The Hospital Nursing Workforce in South Carolina Report: 2017 May 2018
ACKNOWLEDGEMENTS The 2017 Hospital Nursing Workforce study was conducted by the Center for Nursing Leadership s Office of Healthcare Workforce Research for Nursing at the University of South Carolina, Columbia, South Carolina. This report was prepared by Sean Clarke, Ph.D., RN, FAAN, Professor and Associate Dean, Undergraduate Program, Connell School of Nursing, Boston College; Ronda Hughes, Ph.D., MHS, RN, CLNC, FAAN, Associate Professor, College of Nursing, University of South Carolina, Director of the Center for Nursing Leadership, University of South Carolina; Susan Outen, MN, RN, Center for Nursing Leadership, University of South Carolina, and Jennifer King, MA, Center for Nursing Leadership, University of South Carolina. For questions, please contact Dr. Ronda Hughes, at (803) 777-0119 or hughesrg@mailbox.sc.edu. You may also visit the Center for Nursing Leadership s Office of Healthcare Workforce Research for Nursing website at: www.sc.edu/nursing/workforce. 2
CONTENTS Acknowledgements. 2 Background....... 4 Characteristics of the Hospitals Responding to the Survey.... 4 Findings...... 6 Employment of New Graduate Registered Nurses (RNs).... 6 Demand for Experienced vs. New Graduate RNs.... 7 Market Conditions for Various Types of Nursing Positions.... 7 Use of Advanced Practice Nurses (APRNs/NPs) Across Settings.... 9 Contingent Staffing and Experimentation with Staffing Models.. 10 Clinical Education Opportunities Being Provided by Hospitals.. 11 Workforce Dynamics: RN Separations and Retirement Aged Staff RNs... 12 Baccalaureate-Prepared RN Workforce... 12 Strategies to Increase BSN-Prepared RNs... 13 Summary of Major Points.. 15 Conclusions and Recommendations... 16 3
BACKGROUND The 2017-2018 survey of the Chief Nursing Officers (CNOs) in South Carolina was undertaken by The Center for Nursing Leadership s Office of Healthcare Workforce Research for Nursing at the University of South Carolina, Columbia, South Carolina, using REDCap, a secure web platform for surveys. The survey entitled, Nursing Staffing Practices, 2017, asked CNOs to report on their current and future staffing needs. Also, the survey asked the CNOs to respond to topics/questions such as the demand for experienced registered nurses (RNs) versus new graduate RNs in their hospital or system, recruitment difficulty of various personnel, and travel nurse employment versus per diem nurses. Additionally, the survey asked CNOs to report the number of nurses with a Bachelor s of Science degree (BSN) currently employed or will be hired in the future. Lastly, the survey asked respondents to comment on the number of eligible staff retirements that are approaching in the coming years. Electronic surveys were emailed to 62 hospital CNOs and of those 62 who were approached, 46 responses were received. Of those 46 that were received, 41 were fully completed and reflected responses for all but 14 of the hospitals on the original list (a response rate of roughly 77%). One of the hospitals in the survey reported both as a system and as an individual facility (the former was taken out), leaving 40 analyzable responses. The survey responses analyzed here reflect those complete responses. The data from the surveys are summarized in this report. Analyses were conducted using SPSS Statistics Version 24. Characteristics of the Hospitals Responding to the Survey Just over half of the hospitals/hospital systems responding to the survey were from rural areas; the remaining urban facilities were divided evenly between teaching and non-teaching hospitals (Figure 1). The hospitals responding were more or less evenly distributed between the four geographical regions of the state. Examining the characteristics of the nonresponding hospitals (14), representation of non-teaching urban hospitals was perhaps slightly lower in the final sample and hospitals in the Midlands region respond to the survey relative to their total numbers in the original list. It should be noted that there were some hospitals that were part of systems where there was a joint report and others that reported individually. 4
Table 1. Hospital Characteristics Responders Non-Responders n % n % Hospital type Rural 23 58% 7 50% Urban non-teaching 8 20% 6 43% Urban teaching 9 22% 1 7% DHEC region Low Country 7 18% 5 36% Midlands 12 30% 1 7% Pee Dee 12 30% 4 29% Upstate 9 22% 4 29% Figure 1. Hospital Type: Rural vs Urban Hospital Type 18% 26% 56% Rural Urban Non-Teaching Urban Teaching 5
FINDINGS Employment of New Graduate Registered Nurses Virtually all of the hospitals surveyed are and have been hiring new RN graduates. Whereas in 2015, hospitals reported planning no increase in the hiring of new graduates in the coming year. In 2017, nearly two out of three hospitals reported that they were planning to increase new graduate hiring within the coming year. Table 2. Hiring New Graduates 2017 2015 Hiring new graduates Normally yes, including this year 93% 95% Normally yes, but not this year 5% 3% Almost never 2% 3% Expected change in hiring of new graduates Expected increase 63% 23% No changes 35% 74% Expected decrease 2% 3% Approximately half (53%) of the CNOs surveyed indicated that their hospitals hired new graduates into any specialty (i.e., without restrictions) while others indicated that they preferred or required prior RN experiences in specific areas (such as critical care areas, procedural labs, and the emergency department). 6
Demand for Experienced vs. New Graduate RNs In the 2017 survey data, 92% of CNOs responding indicated that there was high or moderate unmet demand for experienced RNs, which is comparable to the 88% of hospitals reporting moderate or high unmet demand in 2015, but with an important shift to almost 80% saying that unmet demand was high (up from 40% in 2015). Demand for new graduate RNs showed a large increase to 51% of respondents claiming high or moderate unmet demand in 2017 (versus 16% in 2015). Table 3. Demand for RNs Experienced RNs New Graduate RNs 2017 2015 2017 2015 High demand 78% 40% 24% 3% Moderate demand 14% 48% 27% 13% Balance 8% 13% 36% 33% Demand less than supply Demand much less than supply 6% 40% 6% 13% Market Conditions for Various Types of Nursing Positions Specific nursing positions were found in all or virtually all of the hospitals surveyed: aides, licensed practical nurses (LPNs), staff RNs, nurse managers, nurse educators, nurse executives, and other RN roles (Table 4). Certified registered nurse anesthetists (CRNAs) are used in 83% of responding hospitals. Nurse midwives (CNMs), clinical nurse specialists (CNSs) and clinical leaders are used in the majority of the hospitals, albeit at lower rates. Approximately one-third of hospitals reported challenges in hiring nurse managers, nurse executives, CNSs, CRNAs, and aides in the past year. However almost two-thirds of hospitals report greater challenges in recruiting staff RNs in the past year (up from 38% in 2015). 7
Table 4. Percent of Hospitals Reporting Various Market Conditions for Nursing Positions Employ Recruited in last 12 months More difficult to recruit in past year (among those who hired in last year) Expected increase in next year (among those who employ) Aides 100% 98% 31% 63% LPNs 90% 55% 22% 21% Staff RNs 100% 100% 63% 58% APRNs/NPs 98% 78% 20% 44% CNMs 60% 58% 14% 0% CRNAs 85% 75% 38% 42% CNSs 63% 58% 33% 13% Nurse managers Nurse educators Clinical nurse leaders Nurse executives Other RN roles 98% 93% 44% 18% 93% 72% 15% 19% 72% 57% 17% 24% 100% 67% 33% 8% 95% NA* NA* 24% *Question not asked 8
Use of Advanced Practice Nurses (APRNs/NPs) Across Settings The use of nurse practitioners (APRNs/NPs) was found to be common in physician practices, emergency departments, and ambulatory care in hospitals (60-90% reporting use), with some use seen in inpatient units and critical care units (Table 5). In contrast, well under 15% of hospitals report the use of clinical nurse specialists in inpatient settings only. Table 5. Percent of Hospitals Employing CNSs and APRNs/NPs in Various Settings Uses APRNs/NPs in this specialty Uses CNSs in this specialty Ambulatory care 58% 0% Physician practices 88% 0% Intensive Care Units (ICUs) 18% 10% Cardiac units 8% 8% Medical-surgical units 18% 8% Pediatric units 10% 8% EDs 60% 5% Education departments 5% 8% 9
Contingent Staffing and Experimentation with Staffing Models This year s survey indicated that 85% of hospitals report using travel nurses (as opposed to 55% in 2015) and 43% report use of per diem nurses (as opposed to 41% in 2015). Traveling nurses are nurses who are hired to work in a variety of locations across the country often working a set number of weeks (typically 13-week periods) at one location. 1 Per diem nurses are defined as nurses who are employed on temporary assignments through a staffing agency, and who often make their own schedules filling in where needed on a temporary basis, such as day to day. 2 In hospitals using travel nurses, 33% of CNOs reported more use in the past year, and 27% of CNOs in hospitals using per diem nurses reported an increase in the past year. Ten (or 25%) of the CNOs report the creation of new RN roles in the past year; one of the most common type of new role was care/patient navigator (4 hospitals). Table 6. Alternative Staffing Models % Reporting Employs or considers employing LPNs 53% Offers an 8 h shift option 38% Offers or is considering offering an 8 h shift option 63% Offers pay differential for specialty certification 45% Exploring using different/new ways to use unlicensed assistive personnel 53% Exploring new roles for RNs 38% 1 What is a Travel Nurse? (n.d.). Retrieved from https://www.travelnursing.org/what-is-travelnursing.php 2 Are You More Comfortable with Per Diem or Travel Nursing? (n.d.). Retrieved from http://remedegroup.com/comfortable-per-diem-travel-nursing/ 10
Clinical Education Opportunities Being Provided by Hospitals The hospitals surveyed report extensive involvement in providing clinical experiences for nursing students. All provided experiences to pre-licensure students. While all provided inpatient unit experiences, and the majority provided emergency department (ED) and operating room (OR) experiences, outpatient experiences were relatively uncommon. Nearly 80% provided placements for graduate students. For pre-licensure students, almost 75% of hospitals offered placements on less conventional schedules such as weekends, nights, and in the summer. Table 7. Clinical Placements for Pre-licensure and Graduate Nursing Students (% of Hospitals Reporting Providing Various Types of Experiences) % Provides clinical for pre-licensure students 100% Settings where pre-licensure clinicals offered Inpatient 100% Emergency Department 78% Operating Room 53% Physician offices 8% Ambulatory or outpatient settings 25% Schedules Weekend 68% Nights 63% Summers 73% Clinical placements for graduate students 78% 11
Workforce Dynamics: RN Separations and Retirement Aged Staff RNs The mean number of RN separations reported by CNOs in the previous year was 79.0 (SD 102.1), and the mean number of retirement-age RN staff was 34.6 (SD 51.3). Together the hospitals responding to the survey reported 2,685 separations in the previous year and 1,107 RNs of retirement age. Baccalaureate-Prepared RN Workforce In the 2017 survey findings: 67% of hospital CNOs reported that over 35% of their RNs held a bachelor s or higher degree up from 57% having these levels of BS prepared RNs in 2015. Table 10. Breakdown of Hospitals by Percent of RNs holding a BSN Degree 2017 2015 <20% 13% 18% 20-35% 20% 26% 36-50% 36% 26% 51-75% 28% 26% >75% 3% 3% 12
Strategies to Increase BSN-Prepared RNs In terms of target goals, 90% of the CNOs (36) indicated a specific goal in terms of bachelor s-level preparation in their RN workforce. Only 55% of CNOs in 2015 reported having such a target. In the current survey, 75% of CNOs reported their goal was having 50% or more of their RNs prepared at the baccalaureate level. A number of strategies for moving towards targets are suggested by study results, beginning with policies around education for new hires. For example, 10 of 40 hospitals (or 25%) report that new RNs holding diplomas or associate degrees (ADs) are expected to earn a BSN within a 2-year (2 hospitals), 4-year (6 hospitals) or 5-year (2 hospitals) period after hire. Interestingly, only 38% of hospitals report offering a salary differential for baccalaureate holders. Table 8. Percent of CNOs Reporting Various Root Causes for Difficulties Increasing Levels of Bachelor s Degree Nurses 2017 2015 Scheduling/staffing barriers 32% 20% Insufficient senior leadership support 0% 2% Insufficient funds for tuition reimbursement 32% 48% Lack of interest in BSN among RNs 54% 30% Low supply of BSN nurses in the community 42% 27% Lack of BSN programs in the community 10% 13% The strongest contrasts between the 2017 and 2015 surveys were that more hospitals in 2017 reported that scheduling/staffing barriers, low supply of BSN nurses in the community, and a lack of interest in bachelor s education among RNs were the main causes of the difficulty of increasing the proportion of BSN-prepared nurses in their workforce. Furthermore, in 2017, fewer CNOs indicate that a lack of resources for tuition reimbursement was a significant barrier to enriching the education mix of RN staff. 13
The majority of hospitals (90%) offer some support for nurses seeking further education, with nearly all hospitals offering tuition reimbursement. Interestingly, somewhat fewer hospitals appeared to be offering unpaid time off for attending classes in 2017 than in 2015. Table 9. CNO Support for RNs Returning for a BSN 2017 2015 No support 10% 10% Tuition reimbursement for prerequisites 20% 53% Tuition reimbursement 85% 90% Approved use of unpaid time off for coursework 25% 40% 14
SUMMARY OF MAJOR POINTS While CNOs responding to the survey indicate that experienced staff RNs were the most sought after type of nursing employees, unmet demand for new RN graduates was also very high--with the majority of hospitals indicating that they hire new graduates routinely and expect to increase recruitment in the coming year. In addition to challenges in recruiting staff RNs, survey respondents indicate increased difficulties recruiting nurse aides/nursing assistants, CNSs, nurse managers and executives, and CRNAs. Survey data suggest that an increase in hiring of staff RNs, CRNAs, and APRNs/NPs was expected by hospital CNOs in the coming year. The use of CNSs in the hospitals who reported their use appeared confined to inpatient settings and was quite low. Use of APRNs/NPs was very common in outpatient settings, physician offices, and emergency departments and was higher than seen for CNSs in inpatient settings. Nearly all the CNOs responding to the survey report using traveling nurses and just under half used per diem staff (an increase and a decrease from the 2015 survey, respectively). Approximately one in three hospitals using travelers and per diem nurses report increasing use in the last year. Just over half of the hospital CNOs report considering increased use of or new roles for LPNs and nursing assistants/aides. One third of the CNOs report offering eight-hour shifts or exploring the possibility of introducing eight-hour shifts. Significant numbers of annual RN separations were reported by hospital CNOs, as were high numbers of RNs who have reached retirement eligible ages. Hospitals who reported during this survey, participate extensively in clinical placement offerings to pre-licensure (and to a slightly lesser extent, graduate) nursing students. Approximately 70% are offering experiences at alternative times of the day, week, and year. A minority are offering outpatient placements at the present time. Almost 70% of hospitals report that 35% or more of their nurses were BSNprepared. Nearly all hospitals report having a goal they are targeting, with a large majority targeting 50% BSN-prepared RN staff. Interest in non-bsn prepared RNs in returning to school appears to be weakening and relatively few hospitals are requiring newly hired RNs to earn a BSN by a specific date. 15
Just under 40% offer a salary differential but nearly all hospitals offer some sort of tuition support for staff RNs returning to school. CONCLUSIONS AND RECOMMENDATIONS The results of this survey suggest strong demand in excess of supply for all RN staff, particularly strong unmet demand for experienced RNs, and pockets of high demand and challenges in recruiting for specific roles. For any employer facing higher demand than supply of skilled workers, increasing the supply of RNs willing to work in agencies for the wages on offer as well as retention would appear to be a priority. Hospitals and regions can hope for an increase in local nursing supply (although the education pipeline for registered nurses is resource and time intensive) or can look at the possibility of drawing in nurses from other institutions or regions. However, among potentially modifiable factors under some control by managers and executives that might facilitate retention--which could be a particularly important strategy, are wages and benefits and working conditions. However, neither of these retention-related issues was directly examined in this survey. National and regional economic trends are likely responsible for some of the patterns in the data, as are the aging of the RN workforce and personal/life decisions of staff. However, compensation of staff and a positive work environment (which can often be improved through support for front-line managers) could be targeted. Additionally, any costs considered in relation to operational difficulties and lost productivity resulting from turnover and staff shortfalls need to be monitored. The significant numbers of hospitals reporting unmet needs for new RN graduates, particularly in light of national trends of balanced supply and demand, suggests that further study of the attractiveness of compensation should be considered. If surveys suggest that compensation is attractive, perhaps targeted recruitment of new graduates from areas of the country facing nursing surpluses or a challenging market for first jobs could be a strategy. Data suggest that clinical nurse specialists (CNS) are in lower demand overall, but that hospitals seeking CNSs are experiencing challenges in recruiting them. There has been a steep, decades-long downturn in the preparation of CNSs in graduate programs nationally. Consequently, factors related to retention should be considered (once again, modifiable areas include compensation and work climate) but looking to the future strategies for meeting institutional needs for CNS-type skills could be met with other types of nurses. 16
Some hospitals heavily use traveling RNs--and survey results suggest that traveling nurses are being used more than per diem staff. Patterns of use of travelers and the implications of reliance on travelers (if this is going on in areas of some or all hospitals that are using them) on unit climate and retention of staff should be examined. South Carolina hospitals appear to offer extensive clinical experience opportunities--an indication that they are collaborating with colleges and universities to address supply side issues. It appears as if timing, other than day shifts in the regular academic year, is being used to expand capacity, but it is unclear to what extent evenings, weekends, and summers are being used or whether some of these alternate scheduling options offer high quality experiences. In assessing the possibilities for the expansion of nursing education capacity, it would be important to examine which units/settings are being used and when, where there is room to grow the number of students and/or student options, and to what extent the availability of qualified instructors is influencing placement possibilities. It is interesting that important functional areas attached to hospitals but outside of inpatient areas, such as physician offices and outpatient settings, are uncommonly used. This is also important in light of calls from many to increase the readiness of nurses to deliver community-based care and to participate in population health practice. The numbers of students that could be reasonably integrated into these settings in meaningful learning opportunities that would not interfere with patient flow is unknown. This deserves attention. A number of the trends in the survey data would seem intertwined: unmet demand for RNs (both experienced and new graduates), decreasing interest in pursuit of the BSN degree by associate degree prepared RNs, and significant numbers of hospitals considering increasing levels of use of practical nurses and unlicensed personnel. They are not necessarily causally linked but the connections are logical--high demand for experienced RNs makes it less compelling for associates degree prepared RNs to return to school. Shortfalls in RN staff (along with interests in controlling costs) are raising interest in increasing roles for practical nurses and unlicensed staff. These trends should be tracked and explored in terms of whether they are isolated or widespread, what their underlying causes are, and what implications they might have for quality of care and other areas of performance in South Carolina hospitals. 17