Chapter II

The National Sample Survey of Registered Nurses (NSSRN) 2000 provides information about the current profile of RNs with an active license to practice (the registered nurse population) in one or more of the fifty States and the District of Columbia. This study has been conducted every four years since 1980 and examines trends over time of the Nation’s largest health profession.

The registered nurse population increased by more than one million between November 1980 and March of 2000. In March 2000, 2,694,540 persons were estimated to have licenses to practice as RNs in this country, an increase of 62.2 percent since 1980. The years between 1996 and 2000 marked the slowest growth in the RN population over the 20-year period between 1980 and 2000. On average, the RN population grew only about 1.3 percent each year between 1996 and 2000 compared with average annual increases of 2-3 percent in earlier years. This slow down in growth reflects fewer new entrants to the nurse population coupled with a larger volume of losses from the nurse population than in earlier years. (See Chart 1).

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In the last two decades the number of RNs employed in nursing increased 72.9 percent (from 1,272,851 in 1980 to 2,201,813 in 2000). Almost 77 percent of the RN population was employed in nursing in 1980, and that percentage grew to a peak of 82.7 percent in 1996. In 2000 an estimated 81.7 percent of those with active licenses were employed in nursing. Despite this slight drop in the percentage of licensed RNs employed in nursing between 1996 and 2000, the total number employed in nursing increased by 85,998. During this period, the number of RNs employed in nursing grew by an average annual rate of only one percent, the lowest of any four year interval between surveys.

The number of RNs employed full-time in nursing increased from slightly less than 1 million to more than 1.5 million between 1984 and 1996. In 2000, this number continued to increase but at a slower rate than in previous years. The sharp increase in the number of RNs employed full-time in nursing between 1984 and 1996 was mirrored in an increasing percentage of nurses employed full-time (from 52 percent to 59 percent). In contrast, while the number of full-time nurses increased slightly from 1996 to 2000, the percentage was virtually unchanged.

The number of RNs not employed in nursing changed little from 1980 to 1992, although the total number of RNs grew substantially during those years. However, between 1992 and 2000 the number of RNs not employed in nursing increased about 28 percent. Between 1996 and 2000 the proportion of RNs not employed in nursing increased slightly among the total RN population (from 17.3 percent to 18.3 percent).

EDUCATIONAL PREPARATION

One of the most substantial changes in the RN population over the past 2 decades has been in the type of program RNs enter to obtain their basic nursing education. Between 1980 and 2000 the percentage of nurses who received their basic education in diploma programs decreased from 60 percent (1,050,661 nurses) to 30 percent (800,000 nurses) of the RN population. During the same period, the percentage receiving their basic education in associate degree programs increased from 19 percent (308,616 nurses) to 40 percent (1,087,602 nurses) of the RN population; and the percentage receiving basic nursing education in baccalaureate programs increased from 17 percent (287,993 nurses) to 29 percent (791,004 nurses) of the RN population. (See Chart 2).

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Between 1996 and 2000, the number of RNs who received their basic education in baccalaureate programs increased at a higher rate than those who received their basic education in associate degree programs (increases of 17 percent and 13 percent, respectively). This was a reversal of the trend for earlier years of the past two decades when the number of nurses educated in associate degree programs increased at a faster rate than those who received their basic education in baccalaureate programs. The number of nurses who received their basic education in diploma programs declined steadily during the period from 1980 to 2000. However, the 12 percent decline between 1996 and 2000 was substantially greater than the declines during any of the earlier years.

The distribution of RNs according to their highest education level, which incorporates any post-RN degree received, also has changed substantially over the past two decades. In 1980, the diploma was the highest educational level of the majority of nurses. Since 1996 nurses with associate and baccalaureate degrees have had the largest presence among the RN population. In 2000, 34.3 percent of nurses reported the associate degree as their highest level of education and 32.7 percent reported the baccalaureate degree as their highest level. (See Chart 3).

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The number of RNs whose highest level of preparation was either a masters or a doctorate tripled over the period. In November 1980, RNs with masters or doctorate degrees were estimated at 86,000 or 5 percent of the RN population. In 2000, they numbered 275,068 or 10 percent of the RN population.

AGE

The National Sample Survey of Registered Nurses documents the continuing trend in the aging RN population in 2000. In 1980, the majority (52.9 percent) of the RN population was under the age of 40, while in 2000 less than one-third (31.7 percent) were under 40. The major drop was among those under the age of 30. In 1980, 25.1 percent of RNs were under the age of 30 compared to only 9.1 percent in 2000. In 1980, 40.5 percent of RNs were under the age of 35 compared to 18.3 percent in 2000. The average age of the RN population was 45.2 in 2000 compared to 44.3 in 1996.

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Men still comprise a very small percentage of the total RN population although their numbers have continued to grow. Of the estimated 2,694,540 RNs in the US, 146,902 or 5.4 percent are men. This is a 226 percent increase in the number of male RNs in two decades. In 1980, the number of men in the RN population was estimated at 45,060 or 2.7 percent of the RN population. Each of the surveys indicates that the number of men has grown at a much faster rate than has the total RN population.

Comparisons of the racial/ethnic composition of the RN population in 2000 with previous years should be interpreted with caution. In accordance with Office of Management and Budget (OMB) guidelines, the question regarding racial and ethnic background in the 2000 study was changed from previous surveys. Unlike previous surveys, which included a single question and asked the respondent to choose only one racial/ethnic background, the 2000 survey collected this information in two questions. Respondents were asked to indicate whether their ethnic background was Hispanic/Latino or not and also were asked to identify all races that described them. The 2000 survey information was aggregated to categories similar to those reported in previous years, with one additional category that includes non-Hispanic RNs who reported two or more races. The number of nurses in this new category is estimated to be 32,536 or 1.2 percent of the RN population.

The number of nurses identifying their background as one or more racial minority groups or Hispanic/Latino numbered 333,368 in 2000. This is nearly triple the number of nurses estimated to be minorities in 1980. Minority RNs grew at a greater rate than non-minority RNs for all of the years from 1980-2000, except the period from 1984-1988 (see Chart 5). The difference in the growth rates for the two groups of nurses is especially pronounced in the period from 1996 to 2000 (see Chart 4). During those years the number of minority RNs increased about 35 percent while the number of non-minority RNs increased about 2 percent. Most of the increase in the RN population between 1996 and 2000 was a result of the growth in the minority nurse population. However, because the population of non-minority nurses is 7 times larger than the population of minority nurses even small percentage changes in the non-minority nurse population involve a much larger volume of nurses.

The representation of minority nurses among the total nurse population increased from 7 percent in 1980 to 12 percent in 2000. Despite these increases, the diversity of the RN population remains far less than that of the general population where minority representation was more than 30 percent in 2000. (See Chart 6).

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The groups comprising the minority RN population differ in the rates at which their numbers have increased over the last two decades. The number of nurses from American Indian/Alaska Native and Asian/Native Hawaiian/Pacific Islander backgrounds showed the highest relative increases over the period from 1980 to 2000, 197 and 207 percent, respectively. Hispanic/Latino nurses increased by 164 percent, while the increase for African American/Black nurses is estimated at 119 percent. Despite these impressive growth rates the actual numbers of minority nurses remain relatively small.

Growth in the number of African American/Black and Hispanic/Latino nurses in the years between 1996 and 2000 was greater than during any other four-year period between 1980 and 2000. The largest relative increase was among Hispanic/Latino nurses, with a 35.3 percent increase followed by African American/Black nurses with an increase of 23.7 percent. Hispanics, despite showing the largest relative increase between 1996 and 2000 remain the most underrepresented group of nurses when compared with the representation of Hispanics in the population. Only 2 percent of the RN population are Hispanic nurses although Hispanics comprise 12.5 percent of the general population.

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EMPLOYMENT SETTINGS

RNs are employed in a variety of facilities, settings and service delivery systems and substantial changes in the health care delivery system over the past two decades have had major effects on the settings in which nurses are employed. Hospitals, public/community health settings, ambulatory care settings, and nursing homes/extended care facilities continue to be the major employment settings for nurses although there have been substantial shifts in the mix since 1980, as Chart 7 illustrates. Each NSSRN survey since 1980 revised the questionnaire and expanded the choices available to nurse respondents for identifying the types of facilities, institutions and service delivery systems in which they were employed. Despite these data collection changes, major employment sectors are sufficiently distinct to allow adjustments in the data in order to analyze trends in the employment settings of nurses over the past two decades.

Hospitals remain the major employer of nurses although the number of nurses employed in other sectors has increased. The number of RNs employed in hospitals increased by nearly one-half million between 1980 and 2000. However, reflecting the growth in nurse employment in other sectors, the percentage of the nurse workforce employed in hospitals, after a peak of approximately 68 percent in 1984, declined steadily. In 1980, approximately 66 percent of employed RNs worked in hospitals; by 2000 the proportion had declined to 59 percent.

Public and community health, ambulatory care, and other non-institutional settings had the largest percentage gain in RN employment between November 1980 and March 2000. RNs employed in public health and community health settings increased by 155 percent and those employed in ambulatory care settings increased by 127 percent between 1980 and 2000. (See Chart 8).

The number of nurses employed in nursing homes and other extended care facilities, although 51 percent higher in 2000 than in 1980, decreased between 1996 and 2000 following a substantial increase between 1992 and 1996. This decline in nursing home employment occurred among nurses of all ages except those between 45 and 54 years of age; but was especially sharp for younger nurses. The number of nurses under 45 years of age who were employed in nursing homes and other extended care facilities in 2000 was 18 percent lower than the comparable number in 1996.

The number of nurses employed in nursing education changed little during the past two decades. This lack of change in the number of nurses in nursing education coupled with an increase in the total number of nurses resulted in a decline in the proportion of employed RNs who are educators. In 1980, 3.7 percent of all RNs employed in nursing were in nursing education, in 2000 the comparable percentage was 2.1.

For the purposes of this discussion, the term ‘earnings’ is used to collectively represent salaries and/or earnings. Actual earnings are those earnings self-reported by survey respondents.

Changes in overall average earnings for RNs between November 1980 and March 2000 are shown using two separate measures. The first measure is the ‘actual’ average earnings reported by RNs employed full-time, and the second measure uses the consumer price index (CPI) for urban consumers to adjust for the changes in the purchasing power of the dollar against the actual earnings of full-time employment.

In examining the extent to which average RN earnings have increased over the years, and the related economic demand for RNs, it is important to consider how earnings have increased during times of relatively high inflation as well as during times of relative stability in the cost of living. However, inflation is only one of the factors influencing the size of increases in RN earnings over time.

The highest increases in actual annual earnings (35.1 percent) were experienced during the period between November 1980 to 1984, followed by a 33.2 percent increase in average earnings between March 1988 and 1992. These were times of relatively high increases in the cost of living. These were also periods when nurses were being actively sought for employment. There were substantial increases in the supply of RNs in the workforce from 1977 to 1984. There was also a perceived nursing shortage from 1988 to 1992. For these reasons, the substantial increases in actual earnings, far greater than would be expected just from the CPI levels, may reflect economic demand by employers for RNs.

The average actual annual earnings of RNs employed full-time in March 2000 was $46,782, 11.2 percent higher than in March 1996. This is similar to the 11.5 percent increase between 1992 and 1996. The eight years from 1992 to 2000 were relatively stable in the cost of living, where the CPI increased about 10 percent over each 4-year period. Thus, it appears that nearly all of the increases over each of these four-year periods may be due to inflationary factors.

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The second measure for assessing trends in average earnings utilizes the consumer price index. Obtaining the trends over time in ‘real’ increases in RN earnings is possible after accounting for the changes in purchasing power of the dollar from the reported earnings found in each respective Sample Survey. For example, the increase in real earnings that RNs experienced between March 1988 to 1992 (11.2 percent) was large and almost equalled by the increase (9.7 percent) experienced between 1980 to 1984. These increases in earnings also occurred during periods when the supply of employed nurses increased substantially. These combined facts suggest that there was a significant economic demand for RNs over this period.

In contrast to the large real earnings increases from 1980 to 1984 and 1988 to 1992, real earnings were relatively stagnant over the years from 1992 to 2000 (see Chart 9). On an annual basis, the CPI averaged about 2.4 percent annually over the 1996 to 2000 period, or about 10 percent over four years. At the same time, RNs who were employed full time in nursing saw earnings increases of roughly the same magnitude as the CPI; their actual earnings increased annually at an average rate of 2.7 percent. Any changes in earnings since March 2000, which may reflect changes in demand for RNs in the health care marketplace, are not reflected in these figures.