Edward Salsberg
GW School of Nursing
and
GW Health Workforce Institute
The Annual Forum of State Nursing
Workforce Centers
Denver Colorado,
June 11, 2015
Overview
• Why I worry about a potential surplus
• What we learned from presentations at this meeting
• Where that leaves us
• Information and data needed to assess, track and
project adequacy of supply to meet needs
Presentations on Supply, Demand & Projections
•Auerbach: Will the RN Workforce Weather the
Retirement of the Boomers?
• Spetz: Demand for Newly-Graduated Nurses: Will the
Labor Market Recover?
• McMenamin: Two “Aging” Phenomena Create
Uncertainty for RNs/APRNs, 2020 – 2045
• Zangaro, Moore and Armstrong: Understanding &
Using HRSA’s New Nursing Supply & Demand Model
Why do we care?
• Problems with a shortage
• Access
• Quality
• Costs
• But great for new grads
• Problems with a surplus
• Unemployed nurses
• New nurses with debt but no job
• Enrollment drops/squeeze for schools
• Wages stagnate
Factors Driving Supply
• Entrants: Enrollment up sharply
• Attrition
• Growing older cohort but retirements delayed
• Many non-patient care options for nurses
Why I Worry about a Possible Surplus
• A history of fluctuations
• Sharp growth in RN education pipeline
• Major national push for delivery system redesign and
constraint in growth of expenditures
A History of Fluctuations
Number of nursing degrees awarded, by type
Buerhaus, PI, Staiger DO, and David Auerbach, “The Rapid Growth of Graduates from Associate, Baccalaureate and
Graduate Programs in Nursing,” Nursing Economics, 2015
Total 1st Time Takers and Passers – US Grads
2001-14
180000
157879
155018
150225
144486
140785
134583
128950
160000
140000
119359
# of Candidates
120000
110549
99089
100000
80000
87085
68700 70540
135703
127008
123079
119006
111849
128684
128740
102063
97464
76618
86518
74222
60000
58779 61148
66703
40000
20000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
U.S. Educated Candidates Passing the
NCLEX-RN_First Time
U.S. Educated Candidates Taking the
NCLEX-RN_First Time
BSN 1st Time Takers and Passers, 2001-2014
80000
68715
65406
62535
70000
58246
55414
52241
57901
57320
49739
55713
45781
51891
# of Candidates
60000
50000
41349
40000
35496
30648
30000
20000
26630
2482325806
49147
46750
43522
39555
36511
30775
25990
23141
2133122374
10000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
U.S. Educated Candidates Passing the
NCLEX-RN_First Time
U.S. Educated Candidates Taking the
NCLEX-RN_First Time
Diploma Graduates – 1st Time Takers and
Passers, 2001-14
4500
4000
3500
# of Candidates
3540
3000
3162 3197
2500
2789
2000
2310
1991
2424
3810
3688 3666 3677 3753
3410
3337 3365
3242 3208
3476
3120 3173
2893 2840
2787
2565
2303
2369 2321
2092
1500
1000
500
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
U.S. Educated Candidates First Time
Passing the NCLEX-RN
U.S. Educated Candidates Taking the
NCLEX-RN_First Time
International Grads - 1st Time Takers & Passers,
2001-14
40000
33768
35000
30007
30000
# of Candidates
25908
25000
21435
1828517980
16490
20000
15000
10000
13593
8613
1064210446
International Educated Candidates
passing NCLEX-RN_First Time
14401
17559
15856
12723
9267
9719
7764 7903 7790
9067
7049
5000
4255
0
International Educated Candidates taking
NCLEX-RN_First Time
5559
3303
2841 2419
2250
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Growth in Nurse Practitioner Graduates*
2001 - 2014
Growth from 2013
to 2014 : 15.3%
19,500
18,484
Graduates
17,500
16,031
15,500
14,310
13,500
12,273
11,500
9,500
6,979
7,500
5,500
7,261
7,583
6,526
6,611
6,900
8,865
11,135
9,698
8,014
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
* Counts include master’s and post-master’s NP and NP/CNS graduates, and
Baccalaureate-to-DNP graduates.
Source: American Association of Colleges of Nursing (AACN) and National
Organization of Nurse Practitioner Faculties (NONPF) Annual Surveys
13
Federal Initiatives Support Systems Redesign
Neither Supply Nor Demand is Static
Typical Workforce Projection
Demand
Supply
Year
Adaptations Occur
More Realistic Health Workforce Projections:
Adjustments over Time (±5%?)
Demand
Supply
Year
So what did we learn
from the presentations at
this conference?
17
From David Auerbach: Attrition from test-takers
- Never pass test
+ Internationally-educated RNs
- Never become licensed
- Work part time (~20%)
- Never work in nursing (~10%)
Domestic NCLEX test-takers
FTE RNs
Observed Workforce: 2007-2013
900,000
850,000
580,000
800,000
370,000
700,000
600,000
Actual net increase
500,000
400,000
300,000
270,000
200,000
100,000
Expected net increase
-
Test-takers Retirements
From Joanne Spetz
• Surveys of employers and new graduates can provide
valuable information on demand and marketplace for nurses
• While indications of shortages in 2009 – 10, employers are
adding jobs, especially hospitals and ambulatory care; and
new grads faring better in job market over past few years
• Reasons for expected increase in hiring: increasing census
and increasing acuity
• Variation in demand for experienced RNs compared to new
RNs
• Shortages in specific settings/skill sets, i.e operating room
From Peter McMenamin
• The aging of the nurse workforce
• The expanding need for care coordinators and the
potential for nurses to provide this care
• Hospital use has been slowly decreasing
• But the baby boom generation is leading to sharp increase
in number of elderly with extensive needs including for
chronic care
• Need to go beyond numbers and consider needed skill
sets for an aging population, including for geriatric care,
chronic care and end of life care
From George Zangaro, Jean Moore and
David Armstrong
• The new and improved nursing projection models
• The web-based capability to use state data and scenarios
• The importance of looking at supply and demand at the
national, state and local levels
• The national supply appears adequate through 2025 but
many state and local shortage areas
The Complexity of Assessing
Adequacy of Supply to Meet Needs
The national number may be sufficient but we can still
have shortages by:
• State/region/local area
• Experience
• Skill set
• Education
Implication:
Need for more refined assessment tools and intervention
strategies
Critical Information: Where Data
and Research Are Needed
• Attrition patterns and drivers
• Retirement
• Jobs outside of patient care
• Redesign of health care, especially hospital care
• Will inpatient demand decline?
• Will ambulatory care increase?
• Emerging new roles
• Migration patterns
• Impact of external factors: economy, generational factors
Data Needs
• Early warning system: for demand and supply
• Systematic survey of employers
• Systematic survey of new nurses
• Employer surveys have to get more detail on roles for
nurses they are employing…particularly important re
hospital nurses as hospitals expand beyond inpatient
Existing Data Sources
• ACS
• IPEDS
• NCSBN
• AACN
• State Nursing Workforce Centers
• BLS/DOL: Wages
• The importance of the Minimum Data Set
Closing Comments
• Danger of repeating 1980s and 90s
• The delivery and education systems capable of
addressing limited shortages and surpluses (5 to 10%?)
• Major improvements in our ability to project but
important gaps in our knowledge
Edward Salsberg
[email protected]