Prospective nurses in California are facing a classic enigma: how to find a job requiring experience if you can’t get hired to gain the experience.
As a result, an excess of nursing graduates in California cannot find jobs, even though employers are declaring a shortage of recruits.
According to UC-San Francisco’s “Survey of Nurse Employers in California, Fall 2013,” approximately 41% of responding hospitals reported moderate to high demand for registered nurses relative to supply. In the 2012 survey of employers, 51% said the same thing.
At the same time, 40.4% said demand was less than or much less than available supply in 2013, a large jump over 29.4% in 2012.
The number of nursing grads hired in 2013 — 76% — was less than the previous three years with the highest number reported in 2010 — 84.6%.
During a webinar last week — “Economic Recovery and the Nursing Labor Market in California” — nursing experts and stakeholders:Examined the state of supply and demand of nurses in California through the perspectives of new graduates and nurse employers; Studied forecasts of future supply and demand and the latest hospital vacancy and turnover data; and Identified next steps for ensuring an adequate supply of nurses.
Sponsored by UC-San Francisco, the Hospital Association of Southern California, the Betty Irene Moore Nursing Initiative and the California Institute for Nursing & Health Care, the webinar suggested that demand for newly graduated nurses has weakened across the state, while at the same time it has become increasingly difficult to fill positions for more experienced nurses, such as case managers, clinical educators and department managers.
Joanne Spetz, professor at the Institute for Health Policy Studies at UC-San Francisco, said hospitals generally reported difficulty in finding experienced nurses. While demand for more nurses might be rising, there is still a mismatch between the number of new graduates and open positions.
Judee Berg, executive director of the California Institute for Nursing & Health Care, said the state’s economic climate has played a role in the nursing marketplace. “The recession is the primary cause of disappearing vacancies,” she said.
“Some nurses delayed retirement, while others moved from part-time to full-time jobs or kept their part-time jobs and took a second job in a community setting. We are still seeing a residual effect,” Berg said.
Prospects for the future are looking up, nursing experts say. Expectations for hiring more new graduates during the period of 2012-2013 grew slightly over the prior year, from 21.6% to 22.3%, and continued to increase into 2013-2014, reaching 24.1%, according to the UCSF survey.
In 2013-2014, hospitals anticipating hiring fewer nurses dropped from 22.3% during the prior year to 14.8%.
Reasons for expecting to hire more nurses included an increase in the census, patient acuity and bed capacity, along with care model redesign. A reduction in census, budget constraints, hiring freezes and less staff turnover were reasons hospitals gave for less hiring.
“Baby boomer nurses are not retiring as early as expected because they like their jobs or need to continue to work to compensate for losses in retirement portfolios during the recession,” Spetz said. “They have a reputation for being more career-oriented and attached to their jobs.”Are New Nurse Graduates Lacking Experience?
Hospitals also are becoming pickier about whom they hire. The proportion of California hospitals requiring new hires to have a bachelor’s degree rose from 4.6% in 2011 to 8.2% in 2013, according to the UCSF survey. More than half of employers require a Bachelor of Science in Nursing for positions beyond staff nurse. Slightly more than 11% require that newly hired RNs obtain a BSN within a specified time period. About two-thirds of hospitals surveyed — 66% — reported they intend to increase the number of hires with a BSN.
Less than one-third of new hires were recent nurse graduates, whether full- or part-time, according to the Hospital Association of Southern California’s quarterly Healthcare Workforce Survey.
The survey focuses on turnover and vacancy trends in the California hospital industry, providing information to hospitals to help them make hiring decisions, said Teri Hollingsworth, vice president of human resources for HASC.
She emphasized the value of the collaboration of the organizations sponsoring the webinar, along with others groups, that are coordinating data collection to streamline the process, something that was unheard of years ago.
“Previously, there were four or five surveys collecting the same data but not sharing them,” she said last week. “Our collaboration is working well and offering quick results; other states are impressed at our robust database and are asking how to replicate it.”Experience, Geography Affect Nursing Workforce
CINHC’s “2012-2013 California New Graduate Hiring Survey” addresses how new nursing graduates are faring based on their experience and where they live.
The survey of newly licensed nurses in California reported:46.6% found jobs within three months (compared with 53% in 2012); 61.6% found their “jobs of choice” (compared with 65% in 2012); and 77.2% were working full time.
For those not employed, 92% cited lack of experience as the primary barrier, while 46.5% said a shortage of available positions as a factor.
California hospitals hired fewer nurses with associate degrees in 2013 (55%) than those with a BSN (63%) and with an entry-level master’s degree (67%).
More than half the state’s hospitals — 55% — developed nursing residency programs in 2013, according to the survey of nurse employers.
“When new graduates finish their education and look for a new job, they need clinical guidance — a residency much like the one for physicians that takes time and mentoring,” Berg said. “Some hospitals offer specialist programs to onboard nurses and provide supervision but not all hospitals can do it,” she added.
“But even when they do, they are not always able to incorporate the new nurses into staffing. Many employers believe residencies are worthwhile, but others don’t consider them important enough as a way to reduce turnover.”
The San Francisco Bay Area experienced the smallest demand for registered nurses last year with only 41.6% of new graduates employed as an RN compared with 80% in the San Joaquin Valley, according to CINHC.
“The Bay Area is the most challenging because there are more nursing schools per capita, making it less likely for new graduates in this area to find a job than in other regions,” Spetz said. “This is consistent with employer perceptions of a surplus of nurses in the Bay Area.”
“Reasons for the differences in regions across the state are not clear, and we would need to study this further to determine what those factors are,” Berg said. “It may be related to locations of schools of nursing; numbers of new graduate RNs, hospital beds and other employment opportunities in each region; stability of the existing nursing workforce; and multiple other factors.
“We do know, however, that the Bay Area has consistently been the part of the state where new graduate RNs have experienced the most difficulty in finding their first jobs,” Berg said.Affordable Care Act’s Potential To Affect Nurse Workforce
With the effects of the Affordable Care Act playing out in communities across the state, Spetz worked with Bianca Frogner, assistant professor at George Washington University, and Steve Parente, managing principal for Health Systems Innovation Network to develop a microsimulation to forecast new job openings for nurses through 2021. The methodology is based on an existing model used to predict insurance coverage demand.
By 2021, California could expect to add 10,000 jobs for RNs because of the ACA and an additional 45,000 positions regardless of the law, the majority (62.1%) in hospitals. Spetz said the forecast is affected by a mix of settings, such as medical homes and home-based health services; health information technology; bundled payments; and accountable care organizations.
The next steps for ensuring adequate supply, Spetz said, depend on how the state defines “shortage,” whether current levels of demand are based on economic or need factors and if California’s nursing ratio should align with the national average or if it should remain in the 25th percentile in terms of supply.
The national average in 2013 was 746 RNs per 100,000 individuals, while the 25th percentile nationwide was 706 RNs per 100,000, according to the California Board of Registered Nursing. For more than 10 years, California has had one of the lowest ratios, ranking 48th among states in 2008.
The number of new nursing school graduates in California has more than doubled in the past decade, adding more than 11,000 nurses a year, according to the California Board of Registered Nursing. Spetz said that is the number projected to be optimal for maintaining enough supply, providing an opportunity to balance supply and demand in the long term.
“We need to identify strategies to retain new graduates’ skills and employ them quickly, promote continued education for RNs who want it and prepare new graduates to work in non-hospital settings,” Spetz said.