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Economic Recovery and the Nursing Labor Market in
California
August 2014
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
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
• 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
3
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
4
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?
5
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
6
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
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%
0% 20% 40% 60% 80% 100%
2013
2012
2011
2010
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 availableOther
8
Differences across regions: Overall RN labor market
9Higher number = more shortage
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
0 1 2 3 4 5
Sacramento & Northern CA
San Francisco Bay Area
Central California
Los Angeles
Inland Empire
Southern Border
California
2013 2012 2011 2010
Differences across regions: New graduates vs. Experienced RNs
10Higher number = more shortage
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
0 1 2 3 4 5
Sacramento & NorthernCA
San Francisco Bay Area
Central California
Los Angeles
Inland Empire
Southern Border
California
New RN Graduates Experienced RNs
Rural vs. urban perceptions
11Higher number = more shortage
3.6
2.65
3.51
2.85
3.69
3.09
3.47
2.86
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Rural Non-rural
2010 2011 2012 2013
Differences by hospital size
12Higher number = more shortage
3.12
2.652.50
2.00
2.46
3.15
2.85
3.233.02
2.79
3.293.17
3.30
2.973.17
3.073.23
2.642.74
2.86
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Less than 100 100 - 199 200 - 299 300 - 399 400 or more
2010 2011 2012 2013
Change in difficulty recruiting, compared to last year, Fall 2013
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%
0% 20% 40% 60% 80% 100%
Staff RN
Other RN
LVN
Aide/assistant
NP
CNM
CRNA
CNS
More difficult About the same Less difficult
13
Change in employment in the past year (2012-2013)
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%
0% 20% 40% 60% 80% 100%
Staff RN
Other RN
New RN graduates
LVN
Aide/assistant
NP
CNM
CRNA
CNS
Increased employment No change Decreased employment
14
Changes experienced in past year (2012-2013)
15
145
121
94
87
82
0 20 40 60 80 100 120 140 160
Budget constraints
Reduction in census
Increased patient acuity
Current staff working more
Fewer nurses retiring
Number of responses
Hiring of newly graduated RNs, 2010-2013
16
84.6% 82.6% 77.6% 76.0%
6.7% 9.4%12.6%
7.8%
8.7% 8.0% 9.8%16.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010 2011 2012 2013
Do not hire ever
Normally hire, butnot this year
Hired this year
Hiring requirements and preferences, 2011-2013
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%
0% 20% 40% 60% 80%
Minimum experiencerequirement
Baccalaureate degreerequired
Baccalaureate degreepreferred
Specific type of experience
No experience required
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 community18
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
67.4%61.4%
70.7%
54.7%
32.6%38.6%
29.3%
45.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010 2011 2012 2013
Residency No residency
19
Overall hiring expectations for the next year
20
31.4%23.5%
31.2% 35.1%
50.0% 67.8% 51.6% 50.0%
18.6%8.7%
17.2% 14.9%
0%
25%
50%
75%
100%
Hire fewer thanlast year
No change
Hire more thanlast year
Reasons for expecting greater employment
21
40
18
18
18
13
13
13
12
10
9
0 10 20 30 40 50
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
Number of responses: 68 maximum possible
Reasons for expecting lower employment
22
23
16
15
14
10
9
8
7
7
0 5 10 15 20 25
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
Number of responses: 29 maximum possible
Hiring expectations for new graduates
23
21.6% 22.3% 24.1%
59.7% 55.4%61.1%
18.7% 22.3%14.8%
0%
25%
50%
75%
100%
2011-2012 2012-2013 2013-2014
Decrease hiring
No change
Increase hiring
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
24
Turnover of full-time personnel, Fall 2012 vs. Fall 2013
25
2.5% 2.4%
3.7%3.5%
2.3%
3.4%
3.1%
2.8%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
Staff RNs Other RNs LVNs Aides
2012
2013
Hiring of full-time personnel, Fall 2012 vs. Fall 2013
2.9%
2.1%
1.5%
3.7%3.5%
2.5% 2.5%
3.9%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
Staff RNs Other RNs LVNs Aides
2012
2013
26
Percent of new hires that were new graduates
32.0%
6.0%
26.0%
34.0%
15.0%
31.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Full-time Part-time Overall
Fall 2012 Fall 2013
27
RN Vacancies, 2010-2013
28
3.4%
4.0%3.8%
4.2%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
All RNs
Fall 2010
Fall 2011
Fall 2012
Fall 2013
Vacancy rates by part-time and full-time status, Fall 2013
4.4%
7.2%
5.5%4.8%
3.8%
2.7%
6.2%
9.9%
5.0%
6.1%
0%
2%
4%
6%
8%
10%
12%
Staff RNs OtherRNs
New RNGrads
LVNs Aides
Full-time
Part-time
29
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
30
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
31
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
59% 58%
42% 43%
63%
48%
68%
59%56% 55%
80%
67%
48%
54%
70%
59%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Working As A RN 2013 Working As A RN 2012
LA/Ventura
SF Bay
Orange/Inland
N CA
San Diego/Imperial
Central Valley
Sacramento
Central Coast
Employment rate varies by education
34
53% 55%59%
55%
63%67%
0%
10%
20%
30%
40%
50%
60%
70%
80%
AD BSN ELM
2012
2013
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%
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
36
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
37
What are unemployed nurses doing?
38
Non-nursing/non-healthcare,
23.0%
Healthcare but not as RN, 20.2%
Continuing education,
15.5%
Volunteering, 12.7%
Other, 28.6%
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
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
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
41
The range of supply forecasts (RN FTEs)
42
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
0
100
200
300
400
500
600
700
800
900
Best Supply Forecast
U.S. average
US 25th percentile
Source: California Board of Registered Nursing Forecasts of the RN Workforce, 2013
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
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
Best Supply Forecast
National 25th percentile FTE RNs/population
National average FTE RNs/population
OSHPD hours per patient day-based forecast, BRN calibration
Source: California Board of Registered Nursing Forecasts of the RN Workforce, 2013
Micro-simulation modelingFrogner, 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 2013
Population by
Insurance Type
(Private, Govt,
Uninsured, etc.)
2021
Population by
Insurance Type
(Private, Govt,
Uninsured, etc.)
2013
Unit of Service
Admissions
MD / OP Visits
SNF days / Rx
2021
Unit of Service
Admissions
MD / OP Visits
SNF days / Rx
2011*
Labor Force
Allied Health and
Direct Care
Professionals
2021
Labor Force
Allied Health and
Direct Care
Professionals
Assumptions: Roll up of Insurance Type / Unit of Service
Hold constant during forecast period
Assumptions: Labor force / Unit of Service
Hold 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
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
70,000
Non-ACA growth ACA growth
Source: Frogner, Spetz, & Parente, 2014
Where will the new jobs be created?
Other settings0.4%
Offices of physicians
6.5%
Other offices0.6%
Outpatient care centers
5.8%
Home health care services
1.8%Other health care services
16.9%
Hospitals62.1%
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
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
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