The North Carolina Center for Nursing

Transcription

1 The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions December, 2006 The North Carolina Center for Nursing Prepared by: Linda M. Lacey, MA Associate Director: Research Jennifer G. Nooney, PhD (Former) Research Associate Brenda L. Cleary, PhD, RN, FAAN Executive Director The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 1

2 The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions Executive Summary Since 2000, a number of publications have forecast a gloomy future for the nation s health care delivery system resulting from a shortage of health care workers. Registered nurses (RNs) top the list of health professions whose future supply concerns state governments, the federal government, and the nation s healthcare agencies, as well as patients and families. The nursing shortage we face in the coming decades is likely to be different from those experienced in the past. This shortage will be driven by demographics, and it will likely be enduring. Complicating efforts to expand the nursing workforce are the current limits in the capacity of nursing education programs. Is this bleak picture of the nation s future nursing supply also accurate in North Carolina? This article presents supply and demand forecasts for RNs and for nurse faculty in North Carolina in order to answer that question. The federally developed Nurse Supply Model and Nurse Demand Models were used to forecast the extent and timing of an expected nursing shortage. Data on the RN and general population in North Carolina were substituted for data supplied with the federal models to provide more accurate estimates. The results show that, after a number of years in which supply and demand for RNs have been in balance, North Carolina is now entering into a growing nursing shortage that could become severe within the next 10 years. A faculty forecasting model was also created, in which the current supply of nursing faculty is aged out of the workforce and projections of new faculty are added to arrive at an estimate of our future supply of nursing faculty. This figure was compared with an estimate of future demand for faculty, based on current faculty-to-student ratios and expected numbers of students. The results show an immediate and rapidly expanding shortage of nursing faculty in the state. We conclude with policy recommendations for mitigating the expected nursing shortage. The state is unlikely to avoid the next nursing shortage, but we can affect its severity if we aggressively work to recruit and retain nurses in both education and practice right now. The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 2

3 The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions Since 2000, a number of publications have forecast a gloomy future for the nation s healthcare delivery system resulting from a shortage of health care workers. Registered nurses (RNs) top the list of health professions whose future supply concerns state governments 1 along with the federal government and the nation s healthcare industry 2. RNs constitute the largest group of health care professionals in this country 3, and shortages of nursing labor at the facility level lead to ER diversions, bed closures, and compromised patient care. 4 The nursing shortage all states face in the coming decades is likely to be different in nature from those experienced in the past. Those cyclical shortages were primarily driven by demand increasing faster than supply, and solved when wages rose high enough to encourage greater numbers into the nursing profession. This nursing shortage will be driven by demographics, and it will likely endure for a decade. In 2011, the first members of the large baby boom generation will turn 65. The demand for health care especially nursing services will increase as the population ages and as chronic illnesses become more prevalent. At the same time, the nursing workforce will suffer a wave of losses as boomer nurses retire. By 2010, more than 40 percent of the nursing workforce will be older than 50 years, and the much smaller generation following the baby boomers has resulted in a smaller cohort of young nurses to take the place of retiring boomers. 5 This confluence of demographic trends, along with tight budgets in our healthcare industries, may result in a perfect storm for nursing: increased demand, decreased supply, and an inability to raise wages high enough to cure the shortage. All of which is likely to lead to unfavorable conditions for nurses and for patients. 6 The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 1

4 Complicating efforts to increase the size of the nursing workforce are the limits in our capacity for producing new nurses. Interest in nursing as a career has risen, and enrollments in the nation s baccalaureate nursing education programs have increased in recent years. Still, more than 32,000 qualified applicants were turned away from U.S. baccalaureate and graduate nursing programs in Factors impeding nursing program expansion include classroom space limitations, a shortage of clinical sites, and most prominently, an evolving shortage of faculty in nursing education programs. The average age of nursing faculty 50.9 in 2001 is even higher than that of the general nursing workforce and faculty retire at an average age of 62.5 years. 8 Causes of the faculty shortage include an inadequate pipeline of graduate-prepared nurses and the declining percentage of such nurses interested in faculty roles, the higher average age at which nurses attain advanced degrees, and non-competitive salaries in education compared with nursing practice. 9 Is this bleak picture of the nation s future nursing supply also accurate in North Carolina? Will we endure a general nursing shortage, and if so, when will it occur and how severe will it be? Will we struggle to prepare new nurses owing to a shortage of nursing faculty? This article offers supply and demand forecasts for RNs and for nursing faculty in North Carolina in order to answer these questions. We present the federally developed Nurse Supply Model and Nurse Demand Model with replacement data for North Carolina to forecast the extent and timing of the general nursing shortage in North Carolina, as well as our own model of faculty supply and demand in the state. We conclude with suggestions for mitigating the state s nursing shortage. The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 2

5 Will North Carolina Experience a Nursing Shortage? In 2005, the Health Resources and Services Administration (HRSA) released new versions of two econometric models designed to forecast nurse supply and demand. The models estimate supply and demand at the state level and then aggregate the estimates to produce projections for the nation. They are available to state-level analysts in user-friendly software that allows manipulation of key assumptions and replacement of state-level baseline estimates of both supply and demand. The Nurse Supply Model (NSM) projects the size of the licensed RN population, the RN workforce, and the full-time equivalent (FTE) RN workforce, each by age and education level. 10 Beginning with state-level estimates of RN supply in 2000, the model adds the estimated number of newly licensed nurses in the state that year and subtracts the estimated number of nurses who will likely leave the state s licensed RN population in that year. Nurses are aged by one year and estimates of education upgrades the number of nurses who attain a higher degree during the year are applied. The result of the process is the estimated RN supply at the end of 2000, by age and education. The model is iterative such that the end-of-year projections are used as the beginning projections for the next year. The NSM forecasts RN supply from 2000 to The Nurse Demand Model (NDM) projects expected demand for RN FTEs, licensed practical nurse (LPN) FTEs and nurse aide/home health aide FTEs annually from 1996 to The NDM separately estimates demand for healthcare services (using national per-capita utilization rates and state-level population projections), and nurse staffing intensity (derived from baseline levels of nurse employment in different sectors of the healthcare economy - hospitals, nursing homes, home health, etc.). These two components are then brought together, along with The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 3

6 modifying variables that affect the healthcare operating environment, economic conditions, and population characteristics associated with health status or healthcare utilization to arrive at annual estimates of demand for nursing services. Utilization data are not available for all settings in which nurses are employed, and in those cases population demographics are used, in conjunction with baseline staffing levels, to arrive at future demand projections. Although the NDM forecasts demand for LPNs and nurse aides, we focus on the demand for RNs here since the NSM does not produce comparable supply estimates for these types of nursing personnel. Together the models forecast a national shortage of more than one million FTE RNs by the year 2020, with only 64 percent of demand for nursing labor being met. 12 However, this national projection depends on the ability of the models to accurately forecast nurse supply and demand at the state level. Some analysts have questioned the accuracy of state-level HRSA projections, especially for small and rural states. 13 The models use data derived from multiple national data sources that may be inaccurate at the state level. We assessed the accuracy of these data for North Carolina, replacing much in both models with more accurate data on the RN and general population of the state. Our replacement data showed that both RN supply and demand were higher at baseline than suggested by the data supplied with the models. However, the projections of shortage timing and severity were similar regardless of the data source. Figure 1 charts the projected RN FTE supply and demand through The supply of RNs will increase steadily through Beginning in 2011, however, the rate of increase will slow dramatically. According to these projections, the RN labor force will grow by fewer than 120,000 Supply 1,000110,000 RN FTEs between 2011 and 2020, and after 2017 the total supply of RN FTEs will of RN 100,000 FTEs in actually decline slightly. In stark contrast, the projected demand for RNs Northwill increase rapidly 90,000 Carolina through ,000 Demand 70,000 for RN FTEs in 60,000 North The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions Carolina 4 50,000 RN FTEs

7 Figure 1. RN FTE Supply and Demand Estimates with NC Replacement Data In the early years of the projection period 2000 to 2004 RN FTE supply and demand are fairly well balanced. This is consistent with independent research on the state of RN supply and demand in North Carolina during the first half of this decade. Recent surveys of North Carolina nurse employers indicate that 8.8% of all RN positions in hospitals were vacant in That percent fell to 6.5 in This decline also occurred in the home health and long term care industries. These and other results from those studies suggest that North Carolina has fared well during the first part of this decade. As of 2003, there was no widespread shortage of RNs in the state. As Figure 1 portrays, however, the rapidly rising demand for nursing services will quickly outstrip the available supply of RNs. The model estimates that a shortage of 5,900 RN FTEs exists in 2006, or about 8% of the total supply of RN FTEs. This shortage more than doubles to about 12,000 RN FTEs in just five years. By 2020, the shortage is forecast to grow to over 32,000 FTEs, or 42% of the total RN FTE supply. Put another way, North Carolina can expect to meet only about 70% of the expected demand for RNs by North Carolina will be The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 5

8 only slightly better off than the nation as a whole, which HRSA projects will be able to meet about 64% of demand for RN FTEs in If current trends continue, North Carolina can expect a nursing shortage to be imminent, become severe in five years, and calamitous in fifteen years. Because this shortage will be demographically driven, it is unlikely that the state will completely avoid a nursing shortage even if policy solutions are implemented immediately. We can, however, affect the severity of the nursing shortage, but only if we aggressively address the barriers to increasing production of new RNs right now. Unfortunately, our data indicate that the state s nursing education programs may be woefully unprepared to meet the challenge. Is there a pipeline problem in North Carolina? North Carolina has a well-developed network of nursing education programs that are well distributed geographically, with the exception of the most sparsely populated counties along the coast and in the mountains. Enrollments in our 69 entry-level RN programs have been growing over the past few years, and in 2005 North Carolina schools graduated 3,422 RN students - a 20% increase over the previous year. This increase is an intentional and pro-active response to calls from the NC Center for Nursing, along with other nursing and healthcare industry leaders to address a nursing shortage expected to hit North Carolina around Interest among potential students also remains high, as indicated by the more than 14,000 qualified applicants to North Carolina s entry-level RN programs during the academic year. However, even though RN programs have expanded, only 45% of those interested and qualified applicants could be admitted. 16 And in order to stay ahead of the nursing The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 6

9 shortage, we will need to expand enrollments even further and quickly. Interest in nursing careers is high, but our ability to translate that interest into an expansion of the nursing workforce has reached its limit. Our programs cannot expand any further without significant increases in classroom space, clinical site placements, and qualified faculty. In 2001, only 10% of RN programs in the state felt they could expand enrollments an additional 15% without having to hire more faculty. 17 Comments received from program directors made it clear that qualified faculty were becoming hard to find, and that a large number of anticipated retirements was expected to exacerbate the problem. At that point in time, approximately 46% of all nursing faculty were age 50 or older. In 2003, 86% of RN programs reported they had turned away qualified applicants in the previous year, primarily due to the fact that all of their available admission slots were filled. Their inability to expand was attributed to an insufficient supply of clinical sites for students, insufficient classroom space, and an insufficient number of program faculty or budget funds to add faculty. Even without expansion, 64% of RN programs reported difficulty recruiting qualified faculty at that point in time. 18 By 2003, 53% of nursing faculty were age 50 or older. The increasing difficulty our education programs are having in finding qualified faculty, and the rapid aging of our existing faculty, are serious impediments to our ability to expand our RN nursing programs as quickly and fully as we need to. But just how much of a problem is it? That question prompted us to develop a supply and demand forecast of nursing faculty for North Carolina. 19 Future demand for nursing faculty was estimated under the assumption that nursing education programs in North Carolina are implementing the recommendations of the 2004 Task Force on the North Carolina Nursing Workforce 20 calling for a 25% enrollment increase in entry- The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 7

10 level RN education programs. In our forecasting model those increases are assumed to be implemented gradually over 5 years, starting in 2004, with enrollments holding steady through Demand for nursing faculty is a product of the number of students enrolled in nursing education programs, and the ratio between students and faculty. These ratios do not take into account the regulatory requirements that limit the number of students per faculty in a clinical setting, but rather aggregate all faculty clinical, didactic, administrative and support together. Two different estimates of demand were calculated by changing our assumption about those student-to-faculty ratios: no change (2004 ratios are maintained), and a 50% increase in the number of students for each faculty member above 2004 levels, implemented gradually over a 10 year period. Changes in the student-to-faculty ratio produce dramatic changes in the expected demand for nursing faculty over time. However, this projection makes no allowance for the other factors that would or could result from such a change, such as the need for increased compensation to retain faculty, increased burnout, or earlier/faster rates of retirement due to such a dramatic change in work load. Faculty supply projections were constructed from two elements: the number of current (2004) faculty that can be expected to retire, given their age and our assumptions about retirement age; and the number of RNs with Master s or doctoral degrees that can be expected to assume a faculty position. The latter element comes from historical analyses of RN education and work patterns in North Carolina from 1995 through These patterns show that, even though the number of licensed RNs holding a Master s or doctoral degree almost doubled between 1995 and 2004, proportionately fewer were employed in Schools of Nursing each year. In 1995, 15% of all RNs with a Masters or doctorate were employed in nursing education, but by 2004 that proportion had dropped to 11%. Using that trend, and extrapolating out over time, that The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 8

11 proportion is expected to be about 8.7% in Actual counts were used for the period Future estimates were extrapolated from those historical trends. We estimated the expected number of faculty likely to be added to the faculty workforce each year by identifying all RNs expected to earn a Master s degree each year, and then applying the proportion expected to choose employment in a school of nursing Total Faculty Supply if Retirement Occurs at Age 62.5 Total Faculty Supply if Retirement Occurs at Age 65.5 Total Faculty Required when 2004 ratios are in effect (8.1 for LPN, 11.5 for RN programs) Total faculty required when ratios are increased by 50% over 10 years ( ) Figure 2. Forecast of Nursing Faculty Supply and Demand in North Carolina, An age profile of all Master s and doctorally prepared RNs employed in North Carolina schools of nursing in 2004 was created and then aged out by identifying how many passed the age of 62 or 65 in any given year. The number reaching these retirement thresholds were subtracted from the faculty supply count, and the annual number of RNs earning new Master s degrees that could be expected to choose faculty roles were added in. The result is the two The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 9

12 supply lines in Figure 2: one assuming that all faculty will leave the workforce between the age of 62 and 63, and another that assumes they will leave between the ages of 65 and 66. Both supply lines drop rapidly from 2004 levels, showing clearly that the number of new faculty coming in each year is not enough to replace those being lost to retirement. In short, it appears we are already facing a severe problem in the educational pipeline for new RNs. The forecast makes it clear that, if current student-to-faculty ratios are maintained, the demand for nursing faculty is already exceeding the available supply. If, on the other hand, the number of students per faculty member can be increased, the point at which demand exceeds supply (i.e., shortage) can be postponed for several years. The extent to which faculty supply and demand can be kept in balance is contingent on how much and how quickly student-tofaculty ratios can be increased and the age at which faculty members actually leave the workforce. It is important to note, though, that faculty workload and faculty retirement age are not unconnected. Our projection does not address the difficult policy questions that will need to be resolved in order to keep nurse educators in the workforce longer at the same time that their workload will increase. Nor does it suggest how to increase the number of Master s prepared RNs who choose faculty roles for their career. What can North Carolina do? Our forecast of the nursing workforce in North Carolina from 2000 to 2020 shows a severe shortage which is just beginning and which will develop rapidly into crisis proportions. Our examination of nursing faculty supply and demand shows a similar crisis already underway The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 10

13 in the educational pipeline that produces our new RNs. Together these analyses paint a dire picture of the future unless we act now to put solutions in place. What, exactly, can be done? Below are some suggestions, presented in order of priority Some of these solutions require policy and/or budgetary action at the state level. Others can be implemented by healthcare facilities or our education institutions and some by nurses themselves. First, address the nursing faculty shortage. We must increase the supply of qualified faculty while simultaneously looking at ways to reduce demand. Primary issues will be increasing faculty wages to levels that are competitive with those in nursing practice in order to improve recruitment rates for new faculty, finding ways to increase the student-to-faculty ratios while maintaining reasonable workloads for faculty, and enticing older faculty to remain in place beyond the age of 65. Some proposed solutions related to these issues are: improve articulation pathways that permit RNs to obtain a Master s Degree in Nursing in the shortest time possible without sacrificing educational quality. acknowledge that nurses, like physicians and other health care professionals, sacrifice earnings when they join the state educational system, and keep salaries reasonably in line with wages in the clinical setting and the private sector. provide tax breaks for nursing educators, similar to those made available to primary and secondary school educators. update current state retirement system rules that delay an RN from teaching in a statesupported school after retiring from a career in public service. The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 11

14 develop faculty-share programs in which healthcare agencies share their best clinicians with local nursing education programs. increase collaboration and sharing of resources among the state s many schools of nursing. Enhance clinical simulation as a teaching modality, to include peer review as well as faculty evaluation. Second, increase the production of new nurses. The bottleneck in our education system will make this a difficult and probably costly solution to implement. Some of the actions that will need to take place are: increase funding for nursing education that provides for more classroom space, educational materials, support services, and increased numbers of faculty increase collaboration between all types of healthcare facilities and schools of nursing to develop and make available more clinical practice sites for students reduce attrition rates from nursing education programs by instituting fair and effective entrance standards in order to select the students most likely to successfully complete nursing education requirements. Third, retain as much of the existing workforce as possible. The aging of the workforce and the additional productivity demands that will inevitably result from a growing shortage will strain the existing nursing workforce in the next decade. Solutions will rest primarily with nurse employers, most of whom are in the private sector. But public sector employers must also The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 12

15 prepare for the dual push/pull factors encouraging nurses to leave the workforce. Some of the obvious, but critical issues will be: growth in wages to counteract the increased workloads and lure of retirement for older nurses. improve working conditions by maintaining an adequate workforce, ensuring a safe and healthy environment, and reducing unnecessary physical demands, especially in light of a rapidly aging workforce. finding ways to combat the brain-drain that will occur as the baby-boomers leave the workforce by maximizing access to the knowledge and skills of older nurses who may not be able or willing to work 12 hour shifts, but still want to contribute to their profession. Fourth, prepare for a nursing shortage. Regardless of how well we improve our education pipeline, increase our supply of new RNs, and retain nurses in the workforce as long as reasonably possible, we will still have a nursing shortage between 2010 and It is a demographic inevitability. The baby boom generation including about half of our current nursing workforce will age into the stage of life when health care demands are highest. And the generations following the baby boomers are insufficient in number to fill the gap. Therefore, we need to find better ways to provide nursing services, and now is the time to start. We need to: study the ways that nurses bring added value to the health care process in all settings and organize care to maximize those efforts. The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 13

16 adopt technologies that improve communication, reduce paperwork burdens, reduce medication errors, and help nurses track the most critical information about their patients in a timely manner. reward (reimburse) nurses for patient education and preventive care that keeps people well and/or functional, and reduces demand for the most labor intensive services harness other innovative solutions that increase the efficiency and effectiveness of nursing care delivery, thereby reducing overall demand. The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 14

17 Bibliography The Next Nursing Shortage in North Carolina: Causes, Projections, and Solutions 15

18 1 U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. State responses to health worker shortages: Results of 2002 survey of states. Available at Accessed June 19, American Hospital Association. In our hands: How hospital leaders can build a thriving workforce. Available at Accessed June 19, Bureau of Labor Statistics. Occupational outlook handbook. Available at Accessed June 20, North Carolina Center for Nursing. Consequences of Inadequate Nurse Supply in North Carolina. Raleigh, NC: North Carolina Center for Nursing. June, Available at %20Statewide.pdf. Accessed June 20, Buerhaus P, Staiger D and Auerbach D. Implications of an aging registered nurse workforce. Journal of the American Medical Association 2000;283(22): Bleich M. and Hewlett P. Dissipating the perfect storm responses from nursing and the health care industry to protect the public s health. Online Journal of Issues in Nursing 2004;9(2); Manuscript 4. Available at Accessed June 26, Berlin L., Wilsey S., and G. Bednash Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, D.C.: American Association of Colleges of Nursing DeYoung S., Bliss J., and Tracy J. The nursing faculty shortage: Is there hope? Journal of Professional Nursing 2002;18(6): DeYoung S. and Bliss B. Nursing faculty an endangered species? Journal of Professional Nursing 1995;11: Biviano M., Fritz M., Spencer W., and T. Dall. What is behind HRSA s projected supply, demand, and shortage of registered nurses? Washington, D.C.: Health Resources and Services Administration Available at Accessed June 21, ibid. 12 ibid. 13 Reinier K., Palumbo MV, McIntosh B et al. Measuring the nursing workforce: Clarifying the Definitions Medical Care Research and Review 2005;62(6): Lacey L. and Nooney J. Findings from the NCCN nurse employer surveys. Presentation to the NCCN Advisory Council. North Carolina Center for Nursing, Raleigh, NC. October, North Carolina Institute of Medicine. Task Force on the North Carolina Nursing Workforce Report: Durham, NC: North Carolina Institute of Medicine. May North Carolina Center for Nursing. North Carolina Trends in Nursing Education: Raleigh, NC: North Carolina Center for Nursing. February Available at Accessed June 26, North Carolina Center for Nursing. Nursing Education Faculty Needs in North Carolina. Raleigh, NC: North Carolina Center for Nursing. November Available at Accessed June 26, North Carolina Center for Nursing. Resource Capacity and Infrastructural Needs in North Carolina Nursing Education Programs: Associate Degree Programs. Raleigh, NC: North Carolina Center for Nursing. December Available at June 26, North Carolina Center for Nursing. Resource Capacity and Infrastructural Needs innorth Carolina Nursing Education Programs: Baccalaureate and Higher Degree Programs. Raleigh, NC: North Carolina Center for Nursing. December Available at Accessed June 26, North Carolina Center for Nursing. Forecasting the Supply and Demand of Nursing Faculty in North Carolina: Raleigh, NC: North Carolina Center for Nursing. March Available at %20North%20Carolina% pdf. Accessed June 26, 2006.

19 2021 North Carolina Institute of Medicine. Task Force on the North Carolina Nursing Workforce Report: Durham, NC: North Carolina Institute of Medicine. May, 2004.