'It's Really Gotten Worse': California Needs Thousands of Nurses

Ashley Hooks always planned to retire at Lakewood Regional Medical Center, where she has been a nurse for 12 years. But now, Hooks said, staffing issues are so bad and burnout so severe that she’s rethinking how she wants to spend the rest of her career.

Since the COVID-19 pandemic began, the number of nurses at the hospital dropped from just below 500 to 330 according to her union’s roster, said Hooks, who is 53.

“It wasn’t even this difficult during the height of the COVID pandemic,” she said.

Hooks’ stress reflects the pressure many California nurses are under because of steep understaffing that she and others say is driving many professionals out of the industry.

According to the Hospital Association of Southern California, nursing vacancy rates among local hospitals exceed 30%. Prior to the pandemic, the average vacancy rate was 6% (PDF).

“Within the last year-and-a-half or so, it’s really gotten worse,” Hooks said.

Now the Legislature is looking at several ideas to address the nursing shortage by bringing more early-career nurses into the field. But so far, the groups with most to gain — or lose — are at odds over how to solve the staffing problems afflicting California’s health care workforce.

Labor organizations and hospitals want nursing schools to prioritize certain applicants for admission, such as people who already have experience in the industry.

“We don’t have enough nurses entering the system as opportunities are opening up for them to leave the system,” said Peter Sidhu, a nurse and executive vice president of United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP).

But the schools say that won’t help them graduate more nurses. They need more faculty and more hands-on training opportunities to increase class sizes.

Hospitals and unions say they don’t have much time to waste. Estimates show California faces a shortage of about 36,000 licensed nurses, according to the UC San Francisco Health Workforce Research Center on Long-Term Care.

Preliminary data from a statewide survey conducted in 2022 shows nurses cut back on the number of hours worked per week since 2020, and nearly half the workforce reports symptoms of burnout, said Joanne Spetz, director of the Institute for Health Policy Studies at UC San Francisco, who has studied nursing workforce issues for more than a decade.

More nurses, even those as young as 35, are thinking about leaving the profession entirely or retiring within the next two years, and half of the workforce had at least one patient die of COVID-19, Spetz said.

“There is a lot of trauma in the nursing workforce,” Spetz said. “The numbers are not good.”

Union-backed bills for nursing shortage

Labor advocates say the nursing shortage creates a vicious cycle. The nurses on shift wind up doing more work. They get burned out and flee the industry, worsening the problem.

Service Employees International Union (SEIU) and the UNAC/UHCP turned their attention to the state’s community college system, where graduates can earn degrees to become nursing assistants, licensed vocational nurses or registered nurses. Both groups say community colleges offer the most affordable and efficient way to earn a nursing degree.

One of their ideas aims to help high school students get into nursing schools faster. Another would give entry-level workers the chance to move into more skilled and higher-paid positions like nursing.

Sidhu’s union is sponsoring a bill that would create a pilot program for high school students who take extra classes to have preferential admission into a community college nursing program.

A second measure, which is co-sponsored by SEIU and the California Hospital Association (CHA), would require community colleges to set aside 15% of enrollment slots for health care workers looking to further their education with a more advanced degree. They say helping current workers get higher-paying jobs within health care will help with retention.

“When we talk to our hospital members, workforce issues are the number one thing that keep them up at night,” said Jan Emerson-Shea, spokesperson for the CHA. “We also hear from employees that they’ve tried getting into community college programs, but because they’re so impacted, it can take them three, four or five years to get into the program.”

California colleges skeptical of union bills

But community college and some university nursing school leaders contend neither bill will boost the number of graduates. Nursing programs are full, they say, and the proposals do nothing to expand the number of admission slots.

“These bills come up and I wonder who on earth would propose something like this to impact the community colleges without getting our input,” said Tammy Vant Hul, south region president of the California Organization of Associate Degree Nursing Program Directors.

Vant Hul is also dean of nursing at Riverside City College, the second largest community college nursing program in the state. High school students would not have completed enough prerequisites to apply directly to a nursing program, much less be guaranteed admission, Vant Hul said, and existing health care workers already get additional points during the admissions process.

The problem isn’t generating career interest in nursing; it’s creating more spots, program leaders say.

Karen Bradley, president of the California Association of Colleges of Nursing, said nursing programs have an overabundance of competitive applicants.

“We have not had a dip at all in enrollment in my program. I have a waiting list,” said Bradley, who is also dean of California Baptist University’s nursing program. “Every dean is going to tell you that they have a waiting list or enough qualified applicants that they turn away students.”

About 14,000 new students enrolled in nursing programs during the 2020–21 school year, according to the Board of Registered Nursing’s annual school report (PDF). That’s about 1,000 fewer students than the previous two years due to smaller class sizes, but schools across the state received more than 55,000 applications, a 10-year record.

The bills’ sponsors say they have spoken with the California Community Colleges Chancellor’s Office, which has not taken a position on any of the workforce bills.

Separate from the bills, the UNAC/UHCP lobbied for a $300 million investment (PDF) over five years to double the state’s nursing school capacity. It was included in the state budget Gov. Gavin Newsom signed earlier this summer.

The details of how the money will be spent have not been decided, Sidhu said, but it could be used to increase faculty salaries and overcome other factors that limit class sizes.

More room needed for California nurse trainees

Representatives for nursing programs say the money will be helpful, but they’re worried about other bottlenecks that they say prevent them from enrolling more students.

Lack of nursing faculty caps class sizes, for instance, with potential educators instead choosing to make more money working in health care. They also say hospitals are not offering enough opportunities for their students to get hands-on training.

“As we move forward with the nursing shortage, clinical placements are an issue. So many hospitals kind of downsized their willingness to bring on students during the pandemic, and those spots never came back,” said Linda Zorn, legislative chair for the California Organization of Associate Degree Nursing and executive director of economic and workforce development for Butte-Glenn Community College District.

A third proposal in the Legislature attempts to clear that hurdle by guaranteeing clinical placement spots for community college students. A mix of opponents are fighting the bill, including hospitals, four-year universities and some community college advocates who say it will take spots away from other students and overwhelm nursing staff.

“Some hospitals aren’t big enough. They can’t take on hundreds of students. They have 25 beds,” said Sarah Bridge, senior legislative advocate for the Association of Health Care Districts, which represents primarily small, rural hospitals in the state.

During the 2020–21 school year, the most commonly cited reason by nursing schools for decreasing class sizes was “unable to secure clinical placements,” according to the Board of Registered Nursing’s annual school report (PDF), in part due to workforce challenges resulting from the pandemic. The report states that more than 15,000 students were impacted by restricted training spots compared to roughly 2,200 students during the 2018–19 school year.

Bridge said many small and rural hospitals also are teetering on the edge of a financial crisis. It costs about $7,000 to train one student, not including the salary cost of nurses who supervise students. Multiply that by the number of student trainees accepted and some hospitals can’t foot the bill, Bridge said.

Zorn said nursing schools know they have to be sensitive to how many students get sent to any one hospital, which is part of the reason many are skeptical of the bill. The number of student training spots recently has been limited by the profession’s thinly stretched workforce.

“It can close down the rural hospitals if you don’t have the correct staffing,” Zorn said.

Leaders from four-year degree programs also say the proposal would displace their nursing students in favor of community college students.

The bill sponsors say the intent of the legislation is to create more training capacity, not to displace existing students, as some critics have claimed, said Eric Robles, legislative director for the UNAC/UHCP.

“If hospitals are getting bailouts, I would sure hope everybody believes our nurse workforce needs a bailout too,” Robles said. “And that bailout can come through strengthening the pipeline, growing the workforce and maintaining the workforce.”