This document summarizes the findings of a webinar on emerging trends in California's RN labor market. It discusses surveys of Chief Nursing Officers and hospital HR directors that show perceptions of the RN labor market are trending toward shortage again, with higher vacancy rates, turnover, and difficulty recruiting experienced RNs. While most hospitals still hire new graduates, the percentage is decreasing, and some hospitals plan to decrease new graduate hiring in the future due to the high costs of transitioning them. Ensuring an adequate future nurse supply will require identifying ways to support nursing education and recruitment of experienced RNs.

1. The End of the Shortage?
Emerging Trends in California’s
RN Labor Market
April 28, 2015

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
2

3. Goals for this webinar
§ Assess how the economic recovery is affecting demand for RNs in
California
• 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
§ Identify next steps for ensuring an adequate nurse supply
3

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, Jesse Smith
4

5. What is going on in our RN labor market?
§ Reports of nurse surplus 2009-now
• Newspaper stories of new graduates who are unemployed
• Shortage may not have ended in some states
§ Emerging reports of shortage
• Anecdotes about using more contract nurses
• Potential mismatch between needs and skills
§ What will happen next?
• Is the economic recovery changing the situation?
• Is the Affordable Care Act changing the situation?
5

6. Goals for this webinar
§ Assess how the economic recovery is affecting demand for RNs in
California
• 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
§ Identify next steps for ensuring an adequate nurse supply
6

7. 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
§ 7 surveys conducted
• Fall 2010, Spring 2011, Fall 2011, Spring 2012, Fall 2012, Fall
2013, Fall 2014
• Fall 2014 survey: 207 CNO responses, 238 HR Director
responses
7

8. Perceptions of employers: Overall labor market
Fall 2014
18.4%
8.6%
5.5%
4.7%
5.3%
49.0%
32.3%
45.2%
43.9%
30.9%
13.1%
18.7%
19.8%
6.8%
11.8%
12.6%
26.8%
17.1%
23.6%
27.0%
6.8%
13.6%
12.4%
20.9%
25.0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2014
2013
2012
2011
2010
High demand: difficult to fill open positions
Moderate demand: some difficulty filling open positions
Demand is in balance with supply
Demand is less than supply available
Demand is much less than supply available
8

9. Differences across regions:
Overall RN labor market
9
3.5
3.1
3.7
3.8
3.6
3.3
1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
Sacramento & North
SF Bay
Central CA
LA
Inland Empire
S. Border
2014
2013
2012
2011
2010

10. Differences across regions: Experienced RNs
10
4.17
3.79
4.21
4.17
4.14
3.70
1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
Sacramento & North
SF Bay
Central CA
LA
Inland Empire
S. Border
2014
2013

11. Differences across regions: New Grad RNs
11
2.33
1.42
1.97
1.68
1.95
1.60
1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
Sacramento & North
SF Bay
Central CA
LA
Inland Empire
S. Border
2014
2013

12. Rural vs. urban perceptions
4.13
3.50
1
1.5
2
2.5
3
3.5
4
4.5
5
Rural Non-Rural
2010
2011
2012
2013
2014
12
Higher number = more shortage

13. Difficulty recruiting, compared to last year,
Fall 2014
25.0%
40.9%
2.9%
12.5%
16.1%
2.1%
7.8%
26.9%
66.0%
54.1%
30.7%
66.1%
70.8%
96.8%
78.4%
71.4%
9.0%
5.0%
66.4%
21.4%
13.1%
1.1%
13.8%
1.7%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Staff RN
Other RN
LVN
Aide/Asst
NP
CNM
CRNA
CNS
More difficult No change Less difficult
13

14. Change in employment in the past year
(2013-2014)
51.2%
28.4%
7.4%
26.5%
36.7%
4.0%
12.2%
10.8%
44.1%
63.9%
44.1%
59.7%
51.7%
90.1%
74.4%
83.5%
4.7%
7.7%
48.5%
13.7%
11.7%
6.0%
13.4%
5.7%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Staff RN
Other RN
LVN
Aide/assistant
NP
CNM
CRNA
CNS
Increased employment No change Decreased employment
14

15. Change in RN hiring by care setting
(2013-2014)
49.8%
33.9%
14.8%
8.0%
44.2%
61.3%
71.1%
85.8%
6.0%
4.8%
14.1%
6.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Inpatient care
Ambulatory care
Home health
Long-term care
Increased employment No change Decreased employment
15

16. Hiring requirements and preferences,
2011-2014
52.3%
4.6%
69.5%
21.2%
60.5%
9.8%
70.7%
14.9%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Minimum experience requirement
Baccalaureate degree required
Baccalaureate degree preferred
No specific requirements
2014 2013 2012 2011
16

17. Plans regarding BSN-educated nurses, 2014
§ 71% plan to increase the share with BSN (was 66% in 2013)
• 54% are targeting more than 50%
§ 11.8% require that hired RNs obtain a BSN within a certain time
§ 55.1% require a BSN for promotion beyond staff nurse
§ 32.9% differentiate RN salary by education degree
• 48.4% differentiate RN salary by advanced certification
17

18. Challenges to increasing the share of
BSN-educated RNs
§ Most common barriers to increasing share with BSN:
• Low supply of BSN-educated RNs in community
• Lack of tuition reimbursement funds
• Lack of funds for financial incentives
• Lack of interest among RNs
18

19. Overall hiring expectations for the next year
31.4%
23.5%
31.2% 35.1%
47.7%
50.0% 67.8% 51.6% 50.0%
48.1%
18.6%
8.7%
17.2% 14.9% 4.2%
0%
25%
50%
75%
100%
Hire fewer than last
year
No change
Hire more than last
year
19
Reasons for expected growth:
Expected increase in census, Expected increase in acuity

20. Expected RN hiring by care setting for next
year (2014-2015)
43.3%
42.3%
31.9%
9.7%
52.1%
57.1%
65.5%
78.6%
4.7%
0.6%
2.7%
11.7%
0% 20% 40% 60% 80% 100%
Inpatient care
Ambulatory care
Home health
Long-term care
Increased hiring No change Decreased hiring
20

21. Hiring of newly graduated RNs,
2010-2014
84.6% 82.6% 77.6% 76.0%
82.9%
6.7% 9.4%
12.6%
7.8%
6.5%
8.7% 8.0% 9.8%
16.1% 10.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010 2011 2012 2013 2014
Do not hire ever
Normally hire,
but not this year
Hired this year
21

22. Percent of new hires that were new
graduates
34.0%
6.0%
26.0%
32.0%
15.0%
31.0%
29.0%
7.0%
24.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Full-time Part-time Overall
Fall 2012 Fall 2013 Fall 2014
22

23. Hiring of new graduates into non-RN roles
28.6%
31.7%
0%
10%
20%
30%
40%
50%
2013 2014
Hire into non-RN roles
23

24. Residency programs for non-employee new
graduates, Fall 2014
§ 39 hospitals have residencies for new graduates not
guaranteed to be hired
• Most common capacity is 20-30 new grads
• Most common length is 12-16 weeks
• 63.2% internally-developed
• 68.3% paid program
§ 77.1% of hospitals said 75-100% of residency completers
were hired in last year
• 14.3% said they hired less than 25%
24

25. Residency programs for non-employee new
graduates, Fall 2014
0% 20% 40% 60% 80% 100%
Medical-surgical
Emergency
Critical care
Obstetrics/newborn
OR/peri-op
Pediatrics/neonatal
Ambulatory care
25

26. Hiring expectations for new graduates
2014-2015
21.6% 22.3% 24.1%
35.1%
59.7% 55.4%
61.1%
57.2%
18.7% 22.3%
14.8%
7.7%
0%
25%
50%
75%
100%
2011-2012 2012-2013 2013-2014 2014-2015
Decrease hiring
No change
Increase hiring
26

27. Reasons for expected changes in new
graduate hiring
§ Expect an increase
• Fewer experienced RNs will
be available
• Partnerships with academic
programs to create
pipelines
• Expansion of own clinical
programs
§ Expect a decrease
• Too many new graduates
already
• Cost of transitioning new
graduates too high
4/28/15Presentation Title and/or Sub Brand Name Here27

28. Goals for this webinar
§ Assess how the economic recovery is affecting demand for RNs in
California
• 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
§ Identify next steps for ensuring an adequate nurse supply
28

29. Hospital Association of Southern
California’s Healthcare Workforce Survey
§ Fielded quarterly by the Hospital Association of Southern California
and FutureSense Inc.
§ Conducted via online survey sent to HR Directors
§ Data collected over a period of one month in September 2014
§ Data describes staffing, turnover, and hiring patterns for third quarter
of the year (July – September 31, 2014)
§ Elicited 193 unique responses, representing 238 general acute care
hospitals, and 51,530 beds
4/28/15Presentation Title and/or Sub Brand Name Here29

30. Quarterly turnover of full-time personnel,
Fall 2013 vs. Fall 2014
2.3%
3.4%
3.1%
2.8%
2.6%
2.9%
3.7%
2.5%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
Staff RNs Other RNs LVNs Aides
2013
2014
30

31. Quarterly hiring of full-time personnel,
Fall 2013 vs. Fall 2014
3.5%
2.5% 2.5%
3.9%
4.5%
2.3%
2.7%
3.6%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
5.0%
Staff RNs Other RNs LVNs Aides
2013
2014
31

32. RN Vacancies, 2010-2014
3.4%
4.0%
3.7%
4.2%
4.6%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
5.0%
All RNs
Fall 2010
Fall 2011
Fall 2012
Fall 2013
Fall 2014
32

33. Vacancy rates by part-time and full-time
status, Fall 2014
5.3%
6.1%
5.4%
4.1%
4.7%
3.5%
5.2%
11.7%
3.5%
5.0%
0%
2%
4%
6%
8%
10%
12%
14%
Staff RNs Other RNs New RN
Grads
LVNs Aides
Full-time
Part-time
33

34. 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
Per Diem
Contract
Agency
34

35. Goals for this webinar
§ Assess how the economic recovery is affecting demand for RNs in
California
• 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
§ Identify next steps for ensuring an adequate nurse supply
35

36. New RN Graduate Hiring Survey
§ Statewide survey of new grads conducted in fall of 2014
§ Collaborators:
• CINHC
• UCLA School of Nursing
• California Board of Registered Nursing
• Association of California Nurse Leaders
• California Student Nurses Association
§ Funder:
• Kaiser Permanente Fund for Health Education at the East Bay
Community Foundation
36

37. California RN graduations per year
6,158
11,291
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
37

38. New RN Graduate Hiring Survey
§ Random selection of 3,429 newly licensed RNs in CA - September
2013 through August 2014
• Sample was mailed letters with invitation to complete web-based
survey
§ 634 responses received (18.5% response rate)
§ Margin of error is +/- 3.8 percentage points
38

39. Findings from the 2014 New RN Graduate
Hiring Survey
0%
10%
20%
30%
40%
50%
60%
70%
Fall 2010 Fall 2011 Fall 2012 Fall 2013 Fall 2014
Percent of new graduates employed in nursing
39

40. Regional variation in employment
40
69%
55%
66%
62%
50%
87%
56%
63%
0% 20% 40% 60% 80% 100%
LA/Ventura
SF Bay
Orange/Inland
N CA
San Diego/
Imperial
Central Valley
Sacramento
Central Coast
Working as RN
2012
Working as RN
2013
Working as RN
2014

41. Employment rate varies by education
41
53% 55%
59%
55%
63%
67%
62%
70%
58%
0%
10%
20%
30%
40%
50%
60%
70%
80%
AD BSN ELM
2012
2013
2014

42. Employment settings of new graduates
42
59%
13%
5% 4% 2% 2%
15%
72%
8%
4% 5%
2% 0%
9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
2013
2014

43. For those employed…
§ 55.7% employed within 3 months
• 46.6% in the 2013 survey
§ 70.2% reported working in “job of choice”
• 61.6% in the 2013 survey
§ 79.4% are working full time
• 77.2% in the 2013 survey
§ 21.3% participated in a transition to practice or residency program
• 26.6% in the 2013 survey
43

44. Why are they not employed?
§ 83.3% no experience
§ 41.3% no position available
§ 38.5% BSN preferred or required
§ 21.8% work experience not applicable
§ 4.5% academic preparation insufficient for position scope
§ 4.3% weak resume related to volunteering or activity to enhance
experience/skills
§ 2.3% out of school too long
§ 0.8% low GPA
44

45. What are unemployed nurses doing?
23.0%
20.2%
15.5%
12.7%
28.6%
19.7%
18.2%
20.5%
8.2%
33.6%
0%
10%
20%
30%
40%
2013 2014
45

46. What do Deans & Directors observe?
2008-
2009
2009-
2010
2010-
2011
2011-
2012
2012-
2013
2013-
2014
Hospital 71.4% 59.0% 54.4% 61.1% 56.7% 56.0%
Long-term care 8.4% 9.7% 7.8% 8.3% 7.9% 7.1%
Comm/public
health
5.4% 3.9% 4.5% 3.6% 3.6% 3.7%
Employed in
CA
83.4% 81.1% 68.0% 69.6% 72.9% 68.8%
Deans’ estimates of the percent of grads from the past year in
each employment setting
46

47. Goals for this webinar
§ Assess how the economic recovery is affecting demand for RNs in
California
• 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
§ Identify next steps for ensuring an adequate nurse supply
47

48. What is happening now?
§ There is current and anticipated job growth
• Inpatient care growth in census and higher acuity
• Ambulatory care growth
§ Shortages are emerging
• Experienced RNs are in short supply
‒ Operating Room
‒ Labor & Delivery
‒ Emergency Department
‒ Intensive care
§ Reservoir of recent graduates who are still unemployed
48

49. Concerns for workforce policy
§ Will recent graduates who can’t find work leave California
permanently?
§ What education changes are needed to ensure new graduates
have the right skills?
§ Can we foster opportunities to gain on-the-job skills and to pursue
additional education?
49

50. Some recommendations
§ Employers: Invest in new graduate hiring
• Less expensive than a shortage
‒ Recruitment costs
‒ Costs of patient care lapses
‒ Costs of rapid wage increases
§ Educators: Partner with employers
• Offer electives in the clinical areas of shortage
• Ensure streamlined education progression
§ Policymakers: Maintain education capacity
• Do not let enrollments drop
• Support scholarship programs such as the HPEF programs
50

51. Check out our website!
http://rnworkforce.ucsf.edu
57

52. Interactive data displays
57

53. Also go to the BRN website
Forms è Publications
53

54. 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
54

55. 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 later this
spring or early summer
• New forecasts in Summer 2015
§ The 2014-2015 BRN Annual Schools Survey will be sent in October
§ The 2015 Employer Survey will be sent in October
55

56. Questions?
Thoughts?
Ideas?
Perspectives?
56