Table of Contents 1. EXECUTIVE SUMMARY BACKGROUND HEALTHCARE INDUSTRIAL AND OCCUPATIONAL OVERVIEW... 8

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3 Table f Cntents 1. EXECUTIVE SUMMARY BACKGROUND HEALTHCARE INDUSTRIAL AND OCCUPATIONAL OVERVIEW HEALTHCARE INDUSTRY PROFILE Histrical Trends Healthcare Industry Mix Occupatinal Mix in Healthcare PROJECTED GROWTH OF HEALTHCARE EMPLOYMENT Healthcare Industry Emplyment Prjectin Healthcare Occupatinal Prjectin ANALYSIS OF NURSE DEMAND AND SUPPLY DETAILED ANALYSIS OF RN DEMAND Demand fr RN by Industry RN Demand by Degree Award TRAINING ALIGNMENT OF REGISTERED NURSES Degree Awards in Registered Nursing Training Cncentratin fr Nurses IMPLICATION FOR TRAINING PROVIDERS OTHER NURSING TRAINING ISSUES CLINICAL ROTATION REGIONAL SIMULATION EDUCATION CENTERS RECOMMENDATIONS Cpyright, 2014 Chmura

4 1. Executive Summary The primary regin fr analysis in this reprt, the Hamptn Rads study area, 1 cvers the lcalities serviced by the Hamptn Rads (area 16) and Virginia Peninsula (area 14) Wrkfrce Investment Bards (WIBs). This reprt primarily examines the current and future demand fr nurses in the area. The key pints are summarized belw: The healthcare industry has experienced faster grwth than ther industries in the regin. The brad healthcare industry in this study is defined as industries with a tw-digit Nrth American Industrial Classificatin System (NAICS) cde f 62 healthcare and scial assistance. Frm 2002 thrugh the first quarter f 2014, verall emplyment in the Hamptn Rads study area averaged 0.1% annualized emplyment grwth. The healthcare industry expanded at a much faster rate f 2.7% per year fr the same perid. Average wages in the healthcare industry are higher than the reginal average but with large disparities. This sectr emplys bth highly-paid physicians and lw-paying hme healthcare wrkers. The regin s healthcare infrastructure is well-balanced, and prvides a variety f healthcare services t reginal residents. 2 In 2014, mre than ne in every fur healthcare wrkers in the regin wrked in reginal hspitals. The tw largest ccupatin grups in the healthcare industry are 1. healthcare practitiners and technical ccupatins (SOC ) and 2. healthcare supprt ccupatins (SOC ). The sectr als utilizes ther ccupatins such as business management and ffice supprt wrkers. The healthcare industry and emplyment in healthcare-related ccupatins in the Hamptn Rads study area are bth prjected t cntinue grwing. Over the next ten years, verall emplyment in the regin is expected t increase an average 0.6% per year. Healthcare sectr emplyment is prjected t grw much faster, at 2.1% per year. The largest number f new jbs is expected in the individual and family services and hme healthcare services sub-industries. Emplyment in tw industries vcatinal rehabilitatin 1 Please see Sectin 2.3 fr a list f cities and cunties included in the Hamptn Rads study area. 2 Veterans r military based health care prviders, such as Naval Medical Center Prtsmuth, and Hamptn Rad Veterans Affairs (VA) Hspital are included in this analysis, such as ccupatin demand and ccupatin gaps. 3 Cpyright, 2014 Chmura

5 services and psychiatric and substance abuse hspitals is prjected t decline mdestly ver the next 10 years. The tp tw ccupatins with the highest demand are bth nursing prfessins. The largest demand at 436 per year is fr registered nurses (RN); this is fllwed by licensed practical r vcatinal nurses (LPN) at 159 per year. Analysis f RN demand pints t a trend f upskilling in the prfessin. Based n staffing patterns, it is prjected that mre than half f the demand fr registered nurses (i.e., mre than 200 per year) will cme frm reginal hspitals. Offices f physicians, hme healthcare services, and nursing care facilities will need dzens f registered nurses each year. Tp healthcare emplyers in the regin are Sentara Healthcare, Riverside Health System, Naval Medical Center Prtsmuth, Bn Securs Hamptn Rads Health System, Chesapeake Reginal Medical Center, Children s Hspital f the King s Daughters, Eastern Virginia Medical Schl and Hamptn Veteran s Affairs Medical Center. The majrity f registered nurses have ne f tw types f degrees: Assciate f Science in Nursing (ASN) and Bachelr f Science in Nursing (BSN). Based n the current educatinal attainment f nurses and annual demand f 436 fr registered nurses, the demand fr nurses with BSN degrees was estimated t be 201, while demand fr nurses with ASN degrees was estimated t be 189. In the past, an assciate degree was the primary qualificatin fr an RN, but mre hspitals are leaning tward hiring nly RNs with BSN degrees. This trend is evident in the Hamptn Rads study area, and will generate demand fr RN t BSN prgrams. The regin has sufficient training capacity fr registered nurses. In the academic year, there were 12 institutins in the Hamptn Rads study area that ffered training prgrams in registered nursing. Thse institutins awarded 652 assciate s degrees r nn-degree certificates, 362 fur-year degrees, and 92 graduate degrees in nursing. Based n training cncentratin, 3 there appears t be n shrtage f training capacity fr RNs verall (117% training cncentratin). Hwever, using current staffing ratis, the adequacy f training capacity differs by RN educatin level with an apparent surplus f ASN, sme surplus f BSN, which is f less cncern due t upskilling trend in RN prfessin, and a shrtage f pstgraduate RN training. 3 Training cncentratin is defined as the rati f the reginal pstsecndary award per emplyment fr an ccupatin with respect t the natinal rate f pstsecndary awards per emplyment. Fr example, if a regin s training cncentratin fr a given ccupatin is 100%, it is prducing awards at the same rate as the natin fr that ccupatin; if a regin s training cncentratin is 50%, it is prducing awards at half the natinal pace fr that ccupatin. 4 Cpyright, 2014 Chmura

6 The study area has a particularly high utput f awards fr licensed practical and licensed vcatinal nurses at clse t three times higher than the natinal average. Cnsidering the upskilling trend in the prfessin, the area has a training shrtage in nurse practitiners. Fcus grups participants expressed cncerns abut ther issues. Clinical training is a critical part f an RN s educatin, prviding hands-n pprtunities in a realwrld setting. Existing clinical capacity in the regin may be sufficient fr the current number f nursing students. Hwever, if the number f students in BSN prgrams expands in the future t keep up with expected increased demand, there may nt be enugh clinical spaces available in the regin. The use f simulatrs may help alleviate the ptential clinical training capacity shrtage. Using simulatin t supplement clinical experience may help lcal nursing prgrams increase enrllment and help the regin keep up with prjected increased demand fr RNs with BSN degrees. Nursing leaders, state medical schls, and ther interested parties may need t cnsider lbbying the Virginia Bard f Nursing t expand the amunt f patient care hurs permitted in simulatins. The fllwing recmmendatins r planned actins were made fr reginal training prviders t better align with the changing demand fr RNs. The unmistaken trend f upskilling in nursing prfessins pints t several pprtunities fr reginal healthcare training prviders, especially fur-year institutins. Opprtunities include starting training prgrams such as RN t BSN as they becme ppular fr existing RNs with an assciate s degree wh desire t stay in the hspital setting while btaining a bachelrs degree. There is significant demand at area fur-year institutins fr nurse practitiner prgrams, yet there are currently limited fferings f such prgrams in the regin. Tw-year institutins will face challenges because demand grwth fr RNs with assciate s degrees r LPNs may slw in the future. These institutins culd partner with fur-year institutins t start 2+2 types f prgrams fr BSN degrees. Tw-year institutins can als partner with nursing care and hme care prviders t upskill their LPNs fr RNs with ASN degrees, starting LPN t RN prgrams. These prgrams are described in greater details in Sectin Cpyright, 2014 Chmura

7 2. Backgrund In 2014, Chmura Ecnmics & Analytics (Chmura) cmpleted a wrkfrce study fr the Hamptn Rads area f Virginia, which analyzed verall wrkfrce trends and key issues. 4 In additin t that reprt, an in-depth analysis f registered nurses (RNs) was requested. Recent trends indicate a strng demand fr upskilling within the nursing prfessin, which culd have significant implicatins fr reginal training prviders. Fr this reasn, Opprtunity, Inc. f Hamptn Rads is seeking t identify the future ccupatinal demand fr RN ccupatins in rder t discuss imprtant training issues such as clinical rtatin and simulatin practices. The infrmatin in this reprt can be used t supprt strategic decisins and tactical effrts ensuring that the regin s healthcare industry and training prviders are prepared fr upcming changes in this prfessin. In additin, existing and future wrkers in RN ccupatins can btain necessary skills fr career success. As such, individuals wh can benefit frm this infrmatin include jb seekers, ecnmic develpment practitiners, career cunselrs, curriculum designers, human resurce managers, trainers, and educatrs. This study utilizes lng-term prjectins (10-year frecasts) as the basis fr determining the trends, gaps, and supply and demand dynamics fr RN ccupatins. Mre specifically, it identifies: Reginal demand fr RNs in general, and thse with bachelr s degrees (BSN) in particular Reginal capacity t train BSNs and hw that capacity cmpares t demand Majr healthcare prviders and their plans t address trends in RN demand Demand and capacity fr clinical rtatins fr healthcare wrkers and nurses Extent f simulatin use in clinical training, and demand fr a simulatin center in the regin The primary regin fr analysis in this study is similar t the gegraphic regin f the Virginia Beach-Nrflk- Newprt News, Virginia-Nrth Carlina metrplitan statistical area (MSA). Fr this study, hwever, Chmura mitted the Nrth Carlina cunty f Currituck and Virginia s Mathews Cunty. Per the request f Opprtunity Inc., Chmura included Suthamptn Cunty. The resulting lcalities represent the Hamptn Rads (area 16) and Virginia Peninsula (area 14) WIBs. The cmbined regin, which is made up f the fllwing lcalities, is referred t as the Hamptn Rads study area: Glucester Cunty Isle f Wight Cunty James City Cunty Suthamptn Cunty Surry Cunty Yrk Cunty City f Chesapeake City f Franklin City f Hamptn City f Newprt News City f Nrflk City f Pqusn 4 Please see the full study fr a discussin f brad wrkfrce trends in the regin: Wrkfrce and Occupatinal Demand Trends-Hamptn Rads Study Area, prepared fr Opprtunity Inc., by Chmura Ecnmics & Analytics, September Cpyright, 2014 Chmura

8 City f Prtsmuth City f Sufflk City f Virginia Beach City f Williamsburg Chmura used bth secndary and primary data t address the abve issues. Emplyment and wage data fr the healthcare industry used in this reprt were derived frm JbsEQ, 5 Chmura s prprietary database and ecnmic analysis system. These emplyment and wage data are primarily based upn the Quarterly Census f Emplyment and Wages (QCEW) frm the Bureau f Labr Statistics (BLS). Where necessary, data were imputed by the JbsEQ technlgy platfrm. Occupatin data were crssed ver frm industry data using the JbsEQ industry/ccupatin crsswalk, a variatin n the natinal industry/ccupatin crsswalk frm BLS. Occupatin and emplyment figures are based upn a fur-quarter mving average as f the latest industry data (2014 quarter 1). Wage data are frm the Occupatin Emplyment Statistics prgram and are current as f Training prgrams related t nursing ccupatins are classified accrding t the Classificatin f Instructinal Prgrams (CIP cdes). Data n current cmpletin and awards are frm the Natinal Center fr Educatin Statistics. While this is helpful fr estimating ccupatin prductin frm training prgram awards data, the crsswalk is neither perfect nr cmprehensive. Fr primary data cllectin, Chmura participated in a Hamptn Rads Healthcare Wrkfrce fcus grup held n April 24, This fcus grup was attended by majr healthcare prviders. Infrmatin gathered frm this fcus grup supplement the secndary data and is the main infrmatin surce regarding clinical rtatin and training simulatin issues. 5 JbsEQ is Cpyright 2014, Chmura Ecnmics & Analytics. All Rights Reserved. JbsEQ is prtected by U.S. Patent 7,480, Cpyright, 2014 Chmura

9 3. Healthcare Industrial and Occupatinal Overview This sectin prvides details n the healthcare sectr and key ccupatins in the Hamptn Rads study area. The brad healthcare sectr is defined as industries with a tw-digit Nrth American Industrial Classificatin System (NAICS) cde f 62 healthcare and scial assistance Healthcare Industry Prfile Histrical Trends In the first quarter f 2014, the healthcare sectr in the Hamptn Rads study area emplyed a ttal f 98,400 wrkers (fur-quarter average), accunting fr 13.7% f the verall reginal wrkfrce. In terms f emplyment, this is the secnd-largest industry sectr, after prfessinal and business services. Cmpared with ttal emplyment, the healthcare sectr in the Hamptn Rads study area has enjyed sustained grwth, despite the severe recessin f Over the past twelve years (frm the first quarter f 2002 t the first quarter f 2014), emplyment in the reginal healthcare sectr expanded 2.7% per year a sharp cntrast with the tepid 0.1% annualized emplyment grwth fr verall emplyment in the regin (Figure 3.1) Figure 3.1: Emplyment in Heathcare Sectr, Fur-Quarter Mving Average, 2002Q1= Recessin 70.0 HealthCare Reginal Overall Nte: Shaded area represents recessin Surce: JbsEQ This pattern is cnsistent with the natinal trend f the healthcare sectr, which was the nly industry that cntinued t expand during the recessin. The grwing elderly ppulatin cupled with the aging f retiring baby bmers ensured sustained demand fr healthcare services even during the recessin. As the reginal and natinal ecnmies climbed ut f the recessin, the federal gvernment instituted drastic budget cuts in 2011, with half f thse budget cuts in defense. 6 With the implementatin f the Affrdable Care Act in 2014, hwever, many previusly uninsured individuals have gained health insurance. This develpment is expected t bst demand fr 6 Please see Assessing the Impact f Federal Budget Cuts n the Virginia Ecnmy, prepared by Gerge Masn University and Chmura Ecnmics & Analytics, Octber Cpyright, 2014 Chmura

10 healthcare services in the regin. As a result, healthcare sectr emplyment will cntinue t utperfrm the reginal average in the near future. As f the first quarter f 2014, the average annual salary per wrker in the Hamptn Rads study area healthcare sectr was $45,085, higher than the reginal average f $43,036. Annual average wages per wrker in the reginal healthcare sectr have grwn fairly steadily frm 2002 t the first quarter f 2014, thugh the pace slwed smewhat during and after the past recessin (Figure 3.2). Over the twelve years ending with the first quarter f 2014, annual average wages grew 2.8% in the healthcare sectr, clse t the reginal average f 3.0% during the same perid. Despite the fact that emplyment in this industry grew much faster than emplyment in ther industries in the regin, wage grwth has nt increased at the same pace. A pssible explanatin is that, within the healthcare industry, lw-skilled ccupatins have been expanding faster than high-skilled ccupatins helping t bring dwn verall wage grwth. Fr example, ver the past five years, emplyment grwth in lwering paying healthcare supprt ccupatins (SOC ) averaged 2.1% per year, versus 1.5% annual grwth fr higher paying healthcare practitiners and technicians ccupatins (SOC ). $50,000 Figure 3.2: Average Annual Average Wage Per Wrker $45,000 $40,000 $35,000 $30,000 $25,000 Recessin Healthcare Reginal Overall $20, Nte: Shaded area represents recessin Surce: JbsEQ Healthcare Industry Mix This sectin examines the varius healthcare sectr sub-industries in the Hamptn Rads study area, based n fur-digit NAICS cdes. Healthcare is the secnd-largest sectr in the regin. The cmpsitin f the healthcare industry in the study area is similar t that f the state and natin as a whle, indicating that the reginal healthcare infrastructure can meet the needs f its residents. Overall, the healthcare industry is fairly balanced, cnsidering that different types f healthcare services are well-represented in the regin. In the healthcare sectr, 26% f jbs (25,500) were in hspitals (fr the year ending in the secnd quarter f 2014). This was fllwed by thse wrking in the ffices f physicians (15,500), and individual and family services (9,400). While verall wages in the sectr were slightly higher than the reginal average, wages at the fur-digit NAICS level vary greatly. The highest average wages were fr ffices f physicians ($82,500 fr the year ending in the secnd quarter f 2014). In cntrast, average wages fr child day care services was $16,700 per year. Other industries such as hme healthcare services and vcatinal rehabilitatin services have annual wages slightly ver $20,000 per year. 9 Cpyright, 2014 Chmura

11 Table 3.1: Emplyment Mix by Sectr, Year Ending First Quarter 2014 Emplyment Hamptn Rads Study Area Average Annual Wages Hamptn Rads Study Area Percentage f Emplyment Hamptn Rads Study Area Offices f Physicians 15,500 $82, % 14.3% 12.7% Offices f Dentists 5,100 $51, % 5.1% 4.5% Offices f Other Health Practitiners 4,200 $41, % 4.1% 3.9% Outpatient Care Centers 3,500 $45, % 3.5% 3.8% Medical and Diagnstic Labratries 1,100 $40, % 1.7% 1.2% Hme Health Care Services 6,900 $20, % 5.7% 6.4% Other Ambulatry Health Care Services 2,300 $45, % 1.6% 1.5% General Medical and Surgical Hspitals 25,500 $49, % 25.4% 28.5% Psychiatric and Substance Abuse Hspitals 1,000 $40, % 1.0% 1.2% Specialty (except Psychiatric & Substance Abuse) Hspitals 400 $53, % 0.5% 1.2% Nursing Care Facilities (Skilled Nursing Facilities) 7,200 $30, % 7.3% 8.8% Residential Intellectual and Develpmental Disability, Mental Health, and Substance Abuse Facilities 3,400 $25, % 3.3% 3.6% Cntinuing Care Retirement Cmmunities and Assisted Living Facilities fr the Elderly 5,100 $23, % 6.0% 4.3% Other Residential Care Facilities 600 $24, % 1.0% 0.9% Individual and Family Services 9,400 $28, % 11.6% 10.8% Cmmunity Fd and Husing, and Emergency and Other Relief Services 700 $33, % 0.8% 0.8% Vcatinal Rehabilitatin Services 2,700 $21, % 2.2% 1.8% Child Day Care Services 4,100 $16, % 4.9% 4.2% Ttal 98,700 $45, % 100.0% Nte: Numbers may nt sum due t runding % Surce: JbsEQ VA USA Table 3.2 presents the tp healthcare emplyers in the regin and emplyment range. They are Sentara Healthcare, Riverside Health System, Naval Medical Center Prtsmuth, Bn Securs Hamptn Rads Health System, Chesapeake Reginal Medical Center, Children s Health System (Children s Hspital f the King s Daughters), Eastern Virginia Medical Schl and Hamptn Veteran s Affairs Medical Center (Table 3.2). Thse tp eight emplyers have ver 40% f all healthcare wrkfrce in the Hamptn Rads Study Area. Table 3.2: Tp Healthcare Emplyers in Hamptn Rads Study Area Emplyers Emplyment Sentara Healthcare 20,000 Riverside Health System 7,050 Naval Medical Center Prtsmuth 5,400 Bn Securs Hamptn Rads Health System 3,000 Chesapeake Reginal Medical Center 2,400 Children's Health System (Children s Hspital f the King s Daughters) 1,900 Eastern Virginia Medical Schl 1,500 Hamptn Veteran s Affairs Medical Center 1,200 Surce: Opprtunity Inc. 10 Cpyright, 2014 Chmura

12 Occupatinal Mix in Healthcare The mix f healthcare ccupatins in the Hamptn Rads study area is listed in Table 3.2. Occupatins are defined accrding t the Standard Occupatinal Classificatin (SOC) with majr grups crrespnding t the first tw digits f the SOC cde. The healthcare industry emplys a wide range f ccupatins. Nt surprisingly, the tw largest ccupatin grups are healthcare practitiners and technical ccupatins (31,700) and healthcare supprt ccupatins (18,200). These tw ccupatin grups accunted fr half f all wrkers in the healthcare sectr. This sectr als emplyed a large number f wrkers in ffice and administrative supprt, and persnal care and service ccupatins. The healthcare sectr als emplyed 3,600 management-related ccupatins, which were paid much higher wages than the industry average. Table 3.3: Majr Occupatin Grups in Healthcare Sectr, Hamptn Rads Study Area, Year Ending 2014Q2 Annual Average Wages SOC Title Current Emplyment per Wrker Healthcare Practitiners and Technical Occupatins 31,700 $72, Healthcare Supprt Occupatins 18,200 $25, Office and Administrative Supprt Occupatins 16,000 $32, Persnal Care and Service Occupatins 9,000 $20, Cmmunity and Scial Service Occupatins 5,900 $41, Management Occupatins 3,600 $98, Fd Preparatin and Serving Related Occupatins 2,800 $23, Educatin, Training, and Library Occupatins 2,700 $33, Building and Grunds Cleaning and Maintenance Occupatins 2,400 $21, Business and Financial Operatins Occupatins 1,700 $65, Transprtatin and Material Mving Occupatins 800 $28, Installatin, Maintenance, and Repair Occupatins 800 $38, Life, Physical, and Scial Science Occupatins 600 $65, Cmputer and Mathematical Occupatins 600 $69, Sales and Related Occupatins 400 $40, Prductin Occupatins 600 $31, Prtective Service Occupatins 400 $29, Arts, Design, Entertainment, Sprts, and Media Occupatins 200 $57, Cnstructin and Extractin Occupatins 100 $41, Legal Occupatins 0 $95, Architecture and Engineering Occupatins 0 $70, Farming, Fishing, and Frestry Occupatins 0 $22,300 Surce: JbsEQ 11 Cpyright, 2014 Chmura

13 3.2. Prjected Grwth f Healthcare Emplyment Healthcare Industry Emplyment Prjectin Overall, emplyment in the Hamptn Rads study area is prjected t expand 0.6% per year ver the next ten years (2014Q2 t 2024Q2). Emplyment in the healthcare sectr is prjected t grw much faster, at 2.1% per year. 7 The sectr is expected t add a ttal f 23,358 jbs in the next 10 years. The largest number f new jbs will be added in individual and family services (+4,612 jbs), fllwed by hme healthcare services (+3,876 jbs). These tw industries emply a large number f basic skill wrkers wh earn relatively lw wages. Jbs in the study area s hspitals and ffices f physicians are prjected t increase by 1,847 and 3,499, respectively. While the verall healthcare sectr is expected t experience rbust grwth, emplyment in tw industries vcatinal rehabilitatin services and psychiatric and substance abuse hspitals are prjected t decline mdestly ver the next 10 years. Figure 3.3: Ten-Year Prjected Emplyment Grwth in the Healthcare Sectr 2014Q2-2024Q2 Individual and Family Services Hme Health Care Services Offices f Physicians General Medical and Surgical Hspitals 1,847 Outpatient Care Centers 1,672 Offices f Other Health Practitiners 1,643 Cntinuing Care Retirement Cmmunities and Assisted 1,521 Offices f Dentists 1,181 Nursing Care Facilities (Skilled Nursing Facilities) 981 Child Day Care Services 737 Other Ambulatry Health Care Services 625 Residential Intellectual and Develpmental Disability, 624 Medical and Diagnstic Labratries 303 Specialty (except Psychiatric and Substance Abuse) 191 Other Residential Care Facilities 134 Cmmunity Fd and Husing, and Emergency and Other 101 Psychiatric and Substance Abuse Hspitals -73 Vcatinal Rehabilitatin Services -85 3,499 3,876 4,612 Surce: JbsEQ -1, ,000 2,000 3,000 4,000 5,000 The abve prjectin is nt meant t be an exact predictin f future events, but rather a baseline scenari that ffers a reasnable mdel fr future emplyment changes in the healthcare industry. A variety f events may ccur that wuld significantly alter future emplyment changes. Fr Virginia s healthcare industry, ne f the largest unknwns is related t the implementatin f the Affrdable Care Act. Virginia has nt expanded Medicaid, even 7 These prjectins, as summarized in Figure 3.9, d nt include replacement demand, but rather emplyment grwth alne. 12 Cpyright, 2014 Chmura

14 thugh Gvernr McAuliffe is pushing fr this expansin t prvide health insurance fr 400,000 individuals. 8 It is expected that the debate n Medicaid expansin will cntinue; and if it is expanded, demand fr healthcare service in Virginia will rise significantly Healthcare Occupatinal Prjectin Chmura examines the ccupatin prjectin fr ver 60 healthcare practitiner and technical ccupatins (thse with SOC cdes beginning with 29 ). Figure 3.3 presents the tp 20 mst in-demand ccupatins. Demand is defined in terms f bth grwth demand and replacement demand which is the replacement needs within an ccupatin due t retirements and wrkers mving frm ne ccupatin t anther. 9 The tp tw ccupatins with the highest demand are nursing. Registered nurses (RNs) have the largest annual demand with a need fr 436 registered nurses per year 248 t replace nurses wh retire r leave the prfessin, and 188 t meet the demand f industry grwth. The demand fr licensed practical r vcatinal nurses (LPNs) is expected t average 159 per year t accmmdate fr attritin and meet new grwth. There is als strng demand fr the highly-skilled and highly-paid ccupatin: physicians and surgens, all ther. Figure 3.3: Annual Demand in Healthcare Occupatins ( ) Registered Nurses Licensed Practical and Licensed Vcatinal Nurses Physicians and Surgens, All Other Emergency Medical Technicians and Paramedics Dental Hygienists Physical Therapists Pharmacists Pharmacy Technicians Medical Recrds and Health Infrmatin Technicians Medical and Clinical Labratry Technicians Nurse Practitiners Radilgic Technlgists Dentists, General Family and General Practitiners Medical and Clinical Labratry Technlgists Physician Assistants Speech-Language Pathlgists Occupatinal Therapists Opticians, Dispensing Veterinary Technlgists and Technicians Replacement Grwth Surce: JbsEQ 8 Surce: 9 Replacement needs are calculated via replacement rates frm the Bureau f Labr Statistics. Based n their methdlgies, these rates understate ttal demand and shuld be taken as a minimum measure f training needs due t replacements. 13 Cpyright, 2014 Chmura

15 4. Analysis f Nurse Demand and Supply 4.1. Detailed Analysis f RN Demand In this sectin, Chmura specifically analyzes the demand fr registered nurses. While sectin 3.2 presents the verall 10-year demand fr nurses, this sectin prvides further infrmatin n the demand fr nurses frm each industry, as well as demand fr RNs with different degrees r certificates Demand fr RN by Industry Chmura uses the current industry staffing pattern f registered nurses t estimate demand fr nurses frm each industry. Hspitals will cntinue t have the largest demand fr registered nurses. The current data indicate that 57% f the nurses in the Hamptn Rads study area were emplyed in general medical and surgical hspitals. As a result, f the annual demand f 436 (Table 4.1), 249 nurses are expected t be hired t wrk in reginal hspitals. After that, ffices f physicians, hme healthcare services, and nursing care facilities will need dzens f registered nurses each year. Other industries hiring nurses include utpatient care centers and public schls. Table 4.1: Registered Nurse Demand by Industry Industry (Fur-Digit NAICS) % in Industry Annual Demand ( ) General Medical and Surgical Hspitals 57.1% 249 Offices f Physicians 8.5% 37 Hme Health Care Services 7.7% 34 Nursing Care Facilities 4.7% 20 Outpatient Care Centers 3.9% 17 All Other Industries 18.1% 79 Ttal 436 Surce: JbsEQ The abve results were cnfirmed by participants f the Hamptn Rads Healthcare Wrkfrce fcus grup. Fr example, the regin received a $5 millin H1B grant fr wrkfrce training fr the healthcare industry. During the fcus grup, Opprtunity Inc. One-Stp Wrkfrce Center reprted that the tp five emplyers fr their prgram participants are all hspitals and physicians ffices Sentara Health System, Bn Securs Health System, Children s Hspital f the King s Daughters, Suthamptn Memrial Hspital, and Bayview Physicians Grup. Similarly, the Peninsula Wrklink One-Stp Career Center reprted that the tp five emplyers are: Riverside Health System, Sentara Health System, Bn Securs Health System, Children s Hspital f the King s Daughters, and Tidewater Physicians Multispecialty Grup RN Demand by Degree Award The majrity f registered nurses have ne f tw types f degrees Assciate f Science in Nursing (ASN) r Bachelr f Science in Nursing (BSN). Chmura used the current degree prfile f registered nurses in the regin t estimate the demand fr nurses with each degree. The current data indicate clse t half (46%) f current RNs have bachelr s degrees, 43% f registered nurses have assciate s degrees, and 10% have graduate degrees. As a result, f the annual demand f 436 fr registered nurses, the demand fr RNs with BSN degrees was estimated t be 201, while demand fr RNs with ASN degrees was estimated t be Cpyright, 2014 Chmura

16 Figure 4.1: Educatinal Attainment f RNs in the Study Area High Schl r Less 1% Graduate degree 10% Bachelr's degree 46% Assciate's degree (including sme cllege) 43% Surce: JbsEQ In the past, an assciate s degree was the primary qualificatin f RNs. Hwever, mre RNs in the regin nw have bachelr s degrees, and this trend is expected t cntinue. Hspitals arund the cuntry are phasing ut LPNs in favr f registered nurses with a bachelr s degree in nursing. 10 Participants in the Hamptn Rads Healthcare Wrkfrce fcus grup cnfirmed that reginal hspitals are mving in the same directin. 11 One reginal hspital has indicated that it will require all f its newly-hired RNs withut BSN degrees t start a BSN prgram within tw years f hire, and cmplete the prgram within five years. This is based n research that emplying nurses with bachelr s degrees result in better patient utcmes. If this trend cntinues and is adpted by ther hspitals, graduates frm LPN prgrams r RNs with assciate s degrees will see their career ptins limited in reginal hspitals. Yet, the demand fr LPNs will still be rbust, as healthcare prviders such as nursing care facilities, assisted living facilities, r hme healthcare services cntinue t grw in the regin. Demand fr nurses with graduate degrees (nurse practitiners) will als increase. Implementatin f the Affrdable Care Act will create an influx f newly-insured patients, creating time cnstraints t physicians schedules. This will present an pprtunity fr nurse practitiners t assume an increased patient lad, which will increase nurse practitiner demand. This upskilling trend in the nursing prfessin will create an pprtunity fr training prviders in the regin, which is discussed in the next sectin Training Alignment f Registered Nurses This sectin prvides an analysis f the training alignment f the Hamptn Rads study area fr registered nurses. First, the current training prviders and their degree awards in nursing are reprted. This is fllwed by an 10 Fr an example, please see 11 The fcus grup was held n April 24, Cpyright, 2014 Chmura

17 assessment f whether the capacity surpasses r falls shrt f demand using a metric created by Chmura called training cncentratin Degree Awards in Registered Nursing Based n data frm the Natinal Center fr Educatin Statistics (NCES) fr the academic year, there were 12 institutins in the Hamptn Rads study area that ffered training prgrams in registered nursing (Table 4.2). Thse institutins vary, including public fur-year universities (Old Dminin, Nrflk State), tw-year cmmunity clleges (Tidewater, Thmas Nelsn, and Paul D. Camp), private fr-prfit clleges (ECPI, ITT Technical Institute, and Suth University), and training schls affiliated with majr healthcare systems (Riverside and Sentara). Amng thse 12 institutins, 8 f them ffered certificates r assciate s degrees (ASN), six ffered BSN degrees, and tw ffered graduate degrees in nursing. 13 Table 4.2: Degree Awards in Registered Nursing ( Academic Year) Institutins Certificate and Assciates Degrees 4-Year Degrees Pstgraduate Degrees ECPI-Virginia Beach/Nrflk Frtis Cllege-Nrflk Hamptn University ITT Technical Institute-Nrflk Nrflk State University Old Dminin University Paul D Camp Cmmunity Cllege Riverside Schl f Health Careers Sentara Cllege f Health Sciences Suth University Virginia Beach Thmas Nelsn Cmmunity Cllege Tidewater Cmmunity Cllege Ttal Surce: Natinal Center fr Educatin Statistics In the academic year at these institutins, 652 students earned awards at the assciate s degree r certificate level, 362 earned a fur-year degree, and 92 earned a graduate degree in nursing. At first glance, the number f degree awards seems t be larger than the reginal demand, especially at the assciate s degree level. The demand fr nurses with BSN degrees was estimated t be 201, while demand fr nurses with ASN degrees 12 Training cncentratin is defined as the rati f the reginal pstsecndary award per emplyment fr an ccupatin with respect t the natinal rate f pstsecndary awards per emplyment. Fr example, if a regin s training cncentratin fr a given ccupatin is 100%, it is prducing awards at the same rate as the natin fr that ccupatin; if a regin s training cncentratin is 50%, it is prducing awards at half the natinal pace fr that ccupatin. 13 Data fr ECPI came frm ECPI directly, as NCES reprted data included graduates frm multiple campuses. 16 Cpyright, 2014 Chmura

18 was estimated t be 189. Althugh reginal awards in bth degrees surpassed reginal demand, the surplus in ASN degrees prductin was larger. Surplus training f BSN degree nurse is less f a cncern fr a number f reasns. First, as mentined abve, reginal hspitals increasingly prefer RNs with BSN degrees, and the current estimate may understate this demand. Additinally, students with BSN degrees are mre mbile, and many f them may seek emplyment utside the regin. Clleges in Hamptn Rads have a large number f students frm bth the Nrthern Neck and the Suthside areas f Virginia because these regins lack fur-year institutins. Students btaining BSN degrees in Hamptn Rads may decide t leave the regin t seek emplyment. Thse upskilling trends culd increase the demand fr BSN in future years. On the ther hand, there appears t be sme surplus in training capacity at bth the assciate s and certificate levels fr RNs. There are cmmunity clleges all ver Virginia, and mst f these students tend t remain in the regin served by their cmmunity cllege after graduatin. Similarly, many students attending fr-prfit clleges are wrking adults wh tend t lk fr emplyment in the area. With an estimated 652 awards, the demand fr graduates with such degrees is less than 200 per year. Many f these graduates may dwngrade their career aspiratins. Instead f seeking emplyment in majr hspitals, they may end up in dctrs ffices, with hme healthcare service prviders, r in nursing care facilities. Chmura s training cncentratin analytic, explained in belw, prvides a mre definite indicatr f the balance between demand and supply fr RNs Training Cncentratin fr Nurses Training cncentratin is defined as the award utput measured against ccupatin demand. T analyze ccupatin training, Chmura first translated the awards by training prgram int ccupatins and then calculated the rate f degree awards as a percentage f ttal emplyment. The natinal percentage f pstsecndary awards in ttal emplyment (in a crrespnding ccupatin) is used as the benchmark, and a reginal rate is cnstructed as a percentage f the natinal benchmark percentage. This relative reginal percentage is termed its training cncentratin fr a given ccupatin. Fr example, if the natin prduces ne registered nurse graduate fr every ten emplyed nurses, the ne-t-ten rati is the natinal standard. If a regin such as Hamptn Rads prduces ne registered nurse graduate fr every twelve emplyed nurses, then we cnclude the regin s utput fr this ccupatin is trailing the natinal rate f prductin. In ccupatins where there exists substantial shrtfalls in training cncentratin (abut 75% r less), Chmura expects that industries struggle t find lcally-available talent with requisite skills. These industries wuld als be expected t recruit applicants frm utside the area Virginia-wide r even ut-f-state. The least favrable ptin is t hire individuals lacking the desired ccupatin-specific skills and backgrund, which wuld require a lnger initial training and rientatin perid. The verall utput f pstsecndary awards fr registered nurses is abve-average in the study area (117% training cncentratin). This percentage implies that there is n shrtage f training capacity fr RNs (training cncentratin des nt break ut the awards by degree levels). Data in Sectin indicate that there is nt a shrtage at the BSN level, and there might be sme surplus at the ASN level. The study area has a particularly high utput f awards fr licensed practical and licensed vcatinal nurses at clse t three times the natinal average pace. 17 Cpyright, 2014 Chmura

19 Table 4.3: Hamptn Rads Study Area Pstsecndary Training Output fr "Highly-Educated" Healthcare Practitiner and Technical Occupatins, Academic Year SOC Title Estimated All Awards Emplyment Training Cncentratin High- Grwth Registered Nurses 1,148 12, % Licensed Practical and Licensed Vcatinal Nurses 865 3, % Medical Recrds and Health Infrmatin % Radilgic Technlgists % Dental Hygienists 72 1, % Surgical Technlgists % Pharmacy Technicians 66 1,875 58% Physical Therapists 58 1, % Pharmacists 57 1,469 79% Physicians and Surgens, All Other 56 1,842 88% Medical and Clinical Labratry Technicians % Physician Assistants % Speech-Language Pathlgists % Emergency Medical Technicians and Paramedics 49 1,381 34% Cardivascular Technlgists and Technicians % Medical and Clinical Labratry Technlgists % Family and General Practitiners % Nurse Practitiners % Respiratry Therapists % Athletic Trainers % Surce: JbsEQ All Other Occupatins 73 7,563 The area has a training shrtage fr nurse practitiners. Based n data frm the academic year, the Hamptn Rads study area had a relatively lw utput f nurse practitiners. With a training cncentratin f nly 31%, degree awards fr this ccupatin are nly 31% f the natinal nrm. That means reginal healthcare service prviders will have t recruit nurse practitiners frm utside the regin, r even ut-f-state. With increasing demand fr this ccupatin, businesses either have t ffer better cmpensatin packages r ther benefits t hire and retain these wrkers Implicatin fr Training Prviders The unmistaken trend f upskilling in the nursing prfessin pints t several pprtunities fr reginal healthcare training prviders, especially fur-year institutins. There are pprtunities fr fur-year institutins t start training prgrams such as RN t BSN, as they becme ppular fr existing RNs withut BSN degrees wh desire t stay in hspitals and btain a bachelr s degree. These prgrams will target current RNs with ASN degrees. Many such prgrams have been set up in Virginia and thrughut the cuntry. The University f Virginia ffers ne such prgram that takes 21 mnths t cmplete n a part-time basis. 14 RN t BSN prgrams are ffered at a number f 14 Surce: 18 Cpyright, 2014 Chmura

20 reginal schls including ECPI, Nrflk State, Old Dminin, and Hamptn Universities, as well as Sentara Cllege f Health Sciences. 15 There is als significant demand fr nurse practitiner prgrams frm fur-year institutins in the area but currently there are limited fferings in the regin. The nurse practitiner prgram is a graduate-level degree prgram, and current fur-year institutins such as ODU, Hamptn University, and Nrflk State are well-suited t start r expand prgrams in this specialty. Unfrtunately, tw-year institutins will face challenges if demand grwth fr RNs with assciate s degrees r LPNs slws in the future. These institutins culd partner with fur-year institutins t start 2+2 prgrams fr BSN degrees. A student may start an ASN nursing degree prgram in a tw-year cllege, and then transfer t a furyear institutin fr a BSN degree, r even a graduate degree in nursing. Due t the trickle-dwn effect, many firms may require LPNs t btain an ASN degree in registered nursing. This will als prvide pprtunities fr tw-year clleges. They can partner with nursing care and hme care prviders and upskill their LPNs t RNs with ASN degrees. Sme reginal schls have started such LPN t RN prgrams, including Tidewater and Thmas Nelsn Cmmunity Clleges. In additin, Nrflk State and Hamptn Universities have LPN t BSN prgrams, which ffer a direct pathway t a 4-year degree fr licensed and practical nurses. Upskilling will affect the entire industry and bth LPNs and RNs will need t gain additinal training. 15 Surce: ; 19 Cpyright, 2014 Chmura

21 5. Other Nursing Training Issues 5.1. Clinical Rtatin Clinical training is a critical part f an RN s educatin, prviding hands-n pprtunities in a real wrld setting. BSN prgrams require extensive clinical training in the range f hurs. 16 While the existing clinical capacity in the regin may be sufficient fr the current number f nursing students, if the number f students in BSN prgrams expands in the future, there may nt be enugh clinical spaces available. Accrding t ne participant in the Hamptn Rads Healthcare Wrkfrce fcus grup, based n a wrkfrce study their rganizatin cnducted, there is nt enugh clinical training space. A recent reprt by the Assciatin f American Medical Clleges revealed cncerns frm medical schls, nurse practitiner prgrams, and physician assistant prgrams acrss the cuntry abut the lack f clinical training space. 17 Accrding t the results f a 2013 survey, 96% f nurse practitiner prgrams reprted cncerns abut the number f clinical training sites. In additin, 86% f respndents representing nurse practitiner prgrams said that it was harder t develp new clinical training sites in 2013 than it had been tw years earlier. The reprt als said that 72% f nurse practitiner prgram respndents believed that the shrtage f training sites was cnstraining enrllment capacity in their prgrams. While these survey results are specific t nurse practitiner prgrams, it is likely that RN prgrams natinwide are experiencing similar challenges. In rder t prepare fr the prjected increased demand fr BSN degrees, the Hamptn Rads study area needs t address the ptential training capacity shrtage. One pssible alternative t alleviate this shrtage wuld be t allw mre clinical experience in a simulated envirnment Reginal Simulatin Educatin Centers The use f simulatrs may help alleviate the capacity issues discussed abve. Using simulatin t supplement clinical experience may help lcal nursing prgrams increase enrllment and help the regin keep up with the prjected increased demand fr RNs with BSN degrees. Many nursing schls, including the University f Pennsylvania Schl f Nursing and New Yrk University Cllege f Nursing, have successfully expanded enrllment because f their ability t supplement clinical training with simulatin. 18 The Virginia Bard f Nursing allws a maximum f 20% f direct patient care hurs t be cmpleted thrugh simulatin. 19 Sme prgrams utside Virginia rely much mre heavily n simulatin. The Schl f Nursing at Texas Tech University, fr example, recently pened a new facility which allws 50% f its students clinical 16 The Virginia Bard f Nursing requires all RN nursing prgrams in Virginia t prvide a minimum f 500 hurs f direct client care supervised by qualified faculty. See Guidance Dcument 90-24, The Use f Simulatin in Nursing Educatin, March 19, 2013, 17 Surce: 18 Surce: Demand_35044.aspx 19 See Guidance Dcument 90-24, The Use f Simulatin in Nursing Educatin, March 19, 2013, 20 Cpyright, 2014 Chmura

22 experiences t be simulated. 20 Nursing leaders, state medical schls, and ther interested parties may need t cnsider lbbying the Virginia Bard f Nursing t expand the amunt f patient care hurs permitted in simulatin. There has nt been a mvement t d s, hwever, pssibly in part due t the high cst assciated with simulatin labratries. One slutin might be fr a reginal simulatin labratry t spread the cst f the center acrss several institutins. 20 Surce: Demand_35044.aspx 21 Cpyright, 2014 Chmura

23 6. Recmmendatins The trend tward the need t upskill will present a cnstant challenge fr area wrkfrce develpment prfessinals and the regin s educatin prviders. Frtunately, reginal educatin and training prviders have respnded t such needs and expanded their capacities in high-demand ccupatins ver the past tw years. There are als ample training pprtunities fr the existing wrkfrce, such as upskilling current RNs with assciate s degrees t bachelr s degrees. Fr wrkfrce develpment agencies, matching jb candidates with demand is imprtant t ensure the efficiency f the reginal labr market. The trend f upskilling in nursing prfessins pints t several pprtunities fr reginal healthcare training prviders. As a result f this trend, there is an pprtunity fr fur-year institutins t start RN t BSN prgrams, as they becme ppular fr RNs with an assciate s degree. This wuld allw registered nurses t cntinue wrking in a hspital setting while btaining a bachelr s degree. Many such prgrams have been set up arund the cuntry and in Virginia at the University f Virginia, Old Dminin University, Virginia Cmmnwealth University, and Sentara Cllege f Health Sciences. There is als significant demand fr nurse practitiner prgrams frm fur-year institutins in the area, but there are limited fferings in the regin. A nurse practitiner prgram is at the graduate-level, and fur-year institutins such as ODU and Nrflk State are well-suited t start r expand prgrams in this specialty. Unfrtunately, tw-year institutins will face challenges in that demand grwth fr RNs with assciate s degrees r LPNs may slw in the future. These institutins culd partner with fur-year schls t start 2+2 prgrams fr BSN degrees. Students culd receive their ASN degree frm a tw-year cllege, then transfer t a fur-year institutin fr a BSN degree, and if they desire, a graduate degree in nursing. They can als partner with nursing care and hme care prviders and upskill their LPN credentials t an RN with an ASN degree, starting LPN t RN prgrams. Upskilling will affect the entire healthcare industry, and bth LPNs and RNs will need t receive additinal training. 22 Cpyright, 2014 Chmura

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