II: The Registered Nurse Population 1980 - 2004

Registered Nurses in the U.S.

The 2004 National Sample Survey of Registered Nurses (NSSRN) provides information about the current population of registered nurses (RNs^[3]) with an active license to practice in one or more of the 50 States and the District of Columbia.  The data in this report focus on the 2,909,357 RNs located in the United States.  RNs are considered to be located in the United States if they were employed in nursing in one of the 50 States and the District of Columbia or, if not employed in nursing, were residents of the United States.  Those RNs with licenses from the United States Territories are not included in this population of RNs from the United States.  This study has been conducted every 4 years since 1980 and examines trends over time in the Nation’s largest health profession.  

The estimated RN population increased by 1,246,975 between November 1980 and March 2004.  In 2004, 2,909,357^[4] persons were estimated to have licenses to practice as RNs in this country, an increase of 75.0 percent since 1980.  From 1992 to 1996, there was a 14.2 percent increase in the RN population.  After a record slow down in growth of the RN population between 1996 and 2000 (5.4 percent), the RN population bounced back to a more robust increase of 7.9 percent between 2000 and 2004. The years between 1996 and 2000 had marked the lowest growth in the RN population over the span of the NSSRN study, increasing only 1.3 percent each year compared with average annual increases of 2-3 percent in earlier years (See Chart 1).  For the past 4 years, the RN population grew just under 2.0 percent per year.

In the last 24 years, the number of RNs employed in nursing increased 90.2 percent (from 1,272,851 in 1980 to 2,421,351 in 2004, with an estimated increase of 219,538 RNs just from 2000 to 2004).  In 2004, 83.2 percent of those with active licenses were employed in nursing, an increase of 1.6 percent from the 2000 estimate of 81.7 percent. The 2004 employment percentage marks the highest employment rate since the start of the study in 1980, eclipsing the previous peak of 82.7 percent in both 1996 and 1992.  From 2000 to 2004, however, the number of RNs employed in nursing grew by an average annual rate of increase of about 2.4 percent.  In contrast, from 1996 to 2000 there was only a 1.0 percent average annual rate of increase in employed RNs.  Larger annual average rates of increases in RN employment rates (3.3 percent), occurred from 1988 to 1996.  From 1984 to 1988, the average annual rate of increase in RN employment rates was 2.3 percent.  From 1980 to 1984, the average annual rate of increase in RN employment rates was the highest, at 3.9 percent.

The total number of RNs employed full-time in nursing nearly doubled from 854,813 to 1,696,807 between 1980 and 2004.  From 2000 to 2004, the percentage of RNs employed full-time in nursing increased by 7.6 percent (or 120,132 RNs), from 1,576,675 to 1,696,807.  This increase represents a significant improvement over the 1996 to 2000 increase of 4.4 percent, the lowest increase over the duration of the study.  However, the 2000 to 2004 increase still falls in lower than the average 4-year rate of increase seen from 1980 through 1996 (15.3 percent).  From 2000 to 2004 there was a 15.2 percent increase in the number of nurses employed part-time (an estimated increase of 95,144 part-time nurses, leading to an overall increase from 28.4 to 29.7 percent in the percentage of employed RNs who work part-time in their principal employment in nursing).

Over the last seven surveys, the numbers, percents, or rates of change of licensed RNs who were not employed in nursing vacillated somewhat across each 4-year period.  The number of RNs not employed in nursing, however, changed little from 1980 to 1992 while the total number of RNs grew substantially over this period.  Between 1992 and 2004, the number of RNs not employed in nursing increased about 26.2 percent, from 386,791 to 488,006.  In 2004, 16.8 percent of all RNs were not employed in nursing, with the number of RNs not employed in nursing decreasing by 1.4 percent from 2000 to 2004.  From a high of 23.4 percent in 1980, this 2004 rate of being not employed in nursing marks the lowest percentage of licensed RNs not employed in nursing since the inception of the study. 

The 2004 finding breaks a pattern over the last two surveys.  While the rates of increase from 1980 to 1988 of those not employed in nursing were low (totaling 4.5 percent), and there was a decrease of 4.7 percent from 1988 to 1992, the rates of increase were much higher from 1992 to 2000.  From 1992 to 1996 the number of RNs not employed in nursing increased by 14.5 percent, and from 1996 to 2000 the number increased 11.7 percent.  All of the survey statistics on nurses who are not in the workforce must be tempered against the unknown numbers who have not renewed their RN licenses for whatever reason and are not being surveyed under the NSSRN sample survey design.  For example, some retired nurses maintain their licenses while others may have chosen not to renew their licenses.

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Educational Preparation

One of the most substantial changes in the RN population over the past nearly quarter century has been in the type of program RNs enter to obtain their initial nursing education.  Between 1980 and 2004, the percentage of nurses who received their initial nursing education in diploma programs decreased from 63.2 percent to 25.2 percent of the RN population (a net decrease of 317,284 nurses).  During the same period, the percentage receiving their initial nursing education in associate degree programs increased from 18.6 percent to 42.2 percent of the RN population (a net increase of 918,640 nurses); and the percentage receiving initial nursing education in baccalaureate programs or higher degree programs increased from 17.4 percent to 31.0 percent of the RN population (a net increase of 613,039 nurses; see Chart 2).

[D]

Between 2000 and 2004, there were similar increases between the percentage of RNs who received their initial nursing education in baccalaureate-and-higher programs (12.6 percent, from 801,811 RNs in 2000 to 902,625 RNs in 2004) and those who received their initial nursing education in associate degree programs (12.8 percent, from 1,087,602 RNs in 2000 to 1,227,256 RNs in 2004).  From 1980 through 1996, the percentage of nurses who received their initial nursing education in associate degree programs increased at a faster rate than those who received their initial education in baccalaureate-and-higher programs.  Between 1996 and 2000, however, there had been a reversal of the trend, when the percentage of nurses educated in baccalaureate-and-higher degree programs increased at a rate faster than those who received their initial nursing education in associate degree programs (increases of 17.3 percent and 12.7 percent respectively).   Meanwhile, the percentage of nurses who received their initial nursing education in diploma programs declined steadily during the period from 1980 to 2004 from 63.2 percent to 25.2 percent (an estimated change from 1,050,661 RNs to 733,377 RNs).  There was an 8.3 percent decline in RNs receiving their initial nursing education in diploma programs from 2000 to 2004 (from 799,354 RNs in 2000 to 733,377 RNs in 2004), the second largest decline in diploma-educated RNs since the inception of the NSSRN.  It follows a decline of 12.2 percent between 1996 and 2000, the largest decline since the inception of the NSSRN.  The number of new RNs prepared in diploma programs from 2000 to 2004 has continued its decline in recent years, now at an average rate of decline of about 2.0 percent per year.

The distribution of RNs according to their highest nursing or nursing-related educational preparation, including any post-RN degree received, also changed substantially over the past 24 years.^[5]  In 1980, the diploma was the highest nursing or nursing-related educational level of the majority of nurses (54.3 percent of all RNs).  Since 1996, nurses with associate and baccalaureate degrees as their highest level of nursing or nursing-related education have had the largest presence among the RN population while the percent of nurses who hold only diploma degrees has continued to drop. While associate degrees have remained the largest entry program into nursing for many years, RNs with baccalaureate, master’s, and doctorate degrees have increased their presence among the nurse population in recent years.  As a result, even though associate degree programs have graduated large numbers of nurses in recent decades from their initial educational programs, the percent of the nurses having associate degrees as their highest level of nursing or nursing-related education decreased slightly since 2000. 

In 2004, 33.7 percent of nurses (981,238 RNs) reported the associate degree as their highest level of nursing or nursing-related education, 34.2 (994,276) percent reported the baccalaureate degree as their highest level and 13.0 percent (376,901) reported a master’s or doctoral degree as their highest level (see Chart 3).  Only 17.5 percent of RNs (510,209) reported that the diploma degree was their highest nursing or nursing-related education.  From 2000 to 2004, the percentage of RNs with associate degrees as their highest nursing or nursing-related education level decreased slightly, from 34.3 percent to 33.7 percent (although the number of RNs increased from 925,516 in 2000 to 981,238 in 2004).  The numbers of nurses whose highest education was the associate degree has increased by 232 percent since 1980 from 295,318.  From 2000 to 2004, the percentage of RNs whose highest nursing or nursing-related educational preparation was a baccalaureate degree increased from 32.7 percent to 34.2 percent (the number increased from 880,997 in 2000 to 994,276 in 2004).  Overall, this is a 170 percent increase in baccalaureate education for RNs since 367,816 RNs in 1980.  Many RNs initially educated in associate degree programs eventually receive their baccalaureate degree.  In 2004, nearly 21 percent (20.9 percent) of RNs initially educated in associate degree programs received baccalaureate degrees and higher. This estimate represents an increase from 2000, when 15.5 percent of RNs initially educated in associate degree programs received baccalaureate degrees or higher.  In 1996, 16.4 percent of RNs initially prepared in associate degree programs received baccalaureate degrees or higher, an increase from 11.8 percent of RNs initially prepared in associate degree programs in  1988 and 10.3 percent in 1984.  In 1980, only 8.8 percent of RNs initially prepared in associate degree programs eventually received a higher degree.

The highest increase from 2000 to 2004 was for the number of RNs receiving nursing or nursing-related master’s or doctorate degrees (an estimated increase of 101,833 or 37.0 percent) compared to a decrease of 91,495 nurses or 15.2 percent in the number of RNs whose highest nursing or nursing-related degree was a diploma. Over the entire period from 1980 to 2004, there was a 43.5 percent decrease (an estimated change from 903,131 to 510,209) in the number whose highest level of nursing or nursing-related education was a diploma, while the number whose highest level of nursing or nursing-related education was a master’s or doctorate increased by 339 percent (from 85,860 to 377,046). Similarly, from 1980 to 2004 the estimated number of RNs whose highest nursing or nursing-related educational preparation was a baccalaureate increased by 170 percent (from 367,816 to 994,276) and the estimated number whose highest nursing or nursing-related preparation was an associate’s degree increased by 232 percent (from 295,318 to 981,238).

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The number of RNs whose highest level of nursing or nursing-related educational preparation was either a master’s or a doctorate degree has more than quadrupled since the inception of the NSSRN.   In November 1980, RNs with nursing or nursing-related master’s or doctorate degrees were estimated at 85,860, while in 2004, they numbered 376,901, an increase of 339 percent.  Therefore, the proportion of RNs with master’s or doctorate degrees has more than doubled from 5.2 percent of the RN population in 1980 to 13.0 percent of the RN population in 2004.  The number of master’s and doctorally-prepared nurses has also grown dramatically since 2000, increasing by 101,833 RNs from 275,068, when it was 10.2 percent of the RN population.  This change represents an unprecedented 37 percent increase in master’s and doctorally prepared nurses over the past 4 years.   

Age

The average age of the RN population continued to climb, increasing to 46.8 years of age in 2004, compared to 45.2 years in 2000, and 44.3 years in 1996.

In 1980, the majority (52.9 percent) of the RN population was under the age of 40, while in 2004 just above one quarter (26.3 percent) were under the age of 40 (See Chart 4).  The major drop was among those under the age of 35.  In 1980, 40.5 percent of RNs were under the age of 35 compared to just 16.4 percent in 2004.  Similarly, in 1980, 25.1 percent of RNs (418,331) were under the age of 30, compared to only 8.0 percent of RNs (233,437) in 2004. The 2004 figure reflects a 4.0 percent decrease from the 243,239 younger RNs estimated under the age of 30 in 2000 (9.0 percent of all RNs).  Meanwhile, the percent of nurses over 54 years of age increased to 25.2 percent in 2004, compared to 20.3 percent in 2000 and 16.9 percent in 1980.

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Gender

Men still comprise a very small percentage (5.8 percent) of the total RN population although their numbers have continued to grow.  Of the estimated 2,909,357 RNs in the US, 168,181 are men.  This represents a 14.5 percent increase over the 2000 NSSRN estimate, when 146,902 RNs were male.  This also represents a 273.2 percent increase over 1980, when the number of men in the RN population was estimated at 45,060. 

Racial/Ethnic Background

Comparisons of the racial/ethnic composition of the RN population in 2004 with previous years should be interpreted with caution.  In accordance with Office of Management and Budget (OMB) guidelines issued in 1999, the question regarding racial and ethnic background changed in 2000.  Unlike earlier NSSRN surveys, which included a single question and asked the respondent to choose only one racial/ethnic background, the 2000 and 2004 surveys collected this information in two questions.  Respondents were asked to indicate whether their ethnic background was either Hispanic or Latino or not; they were also asked to identify all races that described them.  The survey information was aggregated into categories similar to those reported in previous years, with one additional category that delineates Hispanic and non-Hispanic RNs who reported two or more races.  In 2004, the number of nurses in the two or more races, non-Hispanic category, was estimated to be 41,244 or 1.4 percent of the RN population.   In 2004, 7.5 percent of RNs (217,651) did not specify their combined racial/ethnic background, while in 2000 only 1.1 percent of RNs did not specify their combined racial/ethnic background.^[6]

The number of nurses identifying their combined racial/ethnic background as one or more non-white groups, Hispanic, or Latino numbered 311,177 (10.7 percent) in 2004.  This change is a decrease of 22,190 RNs from 2000, but nearly triple the number of non-white, Hispanic, or Latino nurses in 1980 (See Chart 5).  In 2000, 12.4 percent of all RNs (333,368) came from one or more of the identified racial and ethnic non-white, Hispanic, or Latino groups.  It must be noted that this apparent decline may be a result of an increase in the proportion of RNs who did not completely specify their combined racial or ethnic background.^[7].

In the past, non-White, Hispanic, or Latino RNs have grown at a greater rate than white, non-Hispanic RNs for all of the years from 1980-2000, except the period from 1984-1988.  These growth rates were particularly pronounced between 1996 and 2000, when the number of non-white, Hispanic, or Latino RNs increased about 35.3 percent while the number of white, non-Hispanic RNs increased by 1.7 percent.   Most of the increase in the RN population between 1996 and 2000 was a result of the growth in the non-white or Hispanic or Latino nurse population (which increased by 87,003 RNs).  However, because the population of white, non-Hispanic nurses is almost 7 times larger than the population of non-white, Hispanic, or Latino nurses, even small percentage changes in the non-white, Hispanic, or Latino nurse population involve a much larger volume of nurses, and masks the growing presence of non-White, Hispanic, or Latino RNs in the population.

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The racial and ethnic groups comprising the non-white or Hispanic or Latino RN population differ in the rates at which their numbers have increased over the past 24 years. The number of nurses from non-Hispanic Asian or Other Pacific Islander backgrounds showed the highest relative increase at 167.8 percent from 33,600 RNs in 1980 to 89,977 RNs in 2004. The number of Hispanic or Latino RNs increased by 203.8 percent, from 20,816 in 1980 to 63,240 in 2004 (including 15,231 who failed to specify any race in 2004).  The number of RNs reporting American Indian or Alaska Native non-Hispanic backgrounds increased by 122.5 percent from 4,249 in 1980 to 9,453 in 2004.  The increase for Black or African American non-Hispanic RNs over the same period is an estimated 101.3 percent (from 60,845 in 1980 to 122,495 in 2004).  Note that despite the impressive growth rates, the actual numbers of non-white, Hispanic, or Latino nurses remain relatively small. 

The representation of identified non-White, Hispanic, or Latino nurses among the total nurse population increased from 7.2 percent in 1980 to at least 12.2 percent in 2004, after accounting for those who gave responses in 2004 where either the provided race or ethnicity indicated a minority.  Despite these increases, the diversity of the RN population remains far less than that of the general United States population, where 32.6 percent of the United States population identified themselves as non-White, Hispanic, or Latino in 2004^[8] (see Chart 6).

[D]

Hispanic or Latino RNs still remain the most underrepresented group of nurses when compared with the representation in the United States population.  After adjusting for those Hispanic or Latino RNs who provided no response to the question on race, only 2.2 percent of the RN population are Hispanic or Latino nurses, although Hispanics or Latinos comprise 14.1 percent of the general population.  Note however, that of the 7.5 percent of respondents who did not specify one or both of race and ethnicity, 6.4 percent of respondents were of unknown ethnicity in 2004.

Family Status

In 2004, 70.5 percent of all RNs were married; 18.1 percent were widowed, divorced or separated; and 9.2 percent were never married.  Roughly 42.5 percent of all RNs had children under the age of 18 living in the household, including 14.8 percent who had children less than 6 years of age living in the household.  Over half of all RNs, 54.5 percent, had no children under the age of 18 living in the household.  The remaining 3.1 percent did not report any information on the presence of children in the household (see Appendix A, Table 6). 

Nearly 16 percent (15.9) of all RNs were caring for other adults in their home, and 15.5 percent were caring for other adults living elsewhere (see Appendix A, Table 7). The majority (52.1 percent) of RNs have children and/or other adults at home. Of these RNs and allowing for multiple responses, 28.3 percent have children under age 6 at home, 65.2 percent have children of ages 6 to 18 at home, and 30.6 percent have other adults at home. An additional 14.8 percent of these nurses caring for others at home also have other dependents who do not live at home.

Employment Settings

Substantial changes in the health care delivery system over the past two decades have had major effects on the settings in which nurses are employed.  Five major employment settings were identified for RNs: hospitals, nursing homes and extended care facilities, community and public health settings, nursing and other health education, and ambulatory care settings. Community and public health settings include: State and local health departments, visiting nursing services and other health agencies, community health centers, student health services, occupational services and school health.  These settings continue to be the major employment settings for nurses, although there have been substantial shifts in the mix since 1980 (see Chart 7).  Every NSSRN survey since 1980 has revised the questionnaire and expanded the choices available to nurse respondents for identifying the types of facilities, institutions and service delivery systems in which they were employed. Despite these data collection changes, major employment sectors are sufficiently distinct to allow adjustments in the data in order to analyze trends in the employment settings of nurses over the past 24 years. 

Results from the 2004 survey indicate a slight trend away from the hospital as the setting for the principal nursing position, although changes in the structure of hospitals (e.g., more specialty outpatient clinics) may explain some of the change.  Hospitals remain the major employer of nurses, although the number of nurses employed in other sectors has increased (see Chart 7).  Although the estimated number of RNs whose principal position was in hospitals was greater than in 2000, the percentage of RNs working in hospitals decreased from 2000 to 2004. In March 2004, out of an estimated 2,421,351 RNs employed in nursing, 56.2 percent (1,360,847) worked in hospital settings compared to 59.1 percent (1,300,323) in March 2000.  The number of RNs employed in hospitals increased by over one-half million (525,200) between 1980 and 2004.  However, the proportion of the nurse workforce employed in hospitals, after a peak of 68.1 percent in 1984, has declined steadily to its current low of 56.2 percent of employed RNs.  This percentage decline reflects the growth in nurse employment opportunities in other sectors.

In 1980, 65.6 percent of employed RNs worked in hospitals.  From 1980 through 1992, the percentage of nurses employed in hospitals remained relatively stable, ranging only 2.5 percentage points over a 12-year period (65.6 in 1980, 68.1 in 1984, 67.9 in 1988, and 66.5 in 1992).  However, since 1992, there has been a significant drop in the percentage of hospital based RNs, declining to 56.2 percent in 2004.  The 2.9 percent drop from 2000 to 2004 is the second largest, second only to the 6.4 percent drop from 1992 to 1996.

In contrast, the percent of RNs reporting their principal nursing position in other types of settings, particularly ambulatory care, increased from 2000 to 2004.  In 2004, 11.5 percent of RNs were estimated to be employed in ambulatory care settings, including physician-based practices, nurse-based practices, and health maintenance organizations, compared to 9.5 percent in 2000.

Community and public health settings remained the next largest type of predominant employment for RNs; but the percent of RNs employed in these settings also decreased, from an estimated 18.3 percent of RNs reporting public or community health settings in 2000 to 14.9 percent in March 2004. (For the purpose of these comparisons, both school health services and occupational health settings have been added to traditional community/public health settings.)  The percent of RNs reporting nursing homes and extended care facilities as their principal setting remained relatively constant between 2000 (6.9 percent) and 2004 (6.3 percent).

The remaining RNs employed in nursing reported working in such settings as nursing education, Federal administrative agencies, State boards of nursing or other health associations, health planning agencies, prisons/jails, insurance companies, and other miscellaneous settings such as pharmaceutical and durable medical equipment companies (Chart 7). It appears likely that the number and percent of nurses employed in these “other” settings may continue to increase given changes in health care delivery.

Public and community health, ambulatory care, and other non-institutional settings have historically had the largest increases in RN employment.  Between 1980 and 2004, RNs employed in ambulatory care settings increased by 168.7 percent (from 103,362 to 277,774) while those employed in public health and community health settings increased by 128.8 percent (from 157,504 to 360,380; see Chart 8).

The number of nurses employed in nursing education has changed little since 1980.  This, coupled with an increase in the total number of nurses, has led to a decline in the overall percent of RNs employed as nurse educators.  In 1980, 47,507 RNs (3.7 percent of all RNs employed in nursing) were in nursing education settings of RN, LPN/LVN, or nursing aide programs.  In 2004, the number of RNs employed in these same nursing education settings had increased to 57,897 (or 2.4 percent of all RNs employed in nursing).  The number of nurses employed in nursing homes has increased by 51,963 (or 51.3 percent) since 1980, although the numbers and the percentage of nurses employed in nursing homes and other extended care facilities remained essentially the same between 2000 (152,894) and 2004 (153,172), an increase of 278 RNs.  In percentage terms, the share among all RNs dropped from 5.7 percent compared to 5.3 percent, with a drop in its share among employment settings from 6.9 percent to 6.3 percent).

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[D]

Long-Term Trends in Average Salaries/Earnings

Changes in overall average earnings^[9] for RNs between November 1980 and March 2004 are shown using two separate measures.  The first measure is the “actual” average earnings reported by RNs employed full-time, and the second measure uses the consumer price index (CPI) for urban consumers to adjust for the changes in the purchasing power of the dollar against the actual earnings of full-time employment for obtaining “real” average earnings^[10].  In examining the extent to which average RN earnings have increased over the years, and the related economic demand for RNs, it is important to consider how earnings have increased during times of relatively high inflation as well as during times of relative stability in the cost of living.  It is important to note, though, that inflation is only one of the factors influencing the size of increases in RN earnings over time.

The average actual annual earnings of RNs employed full-time in March 2004 was $57,785, reflecting a 23.5 percent actual earnings increase since March 2000 (See Chart 9).  However, it should be noted that there was a change in the context of the question from 2000 to 2004. In 2000, the question asked for income in the year 2000, requiring the RN to estimate income or report for the previous year.  In 2004, the question did not ask for income in a specific year, only for annual income.  In spite of this wording change, this increase in income is substantially higher than the 11.2 percent actual earnings increase between 1996 and 2000 and the 11.5 percent actual earnings increase between 1992 and 1996.  The highest increases in actual annual earnings (35.1 percent) were experienced during the period from 1980 to 1984, with the second highest increase of 33.0 percent increase in average earnings coming between 1988 and 1992.  These were times of relatively high increases in the cost of living, as well as periods when nurses were being actively sought for employment.  For example, there were substantial increases in the supply of RNs in the workforce from 1977 to 1984 and a perceived nursing shortage from 1988 to 1992.

The real increase in earnings is determined by adjusting the actual earnings by changes in the CPI.   Obtaining the trends over time in ‘real’ increases in RN earnings is possible after accounting for the changes in purchasing power of the dollar from the reported earnings found in each respective NSSRN.  In the comparisons over time, 1980 is the starting point of the time frame for analysis of real versus actual earnings.  Thus, it is modeled here that, in 1980, real and actual earnings are assumed to be equal (i.e., the 1980 relative Consumer Product Index (CPI) = 100). 

From 2000 to 2004, the CPI increase was 9.5 percent.  As such, the actual adjusted increase, or real earnings increase, for this period was 14.0 percent (23.5 percent actual increase, less the 9.5 percent CPI).   The 14.0 percent increase in real earnings for 2000 to 2004 is the largest since the inception of the NSSRN.  Comparatively, the 1996 to 2000 actual earnings increase of 11.2 percent and the 1992 to 1996 actual earnings increase of 11.5 percent can be almost completely attributed to the corresponding 10 percent change in the CPI over each of those 4-year periods. Between 1988 and 1992, RNs experienced a real earnings increase of 11.2 percent and a similar real earnings increase between 1980 and 1984 of 9.7 percent.  As in the past, these increased earnings have occurred during periods when the supply of employed nurses increased substantially.  This pattern signals the existence of significant economic demand for RNs over this period.  Note that any changes in earnings since March 2004 are not reflected.

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