Chapter III: The Registered Nurse Population 2004
As of March 2004, an estimated 2,915,309 individuals
had current licenses to practice as registered
nurses (RNs) in the United States. Approximately
2,909,357 of these RNs lived and worked in the
United States. This estimate represents an increase
of 7.9 percent, or 212,817 above the 2,696,540
estimated number of RNs living and working in
the United States in the year 2000. Though
this change is greater than the 5.4 percent increase
seen across the last survey years (1996 to 2000)
it is one of the lowest increases since the inception
of the NSSRN. By comparison, the highest
increase in the RN population was experienced
between 1992 and 1996 when the total number of
RNs increased by an estimated 14.2 percent or
319,058 (from 2,239,816 to 2,558,874). The number
of RNs working outside the United States declined
from 18,131 RNs in 2000 to 5,952 RNs in 2004.
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. Of the 2,909,357 RNs located in
this country, 83.2 percent or 2,421,351 were employed
in nursing (see Appendix A, Table 1). This estimate
of the number employed in nursing is an increase
of 219,538 RNs (10.0 percent) over the estimated
2,201,813 RNs employed in nursing in 2000.
Age
The aging of the RN workforce in the United States
has continued. As of 2004, the average age of
the total RN population (including those who are
retired and not employed in nursing) was estimated
to be 46.8 years. This is the highest average
age since the inception of the survey, more than
1 year older than the average age estimated in
2000 (45.2 years) and more than 2 years older
than the average age estimate in 1996 (44.3 years).
The aging RN workforce reflects fewer young nurses
entering the RN population, large cohorts of the
RN population moving into their 50s and 60s, and
older graduates from initial nursing education
programs entering the RN population. In 2004,
only 8.0 percent of the RN population was under
the age of 30, a decrease from 9.0 percent in
2000 and 25.1 percent in 1980. At the same time,
in 2004, 41.1 percent of RNs were 50 years of
age or older, a dramatic increase from 33.0 percent
in 2000 and 25.1 percent in 1980 (see Appendix A, Table 1). The increase in the number of older
nurses who returned to the workforce in response
to the higher salaries and reported shortages
may have contributed to the trend.
The average age at graduation for recent RN graduates
appears to be slightly lower than in 2000. The
average age at graduation for RNs during the 5
years prior to the survey was 29.6 years for the
2004 survey compared to 30.9 years in the 2000
survey; however, RNs who graduated between 1995
and 1999 in the 2004 survey were 31.0 years of
age at graduation. In 2004, the average age of
nurses who graduated from initial nursing education
in 1984 or earlier was 23.8 years (see Appendix A, Table 2 for statistics on age at graduation);
this is similar to the 23.9 years average age
at graduation in 2000.
When the distribution of age at graduation is
observed by age groups, the indication that graduates
from initial education programs in more recent
years are younger becomes clearer. In the 2004
survey, 39.4 percent of those graduating between
2000 and 2004 were under 25 compared to 30.9 percent
of RNs under age 25 who completed their initial
education between 1990 and 1999. Complementing
this increase in younger graduates, 29.7 percent
of nurses who completed their initial education
between 1990 and 1999 were in the 35 to 49 age
interval, while only 21.0 percent of RNs completing
their initial education programs between 2000
and 2004 were in the 35 to 49 year age interval.
The average age of RNs at graduation from initial
nursing education also varied by type of program.
Graduates of diploma and associate degree programs
in 2000 or later were the same age (31.8 years)
and were older than graduates of bachelor’s degree
or higher programs (26.3 years) during this time
period. In other graduation years, graduates of
associate degree programs were older than all
other graduates. Across survey years, the age
of diploma graduates has steadily been increasing
across graduation cohorts. Baccalaureate degree
recipients graduating after 1989 were the youngest
(see Chart 10). However, the average age at graduation
is lower since 2000 among recent graduates of
associate degree and bachelor’s degree programs
(declining by 1.5 years and 1.2 years respectively,
compared to those who graduated during the 1990s
(see Appendix A, Table 2).
[D]
Gender
Men still comprise a very small percentage of
the total number of RNs living and working in
the United States, although their numbers have
continued to grow. In 2000, 146,902 or 5.4 percent
of RNs were men. In 2004, 5.8 percent (168,181
RNs) were male (see Appendix A, Table 1).
Male RNs are more likely to be younger than female
RNs, with 30.1 percent of male RNs under the age
of 40 compared to 26.1 percent of female RNs,
and 65.7 percent of male RNs under the age of
50 compared to 57.4 percent of female RNs. The
average age for male RNs was 44.6 compared to
female RNs at 47.0 years of age. Male RNs are
more likely to be employed in nursing (88.4 percent)
compared to female RNs (82.9 percent).
Male and female RNs also differ with respect
to the type of program in which they received
their initial nursing education. Male and female
RNs differ in the proportions graduating with
either a diploma or an associate degree, with
males more often receiving an associate’s degree
than a diploma. Approximately 13.5 percent of
male RNs graduated from diploma programs, compared
with 25.9 percent of female RNs; and 52.0 percent
of male RNs graduated from associate degree programs,
compared with 41.6 percent of female RNs.
[D]
When the highest nursing or nursing-related educational
preparation is considered, a similar pattern emerges
with respect to education below the baccalaureate
degree. Females were nearly twice as likely as
compared to males to list a diploma as their highest
nursing or nursing-related educational preparation
(18.0 percent compared to 9.2 percent). Conversely,
42.6 percent of males listed an associate degree
as the highest-related educational preparation,
compared to 33.2 percent of female RNs. However,
more female RNs had baccalaureate degrees (34.3
percent) than male RNs (31.6 percent). The percent
of male and female RNs completing master’s or
doctoral programs as their highest nursing or
nursing-related education were similar, 13.7 percent
and 12.9 percent, respectively (see Chart 11).
Racial/Ethnic
Background
As explained in Chapter II, due to a change in
definitions, caution should be used when comparing
the racial/ethnic composition of the RN population
to surveys prior to 2000. In accordance with
the Office of Management and Budget (OMB), the
question regarding racial and ethnic background
in the March 2000 survey was changed from the
previous surveys. In 2004, as in 2000, nurses
were asked to identify their ethnic background
and then asked to identify all races that could
best describe them. The information was aggregated
to categories similar to those reported in previous
years, with one additional grouping of two or
more races, non-Hispanic. The 2004 and 2000 estimates
for these RNs were relatively unchanged (1.4 percent
and 1.2 percent, respectively). In surveys prior
to 2000, nurses had to choose from one of the
racial/ethnic categories presented and could not
designate multiple races.
In 2004, 10.7 percent (311,177) of all RNs identified
themselves as a racial or ethnic minority in their
responses to both the questions on race and ethnicity.
However, 354,475 RNs (an additional 43,298, or
about 1.5 percent of all RNs) identified themselves
in 2004 as a racial or ethnic minority (see Footnote
6), even if their responses were incomplete through
missing race or ethnicity information. In 2000,
12.4 percent of the RN population (333,368) was
estimated to be members of minority groups. This
apparent percentage decline, even after the adjustment
for minority respondents who did not provide complete
race/ethnicity information, is slight and should
be seen in light of the apparent absolute increase
in minority RNs. In 2004, 7.5 percent of RNs
were of unspecified racial or ethnic background;
in 2000, only 1.1 percent of RNs were of unspecified
racial or ethnic background. Of the 217,651 RNs
in 2004 with missing values for race or ethnicity,
27.0 percent (58,859 RNs) did not specify either
race or ethnicity, 13.9 percent (30,147 RNs) specified
ethnicity but not race, and 52.1 percent (128,645
RNs) specified race but not ethnicity. This increase
in missing information, and the concurrent decrease
in minority RNs who specified both race and ethnic
demographic information, may in part reflect a
change in the data retrieval practices for missing
variables.[11]
Of the RN population who specified both race
and ethnicity background, 4.2 percent (122,495)
were Black or African American (non-Hispanic);
3.1 percent (89,976) were Asian, Native Hawaiian,
or Other Pacific Islander (non-Hispanic); 1.7
percent (48,009) were Hispanic or Latino, with
any race specified; and 0.3 percent (9,453) were
American Indian or Alaska Native (non-Hispanic).
An estimated 1.4 percent (41,244) reported that
they were two or more races and non-Hispanic (see Appendix A, Table 1).
These minority distributions in the RN population
contrast with the minority distribution of the
general United States population. In the United
States population for 2004, 12.2 percent were
Black or African American (non-Hispanic), 4.1
percent were Asian, Native Hawaiian, or Other
Pacific Islander (non-Hispanic), 13.7 percent
were Hispanic or Latino with any race specified,
0.7 percent were American Indian or Alaska Native
(non-Hispanic), and 1.3 percent were of two or
more races (non-Hispanic).[12]
Similar to the 2000 survey, minority RNs were
on average younger than white, non-Hispanic RNs
(45.5 years of age on average versus 47.1 for
White, non-Hispanic RNs). Asian, Native Hawaiian,
or Other Pacific Islander RNs were the youngest,
at 43.9 years of age, followed by Hispanic or
Latino RNs at 44.1 years of age on average. Black
or African American, non-Hispanic RNs were on
average the oldest, at 47.2 years of age.
RNs from minority backgrounds were more likely
than non-minority nurses to be employed in nursing
and to work full-time. Nearly 88 percent of non-Hispanic
minority nurses and 88.0 percent of Hispanic or
Latino nurses were employed in nursing, compared
with 82.6 percent of White, non-Hispanic nurses.
Minority nurses employed in nursing were also
more likely than non-minority nurses to be employed
full-time. The percentage of employed RNs working
full-time ranged from 75.2 percent for Hispanic
or Latino RNs to 81.2 percent for non-Hispanic
minority RNs. In comparison, 68.5 percent of
employed non-Hispanic White RNs worked full-time.
Most RNs in each racial/ethnic group received
their initial nursing education in associate degree
programs, with the exception of RNs from Asian,
Native Hawaiian, or Other Pacific Islander, non-Hispanic
(19.0 percent) backgrounds. RNs from American
Indian or Alaska Native, non-Hispanic backgrounds
were the most likely to receive their initial
nursing education in associate degree programs
(60.8 percent) followed by multi-racial RNs (55.1
percent), Hispanic or Latino RNs (54.5 percent),
Black or African American non-Hispanic RNs (48.7
percent) and white non-Hispanic RNs (42.4 percent).
White, non-Hispanic nurses were more likely than
other nurses to have received their initial nursing
education in diploma programs. Twenty-seven percent
(26.9 percent) of white, non-Hispanic nurses were
prepared for RN licensure in diploma programs
compared with 14.7 percent of Hispanic or Latino
RNs and 17.8 percent of nurses who were non-White
non-Hispanic. The majority (64.0 percent) of
RNs from Asian, Native Hawaiian, or Other Pacific
Islander, non-Hispanic backgrounds received their
initial nursing education in baccalaureate programs.
It should be recognized, however, that most Philippine-trained
nurses had baccalaureate education as their initial
nursing preparation.
Chart 12 illustrates how racial/ethnic groups
compare in terms of highest nursing or nursing-related
educational preparation. White (non-Hispanic)
RNs were most likely to have a diploma as the
highest educational preparation (18.9 percent).
Asian, Native Hawaiian, or Other Pacific Islanders
(non-Hispanic), as well as Black or African American
(non-Hispanic) RNs were more likely than either
Hispanic, Latino, or White (non-Hispanic) RNs
to attain at least baccalaureate preparation.
Black or African American, non-Hispanic (14.2
percent) and White, non-Hispanic nurses (13.2
percent) were the racial/ethnic groups with the
highest percentages of master’s and doctoral degrees.
[D]
Education and Employment Prior to Initial Nursing Education
Individuals come to nursing through various career
paths, and a significant number choose nursing
after employment in other health-related fields
or after receiving other post high school academic
degrees. In 2004, about 1,512,259 (52.0 percent)
of all RNs had worked in other health-related
occupations prior to attending their initial nursing
education (see Appendix A, Table 3). This estimate
is an increase from 2000, when 37.3 percent of
RNs followed the same path, although a change
in question wording can account for this marked
increase. In 2000 the questionnaire asked for
the respondent’s employment status immediately
prior to beginning initial nursing education,
while the 2004 questionnaire asked for employment
status at any time prior to beginning initial
nursing education. In 2004, the majority of these
nurses who had previously worked did so as nurse
aides (974,764 RNs or 64.5 percent), Licensed
Practical Nurses/Licensed Vocational Nurses (LPN/LVNs;
364,527 RNs or 24.1 percent) or as clerks in health
care settings (208,337 RNs or 13.8 percent).
The majority of RNs who were employed before entering
an initial nursing education program tended to
enroll in associate degree programs (797,925 RNs
or 52.8 percent) to prepare for RN licensure.
In addition, 29.9 percent of RNs (451,499 RNs)
who were employed in a health occupation prior
to their initial nursing education received their
education in baccalaureate-or-higher degree programs.
While 484,809 RNs were estimated as ever being
licensed as an LPN/LVN, 120,282 were NOT employed
as LPN/LVNs prior to starting their initial RN
preparation program. Some of these 120,282 may
have obtained RN licenses during the period of
initial RN education for related employment purposes.
In total, there were 364,527 RNs who were employed
as LPNs/LVNs prior to beginning their initial
nursing education. The majority of all RNs who
were once employed as LPN/LVNs (80.2 percent or
292,365 RNs) reported an associate’s degree as
their initial RN education, 11.5 percent had a
baccalaureate-or-higher degree (41,927 RNs; Appendix A, Table 3). In contrast, only 47.1
percent of RNs employed as nurse aides prior to
initial nursing education received an associate
degree as their initial nursing education, while
33.4 percent obtained baccalaureate-or-higher
degrees.
In 2004, about 16.2 percent of the RN population,
or 471,603 RNs, had post-high-school academic
degrees prior to entering an initial nursing education
program (see Appendix A, Table 5). This is an
increase from the 2000 estimate, when 13.3 percent
of the RN population had post-high-school academic
degrees prior to their initial nursing education.
Over half of the 2004 RNs who had a post-high-school
academic degree prior to initial nursing education
had associate degrees (52.6 percent or 247,962
RNs), and half had bachelors degrees[13]
(50.2 percent or 236,871 RNs; Appendix A,
Table 5). RNs with post-high-school academic
degrees prior to their initial nursing education
were less likely to report an associate degree
as their initial nursing education than RNs who
had been employed as LVN/LPNs. Just over 80 percent
(80.2 percent) of those previously employed as
LVN/LPNs reported an associate degree as initial
nursing education, compared to 52.6 percent of
RNs with prior academic degrees. This is virtually
unchanged since 2000, when 82.1 percent of those
previously employed as LVN/LPNs reported an associate
degree and 53.0 percent of RNs with prior academic
degrees reported an associate degree as their
initial nursing education.
Nursing
Educational Preparation
The initial educational preparation for the largest
proportion of RNs is the associate degree. Forty-two
percent, or 1,227,256 of the 2,909,357 RNs received
their initial nursing education in an associate
degree program (see Appendix A, Table 2). Similarly,
in terms of the highest level of preparation for
nursing, the trend from 1980 to 2004 indicates
that an increasing number of RNs receive baccalaureate
and master’s degrees, even if their initial preparation
for nursing was an associates degree or a diploma
(see Chart 13; Appendix A, Table 10).
Of those RNs completing their initial nursing
education in the period between 2000 and early
2004, 56.9 percent graduated from an associate
degree program and 39.9 percent (including 1.0
percent from masters and doctoral initial programs)
graduated from a baccalaureate-or-higher initial
RN program; only 2.8 percent graduated from diploma
programs (see Appendix A, Table 2).
RNs relied on different sources of funding to
finance their initial nursing education. The three
primary sources were personal resources, family
resources, and federally assisted loans. An estimated
53.0 percent of students used some personal resources,
such as earnings and savings; while 48.2 percent
used family assistance to help pay for tuition
and fees. Over 22 percent (22.1 percent) used
federally-assisted loans as a resource. Federal
sources of support in the form of traineeships,
scholarships or grants were a resource for 13.2
percent of RNs, and employer tuition and reimbursement
plans were a resource for about 8.2 percent of
RNs attending school.[14]
Reliance on Federal resources increased with the
educational level. About 60.7 percent of master’s
and doctoral degree students relied on some type
of Federal support compared to about 49.0 percent
of baccalaureate students, 37.1 percent of associates
degree students and 16.9 percent of diploma students
(see Appendix A, Table 9).
The 2004 survey indicates that the RN population
is increasingly prepared with a baccalaureate,
a master’s, or doctoral degree. The highest level
of nursing or nursing-related preparation for
an estimated 17.5 percent of RNs (510,209) is
a diploma; for an estimated 33.7 percent (981,238)
the highest preparation is an associate degree;
for 34.2 percent (994,276) it is a baccalaureate
degree; and for 13.0 percent (376,901) a master’s
or doctoral degree is their highest nursing or
nursing-related education (see Appendix A, Table
10).
In addition to degrees in nursing, it should
be noted that some nurses have advanced degrees
that are not in nursing but related to their career
in nursing (see Appendix A, Tables 10 and 11).
Of the estimated 376,901 RNs with master’s or
doctoral degrees in nursing or nursing-related
areas, 267,963 (71.1 percent) held nursing degrees
as their highest nursing or nursing-related degree.
At the master’s level of highest nursing or nursing-related
education attained, 256,415 (73.1 percent) held
nursing master’s degrees. At the doctoral level
of highest nursing or nursing-related education
attained, 11,548 (44.2 percent) held nursing doctoral
degrees. Nurses reported attaining an additional
105,922 master’s degrees and 29,755 doctoral degrees
in fields that are not related to a career in
nursing.
The highest increase from 2000 to 2004 was for
the number of RNs receiving a nursing or nursing-related
master’s or doctorate degree (an estimated increase
of 101,833 RNs or 37 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. Also noteworthy is the 12.9
percent increase in nursing or nursing-related
baccalaureates, from 880,997 to 994,276. As illustrated
by Chart 13, by 2004 the majority (52.1 percent)
of RNs who earned a master’s or doctoral degree
as their highest nursing or nursing-related educational
preparation received a baccalaureate degree as
their initial nursing education.
Over the entire period from 1980 to 2004, there
was a 43.5 percent decrease (an estimated change
from 903,131 RNs 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 376,901). Similarly, the estimated
number of RNs whose highest nursing or nursing-related
preparation was a baccalaureate increased by 170
percent (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 RNs.
[D]
Of the 1,227,256 RNs initially prepared in associate
degree programs, 20.7 percent or an estimated
253,453 of the nurses (i.e., 8.7 percent of all
RNs) obtained additional nursing or nursing-related
degrees. Of the 733,377 RNs initially prepared
in diploma programs, 30.2 percent or an estimated
221,608 (i.e., 7.6 percent of all RNs) obtained
post-RN nursing or nursing-related degrees. In
addition, of the 887,114 RNs initially prepared
in baccalaureate programs, 22.1 percent or an
estimated 196,494 (i.e., 6.8 percent of all RNs)
subsequently received master’s or doctorate nursing
or nursing-related degrees.
In terms of overall education, including nursing
degrees, nursing-related degrees, and degrees
that were unrelated to nursing, an estimated 391,472
RNs received master’s degrees and 40,038 RNs received
doctoral degrees after becoming RNs (see Appendix A, Table 11). Nearly 44 percent (43.8 percent)
of RNs with post-RN master’s degrees that may
or may not be related to nursing chose clinical
practice as their field of study. Nearly 15 percent
(14.5 percent) focused on supervision/administration
while 13.4 percent studied education. Post-RN
doctoral degrees were frequently focused on either
education (21.3 percent), research (17.7 percent),
or law (11.3 percent). In contrast, clinical
practice was the focus of just 5.8 percent of
post-RN doctoral degrees (see Appendix A, Table
11).
In 2004, 7.6 percent, or 220,412 RNs, were enrolled
in formal education programs leading to an academic
degree or a certificate. Most of these award
programs were in nursing or would enhance a career
in nursing (172,150; Appendix A, Table 12).
The RNs pursuing these academic degree programs
useful to a career in nursing were mostly part-time
students employed full time in nursing (54.0 percent;)
Of the estimated 166,768 RNs pursing academic
degrees in nursing or related to nursing, an estimated
49.1 percent (81,402 RNs) were currently pursuing
baccalaureate degrees, 45.7 percent (75,879 RNs)
were pursuing master’s degrees, and 5.2 percent
(8,617 RNs) were pursuing doctoral degrees. The
majority of these formal nursing or nursing-related
academic degree programs (138,618) were actually
in nursing, while a smaller number (30,151) were
in nursing-related academic programs that would
enhance a career in nursing. Of the 111,282 RNs
initially prepared in associate degree programs
that were enrolled in nursing or nursing-related
educational programs, 71,373 RNs (64.1 percent)
were pursuing baccalaureate degrees. A smaller
number are pursuing certificates in nursing or
related to nursing (20,048). An additional 23,689
RNs were pursuing formal academic education in
other fields not related to enhancing a career
in nursing
Advanced
Practice Nurses
Increased interest in expanding the access and
availability of health care services has led to
particular emphasis on advanced practice registered
nurses (APNs). The APN is an umbrella term used
to describe RNs who have met advanced educational
and clinical practice requirements beyond the
initial nursing education required of all RNs.
Many States require APNs to be recognized either
by a State agency or certified by a national organization
such as the American Nurses Credentialing Center
(ANCC) or the relevant specialty nurses association.
APNs include clinical nurse specialists, nurse
anesthetists, nurse midwives and nurse practitioners.
For this study, APNs were defined as such if they
reported that they were prepared as an APN in
a specific specialty field.[15]
In total, an estimated 240,460 RNs, or 8.3 percent
of the RN population, were prepared for advanced
practice. This estimate represents a 22.5 percent
increase from the 196,279 APNs, or 7.3 percent
of RNs estimated in 2000. Almost three in four
(74.8 percent or 179,932 APNs) of the 240,460
RNs reported a master’s degree for APN educational
preparation; an additional 18,631 APNs reported
at least one post-master’s certificate for their
APN educational preparation. Over 70 percent
of APNs (70.1 percent or 168,546 APNs) were nationally
certified and 61.8 percent (148,647 APNs) were
State recognized to practice in the respective
State in at least one APN specialty[16]
(see Appendix A, Table 13). Others prepared as
APNs may have been not actively practicing in
2004 to have required current APN credentials.
As shown in Chart 14, the majority of those who
completed APN programs were prepared as nurse
practitioners (NPs; 141,209 RNs) followed by clinical
nurse specialists (CNSs; 72,521 RNs). A significant
portion of RNs were at least dually prepared as
both NP and CNS (14,689 RNs). These two groups
together, including those with dual or multiple
preparations as a nurse practitioner, clinical
nurse specialist, nurse midwife, and/or or nurse
anesthetist, comprised over 199,000 nurses (or
82.8 percent) of all APNs.
An estimated 32,523 of those who completed APN
programs were prepared as nurse anesthetists,
and an estimated 13,684 APNs were prepared as
nurse midwives, with 21.1 percent (2,892 APNs)
of nurse midwives being prepared as both NPs and
nurse midwives (see Appendix A, Table 13).
[D]
The most common specialty among those who completed
APN programs was family practice (25.0 percent),
followed by adult health/medical/surgical (14.3
percent), anesthesia (13.1 percent), psychiatric/mental
health (8.2 percent), pediatrics (8.1 percent),
and acute/critical care (6.6 percent). Among APNs
with national certification, family practice was
the most common specialty APNs were certified
in (20.1 percent), followed by anesthesia (12.7)
and adult medicine (7.1 percent) (see Appendix A, Table 14).
Nurse
Practitioners
The nurse practitioner (NP) group included all
RNs prepared beyond initial nursing education
in a formal nurse practitioner program of at least
three months. Generally, a minimum of a master’s
degree in nursing is currently required for academic
achievement in advance of national certification
as a new NP.
In 2004, 141,209 RNs, were prepared to practice
as NPs, which included 14,689 NPs with both NP
and CNS training. This estimate reflects a 37.3
percent increase (38,380) from the 2000 to the
2004 survey. In 2000, there were an estimated
102,829 NPs, which included 14,643 who were also
prepared as CNSs. As reported by the NPs, 77.6
percent (109,582) of APNs with formal preparation
as NPs also had national NP certification. The
number with State Board of Nursing recognition
was 72.3 percent or 102,142 (see Appendix A, Table
13).
Since the early 1990s, master’s degrees have
become almost always mandatory for new NPs. The
data show that the education of NPs takes place
primarily in master’s degree programs, with 65.5
percent (92,449) of NPs reporting having completed
a master’s degree program as part of their formal
APN related education. This is an increase in
master’s degree NP preparation from 2000 (when
62 percent did the same) and 1996 (when 46 percent
of NPs had completed a master’s degree). In addition
to master’s NP training, there were others who
reported having pursued post-master’s certificates
as their NP preparation (14,821 or 10.5 percent).
Almost 88 percent (87.7 percent), or 123,857
of the 141,209 NPs were employed in nursing, although
only 57.7 percent (81,433) of the NPs (i.e., 65.7
percent of the NPs employed in nursing) were employed
with the title of nurse practitioner (see Appendix A, Table 13). The second and third most-common
job titles were staff nurse (14,358 or 11.6 percent
of those NPs employed in nursing) and professor/instructor
(7,715 or 6.2 percent of those NPs employed in
nursing), respectively.
Clinical
Nurse Specialists
Clinical nurse specialists (CNSs) included those
RNs who had formal preparation related to the
clinical nurse specialty. Generally, a minimum
of a clinical master’s degree in nursing has been
required as academic achievement in advance of
practicing as a CNS.
There were an estimated 72,521 RNs (2.5 percent
of all RNs) prepared to practice as CNSs in 2004,
including the 14,689 RNs who were prepared as
both NPs and CNSs (see below). Between 2000 and
2004, the number of CNSs increased by 5.1 percent
(an additional 3,504 CNSs). In 2000, the number
of RNs trained as CNSs was 69,017, including 14,643
who were trained as both a NP and a CNS. In 2004,
of all CNSs a total of 32,385 had national certification,
a 2.1 percent increase over the 2000 level of
31,713 RNs. An estimated 27,379 CNSs had State
certification in 2004, a 31.2 percent increase
over the 2000 estimate of 20,863 (see Appendix A, Table 13).
The highest education of the vast majority of
CNSs takes place primarily in master’s degree
programs, with 93.3 percent (67,666 CNSs) reported
having completed a master’s degree program for
their CNS educational preparation. An additional
3.8 percent of CNSs (2,731 CNSs) reported having
post-master’s certificates and 0.3 percent (194
CNSs) reported having doctoral degrees as their
CNS educational preparation.
Of all those prepared as CNSs, 85.1 percent (or
61,735 CNSs) were employed in nursing but only
16.5 percent of the prepared CNSs (11,988 and
19.4 percent of those CNSs employed in nursing)
used clinical nurse specialist as their position
title. Nevertheless, there were numerous respondents
who reported having a position title of CNS but
who neither appeared from the respondent data
to have completed an APN educational program nor
otherwise reported completing at least a master’s
degree in nursing.[17]
Among a wide variety of other position titles
that prepared CNSs hold were instructor/faculty
member (16.2 percent of those employed in nursing
or 10,022) and nurse practitioner (15.9 percent
of those employed in nursing or 9,802).
Nurse
Practitioners and Clinical Nurse Specialists
In 2004, there were 14,689 APNs with preparation
as both a NP and a CNS, representing only a slight
increase from the 2000 estimate of 14,643. The
majority reported to have received APN educational
preparation in at least one master’s degree program
(93.4 percent or 13,716 APNs); this is consistent
with the master’s educational preparation requirement
for CNS’s. Others, including some of these 13,716
APNs, reportedly received APN educational preparation
through one or more post-master’s certificate
programs (33.9 percent or 4,973 APNs), or Doctoral
degrees (2.6 percent or 377 APNs) Nearly all
were employed in nursing (93.4 percent or 13,717
APNs). Most of these nurses prepared as both NP
and CNS who were employed in nursing had nurse
practitioner as their position title (8,990 APNs
or 61.2 percent of those prepared as both NP and
CNS and 65.5 percent of those employed in nursing),
followed by instructor/faculty member, (1,310
APNs or 9.6 percent of those employed in nursing)
and staff nurse (1,072 APNs or 7.8 percent of
those employed in nursing). Only 5.7 percent of
those employed in nursing (776 APNs) reported
clinical nurse specialist as their position title.
Nurse
Anesthetists
Nurse anesthetists (NAs) are the third largest
group of advanced practice nurses. Included in
the nurse anesthetists category were all RNs with
formal preparation beyond initial nursing education
in which the specialty of anesthesia was studied.
Generally, a minimum of a master’s degree is currently
required for academic achievement in advance of
national certification as a new NA. This national
certification is a prerequisite to practicing
as a NA.
In 2004, 32,523 RNs (1.1 percent of all RNs)
were prepared as NAs. In 2000, there were 29,844
NAs, representing a 9.0 percent increase from
2000 to 2004. Virtually all (30,446 or 93.6 percent)
NAs had national certification and 24,168, or
74.3 percent, had State recognition in 2004 (see Appendix A, Table 13).
The majority (18,870 or 58.0 percent) of all
NAs reported receiving their educational preparation
in post-RN certificate/award programs. Just over
one-third (12,083 or 37.2 percent) of all nurse
anesthetists reported receiving their educational
preparation in master’s degree programs. An estimated
287 NAs (or 0.9 percent) reported educational
preparation through post-master’s certificate
programs. At least a master’s degree is currently
required to become a new NA. Almost all NAs,
89.6 percent (29,150 NAs), were employed in nursing,
with 26,116 NAs (80.3 percent of all prepared
NAs) in positions where the job title was nurse
anesthetist. Other job titles included staff
nurse (1,142 or 3.9 percent of those employed
in nursing) and instructor/faculty member (331
NAs or 1.1 percent of those employed in nursing).
NAs who also had formal preparation as a CNS or
NP were more likely to be employed with the title
nurse anesthetist than either the titles of clinical
nurse specialist or nurse practitioner. Many of
the rest of those who completed NA programs may
be employed in other positions that do not require
certification in their specialty.
Nurse
Midwives
Among the APNs, there are fewer nurse midwives
(NMs) prepared or employed in this specialty than
in the other three groups.[18]
To assure that NMs were appropriately classified,
several screening steps were taken via responses
to the survey questionnaire. The formal education
beyond initial nursing education had to be at
least 9-months in length. A second screen was
needed for the relatively large proportion of
RNs in the sample who indicated they had formal
preparation as NMs and were initially foreign
educated. Such nurses usually need additional
education to qualify for certification in this
country. Generally, a minimum of a master’s degree
in nursing is currently required for academic
achievement in advance of national certification
as a new NM. This national certification is a
prerequisite to practicing as a NM. After these
screening steps were taken, the several hundred
RNs who reported NM preparation was ultimately
reduced to a corps of 175 who were considered
prepared as APNs.
In 2004, there were 13,684 nurses formally prepared
as NMs (0.5 percent of all RNs), including 2,892
who had preparation as both NPs and NMs. This
estimate, though based on a relatively small sample,
represents a 48.2 percent increase in formal NM
preparation from 2000, when 9,232 RNs were trained
as NMs. Virtually all (93.7 percent or 12,820
) of RNs trained as NMs had national certification
as NMs and three-quarters (75.2 percent or 10,296)
had State Board of Nursing recognition.
The majority of NMs (7,733 or 56.5 percent) reported
receiving a master’s degree for their educational
preparation, while 792 NMs (or 5.8 percent) reported
receiving a post-master’s certificate and 5,053
NMs (36.9 percent) reported receiving a post-RN
certificate. Almost all NMs (89.3 percent or 12,217
NMs) were employed in nursing; with 7,037 NMs
(or 57.6 percent of those employed in nursing
and 51.4 percent of all NMs) employed with the
position title of nurse midwife. Other common
job titles included staff nurse (1,636 or 13.4
percent of those employed in nursing) and nurse
practitioner (1,131 or 9.3 percent of NMs employed
in nursing). Over 10 percent (10.7 percent) were
not employed in nursing. NMs who also had formal
preparation as a clinical nurse specialist or
nurse practitioner were more likely to be employed
in the job title of nurse midwife than either
the titles of clinical nurse specialist or nurse
practitioner. Many of the rest of those who
completed NM programs may be employed in other
positions that do not require certification in
their specialty or may be retired from practice
as an NM.
Nurse
Practitioners and Nurse Midwives
In 2004, there were 2,892 RNs (less than 1 percent
of all RNs) who were prepared as both nurse practitioners
and nurse midwives. Comparable information is
not available from the 2000 NSSRN as there were
not enough observations to make reliable estimates.
The largest group reported receiving their APN
educational preparation in at least one master’s
degree programs (45.2 percent or 1,307 NM/NPs),
with additional nurses reporting APN educational
preparation in at least one post-RN certificate
program (33.2 percent or 960 NM/NPs) or post-master’s
certificate program (536 NM/NPs or 18.5 percent).
Most were employed in nursing (80.4 percent or
2,326 NM/NPs) but only 29.9 percent of the prepared
NM/NPs and 37.2 percent of those employed in nursing
used nurse midwife as their position title (865
NM/NPs). Other common titles were nurse practitioner
(29.4 percent of those employed in nursing or
684 NM/NPs) followed by staff nurse (9.0 percent
of those employed in nursing or 209 NM/NPs).
Non-White,
Hispanic, or Latino Advanced Practice Nurses
Only 8.0 percent (19,325 RNs) of APNs were from
racial/ethnic minority backgrounds (that is, non-White
non-Hispanic, Hispanic, or Latino APNs of any
race). Non-White, Hispanic, or Latino nurses
were most likely to be found among NPs (8.9 percent
or 12,529 NPs). In addition, non-White non-Hispanic,
Hispanic, or Latino APNs of any race comprised
7.8 percent (2,538 NAs) of all NAs, 7.6 percent
of NMs (1,040 NMs), and 6.3 percent of CNSs (4,547
CNSs).
Registered
Nurses in the Workforce
In 2004, 83.2 percent of the RN population, or
an estimated 2,421,351 RNs, were employed in nursing.
This estimate represents a 10.0 percent increase
since 2000 (when 2,201,813 or 81.7 percent of
RNs were employed in nursing). Although RNs can
be found in all sectors of the health care system,
the predominant employment setting remains the
hospital, employing 1,360,847 or 56.2 percent
of all RNs. The next largest group was ambulatory
care settings, with 11.5 percent or 277,774 RNs.
Ambulatory care settings include physician-based
practices, nurse based practices, and health maintenance
organizations. The next largest group was composed
of an estimated 259,911 (10.7 percent) who worked
in public/community health settings, including
State or local health departments, community based
home-health agencies, various types of community
health centers, student health services, and occupational
health services. The fourth largest employer
of RNs in 2004 was nursing homes/extended care
facilities, which employed a total of 153,172
(6.3 percent) of all RNs employed in nursing.
The remainder of employed nurses worked in diverse
settings such as nursing education (2.6 percent),
school health agencies (3.2 percent), and insurance
claims/benefits (1.8 percent; Appendix A,
Table 16). Over 4 percent (4.3 percent) worked
in settings categorized as “other”, composed of
RNs working in correctional facilities, clinical
research, home-based self-employment, private-duty
nursing, call-center/telephone triage, and pharmaceuticals/medical-devices
settings.
The percent of RNs employed in hospitals decreased
slightly between 2000 and 2004, declining from
59.1 percent to 56.2 percent. However, the actual
number of RNs employed in hospitals increased
by 4.7 percent, from 1,300,323 RNs in 2000 to
1,360,847 in 2004. This is a somewhat greater
rate than the 2 percent increase from 1996 to
2000. Ambulatory care showed the greatest gain
in RN employment from 2000 to 2004, with a 32.7
percent increase in RNs reporting employment in
ambulatory care settings (from 209,324 to 277,774
RNs). Some respondents may have had difficulty
in distinguishing between ambulatory in a hospital
setting versus ambulatory care outside a hospital
setting such as: a clinic within a hospital, an
ambulatory surgical center in a hospital or run
by a hospital off-site, an ambulatory center nearby
a hospital, a doctor’s private office within a
hospital, and a doctor’s office nearby a hospital.
Over one quarter (25.1 percent) of all employed
RNs (608,940), could not specify one type of patient
with whom they worked, as they worked with multiple
patient types. The majority of employed RNs who
could specify a patient type that they, or their
unit, cared for reported providing general adult
care (513,834 or 21.2 percent), followed by pediatric
care (176,698 or 7.3 percent) and cardiovascular
care (171,219 or 7.1 percent; Appendix A,
Table 17). Comparisons cannot be made with the
2000 NSSRN due to a change in the scope of the
question to include all employed nurses, instead
of nurses only employed in hospital inpatient
or outpatient units. Of all employed RNs, 1,584,615
RNs (or 65.4 percent) reported spending more than
50 percent of their time in direct patient care,
although 81.9 percent of employed RNs (1,984,224
RNs) spent at least some time (1 percent or more)
in direct patient care.
RNs employed in hospitals were asked to report
the function in which they spent 50 percent or
more of their time. Over 19 percent (19.3 percent)
either could not or did not report a dominant
function or reported “other” as the dominant function.
Over two-thirds of RNs employed in hospitals (70.6
percent) reported spending more than 50 percent
of their time in direct patient care, as illustrated
by Chart 15. Just over 5 percent (5.3 percent
or 71,696 RNs) of hospital employed RNs reported
spending more than 50 percent of their time in
supervisory capacities and 2.5 percent (33,446
RNs) reported spending more than 50 percent of
their time in administration. However, 89.0 percent
of all hospital employed RNs (1,211,632 RNs) reported
spending at least some time (1 percent or more)
in direct patient care.
[D]
As shown in Chart 16, inpatient bed units are
where the majority of hospital employed nurses
spend more than half their direct patient care
time. Among nurses who provided direct patient
care services and reported the type of work unit
where they spent more than half their patient
care time, 53.7 percent reported working in inpatient
bed units, similar to 2000 when 53.7 percent of
RNs reported working in these units. In 2004,
382,331 RNs reported working in general/specialty
inpatient bed units; in 2000, 369,832 RNs reported
working in these units, an increase of 3.4 percent.
Hospital-employed RNs working in outpatient departments
experienced the greatest increase at 76.7 percent,
from 69,707 in 2000 to 123,166 in 2004. Hospital-employed
RNs working in critical care or step down units
increased 18.6 percent, from 272,074 RNs in 2000
to 322,740 RNs in 2004 (see Appendix A, Table
18). Comparisons between the results of the 2000
and 2004 NSSRN surveys with respect to this issue
must be interpreted with caution as there was
a high number of hospital-based RNs who did not
specify a work unit in 2000 (8 percent) relative
to 1.3 percent of RNs reporting the same in 2004.
In addition to those unknowns without any response
by the nurse, other responses did not provide
an individual unit for the nominal list of specific
units of Table 18. However, in 2000, an additional
4.0 percent reported no specific area or some
other specific area, in 2004, 4.5 percent of these
hospital nurses providing direct patient care
reported working in multiple units, no specific
area, or other specific area.
[D]
Characteristics
within Employment Setting
An estimated 29.7 percent or 720,283 of the 2,421,351
RNs employed in nursing were employed in nursing
part-time. In general, family status made a difference
in whether nurses were employed full-time or part-time.
Employed married nurses with children, particularly
those with children under the age of six, were
more likely than other employed nurses to be employed
on a part-time basis. Overall, nearly 30 percent
(29.8 percent) of the 2,421,351 employed RNs were
working on a part-time basis. However, slightly
over 45 percent (45.4 percent) of employed married
nurses with children younger than 6 worked part-time.
Married nurses with children under 6 years of
age represented 13.8 percent of all employed nurses
(see Appendix A, Table 6). In addition, these
married nurses with children under 6 years of
age were 10.7 percent of all RNs employed full-time
in nursing as well as 7.5 percent of all employed
RNs.
The employment status (i.e., full-time or part-time
employment) of nurses varied according to the
employment setting. The highest percentage of
part-time employees was found among RNs working
in school health (37.6 percent of all RNs employed
in school health) and ambulatory care settings
(34.4 percent of all RNs employed in ambulatory
care). The lowest percentage of part-time workers
was found among nurses working in the insurance/claims/benefits
field (12.5 percent of all RNs employed in this
setting) and policy/planning/licensing/regulatory
agencies (14.8 percent or all RNs employed in
this setting; Appendix A, Table 19).
In 2004, after excluding the hours of work information
of those nurses with any on-call hours, the average
scheduled work hours per year for full-time nursing
positions, including paid vacations, holidays,
and sick leave was 2,160 hours; for part-time
nursing positions it was 873 hours (see Appendix A, Table 19). Full-time nurses worked an average
of 7.5 hours of overtime per week, while part-time
nurses worked an average of 5.6 hours of overtime
(see Appendix A, Table 20). Due to a difference
in data collection practices, overtime hours cannot
be accurately compared with the data collected
in 2000[19].
Nurses in all employment settings tended to work
more hours than they were scheduled. However,
the greatest amount of overtime for full-time
nurses were in nursing education (8.5 hours per
week). The least amount of weekly overtime hours
for full-time nurses was found in the occupational
health (5.7 hours) and ambulatory care settings
(5.3 hours). For part-time nurses, there were
not enough data points for a reliable analysis
(see Appendix A, Table 20). For full-time employed
RNs with overtime, 32.5 percent, or 2.4 of their
average weekly 7.5 overtime hours, were mandatory.
Staff nurses worked fewer hours of overtime and
a slightly smaller proportion of this overtime
was mandatory than for all other RNs. This finding
may be partly due to the differences between hourly
and salaried nurses, the latter of whom may be
required to work, or believed they are required
to work, additional hours per week as part of
their job duties and base salary. For full-time
staff nurses, 31.7 percent of their average weekly
7.5 hours of overtime were mandatory; for all
other RNs, 35.5 percent of their 7.5 average weekly
hours of overtime were mandatory (see Appendix A, Table 21). This finding held true for staff
nurses in hospitals, where the average amount
of weekly overtime for staff nurses was 7.5 hours
compared to 7.9 hours for non-staff nurses. Additionally,
for a greater percent of non-staff nurses employed
in hospitals, compared with staff nurses employed
in hospitals, overtime was mandatory (39.4 percent
for non-staff nurses versus 29.4 percent for staff
nurses).
As indicated in earlier surveys, younger nurses
were more likely than older nurses to be employed
in hospitals. In 2004, the average age of the
hospital nurse was 43.4, 2 years less than the
average age of 45.4 for all employed RNs. Nurses
in occupational health had the highest average
age at 50.8 years (see Chart 17). Across all
settings, staff nurses were on average younger
than non-staff nurses, 43.6 years of age on average
versus 48.0 years of age. This finding held true
of nurses employed in hospitals, where staff nurses
were 42.1 years of age on average versus 47.2
years of age for non-staff nurses.
[D]
Over three-fourths (77.6 percent) of employed
RNs under the age of 30 worked in hospitals.
In contrast, less than half (46.2 percent) of
employed RNs over the age of 50 worked in hospitals
(see Appendix A, Table 22).
In most employment settings, the majority of
nurses had an associate or baccalaureate degree
as their highest nursing or nursing-related educational
preparation (see Chart 18 and Appendix A, Table
23). Seventy-six percent of the nurses working
in hospitals had an associate (37.7 percent) or
baccalaureate degree (38.3 percent). Nursing
homes and extended care facilities were less likely
than other patient care service settings to have
nurses with baccalaureate and higher degrees.
Less than a quarter (24.1 percent) of nurses employed
in nursing home/extended care facilities had baccalaureate
degrees, while these settings drew 68.4 percent
of their nurses from among those whose highest
preparation was that of a diploma (21.5 percent)
or associate degree (46.9 percent). The majority
of those in nursing education (52.9 percent) had
a master’s or doctoral degree. Nursing education
had the largest proportion of RNs with baccalaureate
degrees or higher (76.0 percent), while nursing
homes/extended care facilities had the least (30.8
percent).
Registered
Nurses in Nursing Faculty Positions
One issue that has received considerable attention
in recent years is the shortage of nurses in faculty
positions involved with the educational preparation
of registered nurses. Based on the setting and
principal nursing position categories used in
the 2004 NSSRN, the faculty position is being
defined for those nurses with principal position
titles of dean, professor or instructor involved
with nursing education of RNs in diploma, associate,
baccalaureate, and/or higher nursing degree program
settings. It is estimated that 30,470 RNs in March
2004 were employed as nursing faculty in principal
nursing positions within these RN programs settings.
Of these faculty nurses, 4.8 percent were in diploma
programs, 39.4 percent were in associate degree
programs, and 55.8 percent were in baccalaureate
and/or higher degree programs. The average age
of faculty nurses was 51.6 years, but the estimated
average age of faculty nurses with doctorates
in nursing or a related field was 55.4 years.
However, the age group with the highest percent
of faculty was the 50 to 54 year age group with
24.9 percent of faculty in this age group. An
additional 27.2 percent were in the age groups
40 to 50 and 5.4 percent of RNs in faculty positions
were in the age group 25 to 34 years. Although
only 8.0 percent of faculty nurses were in the
under 40 age group, 39.4 percent were over age
55.
[D]
Base
of Employment
The vast majority of employed RNs (90.2 percent
or 2,184,921) were employees of the facility in
which they worked. About 5.5 percent of RNs were
self-employed, and 2.3 percent worked in their
principal nursing position through a temporary
employment service (see Appendix A, Table 24).
Approximately 54,493 nurses were employed in
their principal position through a temporary employment
service in 2004, and 3,039 of these nurses were
employed in both a principal and secondary nursing
position through this kind of agency. This temporary
employment principal position level reflects a
37.9 percent increase in the comparable number
in 2000 (39,505) and continues the increasing
trend which the NSSRN first observed in 1996.
In 2004, an additional 37,263 RNs were employed
by a temporary agency for a secondary position
aside from their primary nursing position. Considered
together, the total number of nurses employed
through temporary employment services in 2004
was 91,756, or 3.2 percent of all RNs. RNs employed
through temporary services for their primary nursing
position worked an average of 35.6 hours per week.
The majority of RNs employed through temporary
services for secondary nursing positions (58.9
percent) worked less than 500 hours per year.
Position
Levels
Over fifty-nine percent (59.1 percent), or 1,431,053
of the 2,421,351 employed nurses in 2004 were
in staff nurse positions. This category included
charge nurse, float nurse, public health nurse,
school nurse, travel nurse, and team leader positions
(see Appendix A, Tables 25 and 26). Although
the number of staff nurses increased by 5.4 percent
from 1,357,349 in 2000, their proportion of the
total nurse workforce has declined from 61.6 percent
in 2000 and 66.9 percent in 1988. A total of
222,411, or 9.2 percent of employed RNs, were
in head nurse or supervisory positions in 2004
and 125,011 or 5.2 percent were in administrative
positions.
Charts 19a and 19b illustrate the shifts that
have occurred in the distribution of RNs by selected
position titles since the late 1980s. In addition
to the decline in the percentage of employed nurses
who are staff nurses, there has been a notable
decline in the percentage of those with the position
title of supervisor (from 5.6 percent to 3.1 percent
during the period from 1988 to 2004). At the
same time, significant increases have occurred
in the percentage of those with the position title
of nurse practitioner, growing from 1.3 percent
of employed RNs in 1988 to 3.5 percent in 2004.
[D]
The variation in educational preparation according
to position title is illustrated in Charts 20a
and 20b and Table 27 in Appendix A. The majority
of those with each of the following respective
position titles had less than baccalaureate preparation:
private duty nurse (65.8 percent), supervisor
(61.6 percent), staff nurse (58.3 percent), and
home health nurse (58.6 percent). Nearly half
of head nurses (47.4 percent) had less than baccalaureate
preparation. In Chart 20b, about 50 percent of
those reporting principal positions as a CNS do
not also report having at least a master’s degree,
which is usually required in most States to fully
practice as a CNS. See also footnote 17 for past
acknowledgment of this perceived inconsistency
in reporting of CNS education and position title.
[D]
[D]
[D]
Functions
During Usual Workweek
Overall, the aggregate percent of time RNs spent
in direct patient care was 60 percent in 2004,
with significant percents of overall time spent
in supervision (10.8 percent) and administration
(8.3 percent). (See Chart 21). These are slight
reductions from 2000 for two of these functions,
where the direct patient care percentage of time
was 63 percent and administration was 11 percent.
In 2004, an estimated 65.4 percent of RNs (1,584,615)
employed in nursing spent at least 50 percent
of their usual workweek in direct patient care
activities; down from the 2000 estimate of 68.6
percent of RNs spending at least 50 percent of
their workweek in direct patient care, and down
from the 1996 estimate of 66.9 percent of all
RNs spending their workweek in this manner. Nearly
half of RNs employed in nursing, 49.8 percent
(1,205,389) spent at least 75 percent of their
time in direct patient care activities (see Appendix A, Table 28). Nurses with less than a master’s
degree averaged 60.8 to 64.5 percent of their
usual workweek in direct patient care activities,
and from 10.6 to 11.4 percent of their workweek
on supervisory activities (see Appendix A, Table
29). Nurses with master’s degrees averaged 44.5
percent of their time in direct patient care,
15.6 percent of their time in administration,
and 11.4 percent in teaching. Nurses with doctorates
averaged 16.5 percent of their time in direct
patient care, 27.7 percent of their time in teaching,
and 23.4 percent in administration. Doctorally
prepared nurses were the only group that spent
significant time (e.g., over 10 percent) in research.
In 2004, they averaged 12.8 percent of their usual
workweek in research, a slight increase over the
2000 average of 11.4 percent and the 1996 average
of 9.5 percent.
[D]
Recent
Indices of Annual Salaries/Earnings Trends
In March 2004, the overall average annual earnings
of full-time employed registered nurses in their
principal nursing positions was $57,785 (see Appendix A, Table 30). This is a 23.5 percent actual increase
in earnings from the 2000 NSSRN average of $46,782.
However, as noted in Chapter II, 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 without respect to
the time of the response[20].
The 2004 question text also specified that RNs
should include overtime and bonuses but exclude
sign on bonuses. The 2000 questionnaire text
did not address this kind of income. As indicated
below and in the respective Appendix A Tables,
annual earnings varied by level of nursing education,
position, employment setting, and geographic location.
Average annual earnings varied according to the
highest level of nursing or nursing-related educational
preparation (see Appendix A, Table 31). The pattern
of earnings is predictable in most instances,
with nurses with advanced degrees achieving higher
earnings. For almost all positions where master’s-prepared
RNs were employed in significant numbers, their
average earnings were higher than those with diploma,
associate, or baccalaureate degrees. The earnings
of master’s-prepared nurses averaged $74,377.
Nurses educated at the doctoral level averaged
slightly higher earnings at $80,795.
In those categories where the educational preparation
was less than the master’s level, the average
earnings were noticeably lower. The overall average
annual earnings for those whose highest nursing
or nursing-related educational preparation was
a diploma was $56,504. Those whose highest nursing
education was a baccalaureate degree had slightly
higher average annual earnings than for those
who held a diploma ($57,081). Earnings for those
with diplomas and baccalaureate degrees as their
highest nursing or nursing-related educational
preparation were about 7.4 and 8.5 percent higher,
respectively, than the average earnings for those
with associate degrees ($52,610) as the highest
nursing or nursing-related education. Earnings
and education patterns appear to be more complex
than simply assuming that higher levels of education
automatically translate to higher earnings.
Earnings and education patterns are complex and
subject to many variables. For example, larger
proportions of diploma nurses in the workforce
have more years of experience than do those with
baccalaureate or associate degrees. These circumstances
of the workforce may at least partly explain why
diploma earnings appear to be competitive with
baccalaureate earnings.
Comparisons of nurses’ earnings from 2000 and
2004 were made among each of the levels of nursing
education, to determine whether the increases
were consistent across degree of highest preparation.
Increases were also adjusted for changes in the
CPI,[21]
to determine the real increase in RN earnings.
Adjustments for changes in the CPI were made
based on average annual CPI rate of increase of
2.3 percent, with a resulting 13.9 percent real
increase between 2000 and 2004.
The average annual increase in RN salaries overall
was estimated at 5.4 percent from 2000 to 2004,
based on an overall actual average earnings increase
of 23.5 percent from 2000 to 2004. However, with
an adjustment for the average yearly increase
of CPI through this time period (2.3 percent),
the real average annual rate of increase was 3.1
percent. There was a wide range in the rate of
increases in earnings across the levels of highest
nursing or nursing-related educational preparation,
as RNs with baccalaureate and doctoral degrees
experienced the largest increases. Nurses whose
highest nursing or nursing-related education was
either a diploma or associate degree received
average annual increases of 4.9 percent and 5.4
percent (e.g., CPI adjusted average annual earnings
increases of 2.6 and 3.1 percent), respectively.
RNs with baccalaureate degrees as their highest
nursing or nursing-related education had average
annual earnings increases of 5.2 percent (2.9
percent when adjusted for the CPI). Those with
nursing or nursing-related master’s degrees received
average annual increases of 5.0 percent (CPI-adjusted
real earnings were at a 2.7 percent rate of increase),
and those with doctoral degrees experienced the
biggest average actual annual earnings increase
with 6.2 percent overall (3.9 percent when adjusted
for the CPI).
There are large variations in actual earnings
by position type from 2000 to 2004. Staff nurses,
the largest group of employed nurses, had average
earnings of $53,086 in 2004. The staff nurse
earnings level is about 8 percent below the overall
average earnings for all RNs with full-time employment
in nursing. However, this is an improvement over
2000, when staff nurses earned $42,133, on average
10 percent less than RNs as a whole.
APNs had earnings that were higher than the average
for RNs overall. Nurse anesthetists had the highest
average earnings ($129,530) among RNs in all employment
settings and position types. Nurse midwives had
average earnings of $73,254; NPs had average earnings
of $70,581; and CNSs with master’s degrees had
average earnings of $70,470[22].
Nurse anesthetists experienced a 38.1 percent
increase in average earnings from the 2000 survey,
with NPs reporting the second largest increase
at 17.4 percent.
Annualized growth rates in actual earnings from
2000 and 2004 were compared for selected positions.
While the average reported earnings for all full-time
nurses increased by 5.4 percent on an annual basis
between 2000 and 2004, there was a broad range
to the level of increase across positions. Categories
of nursing positions that experienced annual rate
increases which were higher than the average rate
of increase include: certified nurse anesthetist
(8.4 percent) clinical nurse specialist (6.2 percent),
and staff nurse (5.9 percent). For staff nurses,
this is a difference from the 2000 NSSRN when
staff nurses experienced among the lowest annual
increases (at 2.2 percent). Staff nurse earnings
in hospitals increased by 6.1 percent. The greater
increases for staff nurses than RNs in general
(whose earnings increased by 5.4 percent) may
indicate that demand for staff nurses is beginning
to be reflected in the compensation for these
RNs.
Annual earnings varied according to the setting
in which the RN was employed. At $59,963, the
average annual earnings for those working full-time
in the hospital setting were higher than the overall
full-time earnings average across all types of
settings. Those settings where RNs earned less
than the overall average included public health
settings, at $52,347; nursing homes, at $53,796;
and school health services, with the lowest average
annual earnings of $42,249. However, the average
earnings of RNs employed in nursing homes increased
by 22.9 percent between 2000 and 2004.
The hospital setting earnings average of $59,963
in 2004, when compared to the 2000 average of
$47,759, reflect a substantive real increase of
16.1 percent over the CPI, based on a 25.6 percent
actual increase. The average annual rate of increase
of 5.9 percent is also greater than the overall
5.4 percent annual rate of increase for RNs in
general. Of note, the information in Appendix
A, Table 30 indicates that hospital-based RNs
of each position type generally average higher
earnings than their position counterparts in other
employment settings such as public health nursing,
nursing homes, ambulatory care, occupational health
services, and student health services.
Looking at the full-time earnings of staff nurses
working in the hospital setting across the country,
RNs with associate degrees as the highest nursing
or nursing-related education had average earnings
of $53,514. For those whose highest nursing or
nursing-related education was a diploma, the average
earnings were $58,413. For the baccalaureate-prepared
hospital staff nurse, the average earnings were
$55,392. It is important to note that these numbers
do not take into account years of experience in
nursing, an important factor to be considered
when conducting an analysis of earnings and differences
in education.
A significant percent of employed nurses work
either part-time in their principal job or work
more than one job in nursing. An estimated 14.5
percent of all employed RNs held other paid nursing
positions in addition to their principal nursing
position. For all RNs employed in nursing (regardless
of whether they had more than one position and
if they worked full-time or part-time in their
principal position), the average total annual
earnings were $52,080. This is lower then the
$57,749 for nurses employed full-time in their
principal nursing position and only slightly greater
than the average annual earnings of those with
only one full-time or part-time position ($50,452).
If RNs were employed in more than one nursing
position, the average earnings increased to $61,111.
Those RNs employed part-time in nursing only had
overall average earnings of $34,184; those who
worked in more than one part-time position earned
$44,633; and those who worked only one part-time
position earned $32,002 (see Appendix A, Table
32).
Job
Satisfaction
The level of job satisfaction indicates the general
attitude of RNs toward their work. There is a
wealth of empirical literature linking job satisfaction
and other important workplace features, such as
employee turnover. Correspondingly, there is
an emerging body of work linking job satisfaction
with quality of patient care.
The 2004 survey also examined job satisfaction
and reasons for not working in nursing or for
changing positions, of the nurses currently employed
in nursing. Across the entire sample, just over
three-quarters of nurses (76.4 percent) reported
being either extremely satisfied (26.9 percent)
or moderately satisfied (49.5 percent) in their
current position (see Appendix A, Table 33). Only
13.5 percent of nurses employed in nursing were
dissatisfied (2.8 percent extremely dissatisfied
and 10.7 percent moderately dissatisfied). The
76.4 percent of RNs moderately or extremely satisfied
with their jobs is greater than the 69.5 percent
of RNs who were moderately or extremely satisfied
in 2000,[23]
but is lower than levels seen in the employed
general population. Data from the General Social
Survey of the National Opinion Research Center
indicate that in 2002[24]
, 89.1 percent of employed individuals in the
U.S were moderately or extremely satisfied with
their jobs.
Levels of job satisfaction vary by employment
(see Chart 22). Nurses working in nursing homes/extended
care facilities reported the lowest levels of
job satisfaction, with 73.8 percent saying they
were extremely satisfied (23.6 percent) or moderately
satisfied (50.2 percent) with their jobs. RNs
working in hospital and insurance claims/benefits
settings also reported lower levels of overall
job satisfaction at 74.9 percent each, although
there were differences in the levels of moderate
or extreme job satisfaction. For RNs working
in hospitals, 52.5 percent were moderately satisfied
with their jobs compared with 46.1 percent of
RNs working in insurance claims/benefits settings.
Comparatively, 22.4 percent of RNs working in
hospitals were extremely satisfied with their
jobs, compared with 28.8 percent of RNs working
in insurance claims/benefits. The highest job
satisfaction rates came from RNs working in school
health settings (85.7 percent either moderately
or extremely satisfied, 44.8 percent and 40.9
percent respectively), ambulatory care settings
(83.9 percent either moderately or extremely satisfied,
46.6 percent and 37.4 percent respectively), and
occupational health settings (82.4 percent either
moderately or extremely satisfied, 42.1 percent
and 40.3 percent respectively).
[D]
Across employment settings, two factors appear
to play powerful roles in level of job satisfaction:
education level and position (such as whether
the respondent is a staff nurse or not). In general,
fewer staff nurses reported being moderately or
extremely satisfied with their jobs than non-staff
nurses overall (74.1 percent versus 82.0 percent).
Nearly 16 percent (15.9 percent) of staff nurses
report being moderately or extremely dissatisfied
with their jobs. This difference holds true across
employment settings; fewer staff nurses report
being moderately or extremely satisfied with their
jobs across employment settings (see Appendix A, Table 33 and Chart 23).
[D]
Job satisfaction also varies by level of nursing
or nursing-related education, with associate degree
nurses reporting the lowest overall level of job
satisfaction (75.7 percent) and master’s/doctorally-prepared
nurses reporting the highest level (83.2 percent;
Appendix A, Table 34).
In each educational group, staff nurses report
lower levels of job satisfaction compared to their
counterparts who are not staff nurses. This finding
was true across all levels of educational preparation
(see Chart 24). For example, 81.7 percent of
non-staff nurses whose highest educational preparation
was diploma reported being either extremely satisfied
(34.4 percent) or moderately satisfied (47.3 percent)
with their jobs, while only 75.0 percent of staff
nurses with the same educational preparation reported
the same (25.2 percent extremely satisfied, 49.8
percent moderately satisfied).
[D]
Position appears to be a greater factor regarding
job satisfaction than function. Non-staff nurses
who spend more than 50 percent of their time in
direct patient care report higher moderate/extreme
job satisfaction (84.3 percent) than staff nurses
spending similar amounts of time with patients
(74.9 percent).
Registered Nurses Not Employed in Nursing
In March 2004, 16.8 percent (488,006) of the
2,909,357 individuals with a license to practice
nursing in the United States were not employed
in nursing. This estimate represents both a percentage
and a numerical decrease from 2000 (1.6 percent
or 6,721 decrease) among those not employed in
nursing. About 6.2 percent of these RNs (30,278)
were looking for employment in nursing (see Appendix A, Table 35). RNs not employed in nursing were
older than RNs overall. On average, RNs not employed
in nursing were 54.1 years old, much older than
the average age for RNs employed in nursing at
45.4 years of age.
In 2004, 204,006 or 41.8 percent of RNs who were
not employed in nursing had been employed in nursing
at some time within the 5-year period preceding
the survey. Both the number and proportion of
RNs not employed in nursing with the past 5 years
has declined from 2000, when 263,856 or 53.3 percent
of RNs were not employed in nursing within the
5-year period preceding the survey. The proportion
of RNs not currently employed in nursing and who
have never worked in nursing remained similar;
1.4 percent in 2000 and 1.3 percent in 2004 (see Appendix A, Table 35). In the last two surveys
(e.g. 2000 and 2004) a little over 22 percent
of those not currently employed in nursing had
not worked in nursing for more than 10 years.
Furthermore, only 9.1 percent of those not working
in nursing for more than 10 years were currently
seeking employment in nursing (see Appendix A,
Table 35).
RNs who had most recently not worked in nursing
were most likely to be actively seeking employment
in nursing. Nearly 19 percent (18.9 percent) of
RNs who had left the nursing workforce within
the year preceding the survey were actively seeking
nursing employment at the time of the survey (see Appendix A, Table 35). This estimate is unchanged
from the 2000 survey. The average age of RNs
recently not employed in nursing, 51.2 years of
age, was younger than RNs not employed in nursing
overall (54.1 years of age). Of the estimated
14 percent of RNs (488,006) who are not working
in nursing, and allowing for multiple responses,
49.3 percent were estimated to have left nursing
for personal or family reasons, 49.5 percent for
personal career reasons, 42.7 percent for reasons
connected with the workplace, and 33.8 percent
due to retirement.
Further analysis, by age distribution, of RNs
not employed in nursing was undertaken (see Appendix A, Table 36). Of those RNs not employed in nursing
and over 65 years of age, the period of time since
they have been employed in nursing is well-distributed
across all ranges, particularly between 1 and
19 years. For all other age groupings between
30 and 64 years, the largest numbers of nurses
were in the 1-to-4 year range since last nursing
employment compared to any of the other ranges
of time since last nursing employment. Of those
nurses not employed in nursing, 250,769 (51.4
percent) were 55 years or older and 56.0 percent
of the nurses not employed in nursing for 5-or-more
years (115,103 RNs) are over 55 years of age.
Nurses
Seeking Nursing Employment
The 30,278 RNs not employed in nursing yet actively
seeking nursing employment represent 1.0 percent
of all RNs in the United States. This percentage
has not changed since the 2000 survey. These
RNs were more likely to have been employed in
nursing more recently than other RNs not working
in nursing. Nearly 67 percent (66.5 percent)
of RNs not employed in nursing but actively seeking
nursing employment at the time of the survey had
been employed in nursing within the 5 years prior
to the survey, with most (41.3 percent) having
been employed in nursing less than a year prior
(see Appendix A, Table 35).
The majority of RNs not employed in nursing seeking
employment as RNs are searching for part-time
employment (15,918 or 52.6 percent). Twenty-six
percent of RNs actively seeking employment in
nursing are seeking full-time employment (see
Appendix A, Table 37). Just over 18 percent (18.1
percent) were looking for either full or part-time
employment.
Nurses
Employed in Non-Nursing Occupations
An estimated 120,512 (4.1 percent) of all licensed
RNs were employed in non-nursing occupations in
March 2004. This represents an 11.2 percent decrease
in the number of RNs employed in non-nursing occupations
in 2000, reversing a trend of increased employment
in non-nursing occupations that began in 1992.
The RNs employed in non-nursing occupations include
2,209, or 1.8 percent, who have never worked in
nursing.
Over half (52.3 percent) of RNs employed in non-nursing
occupations were working in health-related occupations;
almost 44 percent (43.9) reported working in non-health-related
occupations (see Appendix A, Table 38). This is
different from 2000, when these percentages were
reversed.
The most often reported health-related occupations
outside of nursing were administration/management
(at 25.2 percent) and health-related service providers
(21.1 percent). Pharmaceutical and medical hardware
services employed the third greatest portion of
RNs in health-related occupations at 12.4 percent.
RNs employed outside of nursing in non-health-related
occupations were most often employed in retail
sales/services (19.7 percent), and administration/management
(14.6 percent; see Appendix A, Table 39).
Like the 2000 survey, RNs employed in health-related
non-nursing occupations were more likely to be
employed full-time. Nearly 71 percent (70.6 percent)
of RNs employed in non-nursing health-related
occupations were employed full-time. In contrast,
45.5 percent of RNs employed in non-nursing non-health-related
occupations were employed full-time (see Appendix
A, Table 38).
RNs employed in non-nursing occupations predominantly
cited career change (65.8 percent), burnout/stressful
work environment (44.9 percent), and scheduling
problems/working too many hours (41.4 percent)
as the reasons why they were not employed in nursing
at the time of the survey. Significant portions
also cited salary/pay better outside of nursing
(34.0 percent), inadequate staffing (33.3 percent),
and taking care of home and family (29.6 percent)
and physical demands of the job (28.1 percent;
see Appendix A, Table 40).
Registered
Nurses Not Employed in Nursing and Not Seeking
Nursing Employment
The largest segment of RNs not employed in nursing
were RNs neither employed in nor seeking employment
in nursing, which for the purposes of this study
will be referred to as non-active RNs. This group
constituted 326,526 RNs, or 66.9 percent of all
RNs not employed in nursing and 11.2 percent of
all RNs. Most of the non-active RNs were older
nurses, at 55.3 years of age on average, compared
to the 54.1 average age for all RNs not employed
in nursing and 46.8 average age for all RNs overall.
Slightly less than half (46.4 percent) were at
least 60 years of age. Only 14.5 percent were
under the age of 40.
Overall, 75.1 percent of non-active RNs were
married. However, of the non-active RNs younger
than 40, 88.2 percent were married. Nearly 30
percent (29.9 percent) of all non-active RNs had
children under the age of 18 in their household.
This was particularly true of married non-active
RNs younger than 40. An estimated 72.1 percent
of these married RNs had children younger than
age 6. An additional 15.9 percent only had children
over age 6 but younger than age 18 (see Appendix
A, Table 41). Twelve percent of non-active RNs
were caring for other adults in their home, and
15.3 percent were caring for others outside of
their home (see Appendix A, Table 42). Overall,
24.7 percent of non-active RNs were providing
care for someone inside or outside their home.
GEOGRAPHIC
AND EMPLOYMENT MOBILITY
The survey instrument provided for the exploration
of a number of changes that registered nurses
might experience during the course of their careers
in nursing and the reasons for such changes.
Among the changes assessed were geographic location,
movement in and out of the nursing workforce,
and changes in employment setting or employer
within the field of nursing.
Location
of Initial Nursing Education
One third (903,206 RNs or 33.3 percent) of RNs
with current licenses to practice nursing in the
United States had received their initial nursing
education in a different State than the State
in which they were located at the time of the
survey (see Appendix A, Table 43).
As would be expected, the longer the time lapse
since graduation from the initial nursing education
program, the more likely that the RN had moved
to a different State. Nearly thirty-nine percent
(38.7 percent) of the nurses who had graduated
more than 15 years prior to the survey were in
a different location compared to 22.5 percent
of those who had graduated within the past 5 years.
There were noticeable differences among the graduates
from the different types of initial nursing educational
programs. Associate degree graduates were most
likely to be located in the State where they received
their initial nursing education (74.0 percent).
Sixty-one percent of both diploma and baccalaureate
graduates (61.0 percent) were located in the same
State in which they had received their initial
nursing education (see Appendix A, Table 43).
Registered
Nurses Educated Outside the United States
The number of RNs who received their initial
RN education outside the United States increased
about 1.3 percent, from 99,456 in 2000 to 100,791
in 2004. [25] Most
foreign educated RNs were educated in the Philippines
(50.2 percent), followed by Canada (20.2 percent)
and the United Kingdom (8.4 percent; see Appendix
A, Table 44). The same pattern was present in
2000, where 40.1 percent of foreign trained RNs
came from the Philippines, followed by Canada
(16.6 percent), and the United Kingdom (9.3 percent).
Fully 59.5 percent (59,972) of foreign educated
RNs were from an ethnic or racial minority background,
31.3 percent were white non-Hispanic (31,514),
while 9.2 percent (9,305) did not report a race/ethnicity.
The most often represented minority group among
foreign educated RNs was Asian non-Hispanic (48.9
percent or 49,297). The second most common was
Black or African American non-Hispanic (6,707
or 6.7 percent) and Hispanic or Latino (2,110
or 2.1 percent). Not surprisingly, about 68.5
percent of foreign-educated RNs speak at least
one language other than English, most often Filipino
(47.9 percent of foreign-educated RNs). Over half
of the foreign-educated nurses (54.7 percent)
speak only one language other than English, 12.1
percent speak two languages, and 1.6 percent speak
three or more languages. A large number (4.3 percent)
speak Spanish, and almost equal numbers speak
French or an Asian language other than Filipino
(3.7 percent and 3.6 percent, respectively).
The majority of foreign educated RNs received
baccalaureate degrees as their initial nursing
education (48,781 or 48.4 percent) followed by
diplomas (41,898 or 41.6 percent). In contrast,
30.5 percent of all RNs received their initial
nursing education in baccalaureate programs, and
42.2 percent of RNs received their initial nursing
education in associate degree program. Over half
of the foreign-educated RNs were estimated to
have baccalaureate or higher degrees (59.2 percent),
two percent of whom have doctorate degrees. Over
two percent of foreign-educated nurses in the
2004 survey (an estimated 2,446) were APNs, of
whom 65.8 percent were NPs, another 13.1 percent
were CNSs, 11.1 percent were NP/CNS, and 10 percent
were NMs.
Nearly 90 percent (89.2 or 89,860 RNs) of foreign
educated RNs were employed in nursing. Although
all States employ foreign educated RNs, the majority
were concentrated in a handful of States in 2004.
Nearly seventy percent (69.7 percent) of foreign
educated RNs worked in six States:
- California
(28.6 percent),
- Florida (10.7 percent),
- New York
(10.4 percent),
- Texas (7.5 percent),
- New Jersey
(6.9 percent), and
- Illinois (5.6 percent; Appendix A, Table 45). Overall, foreign educated
RNs are more likely than RNs overall to be employed
in hospitals (64.7 percent versus 56.2 percent
of employed RNs overall) and more likely to be
staff nurses (72.6 percent versus 59.1 percent
of employed RNs overall; Appendix A, Table
46).
Residence
in March 2004 and 2003
At the time of the survey, most nurses were in
same State in which they lived in 2003 (89.2 percent).
Only about 3 percent (2.6 percent) had changed
their State of residence in the past year (between
2004 and 2003) (8.1 percent did not report if
they had changed their State of residence). The
youngest nurses and the oldest nurses were the
least likely to have changed their State of residence.
Eight percent of the nurses who changed their
State of residence were less than 25 years old.
Over 9 percent (9.3 percent) of RNs aged 55-59,
5.3 percent of RNs age 60-64, and 3.3 percent
of RNs over age 65 had changed their State of
residence between 2003 and 2004 (see Appendix A, Table 47).
Employment
Status in 2004 and 2003
Among the 2,909,357 RNs living in the United
States in 2004, most had the same employment status
in 2003 and March 2004. Over nine out of ten
(90.9 percent) of those employed full-time in
nursing in 2004 were also employed full-time in
nursing in 2003 (1,455,968 RNs). Over 13.2 percent
of the 712,770 RNs employed part-time in 2003
had changed their nursing employment status to
full-time in 2004 and 5.5 percent of RNs employed
full-time in nursing in 2003 had changed their
status to part-time in 2004 (see Appendix A, Table
48). Among the 480,831 RNs who were not employed
in nursing in March 2003, about 23.3 percent (112,954)
were employed in nursing in March 2004. However,
if those who were newly licensed in 2003 or 2004
are excluded (60,853 or 12.7 percent of those
not employed in nursing in 2003 and 2.1 percent
of all RNs), only 52,101 (10.8 percent) of the
RNs licensed before 2003 were not employed in
nursing in 2003 had become employed in 2004.
Employment
Setting Changes
The majority of nurses were employed in the same
setting in 2004 as they were in 2003. Eighty-nine
percent (88.8 percent) of registered nurses who
were working in a hospital in 2004 were also working
in a hospital in 2003 (see Appendix A, Table 49).
In order to get more data on job market conditions
for RNs, the NSSRN asked the nurses whether they
had changed employers or positions between 2003
and 2004 and if so, why. As Chart 25 shows, 62.4
percent of those in the RN population in March
2004 were employed both years in the same position.
Sixteen percent of nurses (16.1 percent or 467,566)
were employed both years but changed employers
and/or positions. The remaining 21.5 percent were
either unemployed in 2003 and/or 2004 or their
status was unknown in 2003. The majority of these
nurses who were employed in the same positions
in both 2003 and 2004 were moderately satisfied
(51.0 percent) or extremely satisfied (27.6 percent)
with their principal nursing position; only 13.3
percent were estimated to be moderately or extremely
dissatisfied with their positions. In addition,
of the nurses who changed employers, 73.2 percent
(202,283) were satisfied with their current position
(47.5 percent were moderately satisfied and 25.7
percent were extremely satisfied). RNs who switched
employer and or positions in the past year were
asked to report the reasons for the change. Of
all RNs who reported making an employer or position
change within the past year, a large proportion,
82.7 percent, cited a workplace issue as a reason
for the change. The second most common reason
for changing employers/positions was for career
considerations (57.4 percent; Appendix A,
Table 50).
[D]
Geographic Distribution of the Registered Nurse Population
The country as a whole had a 5.5 percent increase
in the ratio of employed RNs to population ratio
from 782 per 100,000 in 2000 to 825 per 100,000
in 2004. In 2004, as was true in 2000, the New
England region of the country had the highest
concentration of employed nurses in relation to
the area’s population, with 1,107 employed RNs
per 100,000 population. The West North Central
area had the next greatest concentration with
1,026 employed RNs per 100,000 population. The
West South Central area had one of the lowest
concentrations, 677 RNs per 100,000 population.
The Pacific region had the lowest comparative
concentration, with 645 employed RNs per 100,000
population in 2004. This largely reflects the
impact of the low ratio present in California,
which had 589 RNs per 100,000 in 2004, up from
544 RNs per 100,000 in 2000. By comparison, the
next lowest State ratio within the Pacific region
was Hawaii, with 739 RNs per 100,000 in 2004 and
703 RNs per 100,000 in 2000. The distribution
of the State-by-State ratios of employed nurses
per 100,000 population is shown in Appendix A,
Table 51.
Comparison of the ratios for each of the nine
geographic regions or areas of the country shows
that New England had 71.6 percent more employed
nurses per 100,000 population than did the Pacific
area. In terms of overall gains, the Pacific
region ratio had the second largest increase (8.2
percent) since 2000 (when the ratio was 596 per
100,000). The East North Central region had the
largest increase at 9.3 percent (from 831 RNs
per 100,000 to 908 RNs per 100,000).
Distribution
by State
The number of employed nurses per 100,000 residents
varied by State in 2004 from a low of 589 in California
to a high of 2,093 in the District of Columbia.
The proportion of the RN population employed in
nursing in each State in 2004 (i.e., the ratio
of employed nurses in that State to the number
of RNs residing in that State) ranged from a low
of 76.3 percent in Connecticut to a high of 95.6
percent in the District of Columbia. However
it should be noted that the District of Columbia
has a large number of RNs who do not reside in
the District of Columbia, but are employed there.
(Note: Approximately 4.3 percent of employed
RNs, or 105,136 RNs, were employed in a State
other than the one in which they resided; a disproportionately
large number of these RNs, 10,039 (9.6 percent),
were employed in the District of Columbia).
The RN population in each State ranged from a
low of an estimated 4,498 in Wyoming to a high
of 255,858 in California. Eight States had nurse
populations of over 100,000 while six States had
fewer than 10,000 nurses (see Appendix A, Table
51). The States with more than 100,000 nurses
were New York, Pennsylvania, Texas, Florida, Illinois,
Ohio, Michigan, and California. The States with
fewer than 10,000 nurses were Wyoming, Delaware,
North Dakota, Montana, Alaska, and Vermont. The
RN population increased in all but four States
between 2000 and 2004. The four States are Massachusetts,
Pennsylvania, Louisiana, and Wyoming. In one
other State, West Virginia, there were marginal
changes between 2000 and 2004. California, the
State with the largest RN population, and part
of the Pacific area, had a 13.0 percent increase
in RN population (translating to an additional
29,506 RNs).
As shown in Table 52 of Appendix A, the proportion
of employed nurses who worked on a part-time basis
also varied considerably from State to State.
The proportion of nurses employed on a part-time
basis varied from a low of 17.9 percent in Arkansas
to a high of 44.6 percent in Vermont. Five additional
states had high proportion of part-time employed
RNs; Minnesota (44.2 percent), Massachusetts (42.3
percent), Wisconsin (41.5 percent), Oregon (41.0
percent), Washington (39.5 percent). All six
of these States had high proportions of part-time
employed RNs in 2000.
Metropolitan
Areas
The majority of RNs (83.9 percent) resided in
metropolitan areas. This proportion varied across
geographic areas of the country as would be expected
given the distribution of metropolitan areas across
the Nation. The highest concentrations of RNs
living in metropolitan areas were found in the
Middle Atlantic (91.0 percent) and Pacific regions
(90.2 percent), while the lowest were in the West
North Central (69.6 percent; Appendix A, Table
53). As Table 53 further illustrates, RNs who
were located in metropolitan areas were slightly
more likely than those in non-metropolitan areas
(83.3 percent versus 82.4 percent) to be employed
in nursing. This difference was particularly
strong in the East North Central region, where
87.1 percent of the RNs in metropolitan areas
were employed versus 81.7 percent of RNs in non-metropolitan
areas.
Educational
Background
RNs in the New England and the Middle Atlantic
regions (at 21.7 and 21.2 percent respectively)
were more likely to report a diploma as their
highest nursing or nursing-related education relative
to other regions. In fact, over one quarter of
Pennsylvania RNs (27.5 percent) and 25.0 percent
of Connecticut RNs reported a diploma as their
highest degree. RNs in the East South Central
region were most likely to report having an associate
degree as their highest educational preparation
(46.6 percent of all RNs in this region held this
as their highest degree). This is mainly from
the high percentage of RNs with associate degrees
located in Mississippi (53.4 percent), and Kentucky
(52.2 percent), far above the United States average.
On the other hand, North Dakota had the lowest
percentage (16.0 percent) of RNs with an associate
degree as the highest educational preparation.
With respect to baccalaureate degrees, the regions
were relatively similar, ranging from 31.0 percent
of RNs in the East South Central region to 38.2
percent in the Pacific region. However, there
was great variation between the States; ranging
from 23.2 percent of RNs in Iowa to 51.6 percent
in North Dakota. New England had the most RNs
with master’s and doctoral degrees (at 16.5 percent,
compared with the lowest rates in the West North
and West South Central regions (both at 10.7 percent;
Appendix A, Table 54).
Racial/Ethnic
Background
The Pacific area had the highest proportion of
minority (that is, non-white, Hispanic, or Latino)
nurses at 19.0 percent. The predominant minority
nurse group in the Pacific area were those of
Asian background; 9.0 percent of the nurse population.
In addition to the Pacific area, Asian nurses
were also more likely to be a part of the nurse
population in the Middle Atlantic and West South
Central areas (3.3 and 3.0 percent respectively)
than in other parts of the country. Black or
African American (non-Hispanic) nurses were more
prevalent among the nurse populations in the South
Atlantic (7.3 percent), West South Central (6.4
percent), and East South Central (6.3 percent)
areas than elsewhere. Hispanic or Latino nurses,
although a relatively small proportion of any
area’s nurse population, were more likely to be
found among the nurses in the Pacific (3.6 percent),
West South Central (3.5 percent) and Mountain
(2.7 percent) areas (see Appendix A, Table 55).
Age
Distribution
Nurses in the East South Central area of the
country were more likely to be younger than were
those in other parts of the country, with an average
age of 44.3 (compared to 46.8 for the Nation overall).
New England and Middle Atlantic RNs were the oldest
at an average of 48.3 and 48.2 years old respectively
(see Chart 26). About 34.4 percent of East South
Central RNs were less than 40 years old, compared
with 22 to 30 percent of nurses in other areas
of the country. New England and Middle Atlantic
region nurses were the least likely to be in this
younger age group; in both areas, only 22 percent
were less than 40 years old (see Appendix A, Table
56).
[D]
Employment
Settings
As expected, the predominant employment setting
for the nurses in each area was a hospital setting.
The proportion of the nurse supply working in
hospitals in each area ranged from a low of 50.3
percent of New England RNs to a high of 59.0 percent
in the Pacific region. The New England and West
North Central areas were more likely than the
other areas to have higher proportions of their
nurses employed in nursing homes or other extended
care facilities (9.8 and 8.4 percent respectively).
At 12.2 percent, New England had the highest proportion
of nurses employed in public/community health
settings, the West North Central and Pacific regions
had the least (at 9.8 percent each). New England
also had the highest percentage of RNs employed
in school health settings at 6.3 percent, while
the East South Central region had the least (1.9
percent). Every region but New England (9.8 percent)
had more than 10 percent of their registered nurses
employed in ambulatory care settings. Compared
with the other regions, the Mountain region, at
13.0 percent, had the highest proportion of RNs
employed in ambulatory care (see Appendix A, Table
57).
Changes
in Employers and/or Positions
As reported previously, 16.1 percent of the entire
RN population was employed in both 2003 and 2004
but changed employers and/or positions between
those dates. Nurses from the Mountain (19.6 percent)
and West South Central (19.1 percent) sections
of the country were more likely to have changed
employers or positions than other regions. Nurses
in New England were the least likely to have made
a change (14.6 percent). Nurses in different
regions of the country gave approximately the
same percentages of reasons for changing employers
or positions. The top reason cited overall was
an interest in another position or job, with 51.4
percent of all RNs that changed jobs citing that
reason. This is a large increase from 2000, when
only 17.8 percent of RNs who changed jobs cited
that reason. (However, this may be partly due
to the change in questionnaire specifications
where the 2004 question allowed multiple categories
to be chosen by the respondent for the first time.)
The other top reason listed by nurses overall
was burnout/stressful work environment, with 46.0
percent of all RNs that changed jobs naming this
as their principal reason for change (see Appendix A, Table 50).
Average
Earnings within Geographic Area for Staff Nurses
The average annual earnings of full-time staff
nurses in each of the nine geographic regions
were examined to get some indication of variations
in earnings across the country. The average earnings
for full-time staff nurses in their principal
positions ranged from $46,108 in the West North
Central area to $64,685 in the Pacific area (see Appendix A, Table 58). The areas where earnings
reached above the national average for full-time
staff nurses, $53,086, included the Middle Atlantic
($56,960), New England ($57,451), and Pacific
regions ($64,685).
There were some geographic variations in the
rate at which earnings increased among the nine
regions. Earnings of full time staff nurses in
the Mountain (6.9 percent) and Pacific (6.7 percent)
regions increased at a higher annual rate than
those in the remaining regions.
Compact
States
By 2004, a total of 17 States had entered into
a formal arrangement, called the “Nurse Licensure
Compact”, or “Compact” such that RNs who are living
and licensed in one Compact State, can practice
in other Compact States without needing additional
license(s). An estimated 22.9 percent of RNs reported
permanent residency and licensure in Compact States.
The seven largest States, which together cover
more than three-quarters of the nurses eligible
under Compacts, are: Texas (24.5 percent of the
665,593 nurses in Compacts), North Carolina (13.3
percent), Wisconsin (9.4 percent), Tennessee (8.8
percent), Maryland (7.9 percent), Arizona (6.8
percent), and Iowa (5.6 percent).
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