Nurses' labour supply elasticities: the importance of accounting for extensive margins

Nursing labor supply in Iran: a survey in Shiraz public hospitals in 2022

BACKGROUND

The labor supply of nurses, as one of the main healthcare workers, is an important issue in health human resources planning in all health systems. Finding the factors affecting it, could help policymakers to solve the shortage of nursing work supply. The present study aimed to investigating the quantity and factors affecting the nurses' labor supply in Iran.

METHOD

In this cross-sectional study, a sample of 598 nurses working in public hospitals of Shiraz (Iran) were selected via proportionate stratified random sampling method. The required data was collected using a structured questionnaire which asked working hours and other related factors. To analyze the data, descriptive statistics, univariate analysis and multivariate linear regression were performed using STATA 15. The multivariate labor supply model was estimated separately for married and single nurses.  RESULTS: The average weekly working hours of nurses was 54.65 h in all medical centers and 50.28 h in the main hospital. The regression results showed that the labor supply of nurses with work experience (β = - 0.368, P = 0.014), satisfaction with work shift arrangement (β = - 2.473, P = 0.001), income between 60-89 million rial (β = - 14.046, P = 0.002), income between  90-119 million rial(β = - 12.073, P = 0.012), and working in the emergency department (β = - 5.043, P = 0.017) had negative and significant relationship; But there was a positive and significant relationship with satisfaction of the work environment (β = 1.86, P = 0.011), workload at work (β = 1.951, P = 0.023) and employment status (contractual employees) (β = 4.704, P = 0.004).

CONCLUSION

The labor supply function of nurses is affected by demographic, economic and non-economic factors. The most contributing factors were related to non-economic variables. It seems that the non-financial cost and benefits related to the job as well as internal factors have more important role on the nurses' labor supply.

Analyzing nurses' decisions to leave their profession-a duration analysis

Many countries suffer from skilled labor shortages in nursing. One way to increase the nurse labor supply is to raise their retention rates. Yet, though several studies exist on factors associated with the nurse labor supply at different levels, literature on factors associated with nurses' decisions to leave their occupation is relatively scarce. Based on German administrative data, I analyze the determinants of nurses' decisions to leave their profession. My results suggest that younger nurses, nurses in the social sector, and nurses working with smaller employers leave their occupation more often than their counterparts, irrespective of their specific nursing occupations and care settings. Nurses leave more often where more alternative occupational options are available. Nurses who have been unemployed and nurses who have been employed in a different field have a higher probability of leaving the occupation, whereas nurses who just finished vocational training only have a moderate propensity to leave. Female nurses leave less often if employed part time. Female nurses in part time leave even more seldom if they have children. A change in the hospital reimbursement system and introducing a nursing minimum wage during the first decade of the century did not change nurses' occupation durations.

How do hospitals respond to input regulation? Evidence from the California nurse staffing mandate

Mandated minimum nurse-to-patient ratios have been the subject of active debate in the U.S. for over twenty years and are under legislative consideration today in several states and at the federal level. This paper uses the 1999 California nurse staffing mandate as an empirical setting to estimate the causal effects of minimum ratios on hospitals. Minimum ratios led to a 58 min increase in nursing time per patient day and 9 percent increase in the wage bill per patient day in the general medical/surgical acute care unit among treated hospitals. Hospitals responded on several margins: increased use of lower-licensed and younger nurses, reduced capacity by 16 beds (14 percent), and increased bed utilization rates by 0.045 points (8 percent). Using administrative data on discharges for acute myocardial infarction (AMI), I find a significant reduction in length of stay (5 percent) and no effect on the 30-day all-cause readmission rate. The null effect on readmissions suggests that length of stay declined not because hospitals were discharging AMI patients "quicker and sicker", rather, AMI patients recovered more quickly due to an improvement in care quality per day.

The attractiveness of jobs in the German care sector: results of a factorial survey

The skilled labour shortage in nursing is an issue not unique to Germany. Unattractive characteristics of nursing jobs are one reason for the low supply in nursing personnel. In our study, we analyse the influence of job characteristics on the attractiveness of nursing jobs. We address this issue via factorial survey analysis, an experimental method particularly suited to assessing personal opinions and less prone to social desirability bias than standard interview methods. Around 1300 (current and former) nurses in a distinct region in Germany were asked to rate a set of synthetic job postings, each of which contained information on 9 systematically varied job characteristics. We find that, first, attractiveness of care jobs is most strongly affected by rather "soft" characteristics such as atmosphere within the team and time for patients. "Hard" factors play a considerably smaller role. Second, one hard factor, contract duration, is estimated to be among the most important job factors, however. This is a remarkable finding given that nursing occupations suffer from severe skill shortages. Third, though wage has a statistically significant influence on attractiveness, enormous wage raises would be needed to yield higher attractiveness gains than the top-rated soft factors, or to compensate for less pleasant job characteristics with respect to those factors. Last, even after controlling for other job characteristics, hospital nursing is still rated as more attractive than geriatric nursing.

The role of wage beliefs in the decision to become a nurse

In light of skilled-labor shortage, the effect of a change in the wage of nurses on their labor supply is intensely discussed in recent literature. Using extensive data of German 14- to 15-year-olds, I analyze the role of the beliefs about a nurse's wage in the decision to become one. To estimate a partial effect, I select controls and their functional form using post-double-selection, which is a data-driven selection method based on regression shrinkage. Highlighting the importance of wages at the extensive margin of labor supply, the wage beliefs play a positive and statistically significant role. Although information is publicly available, educational choices knowingly suffer from misinformation. I find that especially those who do not become a nurse understate the wage. The results lead to two important policy implications. First, increasing the wage may help to overcome the shortage observed in many countries. Second, providing more information on the (relative) wage may be a successful strategy to attract more individuals into this profession. To assess the sensitivity of the results regarding omitted variable bias, I apply a novel approach. It turns out that potential unobserved confounders would have to be strong to overrule the conclusions.

Nurse staffing legislation: Empirical evidence and policy analysis

Unsafe nurse staffing conditions in hospitals have been shown to increase the risk of adverse patient events, including mortality. Consequently, United States and international professional nursing organizations often advocate for safer staffing conditions. There are a variety of factors to consider when staffing nurses for patient safety, such as the number of patients per nurse, nurse preparation, patient acuity, and nurse autonomy. The complex issue of staffing nurses often is compounded by cost issues and can become politicized. When nurse organizations' recommendations for safe staffing measures are disregarded by hospital administrations, nurse lobbyists and interest groups often pursue legislative action to protect patients and nurses from unsafe staffing conditions. This article presents a narrative review of safe nurse staffing factors and an analysis of nurse staffing legislation. Using a patient-centric lens, three state-level nurse staffing policies (mandated nurse-to-patient ratios, public reporting of staffing plans, and nurse staffing committees) were evaluated by empirical evidence, cost to hospitals and state governments, political feasibility, and potential to affect patient populations. Although nurse staffing policy analysis can be conducted in several ways, it is crucial that nurses consider empirical evidence related to staffing policies as well as evaluations of implemented policies and political influences.

Predicting polytomous career choices in healthcare using probabilistic expectations data

This paper compares career expectations and career outcomes of Swiss healthcare assistants (HCA), an occupation created to increase the supply of nurses. We investigate whether HCAs can predict their own professional careers two years ahead by eliciting their expectations for a range of career alternatives, including nursing and other studies. Polytomous choice situations have rarely been analyzed using numerical probabilities in the expectations literature. Our results show that almost all respondents give informative answers to the probabilistic online survey question. Individuals express considerable uncertainty about their future careers, with over 60% attaching positive probabilities to more than one career alternative. The analyses reveal that individuals' numerical expectations have substantial predictive value for their future careers, even after controlling for many variables. This finding confirms that individuals have private information not directly available to researchers, and that eliciting choice probabilities for polytomous choice situations is a viable approach in surveys. However, the mean shares for career alternatives implied by individual probabilities do not fully coincide with actual shares and are more accurate over 4 than over 2 years. The information conveyed in expectations and their deviations from outcomes enables us to derive policy recommendations to increase transitions to nursing.

Can the unemployed be trained to care for the elderly? The effects of subsidized training in elderly care

Demographic change has increased the need for elderly care. Training unemployed workers might be one way to increase the supply of elderly care nurses. This study analyzes the effectiveness of subsidized training for unemployed individuals in the elderly care professions in Germany over 11.5 years. We find that short further training and long retraining courses significantly increase workers' long-term employment. As approximately 25% to 50% of trained nurses have permanent jobs in the care sector, we estimate that approximately 5% of all employed nurses are formerly trained unemployed workers.

Are Recessions Good for Staffing in Nursing Homes?

The quality and cost of care in nursing homes depend critically on the number and types of nurses. Recent research suggests that the nursing supply adjusts to macroeconomic conditions. However, prior work has failed to consider the effect of macroeconomic conditions on demand for nurses through the effect on revenues. We test how county-level unemployment rates affect direct-care staffing rates in nursing homes using California data. We exploit the wide variation in the unemployment rates across counties and over time in 2005-2012. We also test whether there are heterogeneous effects of unemployment rates by facility size, staffing level, and profit status. We find that as unemployment rates increase, staffing by registered nurses (RNs) decreases but staffing by licensed practical nurses (LPNs) increases. The increase in LPNs is larger in large nursing homes, nursing homes with higher staffing levels, and in for-profit nursing homes. We also find that as unemployment rates increase, nursing home revenue decreases. While the effect of macroeconomic conditions on nursing supply may be important for cost and quality of care, the mechanism is not simple, direct, or homogeneous for all types of nurses and nursing homes.

What factors affect physicians' labour supply: Comparing structural discrete choice and reduced-form approaches

Little is known about the response of physicians to changes in compensation: Do increases in compensation increase or decrease labour supply? In this paper, we estimate wage elasticities for physicians. We apply both a structural discrete choice approach and a reduced-form approach to examine how these different approaches affect wage elasticities at the intensive margin. Using uniquely rich data collected from a large sample of general practitioners (GPs) and specialists in Australia, we estimate 3 alternative utility specifications (quadratic, translog, and box-cox utility functions) in the structural approach, as well as a reduced-form specification, separately for men and women. Australian data is particularly suited for this analysis due to a lack of regulation of physicians' fees leading to variation in earnings. All models predict small negative wage elasticities for male and female GPs and specialists passing several sensitivity checks. For this high-income and long-working-hours population, the translog and box-cox utility functions outperform the quadratic utility function. Simulating the effects of 5% and 10% wage increases at the intensive margin slightly reduces the full-time equivalent supply of male GPs, and to a lesser extent of male specialists and female GPs.

Pay or conditions? The role of workplace characteristics in nurses' labor supply

Empirically rigorous studies of nursing labor supply have to date relied on extant secondary data and focused almost exclusively on the role of pay. Yet the conditions under which nurses work and the timing and convenience of the hours they work are also important determinants of labor supply. Where there are national pay structures and pay structures are relatively inflexible, as in nursing in European countries, these factors become more important. One of the principal ways in which employers can improve the relative attractiveness of nursing jobs is by changing these other conditions of employment. This study uses new primary data to estimate an extended model of nursing labor supply. It is the first to explore whether and how measures of non-pecuniary workplace characteristics and observed individual (worker) heterogeneity over non-pecuniary job aspects impact estimates of the elasticity of hours with respect to wages. Our results have implications for the future sustainability of an adequately sized nurse workforce and patient care especially at a time when European healthcare systems are confronted with severe financial pressures that have resulted in squeezes in levels of healthcare funding.

Wage Growth for the Health Care Workforce: Projecting the Affordable Care Act Impact

OBJECTIVE

To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA).

DATA SOURCES

Enrollment data came from three large employers and a sampling of premiums from ehealthinsurance.com. Information on state Medicaid eligibility rules and costs were from the Kaiser Family Foundation. National predictions were based on the MEPS and Medicare Current Beneficiary surveys. Bureau of Labor Statistics data were used to estimate employment.

STUDY DESIGN

We projected health insurance enrollment by plan type using a health plan choice model. Using claims data, we measured the services demanded for each plan choice and year. Projections of labor demand were based on current output/input ratios. Changes in wages resulting from changes in labor demand from 2014 to 2021 were based on labor supply and demand elasticities.

PRINCIPAL FINDINGS

Expenditures required to retain and grow the health care workforce will increase substantially. Wages will increase most for professions with the greatest training requirements (physicians and registered nurses). The largest impact will be felt in 2015.

CONCLUSIONS

Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.

What do nurses and midwives value about their jobs? Results from a discrete choice experiment

OBJECTIVES

To examine nurses' and midwives' preferences for the characteristics of their jobs.

METHODS

A discrete choice experiment of 990 nurses and midwives administered as part of a survey of nurses and midwives in Victoria, Australia.

RESULTS

Autonomy, working hours, and processes to deal with violence and bullying were valued most highly. Nurses and midwives would be willing to forgo 19% and 16% of their annual income for adequate autonomy and adequate processes to deal with violence and bullying, compared to poor autonomy and poor processes for violence and bullying. They would need to be paid an additional 24% to increase their working hours by 10% ($73 per hour). Job characteristics that were less important were shift work, nurse to patient ratios, and public or private sector work.

CONCLUSIONS

Policies to improve retention and job satisfaction of nurses and midwives should initially focus on autonomy, processes to deal with violence and bullying, and reasonable working hours. Further research on the cost-effectiveness of these different policies is needed.