jacob wolf cassandra zirbel jenny svobodny march 19 th, 2015 nursing market in the united states
TRANSCRIPT
Agenda:
Who are the nurses?
Registered nurses
Gender, Race, Age, Education, Place of employment
Wages
Nurse Shortage
Monopsony Model
Other causes
Nurse Quality
Main types of Nurses
Certified Nursing Assistant (CNA)
Help provide basic care
Long-term care facility work
Licensed Practical Nurse (LPN)
Basic medical care
Blood pressure, bandages, bathe, etc.
Registered Nurse
Provide and coordinate care
Educate public and patients
Nurse Practitioner
Diagnose, test, prescribe
May order, preform, administer, and interpret tests
Main difference: educationBureau of Labor Statistics
Gender
Gender 2001
MaleFemale
94.6%
5.4%
Gender 2011
MaleFemale
90.4%
9.6%
• Dominated by females (90.4%)• 1970- Males (2.7%)• Males increasing (5.4% 9.6%)
• Highest proportion of males: nurse anesthetists 41%
• Men are paid higher wages• Women get 91 cents on the dollar
U.S. Census Bureau 2011
Race• Predominately white (75%)• Getting Increasingly diverse• Blacks (7% 13%)• Hispanic (4% 7%)• Asian (3% 4%)
American Association Study 2001
Education Options:
Bachelor’s, Associate’s, or Diploma Program
Bachelor’s of Science
Four-year university program
Slow steady growth
Associate’s
Two-year program
Rapid growth
Diploma Program
One-year program
Almost non-existent
HRSA 2010
Education
Highest Degree held by RNS, Census Data
Bachelor'sGraduateAssociate'sRN Diploma
2011
Bachelor’s: 40.8%Associate’s: 38%Diploma: 12.3%Graduate: 8%
U.S. Census Bureau, HRSA 2010
2010
Place of Employment
• Nurses working in hospitals (58% 62.2%)• Rotating shifts to cover 24 hour day• 20% Part time
HRSA 2010
Nursing Monopsony Overview
Registered Nurse Wages
Nursing Shortage
Monopsony Model Overview
Monopsony In the Nursing Market, Empirical Evidence
Other Nursing Shortage Explanations
Registered Nursing Wages
Median Annual Wage $65,470
10% 50% 90%
$65,470 $94,720$45,040
Bureau of Labor Statistics, 2012
Registered Nurse Wages
Source: Payscale Inc
Factors:
Geography, Experience, Education, Title
< 1 Year 1 to 4 Years 5 to 9 Years 10 to 19 Years 20 Years or More
$53,201
$61,962
$68,899 $75,027
$77,855
RN Median Salary with BSN by Years of Experience, 2014
Nursing Shortage Overview
Emerged in 1930’s (Whelan)
Nursing shortage expected to grow to 260,00 RN’s by 2025.
Twice as large since the mid 1960’s (Bernhaus, 2009)
May 2011, 121,000 new job ads for RN’s, up 46% from May 2010 (Wanted Analytics)
Persistent Shortages have attracted many economists’ attention to search for possible explanations
Monopsony Model - Overview
Epc
S= AC
MFC
MRPL
Em
Wages
Quantity of Labor
Wm
Wpc
• Hospital has market power, single buyer
• MFC > S
• Implications: For each additional nurse hired you must pay that nurse more and ALL the nurses more
• Finding Equilibriums
• Elasticity of SupplySupply horizontal (Perfectly elastic) facing firm in competitive markets
Shortage
Empirical Evidence on Monopsony
2 methods Finding the elasticity of a supply curve
Inelastic labor supply indicative of monopsony power
Investigate whether nurses’ wages vary significantly in regards to workers mobility and hospital concentration Herfindahl index measures the concentration of hospitals in a geographic
region
Perfectly competitive market, Herfindahl index approaches 0
Studies in support of monopsonyResearcher
Year Result/ Elasticity
Staiger 2010 Legislated wage change VA Hospitals0.1 Short Run Elasticity
Sullivan 1989 0.79 Elasticity over One Year Changes0.26 Elasticity over Three Year Changes
Askildsen 2003 0.2 Elasticity over 5 year span (1993-1998) in Norway
Link & Landon (1975) Double hospital concentration $400 less in annual
beginning salaries
Robinson (1988) More competitive markets’ hospitals average 86
more employees than did otherwise comparable hospitals
Studies Against Monopsony
Hansen (1992)
Supply elasticity in CA 29 to 56 from 1980 to 1987
Hirsch & Schumacher (2005)
Nurses have higher comparable wages and more mobility than the control group of similarly educated females
Mukharjee (2011)
Used same data as Hirsch & Schumacher but instead used semiparametric regression instead of linear regression concentration has no impact on wages
Hirsch & Schumacher (1995)
No correlation between RN wages and hospital density
Relative wages were not found to be higher in metro areas
Adamache & Sloan (1982)
Hospital concentration has no effect on entry level compensation
Other Nursing Shortage Explanations
Limited faculty
> 75,000 qualified applicants turned away from nursing school each year (Gyurko, 2013)
Pay Equity and Job Conditions
Paid less than other occupations requiring similar levels of skill and responsibility (Sullivan, 1989)
Nights and weekends, 12 hour shifts, can be forced longer (HRSA 2010)
Insufficient staffing levels increase stress, impacting job satisfaction
Other Nursing Shortage Explanations
Aging workforce
Significant segment nearing retirement
Changing Demographics
Increasing demand as baby boomers age and require more healthcare
High Nurse Turnover
28% of respondents of a 2013 survey said an educational paradigm change needed
Clinical apprenticeship model
Fails to incorporate non-traditional settings and health care technology proficiency (Gyurko 2013)
Patient to Nurse RatioTime Spent With Patient
Additional Nurses:• +1 patient per nurse probability of mortality by
7% (Aiken 2002)
• Works both ways
Additional Hours: • Additional 1 HPPD reduced adverse conditions 2%-
10% (Needleman 2002)
• Additional 1 HPPD also decreased length of stay by 5% (Needleman 2002) (American Nurses Association 2000) (Shamian 1994)
• Downside: +6 min/patient = additional part time nurse (Arndt and Crane 1997)
Education
High School, Hospital, and Associates Degree Few quality differences noticed between nurses who
have not obtained a Bachelors Degree. (Young 2007)
Nurses without a Bachelors Degree performed poorly and were disciplined at a higher rate Associate students less professional (Green 1996)
9x likely to make medication errors(Fagin 2001)
High School educated CNA’s do not affect adverse outcomes (Needleman 2002)
High School, Hospital Degree, Associates, or Bachelors
Education
WAI Questionnaire – Low ability rating 37% for nurses without college education, 30% for those with degree (Golubic 2009)
Bachelors degree rated workplace stressors lower than those without an education
Bachelors Degree = more difficult tasks (Young 2007)
High School, Hospital Degree, Associates, or Bachelors
Education
Bachelors Degree (Advanced Degree) An increase in advanced degree nurses results
in… Advanced degree >30%, - below average PTN ratio (5.5
vs 5.7 (Aiken 2003)
71% of CNO’s noticed better critical thinking and leadership skills (Goode 2001)
advanced degree >30% - mortality rate below average of 2% (Aiken 2003)
Additional 10% advanced degree nurses – decrease FTR by 5% (Aiken 2003)
High School, Hospital Degree, Associates, or Bachelors
Working Conditions
Burnout: Each additional patient
decreases job outlook by 15% (Aiken 2002)
Affects Turnover (Aiken 2002)
Turnover in excess of 30% affects quality of care (Castle 2007)
Overworking: Overworked nurses suffer
in accountability, responsiveness, and assurance (Teng 2010)
Overworking/Burnout
Working Conditions
Nursing autonomy, control, and relationships with physicians important (Kramer and Hafner 1989)(Aiken and Smith 1994) (Wunderlich 1996)
Magnet Hospitals (Aiken and Smith 1994)
4.6% decrease in mortality
Job Satisfaction/Magnet Hospitals
Conclusion
Higher Education not only develops procedural skills, but also professional skills.
Bachelors Degree makes a difference
in nursing hours = in adverse conditions, length of stay and mortality rates
Burnout Turnover Lower Quality
Working Conditions keep the good nurses around lower mortality