In addition to the same general shortage of health care workers most of California is experiencing, Los Angeles and Orange counties are grappling with a shortage of instructors to train new nurses, according to some stakeholders.
Difficulty in recruiting nursing instructors may be a harbinger of an inadequate supply of nurses in the future, experts said. There are about 408,000 registered nurses statewide, according to the California Institute for Nursing and Health Care.
For registered nursing, the projected rate of growth in employment between 2010 and 2020 is 26%, according to the U.S. Dept. of Labor Bureau of Labor Statistics -- faster than the 14% average growth rate for all occupations.
California ranks 46th in the nation for the number of RNs working per 100,000 people, according to HHS statistics. Health care professionals and consumers agree hospitals and their patients need nurses and more is always better than less.
According to research from AARP's Center to Champion Nursing in America, increases in registered nurse staffing are associated with reductions in hospital-related mortality and failure to rescue (death after a treatable complication) as well as reduced lengths of stays. Additionally, patients who have common surgeries in hospitals with the worst nurse staffing levels have up to a 31% increased chance of dying. A higher proportion of nursing care provided by RNs and a greater number of hours of care by RNs per day are associated with better outcomes for hospitalized patients.
Nurses and Faculty Wanted
Whether there are enough nurses depends on the definition of "enough" and who's defining, said Carolyn Orlowski, Southern California regional coordinator and workforce issues specialist for the California Institute for Nursing and Health Care.
"No one is really sure how (health care reform) will impact nursing workforce demand -- and all of health care -- and how we're going to position ourselves to manage that well," Orlowski said. "Faculty shortages and nurses getting jobs are not new subjects. They evolve and change over time."
"I think the conventional wisdom is that there is both a nursing shortage and a shortage of nursing faculty to train new nurses," said Dylan Roby of UCLA's Fielding School of Public Health and Center for Health Policy Research.
Robert Rosseter, chief communications officer of the American Association of Colleges of Nursing, said finding nursing instructors is difficult for both large and small schools.
"I understand that many larger nursing schools -- those affiliated with academic medical centers -- are more likely to have enough faculty versus smaller schools. But even the big schools are having trouble finding doctorally prepared nurses interested in teaching," Rosseter said.
An AACN national report found that "U.S. nursing schools turned away 75,587 qualified applicants from baccalaureate and graduate nursing programs in 2011 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints."
The organization's data also revealed a national nurse faculty vacancy rate of nearly 8%, with nearly 90% of positions requiring or preferring a doctoral degree. Many nursing schools report turning away qualified students at the same rate as they accept them, Roby said.
"This is mostly because of the capacity of those nursing programs in terms of classrooms and faculty. A nursing faculty member in the Cal State or junior college system will probably make 30% to 40% less teaching than they could while working at a hospital. Schools like UCLA or Johns Hopkins probably don't have a problem recruiting nursing faculty or admitting qualified students, but it's probably the junior colleges and CSUs that struggle more -- and also want to train a lot more students," he said.
A recent report in the San Gabriel Valley Tribune cited a lack of faculty to train nurses statewide and focused on the Cal State universities in particular.
"It did not help that from 2008 to 2012, when the state higher education institutions were facing huge budget cuts, the schools had to cancel summer school courses, cancel other courses, turn away more students, and faced faculty and resource reductions," Roby said. "If there is a shortage of ASN (associate of science in nursing) and BSN (bachelor of science in nursing)-trained nurses, we missed out on opportunities in the last five years to train them due to those budget limitations."
High Density of Hospitals, Nursing Schools
Both L.A. and Orange counties are heavily populated compared with other regions in the state and they also have more hospitals and nursing schools, according to Orlowski.
"The demand for nursing in the workforce is largely patient-demand driven, and both counties have a high density of hospital work. When you have swings in the economy, you have massive numbers impacted in both counties," Orlowski said.
The adequacy of the supply of nurses in the area depends on who has asked for the assessment, she said.
"Ask some hospital administrators and they'll say, 'Heck, no, we don't need to hire new grads. We used to have to hire 100 grads a year but now we're sitting pretty. We've filled vacancies from within our own workforce.'"
"But it's a statement in the moment," Orlowski said. "A freight train is coming. As the economy recovers, people get enrolled and demand access in a way we've never experienced, we may need masses of nurses."
Many nurses who postponed retirement during the past few years will leave soon, Orlowski predicted. "Remember that it takes three to four years to become a nurse, plus we have to consider the aging population of boomers entering health care and the state with no money to fund nursing schools."
Nursing Challenges Converging
Several challenges to the nursing profession in California are converging -- aging faculty, scarcity of new instructors to take their places, increased competition for students at nursing schools and uncertainty about the job market in a changing health care environment.
"A major problem for the next 10 years will be graying of the faculty," said Suzette Cardin, assistant dean of student affairs at the UCLA School of Nursing. "When senior faculty retires, it takes a while to get a replacement."
Plus, spots for nursing students at desirable schools are limited. For example, UCLA's bachelor's program accepts only 50 students a year, Cardin said.
"We could probably admit five times that amount if we had the state funding for extra nursing seats, along with faculty and clinical sites (patient care settings). The state Board of Registered Nursing requires 60 clinical hours for pediatrics and 90 for mental health -- the two most difficult clinical sites to get and you must have enough staff."
Competition for nursing jobs at top facilities remains stiff. "Every time UCLA calls for new grads, it receives 2,000 applications for 120 nursing jobs," Cardin said. "It's not just about having enough faculty -- we produce all these nurses that can't get jobs. We're very unsure about where the ACA will go and what that means. Maybe once it sifts out we'll have job openings."
"We have good luck getting faculty -- all positions are filled, even though we'd like to have more," said Mary Wickman, a professor and director of nursing at Vanguard University, a Christian institution in Orange County. "We've learned that if you're trying to pull an experienced nurse manager from a hospital to teach in an academic setting, such disparities exist between salaries that they're not willing to make a move."
Because many hospitals don't have the same number of inpatients they used to have, fewer positions come open, Wickman said. "That ultimately affects interest, for when people hear they won't get a job, applications decrease. Then we cycle again, having to recruit more nurses."
In September 2012, West Coast University, which offers nursing programs and has campuses in Los Angeles, Anaheim and Ontario, donated more than $2 million to Children's Hospital of Orange County. Nearly half was allocated to establish a Center of Nursing Excellence at CHOC Children's.
As needs cycle, hospitals must treat patients regardless, said Martin Gallegos, senior vice president of health policy and communications for the Hospital Association of Southern California. "You'd be pretty hard-pressed to find a hospital in L.A. County or Orange County that didn't have some nurse staffing needs, and so many hospitals have to pay high rates for temporary nurses. Providers will have to get creative under the ACA and many use recruiters to bring in internationally trained nurses."
California hospitals overall are doing the best they can to help educational institutions, he said. "They maintain slots or expand their nursing programs, creating public and private partnerships with community colleges. It's just one piece of trying to solve this puzzle," Gallegos said.
State officials said shortages will occur but the state's criteria for nursing instruction won't vary.
"Believe me, we are going to feel a shortage, but our mission is public protection when we approve all state nursing programs," said Louise Bailey, executive officer of the state's Board of Registered Nursing. "We have excellent programs, high standards, and intend to maintain them and to provide the consumer a high caliber of nurse taking care of them."