From The Floor
The Nursing Shortage Paradox in California
The RN supply gets a failing grade, but new grads can't find jobs
With more and more dire reports coming out about California’s growing nursing shortage, you would assume that our state desperately needs nurses. Nearly every day, my email inbox is besieged with messages advertising temporary and permanent nursing positions and a cursory search on one of the national nursing job boards returns more than 1,000 job openings.
However, if you read the forums on those same job boards, you’ll find post after post from nurses — mostly new graduates — complaining that they’re unable to find a job in their chosen profession. To hear them tell it, there are too many nurses vying for too few jobs.
So, what’s going on? Is there a nursing shortage or is there really a nursing glut? The answer is yes and yes. Confused? Read on.
According to the U.S. Nurse Workforce Report Card and Shortage Forecast, published in the American Journal of Medical Quality in 2012, over the next two decades, the demand for nurses will greatly outpace the supply.
Even states that currently have good nurse-patient ratios, like Massachusetts, are expected to slip to mediocre by 2030, so you can guess what that means for our fair state, which is already near the bottom of the heap.
California’s nurse-to-population ratio has ranked a dismal 48th in the nation for the past 10 years. In 2013, California had an estimated 657 RNs for every 100,000 population, well below the national average of 874 RNs per 100,000. The Nurse Workforce Report Card gave California’s RN supply a “D” grade and projects that by 2030, we will be more than 193,000 nurses short of our nursing needs. (So much for the wishful thinking 10 years ago that legally mandated nurse-patient ratios would somehow resolve our nursing shortage!)
By now, we’ve all heard the reasons for the predicted nursing shortage: an aging population that will need more care, more people having access to care due to the ACA and an aging workforce that’s not being replaced fast enough. It paints a worrisome picture.
Unprepared For Nursing School
Between 2001 and 2010, the number of people enrolling in nursing school here in California increased dramatically, leading to predictions that the state’s total nursing workforce would grow by about 60 percent between now and 2030. Currently, the reality looks much less rosy. According to a recent report prepared for the BRN by the Philip R. Lee Institute for Health Policy Studies and School of Nursing at UCSF, nursing school graduation rates for the past few years have been lower than expected and growth has been slow. Only 195 more nurses graduated in the 2012–2013 academic year than in 2011–2012, an increase of only 1.8 percent. The report predicts that graduations for the 2015–2016 school year will actually drop below the 2010–2011 level.
The number of licenses granted to foreign-educated and out-of-state nurses is also down. While fewer California RNs are leaving the state for greener pastures, fewer nurses are moving to California. As a result, the report forecasts that even in a best-case scenario, California’s RN supply will grow only about 10 percent by 2030 — not nearly enough.
The UCSF report recommends “growing our RN programs a bit more,” but that may be easier said than done. In California, many students are ill-prepared to enter a nursing program due to a lack of prerequisites like microbiology, statistics or psychology. Having to play catch-up will delay admission.
Students who do enter nursing programs may face a shortage of instructors. Quality nursing faculty is already in short supply and that shortfall is also getting worse.
New Grad “Catch-22”
If all that is true, why are so many newly minted RNs (both ADN-prepared and those with BSNs) having a hard time finding work? And why do many chief nursing officers in California believe there are more than enough RNs to meet current requirements?
First, keep in mind that the various estimates and projections of nursing shortages are for the state as a whole. California is a big state and even if you live in a county that’s been designated as a registered nurse shortage area (like Los Angeles County), that doesn’t mean you can just stroll over to your neighborhood hospital and get a job tomorrow.
Healthcare provider shortages are usually most severe in poor or rural areas where new grads may not think — or want — to look for jobs. Hospitals in more prosperous areas often have plenty of nurses and lots of applicants and can therefore be pickier about education and experience.
One of the most common demands is acute care experience, something in which far too many new grads are sorely lacking. Getting enough experience to satisfy a hospital recruiter may require some creative solutions on the part of new grads.
Back in the “good old days,” a new nurse could gather a plethora of real-world experience by working as a travel nurse, but today, most travel nurse services require at least two years of hospital experience prior to placement.
Adding to the frustration of the new grad looking for work is the fact that many current RNs are still putting off retirement. The UCSF report confirms that employment rates are higher among older RNs, many of whom continue to practice because they can’t afford to retire. That means new grads are competing for jobs with older nurses who have far more clinical experience.
The Spectrum of Staff Experience
While some parts of California do have a nursing glut right now, hospital nursing directors and chief nursing officers need to recognize that in many cases, the current honeymoon won’t last. Eventually, older nurses will leave the nursing workforce, either because the economy has improved enough to rebuild their retirement nest eggs or for health reasons.
The vacuum left by those departures will need to be filled — in all likelihood, by the same new grads being turned away now. Even without an overall RN shortage, such “backfilling” is critical to maintaining a healthy and vibrant nursing workforce.
During my tenure as a director of nursing, I worked hard to ensure that our hospital’s nursing team was as diverse as possible. A critical component of that diversity was having a wide spectrum of experience, from new nurses to seasoned veterans.
In that way, our experienced nurses could mentor the new grads, who would in turn bring a level of enthusiasm and cutting-edge knowledge that benefited their more experienced colleagues. It was a win-win situation.
What’s the outlook for new grads? There are nursing jobs to be had, but in the short term, finding one without acute care experience will continue to be a challenge. That leaves the new grad with a choice: If you don’t want to wait around for your more experienced colleagues to retire, you’ll need to either find ways to build your clinical experience or be willing to look for jobs in areas off the beaten path.
Few will deny that California’s nursing population needs to grow or that there are real obstacles to that growth that need to be addressed, such as the shortage of nursing faculty. However, it’s important to recognize that nursing shortages (or surpluses) are not cut and dried. The future of nursing in California is in our hands.