California’s Nursing Schools Need to Up Enrollment by 60 percent to Avoid Shortage

Los Angeles recently endured a teachers strike, lasting seven days and affecting over 30,000 employees of Los Angeles Unified School District. In the time leading up to the LAUSD teachers strike, 7,000 Los Angeles County nurses narrowly avoided a strike, an event that did not make headlines.

As reported by ABC’s local Los Angeles affiliate, the main grievances of the nurses union were that LA County had violated a law requiring minimum nurse to patient ratios and failed to retain nurses. The inadequate staffing leading to these grievances might be attributed to a shortage of nurses, but apparently that is a controversial topic.

For example, why, if there is a nursing shortage, has the California Board of Registered Nursing (BRN) issued guidelines designed to limit the annual enrollment in approved schools of nursing? These guidelines stipulate that even within fully accredited nursing schools, prior BRN approval is required to increase or decrease the number of student enrollments, or make changes in enrollment cycles.

Apparently, not much approval is forthcoming. For example, according to the BRN’s own surveys over the five year period from 2014 through 2018, nursing programs in California turned away 62 percent of qualified applicants for lack of openings. The problem is so acute, that public nursing programs in California are actually admitting qualified applicants based on a lottery, instead of based on their academic achievement and other qualitative factors.

But is there a shortage of qualified nurses in California? And if so, will the shortage get worse over the coming decades? According to the Federal Bureau of Labor Statistics, over a million new nurses will be required within the next five years to accommodate rising demand and to make up for retiring nurses. California is at the top of the list for the greatest shortage.

A report published in the American Journal of Medical Quality notes that California will need 193,000 new nurses by 2030. Corroborating this is a 2017 registered nursing study, based on federal labor statistics, that found by 2030 the demand for nurses in California would outpace supply by 11.5 percent.

Using data compiled by the Kaiser Family Foundation, as of October 2018 there were 337,738 registered nurses in California. Another  survey conducted by the National Council of State Boards of Nursing, found that 55 percent of the nursing workforce is older than 50. Assuming the average retirement age of a nurse is in their early sixties, this means by 2030, if not sooner, California will have to replace more than half of its nursing workforce, over 165,000 positions.

Meanwhile, other factors are likely to increase that number. Job stress, often induced by low nurse patient ratios, prompts nurses to change careers. Put another way, the shortage of nurses causes job conditions that drive nurses out of the profession, which makes the shortage of nurses even greater. And, of course, if mandated nurse to patient ratios are lowered, either through labor negotiations or legislation, overnight the existing shortage will rise.  The other primary factor that’s driving up demand for nurses is increased patient demand.

California’s nursing shortage has been downplayed by critics who claim that compared to the rest of America, California’s population is younger than average. This contention doesn’t appear to conform to available data, however. According to the US Census Bureau, in 2017, the median age in the US is 38 years old, whereas the median age in California was 36 years old. Moreover, as reported by the Los Angeles Times in October 2018, California’s senior population is growing faster than any other age group.

As can be seen on the population pyramid below, which uses 2016 data, in that year, 384,000 Californians turned 65. In 2021, as can be seen from the data, 470,000 Californians will turn 65, and in the year 2026, only seven years from now, 535,000 Californians will turn 65. California’s senior population is increasing, and it is increasing as a proportion of the general population at almost exactly the same rate as it is in the US population.

If, as noted, projected retirements between now and the early 2030s suggest approximately 165,000 nursing positions will open by then, poor retention, increases to the mandated nurse/patient ratio and an aging population all suggest that is the low estimate. Another way of evaluating demand for nurses in California uses the ratio of professionally active nurses per 100,000 population. Using Kaiser Family Foundation data, there are 3.4 million active nurses in the U.S., which equates to 1,030 nurses per 100,000 of population. In California, a state with 40 million residents, there are 338,000 nurses – a ratio of only 844 nurses per 100,000 population. To bring California up to the national average would require another 74,000 nurses.

One of the demands of California’s nurses in the recently averted strike in Los Angeles was to improve the nurse to patient ratio. This demand appears credible in view of California’s lower than average number of practicing nurses per 100,000 residents. Therefore it is reasonable to assume that between now and 2030, to replace retirees, compensate for attrition, cope with an aging population and bring the nurse/patient ratio up to national standards, at least 220,000 new positions will have to be filled. How many nurses currently graduate each year in California?

On this, the data is readily available. An authoritative study, “Forcasting the RN Workforce in California,” using information from the Annual Schools Report produced by the California Board of Registered Nursing, predicted 10,627 graduates for the academic year ended June 2018. For the 2018-19 academic year, it predicted 11,200; for 2019-20, 11,489. Clearly this is not enough.

Based on current graduation numbers, assuming an average of 11,500 per year, the next 12 graduating classes through 2030 will add 138,000 nurses to California’s workforce. That falls 82,000 short of what the industry needs. To meet likely demand, the number of nursing graduates in California need to immediately increase by 60 percent.

These are all conservative estimates. California not only has an aging population in proportion to the overall aging U.S. population, but also a disproportionate share of the nation’s low income welfare recipients and undocumented immigrants – cohorts that likely require more medical care than typical middle class residents. And what if state law requires California’s 10,473 K-12 schools to all have a full time RN on staff, as appears to be a trend based on the settlement agreement in the recent LAUSD strike?

California appears to be facing an increasingly serious shortage of nurses in the coming years. The grievances of California’s overworked nurses, already sufficient to nearly warrant a strike last Fall in Los Angeles, appear to be legitimate indeed.

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Edward Ring is a co-founder of the California Policy Center and served as its first president.