

2.95

2013 2012 2011 2010

Differences across regions: New graduates vs. Experienced RNs


Sacramento & Northern CA

San Francisco Bay Area

Central California

Los Angeles

Inland Empire

Southern Border

California

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

3.91

2.71

3.98

4.13

4.20

4.12

3.83

1.77

1.31

1.70

1.53

1.45

1.29

1.52

New RN Graduates Experienced RNs

Rural vs. urban perceptions


Rural Non-rural0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

3.6

2.65

3.51

2.85

3.69

3.093.47

2.86

2010 2011 2012 2013

Differences by hospital size


Less than 100 100 - 199 200 - 299 300 - 399 400 or more0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

3.12

2.652.50

2.00

2.46

3.15

2.85

3.233.02

2.79

3.293.17

3.30

2.973.173.07

3.23

2.64 2.742.86

2010 2011 2012 2013

Change in difficulty recruiting, compared to last year, Fall 2013

Staff RN

Other RN

LVN

Aide/assistant

NP

CNM

CRNA

CNS

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

14.4%

39.3%

8.8%

13.4%

6.0%

18.3%

66.3%

51.5%

68.6%

76.3%

76.4%

89.4%

81.0%

72.2%

19.3%

9.2%

29.8%

15.0%

10.2%

8.2%

13.1%

9.6%

More difficult About the same Less difficult13

Change in employment in the past year (2012-2013)

Staff RN

Other RN

New RN graduates

LVN

Aide/assistant

NP

CNM

CRNA

CNS

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

32.0%

23.8%

24.1%

6.6%

16.2%

32.9%

3.1%

3.7%

18.7%

46.4%

59.1%

61.1%

40.4%

57.5%

63.9%

83.2%

84.4%

65.3%

21.6%

17.1%

14.8%

53.0%

26.3%

3.2%

13.7%

11.9%

16.0%

Increased employment No change Decreased employment

14

Changes experienced in past year (2012-2013)

15

Budget constraints

Reduction in census

Increased patient acuity

Current staff working more

Fewer nurses retiring

0 20 40 60 80 100 120 140 160

145

121

94

87

82

Number of responses

Hiring of newly graduated RNs, 2010-2013

16

2010 2011 2012 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

84.6% 82.6% 77.6% 76.0%

6.7% 9.4%12.6%

7.8%

8.7% 8.0% 9.8% 16.1%

Do not hire everNormally hire, but not this yearHired this year

Hiring requirements and preferences, 2011-2013

Minimum experience requirement

Baccalaureate degree required

Baccalaureate degree preferred

Specific type of experience

No experience required

0% 20% 40% 60% 80%

52.3%

4.6%

69.5%

52.3%

21.2%

53.7%

7.3%

67.9%

55.5%

21.6%

63.9%

8.2%

72.2%

56.7%

12.4%

2013 2012 2011

17

Care experience most often needed in ICU/CCU, OR, ED, L&D

Plans regarding BSN-educated nurses

• 66% plan to increase the share with BSN– 36% have a target percentage in mind

• Most often over 75%

• 11.1% require that newly hired RNs obtain a BSN within a certain time

• 52.1% require a BSN for promotion beyond staff nurse

• Most common barriers to increasing share with BSN:– Lack of financial incentives

– Lack of tuition reimbursement funds

– Low supply of BSN-educated RNs in community

– Lack of BSN programs in community

18

New graduate training programs, Fall 2013

• 55% had a residency in 2013

• 80% developed program internally

• Most common capacity is 40-80 new grads

• Most common length is 12 weeks

2010 2011 2012 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

67.4%61.4%

70.7%

54.7%

32.6%38.6%

29.3%

45.3%

Residency No residency

19

Overall hiring expectations for the next year

20

2010-2011

2011-2012

2012-2013

2013-2014

0%

25%

50%

75%

100%

31.4%23.5% 31.2% 35.1%

50.0% 67.8% 51.6% 50.0%

18.6%8.7%

17.2% 14.9%

Hire fewer than last year

No change

Hire more than last year

Reasons for expecting greater employment

21

Increase in census

Increased patient acuity

Care model redesign

Increase in bed capacity

Current staff working less

Current staff convert FT to PT

More nurses retiring

Decrease in use of travelers

More turnover

Current staff working more

0 5 10 15 20 25 30 35 40 45

40

18

18

18

13

13

13

12

10

9

Number of responses: 68 maximum possible

Reasons for expecting lower employment

22

Reduction in census

Budget constraints

Hiring freeze

Less turnover

Care model redesign

Decrease in use of travelers

Decrease in bed capacity

Current staff convert PT to FT

Fewer nurses retiring

0 5 10 15 20 25

23

16

15

14

10

9

8

7

7

Number of responses: 29 maximum possible

Hiring expectations for new graduates

23

2011-2012 2012-2013 2013-20140%

25%

50%

75%

100%

21.6% 22.3% 24.1%

59.7% 55.4%61.1%

18.7% 22.3%14.8%

Decrease hiringNo changeIncrease hiring






• Examine new estimates of future demand• Identify next steps for ensuring an adequate

nurse supply

24

Turnover of full-time personnel, Fall 2012 vs. Fall 2013

25

Staff RNs Other RNs LVNs Aides0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2.5% 2.4%

3.7%3.5%

2.3%

3.4%3.1%

2.8%

20122013

26

Hiring of full-time personnel, Fall 2012 vs. Fall 2013

Staff RNs Other RNs LVNs Aides0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

2.9%

2.1%

1.5%

3.7%3.5%

2.5% 2.5%

3.9%

20122013

Percent of new hires that were new graduates

Full-time Part-time Overall0%

5%

10%

15%

20%

25%

30%

35%

40%

32.0%

6.0%

26.0%

34.0%

15.0%

31.0%

Fall 2012 Fall 2013

27

RN Vacancies, 2010-2013

28

All RNs0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

3.4%

4.0%3.8%

4.2%

Fall 2010Fall 2011Fall 2012Fall 2013

Vacancy rates by part-time and full-time status, Fall 2013

Staff RNs Other RNs

New RN Grads

LVNs Aides0%

2%

4%

6%

8%

10%

12%

4.4%

7.2%

5.5%4.8%

3.8%

2.7%

6.2%

9.9%

5.0%

6.1%

Full-timePart-time

29







nurse supply

30

31

New RN Graduate Hiring Survey

• Statewide survey of new grads conducted in fall of 2013

• Collaborators:– CINHC

– UCLA School of Nursing

– California Board of Registered Nursing

– Association of California Nurse Leaders

– California Student Nurses Association

• Random selection of >5,000 newly licensed RNs in CA - September 2012 through August 2013– Sample was mailed letters with invitation to complete

web-based survey

Findings from the 2013 New RN Graduate Hiring Survey

• 59.3% employed as an RN– 54% in 2012 (57% in 2011 & 2012)

– 2012-13 BRN Annual Schools Report (Deans & Directors’ estimate)

• 76.3% employed as RN

• 63.7% employed as RN in CA

• 18.3% unable to find employment

32

Regional variation in employment

33

Working As A RN 2013 Working As A RN 20120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

59% 58%

42% 43%

63%

48%

68%

59%56% 55%

80%

67%

48%54%

70%

59%LA/Ventura

SF Bay

Orange/Inland

N CA

San Diego/Imperial

Central Valley

Sacramento

Central Coast

Employment rate varies by education

34

AD BSN ELM0%

10%

20%

30%

40%

50%

60%

70%

80%

53% 55%59%

55%

63%67%

20122013

Employment settings of new graduates

35

Hospital; 58.6%

LTC; 13.1%Home Health;

4.8%

Community; 4.3%

Behaviorial; 2.3%

Corrections; 1.5%

Other; 15.4%

36

For those employed…

• 46.6% employed within 3 months

• 61.6% reported working in “job of choice”

• 77.2% are working full time

• 26.6% participated in a transition to practice or residency program

37

Why are they not employed?

• 92% no experience

• 46.5% no position available

• 37.8% BSN preferred or required

• 33.2% work experience not applicable

• 6.6% academic preparation insufficient for position scope

• 6.1% weak resume related to volunteering or activity to enhance experience/skills

• 3.9% out of school too long

• 0.9% low GPA

38

What are unemployed nurses doing?

Non-nurs-ing/non-

healthcare; 23.0%

Healthcare but not as RN; 20.2%

Continuing education;

15.5%

Volunteering, 12.7%

Other; 28.6%







nurse supply

39

What do Deans & Directors think is happening?

Type of degree 2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

Hospital 71.4% 59.0% 54.4% 61.1% 56.7%

Long-term care 8.4% 9.7% 7.8% 8.3% 7.9%

Comm/public health

5.4% 3.9% 4.5% 3.6% 3.6%

Employed in CA 83.4% 81.1% 68.0% 69.6% 72.9%

40

Deans’ estimates of the percent of grads from the past year in each employment setting

Source: California Board of Registered Annual Schools Report, 2012-2013

California RN graduations per year

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

41

The range of supply forecasts (RN FTEs)

42

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Best Supply Forecast

Low Employment Rate Forecast

High Employment Rate Forecast

2011 Forecast

Source: California Board of Registered Nursing Forecasts of the RN Workforce, 2013

Forecast of Full-time Equivalent RNs per 100,000 population

43

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

0

100

200

300

400

500

600

700

800

900


U.S. average

US 25th percentile








nurse supply

44

What is demand?

• Employer surveys tell us about current demand

• Employers often can estimate 1-2 years ahead

• Track record for long-term estimates by employers is not great– Extremely complex competitive environment

– Short-term demands make it hard to prepare for long-term needs

– Financial imperatives are focused on 1-2 year window

45

How can we forecast demand?

• National benchmarks: Employed RNs per 100,000

• Bureau of Labor Statistics forecasts– These forecast total employment, which results from

a mix of supply and demand

• Forecasting from projected hospital utilization: RNs per patient day– Estimate growth in patient days based on population

growth

– Predict hospital RN demand from patient days forecast

– Estimate overall demand as function of hospital demand

• Micro-simulation models46

BRN supply and demand forecasts for RNs, 2013-2030

47

0

100,000

200,000

300,000

400,000


National 25th percentile FTE RNs/population

National average FTE RNs/population

OSHPD hours per patient day-based forecast, BRN calibration


Micro-simulation modeling Frogner, Spetz, & Parente 2014

• ARCOLA (Adjusted Risk Choice & Outcomes Legislative Assessment) model – Estimates insurance coverage and health service

demand

– Built using employer and commercial insurer data

• Using ARCOLA to assess impact of ACA on labor force in California from 2011 to 2021– Customized model specific to CA

• Survey data (CHIS and CEHBS)

• CalSIM forecasts

• Workforce policies in CA

• Regional estimates

• Iterate and revise model assumptions with industry experts

48

Micro-simulation methodology

Assumptions • Premium growth (4%-8%)• ACA unfolds as legislated• Medi-Cal/Exchanges fully

implemented

ARCOLA 2013Population by

Insurance Type(Private, Govt,

Uninsured, etc.)

2021Population by

Insurance Type(Private, Govt,

Uninsured, etc.)

2013Unit of Service

AdmissionsMD / OP VisitsSNF days / Rx

2021Unit of Service

AdmissionsMD / OP VisitsSNF days / Rx

2011*Labor Force

Allied Health andDirect Care Professionals

2021Labor Force

Allied Health andDirect Care Professionals

Assumptions: Roll up of Insurance Type / Unit of ServiceHold constant during forecast period

Assumptions: Labor force / Unit of ServiceHold constant during forecast period

CalSIM

Assumptions • Premium growth (4%-8%)• ACA unfolds as legislated• Medi-Cal/Exchanges fully

implemented

Blended models

customized to CA

* Apply ARCOLA growth assumptions from 2013 to 2021 to 2011 baseline workforce data

49

Projected new jobs by industry due to ACA, 2021

50

Hospita

ls

Oth

er Hlth

Care

Svc

s

Dentist O

ffice

Physici

an Offic

e

OP C

are C

trs

Nursin

g Care

Fac

Home H

lth C

are S

vcs

Pharm/d

rug s

tore

s

Oth

er Health

Pra

ct.

Res. C

are n

o nurs

ing

Opto

metri

sts

Offic

e

Chiropra

ctors

Offic

e

13,394

8,649 8,287

5,490

3,830 3,407

1,395 1,217 821 777 481 364

Source: Frogner, Spetz, & Parente, 2014

Forecasted new jobs in California by 2021

51

-10,000

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000Non-ACA growth ACA growth

Source: Frogner, Spetz, & Parente, 2014

Where will the new jobs be created?

Other settings 0.4%

Offices of physicians

6.5%

Other offices 0.6%

Outpatient care centers 5.8%

Home health care services

1.8%Other health care services

16.9%

Hospitals 62.1%

Nursing care facilities 5.8%

52Source: Frogner, Spetz, & Parente, 2014

What could affect the mix of settings?

• Emerging care delivery models– Patient-centered medical homes

– Home-based long-term care services & supports

• Expanded use of health information technology

• New payment models– Performance-based payment

– Bundled payments & Accountable Care Organizations

• These things will be explored in early 2015

53







nurse supply

54

Implications for policy

• How do we define shortage?– Are current employment levels adequate?

– Should California be at the national average? 25th percentile? Bottom?

– Economic demand vs. need-based demand

• How will the ACA continue to impact demand?

• In this economy…– Demand is starting to ramp up again

– Reservoir of recent graduates who are still unemployed

55

Concerns for workforce policy

• If RN education contracts, our supply will fall far short of demand

• Will recent graduates who can’t find work leave California permanently?

• Can we foster opportunities to gain on-the-job skills and to pursue additional education?

• What do we need to do?– Identify strategies to retain new graduates’ skills and

employ them quickly

– Help RNs continue education if they want to do so

– Prepare new graduates to work in non-hospital settings

56

Check out our website!• http://rnworkforce.ucsf.edu

57

Also go to the BRN website• Forms Publications

58

Available from the BRN website

• Annual Schools Report– Public-use Excel workbook to summarize data by

region, type of program…

• RN Surveys (every 2 years)– Full reports

– Link to a webpage with summary data, and ability to get regional and other cuts of the data

• RN Forecasts– Full reports

– Regional reports when we have them

• Other studies

59

What is happening next?

• UCSF and HASC are continuing our collaboration– HASC does quarterly surveys of HR directors

– UCSF does annual CNO surveys

• The 2014 BRN Survey of RNs report will be published Spring 2015– New forecasts in Spring/Summer 2015

• The 2013-2014 BRN Annual Schools Survey will be sent in October

• The 2014 Employer Survey will be sent in October

60

Questions?

Thoughts?

Ideas?

Perspectives?

61

Economic Recovery and the Nursing Labor Market in California

Healthcare

university of california

thecurrent rn labor

new estimates of future

hospital size3

rn labormarket

overall rn labor market2013

latest hospital vacancy

lee institute