Ernell Spratley
Ayah Johnson, Ph.D.
Julie Sochalski, Ph.D.
Marshall Fritz, M.S.
William Spencer

U.S. Department of Health and Human Services
Health Resources and Service Administration
Bureau of Health Professions
Division of Nursing

The Health Resources and Services Administration, Bureau off Health Professions, Division of Nursing is the key Federal focus of information regarding nursing education and practice in the U.S. It provides national leadership to assure an adequate supply and distribution of qualified nursing personnel to meet the health needs of the nation. In support of this responsibility, the Division maintains comprehensive data and analysis of current and future nursing personnel resources and requirements. The acquisition and the presentation of data on the registered nurse population and its characteristics are an essential part of the Division’s program.

The National Sample Survey of Registered nurses is the Nation’s most extensive and comprehensive source of statistics on all those with active licenses to practice in the United States whether or not they are employed in nursing. It provides information on the number of registered nurses, their educational background and specialty areas; their employment settings, position levels, and salaries; their geographic distribution; their personal characteristics including gender, racial/ethnic background, age, family status, and, in this study, satisfaction with their job.

The development of a design for collecting data through national sample surveys of registered nurses originated in July 1975 in a contract with Westat, Inc. Subsequently, the Division of Nursing conducted seven national sample surveys. Reports for six studies, those conducted in September 1977, November 1980 and 1984, and March 1988, 1992, and 1996, have been published and made available to those involved in health care planning and evaluation as well as to the public. This publication is the report of the seventh study, conducted in March 2000.

The data collection for this study was carried out by Research Triangle Institute through a contract. The report was authored by Ms. Ernell Spratley, Dr. Ayah Johnson, Dr. Julie Sochalski, and Mr. Marshall Fritz. Mr. William Spencer programmed and summarized the data into tables. Ms. Lisa Gentry formatted the report for printing. Ms. Dena Saunders provided secretarial assistance and Ms. Carol Jordan provided editorial services. The Division of Nursing is pleased to make this important information on the nation’s registered nurse resources available through the report.

Since its inception, the Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing has had primary responsibility for the assessment and examination of the Nation’s nursing workforce. This responsibility includes examination of the supply, the composition, and the distribution of nurses nationally and on a State level. The Division of Nursing has worked with other agencies within Federal and State governments, and with various nursing organizations in the development of methods for the study and acquisition of data on the nurse population.

The ANA conducted a similar study in 1951, but decided to mail the questionnaires with the license renewal notices to registered nurses (RNs) in each State. About 71 percent of the questionnaires were returned. This change in data collection methodology improved the response rate but lengthened the data collection period because of variation in renewal dates from State to State. The number of nurses who had licenses to practice in 1951 was estimated using the same estimation procedures used in the 1949 inventory: elimination of duplication due to RNs’ licensure in more than one State, and accounting for nonrespondents to the inventory.

The nursing inventories were based on data collection at the State level using the licensing mechanism as an opportune time for asking registered nurses to complete a questionnaire. This data collection process, although logical and potentially comprehensive, encompassed some serious limitations. The size of the questionnaire had to be limited and follow-up on forms not returned, missing data, or ambiguous data were not part of the data collection process. Moreover, the wide variation in renewal dates from State to State led to a lengthy data collection period. It took as long as three years to present a national picture through analysis of data from all States.

The sample survey collected data as of March 2000. Research Triangle Institute, under a contract with the Division of Nursing, carried out the sample selection, data collection, and processing of this study. This report summarizes results of the study.

As in previous NSSRN studies, the data collection instrument responds to specific data requirements cited in section 951 of P.L. 94-63 and provides the necessary base data for developing projections of the supply and distribution of and requirements for registered nurses. It also contains some new areas of inquiry designed to provide information on issues of current importance. However, as in prior studies, the survey instrument was designed to ensure that the data collected from study to study provides sufficient continuity so that an evaluation can be made of trends in nursing resources.

In this study series, samples were drawn for each State’s list of active licensees, because no single unduplicated list of licensed registered nurses exists in this country. Disproportionate sampling from State to State was used to provide statistically improved estimates of the number of nurses in each State while maintaining the overall sample size within reasonable bounds. Larger proportions of licensees were sampled in the States with fewer registrants than in States with more registrants. In the 2000 study, the sampling methodology included oversampling of minority RNs into the sample. The intent was to increase the sample size for minorities so as to provide more reliable estimates for this group of the RN population. A weighting procedure was used to account for duplication of licenses from State to State so that estimates could be developed of the number of individuals who hold active licenses to practice as RNs regardless of the number of State licenses they hold. Based on March 2000 data, over 3,066,000 licenses to practice as registered nurses in the United States were held by an estimated 2,696,540 nurses.

The initial sample selection for this survey consisted of about 54,000 licenses of which 4,520 were identified at the time of selection or in subsequent data collection as duplicates for nurses licensed in other states or other frame errors. Ninety-seven registered nurses listed as having active licenses were identified as deceased. After taking account of duplications and sample selection errors, the overall response rate was estimated at 72 percent. Responses from a total of 35,579 individual nurses were used to derive the data. This report primarily presents data and analysis of those RNs who, as of March 2000, were employed in nursing in the United States, or, if not employed in nursing, reside in the country—35,358 of the 35,579 respondents fit this definition of location.

To ensure an adequate response to the survey, three mailings were sent out, and these were followed by telephone interviews of those who did not respond. Unlike previous iterations of the RN study, the packages for the third mailing were shipped via Federal Express in an attempt to improve responsiveness. In addition to the efforts to reduce the nonresponse to the survey, careful screening of responses was undertaken to minimize ambiguous responses and nonresponse to individual questions.

Questions on the survey instrument were prioritized as to their importance to the overall registered nurse database, and the degree to which a question might be sensitive in nature. A response rate goal was established for each question. Based on the priority rankings and the response rate goals, respondents were called to clarify the response made or to obtain the missing information. When a call was made concerning a high priority question, the respondent also was queried about any other ambiguous or missing items regardless of their priority order. All respondents to the survey were classified according to whether they were employed in nursing as of March 2000, and also according to State of residence and/or employment.

In addition to the identification and follow-up of missing data, items specified in the "other" categories within the questions were reviewed and reclassified to already stated categories if possible. The remaining ones were reviewed to determine whether there was a sufficient number of a particular response to warrant a separate itemization.

The substantial database resulting from the 2000 study may be used for many different types of analyses concerning a variety of subjects. This report presents an overview of the personal, professional, and employment characteristics of the almost 2.7 million registered nurses in the country as of March 2000. A summary of the findings from the study and some comparisons to the findings of prior studies in this series, are presented in the succeeding chapters. Appendix A contains a series of tables summarizing the data. A review of the survey methodology and the statistical techniques used in sample selection, response weighting, and identification of sampling errors are found in Appendix B. The survey instrument is included in Appendix C.

In March 2000, an estimated 2,714,671 individuals had current licenses to practice as RNs in the United States. Of these, 2,696,540 were located in this country, 9,831 were located outside the United States and the District of Columbia, and 8,300 who were listed as having an active license to practice were identified as deceased. The data in this report focus on RNs located in the United States. RNs are considered to be located in the U.S. 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 U.S. Of the 2,696,540 RNs located in this country, 81.7 percent or 2,201, 813 were employed in nursing (see Appendix A, Table 1).

The average age of the total RN population (including those who are retired and not employed in nursing) was estimated as 45.2 years in March 2000, the highest since the survey series was initiated. Only 9.1 percent of the RN population were under the age of 30, 18.3 percent were under the age of 35 and 31.7 percent were under the age of 40. (See Appendix A, Table 1). Despite the increasing age of RNs, the percent of RNs who are employed in nursing continues to be at a relatively high level.

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 basic nursing education programs who have been entering the RN population.

The average age of an RN who graduated from a basic education program in the five years preceding the March 2000 study, was 30.9 years compared to 23.9 years for those who had graduated 16 or more years before the survey (see Appendix A, Table 5).

The average age of graduates from basic nursing programs varies by type of program. Graduates of associate degree programs tend to be older than diploma graduates, while baccalaureate graduates tend to be the youngest. The average age of graduates from the basic nursing programs during the five-year period preceding the 2000 survey was: 33.2 for associate degree graduates, 30.8 for diploma graduates, and 27.5 for baccalaureate graduates. Data show that, for each type of basic education program, the average age at graduation is higher for those who graduated in 1995 and later than for those who graduated in the years prior to 1995. (See Chart 10).

[D]

However, age at graduation has increased less among 1990 and later graduates than it did among those who graduated prior to 1990 (see Appendix A, Table 5).

With respect to the type of program in which they received their basic nursing education, differences between male and female RNs are found in the proportions graduating with either a diploma or an associate degree. Approximately 15 percent of male RNs graduated from diploma programs, compared with 30 percent of female RNs; and 53 percent of male RNs graduated from associate degree programs, compared with 40 percent of female RNs.

These gender differences can also be observed in the highest educational preparation of RNs. Diploma preparation is more likely to be the highest preparation of female RNs than of male RNs, while males RNs are more likely to have associate degree preparation. Men and women are comparable in the percentages prepared at the baccalaureate and higher levels. (See chart 11).

[D]

An estimated 333,368 RNs, (12 percent) came from racial and ethnic minority backgrounds. Of these RNs, 133,041 were African American/Black (non-Hispanic); 93,415 were Asian; 54,861 were Hispanic/Latino; and, 13,040 were American Indians/Alaska Natives. For the first time in the survey series, estimates also are available of the number of Native Hawaiian and Other Pacific Islander RNs apart from the Asian total – an estimated 6,475; and of non-Hispanic RNs who reported two or more races – an estimated 32,536.

RNs from minority backgrounds were more likely than non-minority nurses to be employed in nursing and to work full time. Eighty-six percent of minority nurses were employed in nursing compared with 81 percent of non-minority nurses. Minority nurses employed in nursing were also more likely than non-minority nurses to be employed full time. The percentage of the workforce employed full time ranged from 77 percent for Hispanic/Latino RNs to 86 percent for African American/Black, Asian, and Native Hawaiian and Other Pacific Islander RNs. In comparison, 70 percent of employed non-Hispanic White RNs worked full time.

With the exception of RNs from Asian, Native Hawaiian and Pacific Islander backgrounds, most RNs receive their basic nursing preparation in associate degree programs. The proportion of RNs who received basic nursing education in associate degree programs ranged from 40 percent of white nurses to 57 percent of American Indian/Alaska Native nurses. White nurses were more likely than other nurses to have received their basic nursing education in diploma programs. Thirty-one percent of white nurses were prepared for RN licensure in diploma programs compared with 16 to 25 percent of minority nurses. On the other hand, the majority (54.3 percent) of RNs from Asian backgrounds and Native Hawaiian and Pacific Islanders (55.7 percent) received basic nursing education in baccalaureate programs.

Chart 12 illustrates how racial/ethnic groups compare in terms of highest educational preparation. Asians, Native Hawaiians and Other Pacific Islanders; and African Americans/Blacks were more likely than all other nurses to have at least baccalaureate preparation. Native Hawaiian and Other Pacific Islander, African American/Black, and white nurses were the racial/ethnic groups with the highest percentages of masters or doctoral degrees.

Nurses who had been health occupation workers just before entering a basic nursing education program tended to enroll in associate degree programs (56.3 percent) to prepare for RN licensure. This is particularly true of those who worked as LPNs/LVNs. Eighty-two percent of RNs who were employed as LPNs/LVNs immediately prior to beginning their basic education program,selected associate degree programs. In total there were 305,842 RNs who had been LPNs/LVNs sometime prior to becoming registered nurses. It is estimated that 256,730 of these nurses were employed as LPNs/LVNs immediately prior to their basic nursing education.

In 2000 about 13 percent of the RN population, or 358,520 RNs, had post high school academic degrees prior to entering a basic nursing education program (See Appendix A, Table 4). RNs with post-high school academic degrees were less likely to receive their basic education in an associate degree program than those who had been licensed practical/vocational nurses. About 53 percent of these RNs received their basic education in an associate degree program, compared with 80 percent of those who had been LPNs/LVNs sometime before becoming RNs.

There are more RNs who had post high school academic degrees prior to their nursing education than RNs who had been LPNs/LVNs among recent entrants to the RN population. Twenty-five percent of RNs who graduated 5 years or less before the 2000 survey had post high school academic degrees compared with 15 percent who were previously employed as LPNs/LVNs.

[D]

In March 2000, 71.5 percent of all RNs were married, 17.9 percent were widowed, divorced or separated and 9.9 percent were never married. Fifty two percent had children living at home, and 16 percent had children under 6 years of age. (See Appendix A Table 6)

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. Approximately 28 percent of the 2,201,813 employed RNs were working on a part-time basis. Nearly 45 percent of employed married nurses with children under 6 worked part time. Married nurses with children under 6 years of age were 8.1 percent of all employed nurses.

When all formal education of the RN population in 2000 is taken into account, including initial education preparing individuals for licensure and any education subsequent to licensure, 22.3 percent or 601,704 had a diploma, 34.3 percent or 925,516 had an associate degree, and 32.7 percent or 880,997 had a baccalaureate as their highest educational preparation for nursing. The number of RNs with a master’s or doctoral degree is estimated at 257,812 (9.6 percent) and 17,256 (0.6 percent) respectively (see Appendix A, Table 8).

[D]

It should be noted that a number of nurses have degrees that are not in nursing but related to their career in nursing. About 21 percent of master’s degrees and 51 percent doctoral degrees held by RNs are in nursing related fields.

One-half of the nurses who had post-RN master’s degrees in nursing or a nursing-related field chose clinical practice as their field of study (see Appendix A, Table 9). Sixteen percent majored in supervision /administration and 13 percent in education.

Post-RN doctoral degrees were focused primarily on either education or research. The primary field of study for 30 percent of the RNs with such degrees was education while 24 percent focused on research. Clinical practice was the focus of about 13 percent of nurses receiving post-RN doctoral degrees.

In March 2000, 6.7 percent of the country’s RNs, or 180,765 of the 2,696,540 population, were enrolled in formal education programs leading to a nursing or nursing related-degree. Those enrolled in academic programs tended to be part-time students (76 percent) and to be employed in nursing on a full-time basis (72 percent) (see Appendix A, Table 10.)

Approximately 53 percent of the 180,765 nurses pursuing formal education were enrolled in programs leading to a baccalaureate degree, 36.4 percent were enrolled in programs leading to a master’s degree and almost 4 percent were enrolled in doctoral programs (see Appendix A, Table 11).

RNs attending school relied on multiple resources to pay for some portion of education expenses. The two primary sources were personal resources and employer reimbursement plans. An estimated 73 percent of students used some personal resources such as earnings, savings and/or family assistance to pay for tuition and fees; 41 percent obtained assistance from employer reimbursement plans. Federal sources of support in the form of traineeships, scholarships or grants were a resource for six percent of RNs, and Federally assisted loans were a resource for about 12 percent of RNs attending school. Federal resources were more likely to be used to support master’s and doctoral degree students than baccalaureate students. About 28 percent of master’s degree students and 26 percent of doctoral degree students had obtained some type of Federal support compared to about 12 percent of baccalaureate students (see Appendix A, Table 11).

Increased interest in expanding the access and availability of health care services led to particular emphasis on advanced practice nurses. Advanced practice nurses include clinical nurse specialists, nurse anesthetists, nurse midwives and nurse practitioners. Responses to multiple areas of the questionnaire were combined to determine appropriate classification of nurses for each category of advanced practice nurses. In total, an estimated 196,279 RNs, or 7.3 percent of the RN population, were prepared to practice in at least one of these advanced practice roles (see Appendix A, Table 12).

As shown in Chart 14, the largest group among advanced practice nurses were nurse practitioners (88,186) followed by clinical nurse specialists (54,374). These two groups together, including those with dual preparation of nurse practitioner and clinical nurse specialist (14,643) make up an estimated 80 percent of all advanced practice nurses.

The data show that increasingly the education of NPs takes place primarily in master’s degree programs. In March 2000, it was estimated that about 62 percent of NPs completed a master’s degree program, compared with about 46 percent of NPs in 1996.

[D]

The number of RNs educated as NPs increased by 44.8 percent between March 1996 and March 2000. In 1996, there were an estimated 70,993 NPs which included 7,802 nurse practitioners that also were prepared as clinical nurse specialists. By March 2000 these numbers had increased to 102,829, which included 14, 643 with both nurse practitioner and clinical nurse specialist training.

Eighty-nine percent, or 91,591 of 102,829 NPs were employed in nursing, although not necessarily with the position title of Nurse Practitioner. It was estimated that 58,512 or 64 percent of those trained as NPs and employed in nursing had the title of nurse practitioner.

An estimated 74 percent or 75,650 of the 102,829 RNs with formal preparation as nurse practitioners, also had national nurse practitioner certification as an advanced practice nurse or nurse practitioner. The number with State Board of Nursing recognition was 67,490. (See Appendix A, Table 12)

Because the 2000 survey shows that RNs who are prepared as both clinical nurse specialists and nurse practitioners are more likely to function in the nurse practitioner role, the following data refer only to the 54,374 RNs identified as having formal preparation as clinical nurse specialists but not also as nurse practitioners.

Eighty-seven percent, or 47,225 of the 54,374 were employed in nursing, however, only 11,309 (24 percent) were practicing with the position title of clinical nurse specialist.

Therefore, in addition to the nine-month educational requirement, anyone who was foreign educated had to be nationally certified as a nurse midwife in order to fit the definition. Based on these criteria there were 9,232 nurses formally prepared as nurse midwives, 85.7 percent of whom were employed in nursing. Of the 7,914 nurse midwives employed in nursing, 4,773 had the position title of nurse midwife. Virtually all of those employed in nursing with the position title of nurse midwife had national certification as nurse midwives and two-thirds had State Board of Nursing recognition.

Nearly 10 percent of advanced practice nurses were from racial/ethnic minority backgrounds. Minority nurses were more likely to be found among nurse practitioners than among other advanced practice nurses. Approximately 11 percent of nurse practitioners were minority nurses compared with 8 to10 percent of other advanced practice groups.

In March 2000, 81.7 percent of the RN population, or 2,201,813 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. Of the 2,201,813 RNs employed in nursing, 1,300,323 or 59.1 percent, worked in hospitals. The next largest group, 402,282, or 18.2 percent, 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. An estimated 9.5 percent or 209,324 RNs were in ambulatory care settings, including physician-based practices; nurse based practices, and health maintenance organizations. A total of 152,894 (6.9 percent) of all RNs employed in nursing, worked in nursing homes and extended care facilities. The remaining group of those employed in nursing were working in such settings as nursing education, federal administrative agencies, State boards of nursing or other health associations, health planning agencies, prisons/jails, or insurance companies (see Appendix A, Table 13).

The percent of RNs employed in hospitals did not change substantially between 1996 and 2000, declining from 60.1 percent to 59.1 percent. The number of RNs employed in hospitals increased by 2 percent compared with a 4 percent increase in the total number of RNs employed in nursing.

Nearly three-fourths of RNs employed in hospitals reported spending more than 50 percent of their time in direct patient care, as illustrated in Chart 15. However, approximately 90 percent of RNs employed in hospitals spent some portion of their time in direct patient care. As shown in Chart 16 in both 1996 and 2000, inpatient bed units were by far the work site where hospital nurses spent the majority of their direct patient care time. The data for 2000 indicate the number of nurses who provided care in these units decreased five percent between 1996 and 2000, in contrast to the two percent increase in hospital nurses overall. Also, RNs working in outpatient departments decreased by 10 percent from 77,437 in 1996 to 69,707 in 2000. Among nurses who provided direct patient care services in 2000 and reported the type of work unit, 58 percent worked in intensive care bed units, step down/transitional bed units, and general/specialty bed units (see Appendix A, Table 14). In 1996, 59 percent of hospital RNs providing direct patient care worked in these units. Changes between 1996 and 2000 in the number of nurses providing direct patient care in specific types of units in the hospital should be interpreted with caution because of the significant increase in the number of nurses in 2000 who did not report the type of unit in which they spent the majority of their patient care time. Eight percent of hospital employed RNs who provided direct patient care in 2000 did not report the type of work unit in which they spent the majority of their time. In 1996 virtually all nurses reported this.

[D]

As might be expected, nurses worked predominantly with medical/surgical patients in both inpatient bed units and outpatient departments. In 2000, an estimated 32 percent of the nurses primarily cared for such patients (see Appendix A, Table 15). The next single largest percentage of RNs (18 percent) reported that they worked predominately with coronary care patients.

An estimated 28.4 percent or 625,139 of the 2,201,813 RNs employed in nursing, were working on a part-time basis in March 2000. The percentage employed part-time varied according to the employment setting. The highest percentage of part-time employees was found among RNs working in ambulatory care settings. The lowest percentages of part time workers were found among those working in nursing homes and other extended care facilities and occupational health settings, 23 and 24 percent, respectively. (See Appendix A, Table 16)

The average scheduled work hours per year for full-time principal nursing positions, including paid vacations, holidays and sick leave was estimated to be 1,996 hours; for part-timers it was 1,102 hours. A comparison of the number of scheduled hours per week and the actual number of hours worked showed that for the week of March 22, 2000, nurses in all employment settings tended to work more hours than they were scheduled. During that week, full-time nurses averaged 42.4 actual hours in contrast to average scheduled hours of 39.5. The difference between scheduled and actual hours worked was less for part time employees—24.7 actual hours worked compared with 23.1 hours scheduled (see Appendix A, Table 17).

[D]

As indicated in earlier surveys, younger nurses are more likely than older nurses to be employed in hospitals. In March 2000, the average age of the hospital nurse was 41.8, almost two years less than the average age of 43.3 for all employed RNs. Nurses in student health services, nursing education, and planning or licensing agencies had the highest average ages (see Chart 17). Nearly three-fourths of all employed nurses under the age of 30 worked in the hospital. In contrast, less than half of nurses who were 50 years of age or older worked in hospitals (see Appendix A, Table 18).

In most employment settings the majority of nurses had an associate or baccalaureate degree as their highest nursing educational preparation (see Chart 18). Seventy-four percent of the nurses working in hospitals had an associate or baccalaureate degree; 57 percent had less than a baccalaureate. Nursing homes and extended care facilities were less likely than other patient care service settings to have nurses with a baccalaureate and higher degrees. Nursing homes drew 73 percent of their nurses from among those whose highest preparation was that of a diploma or associate degree. As would be expected, the majority of those in nursing education (64 percent) had a master’s or doctoral degree (see Appendix A, Table 19).

Most nurses were employees of the facility in which they worked. About 2 percent of RNs were self-employed, and 2 percent worked in their principal nursing position through a temporary employment service (Appendix A, Table 20).

Nearly 40,000 nurses were employed in their principal position through a temporary employment service in 2000. This number is 36 percent higher than the comparable number in 1996 (28,971) and reverses a declining trend observed between 1988 and 1996. An additional 71,490 nurses were not employed in their principal positions through a temporary employment service, but had additional positions through temporary agencies. Considered together, the total number of nurses employed through temporary employment services in 2000 was 110,994 an increase of 65.6 percent from the 1996 estimate of 67,016, and considerably higher than the 84,414 estimate in 1992 and the 88,444 estimate in 1988.

[D]

[D]

More than 60 percent or 1,357,349 of the 2,201,813 employed nurses in 2000 were in staff-level positions. (See Appendix A, Tables 21 and 22). Although the number of staff nurses has increased, their proportion of the total nurse workforce has declined from 67 percent in 1988 to 62 percent in 2000. A total of 184,098, or 8.4 percent of RNs were in head nurse or supervisory positions in 2000 and 124,461 or 5.7 percent were in administrative positions. Chart 19 illustrates 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 3.6 percent during the period from 1988 to 2000). At the same time, significant increases have occurred in the percentage of those with the position title of nurse practitioner - they grew from 1.3 percent of employed RNs in 1988 to 2.8 percent in 2000. It should be noted that the survey respondents’ use of the position title "nurse practitioner" as well as the position title for other advanced practice nurses (i.e. clinical nurse specialist, nurse midwife and nurse anesthetist) is not restricted to those who had formal educational preparation in programs to prepare them as such.

The variation in educational preparation according to position title can be seen in Chart 20 and Table 23 in Appendix A. Those data show that 60 percent or more of those with the position titles of supervisor, staff nurse, and private duty nurse have less than baccalaureate preparation. Whereas more than one-half of nurses employed with other position titles (except head nurse) had baccalaureate preparation or higher. Head nurses were nearly evenly divided between those with less than and those with at least baccalaureate preparation.

[D]

In 2000, an estimated 69 percent of RNs employed in nursing spent at least 50 percent of their usual workweek in direct patient care activities; up slightly from the 1996 estimate of 67 percent. More than half of RNs employed in nursing, 53.9 percent, spent at least 75 percent of their time in such activities (See Appendix A, Table 24). The proportion of nurses who spent at least half their time in direct patient care activities tended to increase from the 1977 study to the 1988 study. The 1992 and the 1996 studies, however, showed a decreasing percent of nurses who spent more than half their time in direct patient care.

Overall, the average percent of time RNs spent in direct patient care was about 63 percent in 2000 (See Chart 21). Nurses with less than a master’s degree averaged 63-66 percent of their usual workweek in direct patient care activities (See Appendix A, Table 25). Nurses with master’s degrees averaged 43.9 percent of their time in direct patient care, 19.8 percent of their time in administration, and 12.4 percent in teaching. Nurses with doctorates averaged 31.6 percent of their time in teaching and 29.2 percent in administration. Doctorally prepared nurses were the only group that spent significant time in research. In 2000, they averaged 11.4 percent of their usual workweek in research, higher than the 1996 average of 9.5 percent, but lower than the 13 percent in 1992 and the 16 percent shown in the 1988 study.

[D]

In March 2000, the average annual earnings of full-time employed registered nurses in their principal nursing positions was $46,782 (See Appendix A, Table 26). As indicated below and in the respective Appendix A Tables, annual earnings vary by level of nursing education, position, employment setting, and geographic location.

Average annual earnings varied according to the highest level of nursing educational preparation. (See Appendix A, Table 27). The pattern of earnings is predictable in many instances, nurses with advanced degrees achieved 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 $61,262. Holders of doctoral degrees, numerically much smaller, averaged slightly higher at $63,522.

In those categories where the educational preparation did not reach the master’s level, the average earnings are noticeably lower. The overall average earnings for those whose highest nursing educational preparation was a diploma was $46,624, while it was $46,570 for those whose highest nursing education was a baccalaureate degree. Earnings for those with baccalaureate degrees and diplomas as their highest nursing educational preparation are about 10 percent higher than the average earnings for those with associate degrees ($42,676) as the highest nursing education. Earnings/education patterns appear to be more complex than simply assuming that higher levels of education automatically translate to higher earnings. Larger proportions of diploma nurses in the workforce have more years of experience than do those with baccalaureate or associate degrees. They also comprise a large percentage of those RNs in administrative positions (see Chart 20). These circumstances of the workforce may possibly explain why diploma earnings appear to be competitive with baccalaureate earnings.

[D]

Comparisons of nurses’ earnings from 1996 and 2000 were made among each of the levels of nursing education, to determine whether the increases were consistent across degree of highest preparation. There was a wide range in the rate of earnings increases across the levels of highest nursing educational preparation. Those with master’s degrees in nursing received annual earnings increases of 3.8 percent, while those with baccalaureate degrees as their highest nursing education only averaged salary rate increases of 2.2 percent, a rate slightly less than the CPI. Nurses whose highest nursing education were either diploma or associate degrees, experienced increases of 2.8 percent and 2.7 percent, respectively.

There are large variations in actual earnings by position type. Staff nurses, the largest group of employed nurses, had average earnings of $42,133. The staff nurse earnings level is about 10 percent below the overall average earnings for all RNs with full-time employment in nursing. To some extent, higher earnings can be attributed to highest education level at the masters degree and above which prevail in some positions. Those RNs in advanced practice nurse (APN) positions had earnings that were higher than average, overall. Certified registered nurse anesthetists had the highest average earnings, $93,787, among RNs in all employment settings and position types. Nurse practitioners had average earnings of $60,126. Nurse midwives had average earnings of $64,940. Clinical nurse specialists had average earnings of $50,800.

Growth in actual earnings from 1996 and 2000 were compared for selected positions. While the average reported earnings for all full-time nurses increased by 2.7 percent on an annual basis between the 1996 and 2000 Sample Survey, 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: administrators (3.7 percent), instructors (3.4 percent), supervisors (3.3 percent), and head nurses (3.3 percent).

However, staff nurse earnings only increased on average by 2.2 percent annually. Furthermore, staff nurse earnings in hospitals only increased by 2.0 percent. This lower increase contrasts to the earnings increases of staff nurses in nursing homes, where the latter reported increases of 3.6 percent annually. It appears that demand for a high level of skills in staff nurse hospital service is not being compensated at a rate that meets even the CPI. Nevertheless, the larger rate of increases in earnings for nursing home staff RN services may begin to raise basic compensation levels for nursing home staff RNs who have been difficult to recruit and whose earnings have been historically-lower than comparative earnings in hospitals.

Among those working as advanced practice nurses, earnings of the nurse practitioner/nurse midwife group increased by 2.8 percent annually while clinical nurse specialists and certified nurse anesthetists experienced average annual earnings increases of 1.9 and 2.1 percent, respectively, between 1996 and 2000. Over this period, the number of nurse practitioners entrants grew sharply. It appears that these newly-trained nurse practitioners are in demand and are finding professional employment, since the number of RN’s working as nurse practitioners has increased by more than 50 percent over this period.

Annual earnings varied according to the setting in which the RN was employed. At $47,759, 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 ambulatory care, at $45,256 public health settings, at $45,150; nursing homes, at $43,779; and student health services, with the lowest average annual earnings of $38,204.

The hospital setting earnings average of $47,759 in 2000 and the 1996 average of $43,496, both reflect the CPI annual increase of 2.4 percent. Of note, the information in Table 26 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, it was found that those with associate degrees as the highest nursing education had average earnings of $41,863. For those whose highest education was a diploma, the average earnings were $45,807. For the baccalaureate-prepared hospital staff nurse, the average earnings were $43,934. It is important to note that these numbers do not discriminate by 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. Fifteen percent of all the employed nurses held other paid nursing positions in addition to their principal nursing position. As would be expected, the average actual annual earnings of the latter group were higher than the average annual earnings of nurses with only one nursing position. For all RNs employed in nursing, regardless if they had more than one position and if they worked full-time or part-time in their principal position, the average annual earnings was $42,475. If they had more than one nursing position the average earnings were $49,769. Those with only one full-time or part-time position in nursing averaged $41,298 (See Appendix A, Table 28). The increase in earnings for those with additional part-time employment in nursing is substantial, adding an average of approximately 20 percent to their nursing earnings.

Looking at the full-time earnings of staff nurses working in the hospital setting across the country, it was found that those with associate degrees as the highest nursing education had average earnings of $41,863. For those whose highest education was a diploma, the average earnings were $45,807. For the baccalaureate-prepared hospital staff nurse, the average earnings were $43,934. It is important to note that these numbers do not discriminate by 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. Fifteen percent of all the employed nurses held other paid nursing positions in addition to their principal nursing position. As would be expected, the average actual annual earnings of the latter group were higher than the average annual earnings of nurses with only one nursing position. For all RNs employed in nursing, regardless if they had more than one position and if they worked full-time or part-time in their principal position, the average annual earnings were $42,475. If they had more than one nursing position the average earnings were $49,769. Those with only one full-time or part-time position in nursing averaged $41,298 (See Appendix A, Table 28). The increase in earnings for those with additional part-time employment in nursing is substantial, adding an average of approximately 20 percent to their nursing earnings.

For the first time in the seven national surveys of RNs conducted by the Division of Nursing, the March 2000 survey asked respondents working in nursing to assess their level of job satisfaction. The level of job satisfaction provides a window into the working conditions that nurses face, and the relationship between these conditions and nurses’ expectations regarding their work. There is a wealth of empirical literature linking job satisfaction and other important workplace features, such as turnover rates while the body of work linking job satisfaction with quality of patient care is just emerging. The growing reports of nursing shortages across the country, declining enrollments in nursing schools and the aging of the nursing workforce all provide ample reason to examine job satisfaction and what it may reveal regarding the retention of the current nursing workforce.

[D] 

Aggregate levels of job satisfaction vary by the setting where nurses work (see Chart 22). Nurses working in nursing homes and hospitals report the lowest levels of overall job satisfaction, at 65 percent and 67 percent, respectively, while 83 percent of those working in nursing education are satisfied with their job. Even at 83 percent, the job satisfaction level among those in nursing education only approaches the level of job satisfaction in the general population.

Across employment settings, two factors appear to play powerful roles in level of job satisfaction: age and position, specifically, whether the respondent is a staff nurse. In the four settings that employ 88 percent of all nurses, and substantial numbers of staff nurses, we find that staff nurses in each setting report lower levels of job satisfaction when compared to those in the same settings who are not staff nurses (see Chart 23). In each instance these differences are noteworthy.

[D]

The lower job satisfaction among staff nurses endures across other comparisons. For example, job satisfaction varies by level of nursing education, with diploma nurses reporting the lowest overall level of job satisfaction and doctoral-prepared nurses reporting the highest level.

In each educational group, staff nurses report lower levels of job satisfaction compared to their counterparts who are not staff nurses. Furthermore, 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 job satisfaction than staff nurses spending similar amounts of time with patients. This suggests that it is the structure of the job, rather than the composition of the work, that is influencing satisfaction.

Furthermore, with the exception of ambulatory care, job satisfaction levels decline with age among staff nurses in each setting. The contrast between ambulatory care and the other sites suggests that working conditions in ambulatory care settings may accommodate older workers better than other settings, with regards to physical demands as well as other job features.

Data indicate that job satisfaction declines with age and does not seem to return to the higher levels seen earlier in nurses’ careers. However, the higher satisfaction levels early in the careers of nurses suggests that attention to working conditions could improve job satisfaction and help retain a well-trained and experienced workforce.

In March 2000, of the 2,696,540 individuals with current licenses to practice as registered nurses, 494,727, or 18.3 percent, were not employed in nursing. Twenty-seven percent of the 494,727 RNs were working in non-nursing positions. About seven percent (35,968) of those not employed in nursing were actively seeking nursing employment (See Appendix A, Table 30).

In 2000, 263,856 nurses who were not employed in nursing at the time of the survey had been employed as nurses within the 5-year period preceding the survey. These nurses who recently became unemployed in nursing accounted for somewhat more than one-half (53 percent) of all RNs who were not employed in nursing. The number of nurses recently unemployed in nursing in 2000 is lower than the comparable number in 1996, which was 311,583. Moreover, they comprise a much smaller proportion of the total pool of those not employed in nursing than in 1996—53 percent compared with 70 percent in 1996. The percent of RNs who never worked in nursing dropped from 1.9 percent in 1996 to 1.4 percent in 2000.

RNs who had most recently become unemployed in nursing were the most likely to be actively seeking nursing positions. Approximately 18 percent of those who had become unemployed in nursing within 1 year of the 2000 survey were actively seeking nursing employment compared with only seven percent of all inactive nurses. The average age of nurses who had recently become unemployed in nursing was 51.7 years compared to 53.6 years for all those not employed in nursing.

The 35,968 registered nurses not employed in nursing in March 2000 but actively seeking nursing employment, represented 1.4 percent of the 2.7 million RNs in the country. This percentage is about the same as in 1996.

RNs not employed in nursing but actively seeking nursing employment were likely to have been employed in nursing more recently than other RNs not working in nursing. Seventy-eight percent of the job seekers had been employed in nursing less than five years prior to the study with most (47.5 percent) having been employed less than a year before. Only 8.8 percent of the nearly 7,