Nursing labor marketsAn introduction

Joanne Spetz, Ph.D.University of California, San FranciscoApril 20, 2012 1

Nursing in a nutshell

• Focus on helping people and communities attain, maintain, and recover optimal health

• Science and art

• Care, not cure

• Modern nursing developed as a profession in the 1800s– Military and religious roots

– Florence Nightingale and the Crimean War

• 3 million US nurses today

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What do nurses do?

• Nursing process– Assess and diagnose needs of patients

– Plan and implement interventions

– Evaluate the outcomes of care

Types of nurses

• Registered nurses (RNs) (associate degree or higher)

• Licensed practical / vocational nurses (1-2 years of education)

• Unlicensed assistants, certified nursing assistants

• Advanced practice RNs (master’s degrees)– Nurse practitioners (NPs)

– Certified Nurse Midwives (CNMs)

– Clinical Nurse Specialists (CNSs)

– Certified Registered Nurse Anesthetists (CRNAs)

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Basic RN education, 2008

Source: 2008 National Sample Survey of RNs

Highest education of U.S. RNs, 2008

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Source: 2008 National Sample Survey of Registered Nurses

After receiving an RN license, many nurses continue their education.

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Age distribution of RNs, 1980-2008

Source: 2008 National Sample Survey of RNs

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Gender distribution of RNs

6.6%

93.4%

MaleFemale

Source: 2008 National Sample Survey of RNs

Racial/ethnic distribution of RNs

White, non-Hispanic

Hispanic/Latino

Black/African-American

Asian or Pacific Islander

American Indian/Alaska Native

Two or more races

0% 20% 40% 60% 80% 100%

83.2%

3.6%

5.4%

5.8%

0.3%

1.7%

65.6%

15.4%

12.2%

4.5%

0.8%

1.5%

US populationRN population

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Source: 2008 National Sample Survey of RNs

Geographic variation in RN supply

New England

Middle Atlantic

South Atlantic

East South Central

West South Central

East North Central

West North Central

Mountain

Pacific

0 200 400 600 800 1,000 1,200

Employed RNs per 100,000

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Source: 2008 National Sample Survey of RNs

Where do nurses work in the US?

Hospital62.3%

Nursing home5.3%

Education3.8%

Community/ public health7.8%

Ambulatory care10.5%

Home health6.4%

Other3.9%

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Source: 2008 National Sample Survey of Registered Nurses

What determines nurse supply?• Number of licensed nurses able to work

• Flow of nurses into labor force (graduations & immigration)

• Flow of nurses out of labor force (retirements & emigration)

• Decisions of licensed nurses to work– Wages that can be earned

– Family economic situation

– Marital status, children, other dependents

– Burnout, stress, schedules, interests

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Percent of RNs Working in Nursing, by Age, 2008

0%10%20%30%40%50%60%70%80%90%

100%

Source: 2008 National Sample Survey of RNs

Nurses under 60 years old work at high rates, but at older ages, their employment rates drop substantially.

We might collapse some of these groups by decade to simplify the chart.

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What determines RN demand?

• Demand for health care services– Mix of services

• Licensure regulations– RN scope of practice limits what non-RNs can do

– Technology can substitute

• Policy– Minimum staffing regulations

– Reimbursement levels from insurance

– Pay for performance

Nursing Labor Markets: Cycles of Shortage and Surplus• Since WW2, there have been near-constant

nursing shortages• Cycles of surplus and shortage have been

studied by policymakers and economists• Most recent “surplus” was mid-1990s• We have had a “shortage” since the late 1990s,

although this might be changing

Why do we see shortages or surpluses?• Delays in wage increases

• Delays in increasing or decreasing the number of new nurses

• Licensing regulations

• Minimum staffing requirements

• Limited number of employers– Some workplaces are more desirable than others

Predictors of Shortage of Hospital Nursing Workforce in US• Higher probability of shortage for in Hospitals

that are :– Public

– In Southern states

– That serve a high share of Medicare and Medicaid patients

– That serve patients that are sicker or have more complex health needs

– Use of “team” nursing staffing structure

(Seago, Ash, et al., 2001)

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18Source: Board of Registered Nursing 2006 Survey

Leading Reasons for not working in nursing

Job-related illness/injury

Benefits

Try another occupation

Inconvenient schedules

Salary

Other family

Dissatisfaction w/ nursing profession

Childcare

Other dissatisfaction (job)

Stress on the job

0% 10% 20% 30% 40% 50% 60%

(% important or very important)

There are few ways to increase nurse supply

• Short-term supply– Increase work hours of those now working– Recruit nurses who are licensed but not working

• Long-term supply– Attract more people to the profession

• Improve working conditions, salaries• Marketing – men, underrepresented minorities

– Expand nursing education pipeline– Increase efficiency of nursing programs

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Was the shortage of the 2000s different from prior shortages?

• Severity of shortage was greater than in the past

• Demand did not adjust even when wages rose– Focus on staffing due to recent research

– Minimum nurse-to-patient ratios

• Delays in generating new graduates– Projected retirements of aging nurses are large

– Difficult to generate enough new graduates to keep up

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Has the shortage ended?

• Newly graduated RNs are having trouble finding jobs in some markets

• Demand has dropped due to less health care demand– More people are uninsured

• Supply of current RNs has risen– Working RNs taking extra shifts and overtime– Experienced nonworking RNs seeking jobs

• Is this a temporary situation?

The Affordable Care Act and Nursing: Changes in Care• Health insurance expansions higher demand

for all health services– RN demand will rise

• Programs to emphasize preventive care higher demand for primary care providers– Higher demand for Nurse Practitioners

– RN demand could rise because they can provide many of these services

• Incentives for more home and community care– Greater need for RNs who work in home health and

public settings

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The Affordable Care Act and Nursing: Changes in Payment and Training• Performance-based payment more emphasis

on quality– RNs contribute to better quality demand will rise

• Bundled payments efforts to increase continuity of care– RN case managers will become more important

– RNs in home and transitional settings needed

• Health workforce investments– Funding increases for advanced nursing education

– Grants to increase diversity

– Loan repayment and scholarships to work in underserved areas

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Some final thoughts…

• Nursing is one small piece of health care in the US…

• But it reflects all the problems of health policy– Quality of care

– Cost of care

– Access to care

To learn more

• Robert Wood Johnson Foundation Future of Nursing http://www.thefutureofnursing.org/

• U.S. Health Resources and Services Administration reports http://bhpr.hrsa.gov/healthworkforce/allreports.html

• American Nurses Association http://www.nursingworld.org/

• Johnson and Johnson’s Discover Nursing http://www.discovernursing.com/

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