CALIFORNIA S LATEST NURSING WORKFORCE CHALLENGE: THE HIRING DILEMMA OF NEW GRADUATES

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1 CALIFORNIA S LATEST NURSING WORKFORCE CHALLENGE: THE HIRING DILEMMA OF NEW GRADUATES Newly graduated nurses are having great difficulty finding jobs as registered nurses (RNs), as they compete with experienced nurses who are working more because of the economy. With fewer nurses retiring or working part-time, positions typically available to new nurses have dried up and hospitals and health systems have cut back dramatically on new graduate hires. As a result, an alarming number of new nurses are unemployed or opting for non-nursing opportunities. Unfortunately, this is occurring as the nursing workforce continues to age and California prepares for a looming nurse shortage. Ultimately, large numbers of nurses will retire. And, as the state s population ages and grows, so does the demand for nursing care. At some point in the near future, California will again face a significant nursing shortage. California s unemployment rate is 12.2% i - the fifth highest in the nation - and a recent report indicates the state may be slower than others to recover from the recession. ii California has been among the nation s lowest RNs per capita - 50 th in Prior to the recession, California was forecast to have a shortfall of 116,000 RN FTEs by meeting only 65% of the state s demand for nurses. iii The magnitude of the looming shortage has the potential to result in a nurserelated healthcare crisis. The California Employment Development Department reports the state needs 9,900 new nurses each year to replace those retiring and to fill new positions. It forecasts a 25% increase in RN jobs through iv In recent years significant efforts and expense have been invested in addressing the nurse shortage. For example, the Governor s Nursing Education Task Force has led a multi-million dollar effort to build educational capacity, anchored by public-private partnerships. v

2 Working with the Governor s Task Force, the California Labor and Workforce Development Agency (LWDA), and the California Institute for Nursing & Health Care (CINHC) (which serves as the state s nursing workforce center) have been the California Hospital Association (CHA), the Association of California Nurse Leaders (ACNL), and the California Board of Registered Nurses (BRN). These organizations are joined by the state s Workforce Investment Boards (WIB), employers of nurses, deans and directors of schools of nursing, educational institutions, foundations, other state agencies, California AARP 1, and organized labor. The effort to build the nursing workforce in California has paid off. Since 2004, schools of nursing have increased educational capacity by 53.5% and there are now 31 more nursing programs. In 2008, 9,580 nurses graduated; this was 3,368 more than in vi Recent data indicates that California now has 638 RNs per 100,000 population, improving its ranking to 46 th in the nation a major improvement from the 580 per capita reported in vii The most recent forecast of the state s nursing workforce indicated that on the current trajectory, California will reach the 25% percentile of RNs per capita by 2016 and the national average by viii Solutions to building the workforce have included funding (both public and private) for schools of nursing to increase enrollments, statewide systems to access untapped capacity for clinical placements, programs to educate nurses to serve as both tenured-track and adjunct faculty, high-fidelity simulation centers, scholarships and loan forgiveness/assumption programs, and regional academic/service partnerships to develop locally-driven action steps to meet regional needs. Difficulty finding employment is an unusual phenomenon for new RNs and threatens statewide efforts to build a stable, adequate long-term nursing workforce. This predicament is driven by the recession and the elasticity of nursing workforce employment patterns - when the economy is good, nurses work less; when the economy is bad, nurses work more. ix 1 These organizations also work with national efforts such as the Center to Champion Nursing in America, under the auspices of AARP. 2

3 California s high unemployment rate is reflected in nurses working more, as the demand for health care remains strong, even in tough economic times. RN vacancy rates in hospitals have decreased to 4%, compared to 7% in x Senior nurses have postponed retirement, part-time RNs have increased hours worked, and RNs who were not working have returned to the workforce. Low RN position vacancy rates are compounded by a lower census in many hospitals - a result of concerns of health insurance loss with growing unemployment, which is keeping people from scheduling surgeries and other elective procedures. Furthermore, the high cost of hiring and preparing new graduates to perform safely and competently after they have completed their academic studies, which is absorbed by the employer, has further limited employment opportunities especially as more experienced nurses seek employment and compete with new graduates. To quantify the extent of this hiring dilemma, in March of 2009 CINHC surveyed employers and found that approximately 40% of new graduates may not find jobs in California hospitals (the usual place of first employment for nurses) as only 65% of hospitals reported hiring new graduates, and these hospitals were also significantly decreasing the number of new RNs they plan to hire from the number hired the previous year. xi All hospitals hiring new graduates reported overwhelming numbers of applicants for few positions. The survey (and another conducted by the hospital association) indicated jobs were available but hospitals wanted experienced nurses. Five regional forums were held across the state to report the findings from the CINHC survey and identify solutions to this hiring dilemma. Participants included healthcare employers, schools of nursing, state agencies, state nursing organizations, Workforce Investment Boards and community organizations. The solution that most resonated was development of communitybased transition to practice programs (internships) to keep newly graduated RNs in the workforce and improve employability. Bringing together leaders from education, service, and the community, the collaboratives will create transitions programs to retain new RN graduates in 3

4 nursing and further develop their competencies so they will be valuable employees when the demand for hiring new nurses inevitably grows again. These programs will be based in the continuing education division of a school of nursing. Service partners will provide the clinical experience (without the requirement to hire). Under the sponsorship of a regional collaborative, the programs will provide extended experiential learning for new nurses. Depending on the needs of regional employers, the proposed programs would be 12 to 18 weeks in length, and either include training for an acute area specialty (e.g., labor and delivery, emergency room, critical care, or operating room), a non-acute healthcare setting (e.g. long-term care, hospice, public and community health, or home health), or focus on developing more advanced generalist skills, New nurses would have the opportunity to increase competencies, confidence, and skills to strengthen the transition from education to service. These programs could include college credit, applicable towards a higher degree in nursing education and a certificate for the additional clinical experience and training. Programs will be based on principles from successful hospital-based residency models, which have demonstrated the ability to raise the baseline level of patient care quality and content, and will focus on strengthening clinical competencies from the Quality and Safety for Education of Nurses (QSEN) model and the statewide ACNL initiative to apply the QSEN competencies to the professional nursing role. CINHC, along with partner organizations concerned about the nursing workforce, seeks funding to support development of these transition programs. The Gordon and Betty Moore Foundation (GBMF) contributed $500,000 to establish transition programs in the five counties in the San Francisco Bay Area (SFBA), resulting in a Request for Proposals issued to regional collaboratives that would be comprised of schools of nursing, employers, and community-based organizations. Funding from other sources is being sought to expand this novel approach to other 4

5 collaboratives in California. A proposal was recently submitted to the US Department of Labor to access ARRA Stimulus Funds based on the new graduate as an unemployed worker. Not only will these programs provide additional clinical experience for the new RNs - increasing their marketability - they will also meet the needs of healthcare employers by developing a better-prepared nursing workforce. The California Labor & Workforce Development Agency and the California Hospital Association, along with regional hospital councils, support this approach which may be the first in the nation to establish community-based transition programs. We are very hopeful that these demonstration projects will merit replication and lead to long-term solutions facing the transition of new graduates as they enter practice as registered nurses. More information is available at: i CA EDD Labor Market Information, current statistic, 9/18/09. ii UCLA Forecast: CA Economy Slow Through 2010, 9/16/09. iii Registered Nurse Population: Preliminary Findings from the National Sample Survey of Registered Nurses March Washington D.C.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing. iv CA EDD Labor market Information 2008, 2009 fastest growing occupations. v California Nurse Education Initiative, Annual Report rd d Annual Report vi California Board of Registered Nursing Annual School Report. vii Registered Nurses per 100,000 Population, viii Spetz, Joanne, Forecasts of the Registered Nurse Workforce in California, CA Board of Registered Nursing, September 29, ix Buerhaus, Peter, et.al., The Future of the Nursing Workforce in the United States, Personal communication. x HASC 2009 Quarterly Turnover and Vacancy Report, 1 st Quarter xi CINHC Presentation: New RN Graduate Workforce Planning Meetings, July ww.cinhc.org 5