Millions of dollars in state funds, competitive salaries and numerous job opportunities haven't been enough to overcome California's nursing shortage.

California ranks last when it comes to having enough nurses to care for its population, according to the California Hospital Association. In the Inland area, the ratio is lower, with 18,000 registered nurses for an estimated 4 million people.
Two years ago, more than 2,500 nurses rallied outside the Capitol and blasted Gov. Schwarzenegger. They criticized him for an emergency order delaying requirements that hospitals reduce the number of patients cared for by nurses.
Since then, the state has taken some steps, but the nursing shortage remains.
Nursing school graduation rates have climbed to about 6,600 a year from around 5,175 from a couple of years ago. However, that's less than the state's annual shortage that averages about 9,900 due to the aging population, retiring nurses and lack of enough faculty and spots in nursing schools.
Nursing advocates and hospital officials say that sign-on recruitment bonuses don't work. They often create staff morale problems and job turnover, which increases hospital training costs.
The state still won't have the projected 116,000 nurses needed by 2020 to care for the population, which is expected to grow as baby boomers, including nurses, retire. The average age of a California nurse is 48. Nationally, the average age is 43.
The $90 million Schwarzenegger promised for nursing programs last year will eliminate 25 percent of the state's nursing shortage in four years, according to the governor.
"Overall, the nursing shortage in Southern California persists and is quite significant in all of California," said Doug Bagley, chief executive of Riverside County Regional Medical Center. "It seems to be especially prevalent in the Inland area. We'd probably hire 100 nurses if we could."
He and others say the Inland area's growth has made openings tough to fill.
"I have seen more progress and more positive activity in this past year and a half than I have seen in decades," said Deloras Jones, executive director of the California Institute for Nursing and Health Care. "But, we've just begun to scratch the surface. The state has to come up with a way to deal with this over the long term."
Jones, Kaiser Permanente's former director of divisional nursing services for California, founded the institute in 2002 to find ways to solve the problem. The institute is preparing to study nursing education and how to better prepare graduates for work, thus reducing turnover, Jones said. She expects the report to be completed in about a year.
State Assistance
In 2005, Schwarzenegger pledged $90 million in federal, state and private fundsover five years toward nursing education and recruitment. Almost $43 million was budgeted to expand nursing school programs, plus boost efforts to retain nurses during the 2005-06 budget year. Schwarzenegger has said his plan will reduce the state's projected shortage by 25 percent within four years.
"Essentially, during the first year, the (initiative) was laying its foundation," said Jehan Flagg, spokeswoman for California's Labor and Workforce Development Agency. "You're not going to see that affecting the bottom line until we get graduating nurses."
Flagg said it's unclear whether the nursing shortage issue will re-emerge during the legislative session, which began last week. Most discussion has revolved around ways to provide health insurance for the state's 6.5 million people without coverage. The governor is expected to unveil his health care proposals next week.
Donna Gerber, the California Nurses Association's government relations director, said Schwarzenegger's initiative won't work because it involves one-time, $30 million federal grant money that requires raising a matching $30 million from community colleges and $30 million from private health-care groups.
"You're not going to expand based on that iffy money," she said. "It has to be ongoing money."
Though Gerber's association, which represents more than 65,000 registered nurses, persuaded lawmakers last year to budget almost $10 million for nursing education, she said the legislature must commit to spending that money each year. Such funding could add about 1,125 nursing school slots per year.
The state has never had enough slots to educate all the nurses it needs, Gerber said. It has relied on nurses from other states and countries to fill the gaps, she said.
"These are all good middle-class jobs," Gerber said. "It makes a lot of sense for California to invest in these kinds of jobs.
Statewide, nurses earn between $50,000 and $85,600 annually, according to a report last year by the Hospital Association of Southern California. Nurses with four-year college degrees can earn $90,000 with bonuses, overtime and shift differentials.
Hired Before Graduation
At least half of Riverside Community College's 73 nursing program graduates already accepted jobs before they stood before cheering friends, relatives and instructors in December to receive their certificates.
During the ceremony, Nursing School Dean and Director Sandra Baker announced the graduates could go almost anywhere and immediately earn more than $50,000 annually. That's more than Riverside County's 2003 median household income of $45,135, according to U.S Census Bureau data.
Meanwhile, nursing schools still reject thousands of applicants every year because they don't have the faculty to meet the demand.
"That is really significant," said Baker, who receives about 700 qualified applicants for 180 slots. "Fifty-five to 56 is the average age for nurse faculty. (Retirements) will become a tremendous issue."
More attention needs to be paid to reducing nurse turnover and improving hospital working conditions, said Joyce Mills, program development director of the California Nursing Foundation. The nonprofit organization focuses on the nursing profession.
High Turnover Rate
Hospitals statewide once offered car leases and home closing cost payments or signing bonuses to recruit new nurses in exchange for multiyear contracts. The recruits would fulfill their commitments and then leave for other offers.
Signing bonuses "created a lot of unrest in my unit," said Pat Chambers of Southern California's Nurse Leadership Council. "The nurses who took them were not well-received. They created a morale issue with the veteran nurses."
The California Institute for Nursing and Health Care and Hospital Association of Southern California studied turnover among nurses last year and found that 39 percent of new Inland nurses leave their jobs at hospitals after six months.
Hospitals may spend at least $102,000 to hire and train a new nurse, Mills said.
"It doesn't do any good to spend money on all these extra slots," Mills said. "You have all these new nurses leaving in the first six months or a year. You're always hiring and training new nurses. That's where the extra cost comes in."
Some nursing schools are using hospital facilities and staff to teach students and boost enrollments. In exchange, students sign multiyear contracts to work at those hospitals after graduation.
In a $4 million, four-year deal, Cal State San Bernardino doubled its annual nursing school enrollment to 160 by sending half its students to Riverside Community Hospital for training. In exchange, the nursing students sign three-year contracts.
Cal State's nursing program recently accepted Máame Donkorh. The 21-year-old Fontana resident said she spent about $1,000 to apply to every nursing school in the state. Cal State's arrangement with Riverside Community Hospital improved her chances for acceptance, Donkorh said.
"It was an opportunity I never would have had," she said. "I didn't have any second thoughts about (signing a contract) at all."
Mentor Study
St. Bernardine Medical Center in San Bernardino is one of seven hospitals across the state that is part of a three-year mentor study organized by the state nursing foundation. Veteran nurses work with new nurses to help them adjust to their jobs and set goals. The veterans earn an extra $30 per hour during mentor activities.
Researchers have found that new nurses who do not have mentors are seven times more likely to leave hospitals than those who do have mentors, according to preliminary reports.
St. Bernardine nurse Katrina Williams said her mentor helped her gain confidence and better prepared her for work in the intensive care unit. Williams, who graduated from nursing school in 2005, started in that unit, but left it after three months because she said she felt unprepared. She then was invited to join the hospital's mentor program.
"You know what to do, but you don't trust your instincts," said Williams, who returned to ICU in August. "My mentor helped me feel way more comfortable. She was more there for support."
Chambers said nurse mentor programs could become inexpensive ways to keep nurses if hospital administrators find ways to implement them.
"In hospitals, nurses are very busy," she said. "The idea of someone asking a lot of questions can be very draining. Hospitals need to support nurses doing something else in the hospital other than work with patients."