I am on many mail lists for Nursing. This gives me an oppourtunity to gain some insight to "what is out there" in the wide world of Nursing. Perhaps this article will also spark your interest and conguer some interesting conversation here on the board:
By Barbara Drosey-Travetti, Brian W. Ferrie & Timothy A. Mercer
Last year, ADVANCE for Nurses conducted an online salary survey of 11 common nursing specialties. Almost 4,000 respondents shared information regarding their average hourly rate, years of experience, certifications and education.Once we had the raw data in our hands, we shared the information with nurse leaders from around the country. We wanted to see what they might glean for the statistics.Though our survey was an informal one, it did create some interesting dialogue about the state of nursing salaries. The results confirmed some of the concerns regarding nurse pay that already have been expressed in the public arena, including the low salaries offered to nurse educators, and the compression of rates relative to both age and experience level.What's it all mean? Hopefully this review provides a starting point for nurses trying to understand the myriad of factors affecting pay, and helps each individual consider what really is important to his or her bottom line.Med/SurgSix hundred and thirty-three nurses reported working in med/surg at an average rate of $31.13 an hour, slightly higher than the $31.03 overall average respondent salary.Karen Hughes, MS, RN, vice president of nursing at New England Sinai Hospital and Rehabilitation Center in Stoughton, MA, said this was consistent with the salary range at her hospital and with what she has seen med/surg nurses earn in the New England market.She also said ADVANCE's numbers hinted at some of the difficult situations nurse leaders find themselves in when attempting to hire qualified help.For example, "salary compression is a huge concern," Hughes said, speaking to our results regarding wage and experience. In med/surg, nurses with less than 1 year of experience averaged about $23.27 an hour, while a nurse in the same specialty with more than 25 years experience reported making an average of $32.69 an hour."Today, you have to raise the hiring rate to get new grads in the door, but there is only so much money to distribute based on what we are reimbursed for care," Hughes said. "It creates a problem because you cannot raise everyone's salary by the same amount you are raising starting pay. And that's hard when you are trying to make market adjustments and you can't give your senior staff members what you would like."Sally Norton, vice president of human resources for the Visiting Nurse Association of South Central Connecticut, said the same situation is being played out in other specialties like home care."We have a salary grid based on years of experience, but the nursing shortage has forced us to offer higher salaries even to those with minimal experience (1-year +)," she said."Our starting wage for an RN with less than 3 years' experience is $22.32. But if I don't offer new nurses at least $25 to start, they won't even pursue the interview process further."It is also frustrating, Hughes said, not to see increased compensation for achieving certifications. Those med/surg nurses responding to our poll who hold certifications made an average of $30.18, slightly less than those who were uncertified, who averaged $31.65 an hour. Less than 40 percent of med/surg nurses participating in our poll were certified."Achieving certification is valuable to an organization," Hughes said. "We want our nurses to continue their education. But in order to demonstrate that we value this, credential organizations must be willing to reimburse nurses to sit for the exam and recognize the advanced knowledge through their salary."Hughes expressed surprise in the number of master's-prepared med/surg nurses replying to our survey. Approximately 15 percent of our med/surg respondents had master's degrees or doctorate degrees."While it improves patient care to have them practicing at the bedside it raises more questions than can be answered from the results of the survey. Anecdotally I hear of nurse managers and directors of nursing leaving administrative positions and returning to patient care due to the stress and lack of rewards in management positions. Is that supported by the number of master's-prepared nurses responding to this survey?"ORTwo hundred and forty-three OR nurses weighed in with their rate of pay, with an average of $31.27. Certification made a notable positive difference in this group, with noncertified pay rates averaging $28.15 and certified nurses making $33.79 on average.While the numbers weren't surprising to Sheila Everly, MS, RN, CNAA,BC, FACHE, vice president and chief nurse executive at Medical City Dallas Hospital, she was impressed by the number of OR nurses who were certified-nearly 50 percent of those who responded."I would like to see more certifications [among all the specialties]," said Everly.Following a big jump (upward of $10 an hour) in the first 5 years of employment, rates actually decreased and leveled off until the group holding more than 16 years experience, where the rate again rose and slightly increased among the responders with more than 25 years experience.Education generally had a positive impact on salary, although the associate degree nurses made the least, with diploma nurses actually earning more than their peers with bachelor's degrees."It is hard to make interpretations without looking at it in a multivariate way," said Bette Case, PhD, RN,C, editorial nurse consultant, Clinical Care Solutions, Chicago. "We can see that sometimes diploma nurses earn more than those with more advanced education. However, it is likely that it's because most diploma nurses are older and, therefore, it is probably their tenure and not their education that commands the high rate."
It is perhaps no surprise that the 364 ED nurses participating in our poll reported making more than almost all other specialties polled-an average of $31.67 an hour. Only nurses in critical care and ambulatory settings reported making more.However, the discrepancy between our ED and critical care results-641 critical care nurses reported making an average of $33.51 an hour-were a bit odd, according to Kathleen Guyette, MSN, RN, vice president and associate chief nursing officer of the University of North Carolina Hospitals.She said many people would consider ED nursing akin to critical care nursing, "and yet in the results, ED salaries are more in line with med/surg salaries, so that difference is an interesting one to me."Some of this could be due to responses from nurses working in emergency satellite offices, in which case the outpatient nature of the work might account for some of the difference, Guyette added.Certification did not seem to have a large impact on ED nurse salaries, with noncertified nurses reporting average hourly wages of $30.82 and certified nurses averaging $31.30 an hour. About 53 percent of participating ED nurses were certified.Experience did not translate to substantially more pay either. Only $7.21 separated the average hourly rate of ED nurses with 1 year or less of experience and those with 25 years or more under their belts.Guyette shed some light on the predicament."Our organization, like many others, has begun to look at our salary increases as purely performance-based, so once we get to that market reference point, a nurse has to meet and preferably exceed the performance expectations to earn more than that. Experience in and of itself is not necessarily going to equate to a higher salary."There also was compression in our results concerning positional pay. The average ED staff nurse reported making $30.06 an hour, while the average for an ED nurse manager was only 4 cents higher, or $30.10.Equally noteworthy was the fact that staff development nurses in most specialties made more than the staff nurses, but staff development nurses in ED reported making almost $3 less per hour than staff nurses.Critical CareCritical care nurses were the most represented group in the survey. The 641 nurses who responded in this field earn, on average, $33.51, the highest average rate of the 11 specialties polled.Of all the specialties polled, critical care nurses also reported the greatest percentage (49 percent) of BSN-prepared nurses and the highest paid group of staff nurses at $32.66 per hour."I believe [BSN-prepared nurses] are more of a trend in critical care because they are better prepared to handle the rigors and intellectual challenges of critical care nursing," said Nicholas O'Hearn, MSN, RN, CCRN, CNRN, senior director, critical care, University of Chicago Hospitals, Chicago. "I prefer to hire BSN-prepared nurses-they are more well-rounded in their education and as individuals, and tend to have a more solid base in pathophysiology and research-based practice."Diploma nurse
responders reported an average of $30.36; master's-prepared critical care nurses make an average of $35.59 per hour. Similar to those working in the ED, certification for critical care nurses did not seem to positively affect pay. In fact, our poll showed that certified nurses in this specialty earn actually slightly less ($32.39) than those who are not certified ($32.88). Behavioral HealthWith an average rate of $31.43, behavioral health was one of the mid-range specialties in the survey, higher than six of the other specialties, lower than four, and earned 40 cents more per hour than the average nurse in the entire survey.That was surprising to Alain Bois, BSN, RN, director of nursing at Forest Hill Rehabilitation Center, and nurse manager of children/adolescent psychiatric services at Northern Maine Medical Center, Fort Kent, ME."That is not what I expected," he told ADVANCE. "I thought it would be a little bit less because it's been my experience that some other disciplines or areas of nursing might not consider behavioral health to be a challenging and rewarding specialty."Bois said this perception might necessitate higher compensation rates, so nurses would be attracted to the specialty. "Because depending on where you work and the type of population you work with-I manage a child and adolescent psych unit-there's a certain level of verbal abuse you take from the kids. They'll try to spit at you sometimes or hit or bite you, and sometimes positions might be a little more difficult to fill [than in other specialties]."Bois also emphasized how region can play a part in compensation."One thing I want to say is these numbers are significantly higher than what we are experiencing in northern Maine," he said with a laugh. "But it's also true that the cost of living is probably a lot less here than in other places. We can still go to the movies and get our ticket, popcorn and soda for $5.50."Long-Term CareAccording to a national sample survey of RNs in the United States, approximately 152,894 nurses work in nursing homes or some other type of extended care setting (Health Resources and Services Administration, 2000). The ADVANCE survey revealed some good news for this group of RNs; earning certification and advancing education appear to have a positive effect on salary.Among our 321 long-term care (LTC) responders, the average rate was $30.73 per hour. LTC nurses with certification earned a slightly higher average of $31.86 (click on Fig 5), those with BSNs earned about the same while master's-prepared responders reported an average rate of $35.24.Margaret Chizek, MBA, BSN, FNP, AAS, CLNC, risk management and legal nurse consultant, Chizek Consulting Inc., Chicago, who works nearly exclusively in LTC, said she found a couple of the conclusions both unsettling and surprising."I consistently hear that LTC nurses make less money [than other specialties]. However, based on this data, variables other than salary are factors in the LTC segment recruitment and retention of nursing staff," said Chisek. "I was frankly shocked at the lack of variation in salary for these nurses compared to other settings. I also was interested in the salary differential based on training, as the diploma nurse made less on average than the associate degree nurse."Tenure appeared to make a marked difference in LTC salaries. During the first 5 years of employment, our responders' rates rose steadily and jumped again among the group with more than 25 years experience. (click for Fig. 11).AmbulatoryNurses working in ambulatory settings reported making $31.76 an hour, the second-highest hourly rate of the 11 specialties polled.Certification played a large role in earning a greater salary in the field of outpatient and same-day surgery nursing. Certified ambulatory nurses responding to our survey reported earning an average of $34.45, as opposed to the $29.42 earned by those without certification.Pay rates rose incrementally based on level of responsibility. The position held by the majority of respondents-staff nurse-earned an average of $28.72. Rates vary widely in this specialty when it comes to level of education (click for Fig. 12). Master's-prepared ambulatory RNs reported the highest rate at $35.43, and most of them appear to hold advanced practice or staff nurse positions.Case stressed the importance of noting the variety of positions in relation to education."I think the range within specialties is influenced by what job the nurse does," she explained. "For example, there's a big range in ambulatory. The jobs the master's-prepared RNs are doing seem to be mostly administrative and advanced practice positions, although there are a greater number of master's-prepared staff nurses than administrators."Still, assumptions cannot always be made concerning positions, education and salary, none of which consistently dictate highest pay rates. While compensation at the clinics of DuPage Medical Group, Glen Ellyn, IL, is not directly in line with the ADVANCE survey results, Audrey Reineberg, recruitment manager, finds this to be true in her own hiring practices."We are not currently differentiating [pay rates] on education, but rather the experience [the nurse has]."But as Guyette and Hughes noted earlier, hospitals are not always in a position to compensate accordingly for experience. In other words, there's no one factor that is going to get you a better salary.Home HealthThe 211 nurses practicing in home health who responded to our survey made an average of $31.53 an hour (click for Fig. 4). Only ED, critical care and ambulatory nurses reported averaging more per hour.Sally Ann Corbo, EdS, RN, CNAA, president of Epicare Associates Inc., West Caldwell, NJ, said several specialties like home health seem to be holding their own in terms of pay when compared with figures from 10-15 years ago."There is not as much difference between specialties like critical care, which has traditionally been seen as high-skill, and behavioral health, so it seems people are realizing each specialty has its own unique demands and required skill sets."Because home health is provided on an outpatient basis, other factors come to bear on our results. "In any of the outpatient settings, we are bound to see some state-to-state differences," Corbo admonished.Reimbursement is the biggest variable affecting outpatient rates, she explained. Some states might reimburse providers better than others for some services, particularly in states where home health helps deliver care to a largely rural population. Also, the services provided under the umbrella of "home health" can vary widely.Marvin Siegel, RN, CRNI, is director of nursing for Town Total Health of New York City. He said the way in which reimbursements are determined has been one of the biggest changes in home health he's seen during the past decade. That's affected the pay for specialty infusion nurses like the ones he works most closely with."In home health, if you had a CRNI certification 10 years ago, you could command a lot of money. Not as many nurses had the necessary infusion skills to start various lines, so reimbursement at the time paid them for their specialty procedure."Reimbursement rates now are paid in x number of dollars for a given nursing visit, basically a flat rate for the visit, no matter what procedures are performed," Siegel continued. "That means care providers are not going to pay for the specialty expertise, and those with expertise with one type of infusion need to become skilled in several to remain marketable."Norton, of the Visiting Nurse Association of South Central Connecticut, said she was surprised by the average rates rendered in our poll. "We are lower here at our agency and in Connecticut in general. Our max of the range is $27.50. The Connecticut Association for Homecare reports the average salary for a home care RN is $25.37."Norton said her nurse managers earn about $2 an hour less than what was reported in our poll, and they generally earn only a few dollars more an hour than the staff nurses. "So, it surprises me that, in this survey, staff nurses earn $30.83 and nurse managers earn less at $29.73."In our survey, home health nurses with certification in their specialty reported making $29.52 an hour, while those without certification reported making $30.57 an hour. Norton offered some insight into this perhaps surprising result."We pay $1,000 more per year for a specialty skill such as experience in maternal-child health, IV, cardiac or mental health," Norton said. "They do not necessarily have to possess a certification in those areas, but they must have at least 1 year of specialty experience we can verify through references."The majority of our nurses are not certified in a specialty," she added. "We really only see certifications on our IV team."HospiceCertainly, hospice nurses might feel they deserve more compensation. At $26.19 an hour, their average rate was the lowest of the 11 nursing specialties that were surveyed-nearly $5 less than what the average nurse overall in the survey made.Susan Rogers, MS, BSN, CHPN, director of public and professional education for the Institute for Education and Leadership at The Hospices of the National Capital Region, Fairfax, VA, was not surprised by this statistic."Hospice nurses are notoriously underpaid," she said. "There's just not a whole lot of money in hospice."But Rogers, who has been an RN for 40 years and has spent 15 years in hospice, added the compensation statistics have no affect on her level of satisfaction with hospice."Originally, I just thought it was something I wanted to try. I loved it and I stayed."Years of experience did not have the gradually increasing effect on hospice nurse salaries that you might expect, but for the most part, education level did have a predictable impact. Associate degree nurses averaged $23.85 per hour, BSN nurses $27 and MSN nurses $28 an hour. The anomaly in this case was that diploma nurses in hospice ($27.29) averaged more than BSN nurses.Certification definitely pays in hospice, the survey revealed. Among hospice nurses who were not certified in their specialty, the average hourly rate was $24.94, while those who were certified earned $27.42.Because the compensation level is lower than other nursing specialties and a host of other issues, Rogers feels it requires a certain kind of person to want to go into hospice and succeed at it."It really takes someone who cares about human beings and quality of care," she explained. "I think it's the kind of care all people should receive-a model for healthcare in the United States, because it looks at the person rather than the disease."Rogers does think nurses generally-and hospice nurses specifically-deserve greater compensation."Obviously, I believe nurses should make more money," she said. "The work they do in hospice, and palliative care in particular, is exemplary. And it does take a very special person to work in this area."
Community HealthCommunity health represented another of the lower paying specialties that ADVANCE surveyed. At an average rate of $29.05 an hour, it was the only specialty besides hospice to average less than $30, and was nearly $2 less than the $31.03 made by the average nurse responding to our survey.Like Rogers, Barbara Mallory, MSN, RN, a director at Healthy Solutions Inc., Sharon Hill, PA, which specializes in community health and immunization programs for Delaware County, was not caught off guard by the lower average rate made by nurses in her specialty."It doesn't surprise me, because it seems to be a tradition in healthcare and most professions that compensation is based on supply and demand," she told ADVANCE. "And right now there is a desperate need for nurses in acute-care settings and hospitals."For the most part, increasing experience level had a predictable impact on hourly rates in community health, and the same could be said of educational background. BSN nurses averaged $27.41 an hour, MSN nurses $33.38 and doctoral nurses $35.75. One interesting result, however, was that diploma nurses averaged significantly less per hour ($22.76) than associate degree nurses ($25.92). Certification also revealed a unique dichotomy, in that those who were certified actually averaged less per hour ($28.25) than those who were not ($29.59).Mallory related that she is very satisfied with her specialty despite its lower average pay rate than other nursing specialties."There are so many opportunities and nurses can play such a great role in this setting," she explained. "I remember when I first entered the profession [as a graduate from an associate degree program]. I thought in order to be a nurse you needed to be in the ICU with a lot of tubes."Later, while pursuing her BSN, Mallory had what she called a "light bulb experience.""It occurred to me that if we did a better job of keeping people healthy outside the hospital, there wouldn't be such an incredible need for heart transplants and ventilators."Though she remains happy and satisfied with her specialty, that doesn't mean she thinks it is right for community health nurses to be paid less, on average, than nurses in most other nursing specialties."Certainly, that's still an issue for me," she said. "I think it continues to be a challenge for community health nurses to demonstrate our value in keeping people well. We need more research and to be more vigilant in documenting our experiences, effectiveness and areas for improvement."Mother/BabyAs a specialty, the average rate for a mother-baby nurse ($31.19) was one of the closest to the average rate overall for nurses in the survey ($31.03).When asked if that's what she would have expected, Kim Armour, MSN, APN, CNP, RDMS, maternal-fetal nurse practitioner/sonographer and manager of maternal-fetal services, Central DuPage Hospital, Winfield, IL, said, "I would expect [the mother/baby rate] to be in the middle among subspecialties. I guess it has a lot to do with what region you're working in, the acuity of the patients and also how many years these nurses have been practicing."Armour noted, however, that when she was considering which nursing specialty to pursue, comparative compensation did not enter her mind. Still, she thinks a pay rate should be fairly based on how much work she does and how committed she is to her work."I think people should be appropriately compensated for how dedicated they are, how much responsibility they take on and their educational level. And I feel sometimes in nursing we're not. There are many people who really don't understand that patients come to a hospital for nursing care as well as physician/medical care."Armour is not shy about trying to earn the pay she feels she deserves. In the past, she had worked as a staff nurse at a physician's office in Upstate New York. But after she earned her bachelor's and master's degrees and nurse practitioner credentials, the physician was not willing to pay her any more than she could have made as a night-shift staff nurse at the local hospital.With the support and encouragement of an NP colleague, Armour left that job and has more than doubled her previous income by looking into other options."I really think you're worth what you believe you're worth based on your job performance," she told ADVANCE. "There's no harm in asking. And all you have to do to acquire the compensation you deserve is make someone else understand how valuable you are." ResourceThe Health Resources and Services Administration. (2000, March). The registered nurse population. Retrieved Jan. 28, 2004 from the World Wide Web: http://bhpr.hrsa
gov/healthworkforce/reports/rnsurvey/rnss1.htmBarbara Drosey-Travetti is assistant editor, Brian W. Ferrie is senior associate editor and Timothy A. Mercer is associate editor at ADVANCE.