Nursing

Practice Alerts & Guidelines

Results of the September 2002 Survey of Registered Professional Nurses, Volume I

Summary:

In April 2001, the State Education Department presented the Board of Regents with a report on the nursing shortage in New York State.¹ The report was part of a series of horizon issue reports designed to address important issues affecting the future of professional regulation. The analysis offered compelling evidence of the nursing shortage projected in coming years. The report highlighted the root causes of the shortage and described how the current shortage differed structurally and demographically from previous shortages. The Board of Regents acknowledged the impending nursing shortage as having significant implications for the health care system and for public protection. As Commissioner Richard P. Mills emphasized:

“One important role of the Board of Regents is to identify public protection issues and to take action to address them swiftly. Nothing is more important to ensure our future well-being. Health care and education go hand in hand to make our State an economic leader and a good place to live.” ²

In response to the potential crisis and in carrying out the Regents regulatory responsibility for over 300,000 licensed nurses in the State, Chancellor Carl Hayden called for the formation of a Blue Ribbon Task Force on the Future of Nursing and tapped Regent Diane O’Neill McGivern, an innovator in nursing education, to serve as Chair. Regent McGivern convened two Task Force meetings later that year. She invited 26 influential leaders in health care, education, and government to participate in the Task Force. Members were selected to represent significant areas of responsibility uniquely positioned to address the shortage. The Task Force advanced a set of recommendations focused upon the growing shortage.³

One of the six broad strategies recommended by the Task Force was to improve data collection and develop a reliable, centralized source of data for New York State upon which employers, policymakers, futurists, researchers and legislators may base public policy and resource allocations. In addition, the Regents recognized that the data source needed to include current, comprehensive information about specific characteristics, attributes, and expectations of New York’s nurses. Accordingly, a large scale randomized survey of registered nurses was designed during the summer of 2002 through a partnership with the Fiscal Analysis and Research Unit and the Office of the Professions in the New York State Education Department (SED) and other key stakeholders, including members of the Task Force and the State Board for Nursing. The survey was sent to over 31,000 nurses registered with the Department. A useable response rate of 45.6 was achieved. Four different tests of sample representativeness revealed that survey respondents mirrored very closely the characteristics of the active licensure file from which the sample was drawn.

The results of the study are presented in three volumes. Volume I describes basic demographic characteristics, education, employment status, salary, and the nursing supply. Volume II analyzes the types of organizational climate factors affecting nurses, the impact of these factors on staff turnover, and nurses' support for a variety of policy initiatives. Volume III focuses exclusively on inpatient staff RNs and includes comments from survey respondents. The findings of volumes II and III will be presented at the Regents November meeting.

This Regents report focuses on the major findings of Volume I. The following snapshot of Volume I highlights the ten most critical findings of the survey:

1. Based upon the Fall 2002 survey, an estimated 165,640 RNs are working in the State, which is a little more than half the number of RNs registered to practice.
2. The average RN today is 47 years of age.
3. Of the nurses in the sample who completed their basic degree preparation during the 1980s, 57 percent completed their basic credential before the age of 25. In contrast, of survey respondents who received their initial educational credential in the year 2000 or later only 35 percent completed it before age 25.
4. Approximately one in five RNs working in New York State is a member of a minority group. In 1989, 3.8 percent of the active RN workforce was male, a figure which increased to 5.3 percent by 2002.
5. Among respondents who completed their education in the last two to three years, 1.4 percent received a diploma, 61.3 percent received an associate’s degree, and 37.0 percent completed a bachelor’s degree as their initial educational credential.
6. Although 54 percent of RNs are employed in hospital settings, that figure has fallen substantially since 1989 when 66 percent of the active workforce worked in hospital settings.
7. Roughly eight of every ten RNs in the State spend at least some portion of their workday in direct patient care, but for those who do, only slightly more than half of their workday is actually spent in direct patient care activity.
8. Almost 45 percent of full-time, single-job RNs work overtime, typically around seven hours per week. For 14.9 percent of this group, that overtime work is always mandatory, while for another 43.2 percent the overtime work is sometimes mandatory.
9. The average total annual earnings for all nursing jobs in New York City is over $66,000 per year, about 25 percent higher than the statewide average of $53,000. Earnings of upstate RNs (both urban and rural) are around $41,000, which is over 20 percent lower than the statewide average.
10. Approximately 37,852 RNs or 22.9 percent of the current New York workforce will be leaving the profession in the next 4.9 years. Results of the survey predict that the nursing shortage is worsening. An increasing number of baby boomers will be retiring and we will no longer be able to “stretch” the existing workforce by expecting nurses to work extra hours and increasing part-time work.

The survey results directly support two of the major recommendations of the Regents Blue Ribbon Task Force – recruitment and education. Strategies targeted toward increasing recruitment and creating career ladders will be necessary to ensure a strong future for the nursing profession. Addressing the nursing shortage will require continued collaboration and commitment from government leaders, association representatives, employers, educators, nurses, and all members of the health care community.

Volume I: Major Findings

Basic Demographics

• Based upon the Fall 2002 survey, approximately 165,640 RNs are working in the State, which is a little more than half the number of RNs registered to practice. This figure corresponds closely to a 1996 figure of 165,667 RNs in New York State developed by the Health Resources and Services Administration (HRSA)—indicating virtually no growth during this six-year period.

Age

• The average RN today is 47 years of age, a figure that reflects a substantial aging of this workforce over time. In 1989 and 1995, the comparison figures were 41 and 44 years respectively. (See Figure 1.) More importantly, the “shape” of that age distribution has shifted greatly. In 1973, 30 percent of the workforce was 29 or younger while only seven percent was 60 years of age or older, i.e., for every nurse aged 60 or over in the labor pool there were four nurses under 30. Thirty years later, that four to one ratio is one to two; for every two nurses 60 and over, only one RN under 30 is in the workforce.
  
  
  
  
• The pronounced shift in the age distribution is also reflected in the average age of career entry. Nurses in the sample who completed their basic degree preparation during the 1980s averaged 26 years of age at that time; 57 percent completed their basic credential before the age of 25. In contrast, survey respondents who received their basic credential in the year 2000 or later averaged 31 years of age and only 35 percent completed it before age 25.

Minorities and Men

• Approximately one in five RNs working in New York State is a member of a minority group, where minority is defined as either (non-Hispanic) Black, Hispanic, Asian, Native American, or individuals of “two or more races.”
• The racial and ethnic diversity of nurses is far greater in New York City than elsewhere in the State. While 52 percent of the nurses working in New York City are members of minority groups, only 13 percent work in the downstate suburbs, and less than 4 percent for RNs working in the rest of the State.
• In 1989, 3.8 percent of the active RN workforce was male, a figure which increased to 5.3 percent by 2002.
• While 20.4 percent of RNs statewide are born outside of the United States, in New York City the number of RNs born outside of the U.S. more than doubles to 45.9 percent. Similarly, while only 12.4 percent of the State’s RNs were educated outside of the U.S., almost 30 percent of New York City’s registered RNs are educated abroad.

Work Location

• Roughly a third of RNs work in New York City, while another third work in the upstate metropolitan areas. Just under a quarter work in the downstate suburbs while eight percent work in rural counties. (See Figure 2.)
  
  
  

Education

• A significant percent of nurses have exceeded the basic preparation for entry into the profession. Nurses who have attained either a master’s degree or doctorate represent 17.5 percent of the active workforce.
• Nearly a third of RNs actively working in New York State plan to pursue additional nursing education. If they follow their plans, an estimated 15,000 RNs should have returned to nursing education programs in 2002-2003, while 18,000 more plan to head back to school between 2003-2005 and another 18,000 expect to return sometime after that.
• The professional educational preparation of RNs has changed remarkably over the past four decades. The survey indicates that almost 82 percent of active RNs who completed their education before 1960 received a diploma as their basic credential, while 6.3 and 12.0 percent received an associate's or bachelor's degree, respectively. In contrast, among those who completed their education in the last two to three years, only 1.4 percent received a diploma, while 61.3 percent received an associate's degree and 37.0 percent completed a bachelor's degree as their basic credential. (See Figure 3.)
  
  
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• Late or deferred entry into nursing has become typical for nurses graduating since 1990. However, the later pursuit of the basic education credential is far more pronounced among those entering via the associate’s degree career path (whose average age at completion of the basic credential is 33.4 years) than those entering via the four-year bachelor’s path (whose average age at completion of the basic credential is 27.3 years). (See Table 1.)
  
  

• Table 1. Average Age at Completion of Basic Nursing Preparation by Decade of Basic Preparation Completion and Basic Credential (RNs Working in Nursing in New York State)

  Year of Completion of Basic Nursing Preparation & Basic Credential		Estimated Count	Mean Age at Completion (Years)	Standard Deviation
  Before 1970
  	Diploma	19,551	21.2	1.8
  	Associate's	3,521	21.6	3.6
  	Bachelor's	3,671	21.9	1.5
  1970-1989
  	Diploma	21,853	22.5	3.7
  	Associate's	40,039	26.8	7.0
  	Bachelor's	30,613	23.3	3.8
  1990 or Later
  	Diploma	1,674	29.8	9.4
  	Associate's	29,906	33.4	8.5
  	Bachelor's	13,968	27.3	7.1
  Overalla		164,796	26.0	7.2
  a Overall mean age is for all RNs working in New York, even those whose basic nursing preparation is a master's degree.

  
  
• Plans for higher-level educational preparation also differentiate RNs whose basic educational credential for licensure is a bachelor's degree from those who entered nursing with an associate's degree. For example, RNs whose basic preparation was a bachelor’s degree were almost 2½ times more likely to already have a master’s degree than their associate degree entrant counterparts (26.7 percent vs. 9.6 percent). Bachelor's-prepared nurses are more likely to plan on pursuing a master's degree in the next two years than their associate’s degree counterparts (22.5 percent vs. 11.0 percent).
• While numerous factors account for the decision to pursue additional educational preparation, over 50 percent of active New York RNs surveyed cited their belief that "the benefit does not justify the tuition or time cost" as one of their top three reasons for not furthering their formal education.

Employment Status

Workload

• Well over half (56.4 percent) of New York's RN workforce is working in a traditional single job on a full time basis. Three out of every ten nurses choose to work exclusively on a part time basis-either in a single part time job (22.5 percent) or in multiple part time jobs (7.3 percent). For 13.9 percent, a full-time job is complemented by one or more part time jobs, resulting in an average workweek of 55.7 hours for this group. (See Figure 4.)
  
  
  
  
  
• RNs who reported earning lower levels of hourly monetary compensation tended to work more hours each week. This finding suggests that many nurses incur these heavier workloads because of poor hourly wage benefits.

Employment Settings

• Although 54 percent of RNs are employed in hospital settings, that figure has fallen substantially since 1989 when 66 percent of the active workforce worked in hospital settings.

Patient Care

• Roughly eight of every ten RNs in the State spend at least some portion of their workday in direct patient care, but for those who do, only slightly more than half of their workday is actually spent in direct patient care activity.
• For those nurses who provide direct care, almost a third of their average workday time is spent on paperwork. RNs in New York who work in direct patient care spend approximately 1.55 million hours collectively every week on paperwork alone.
• Age plays a pivotal role in survey respondents’ decisions to work in a direct-care capacity. Among nurses under 30 years of age in the sample, 96 percent spent some portion of their day in direct patient care. As nurses get older, that figure continuously drops so that among RNs 60 years of age and older, only 68 percent work in direct patient care in some capacity.

Overtime

• The percentage of RNs who work overtime in some capacity, including any extra hours beyond their regularly scheduled workweek, varies substantially by setting—from 46.5 percent for hospital-based nurses to 13.2 percent for school health nurses. Among inpatient staff nurses, 52 percent are routinely involved in overtime work of some type.
• Overall, 16 percent of active New York RNs who work overtime report that their overtime is always mandatory. Forty-three percent report that it is sometimes mandatory, while the remaining 41 percent indicate that it is never mandatory. (See Figure 5.)
  
  
  
  
  

Salary

• The salary compensation of RNs varies substantially by region, work setting, and job title.
• During the 1995 to 2002 period, nurses gained about nine-tenths of a percent of their average earnings in real, inflation-adjusted terms during each year. This marks a substantial slowing from the 2.7 annual percentage increase from 1989 to 1995 when the average nurse experienced a real, inflation-adjusted earnings gain of over $8,000. (See Figure 6.)
  
  
  
  
  
• The average total annual earnings for all nursing jobs in New York City is over $66,000 per year, about 25 percent higher than the statewide average of $53,000. Earnings of upstate RNs (both urban and rural) are around $41,000, which is over 20 percent lower than the statewide average.
• The earnings of RNs whose positions typically require advanced academic or clinical training are well above statewide averages. For example, adjusting for hours worked, certified registered nurse anesthetists, nursing executives, and nurse practitioners earn $85,862, $69,703, and $65,092 per year, respectively.
• When both region of practice and highest educational credential are controlled for, there are no differences in salary between minority and non-minority RNs.
• Earnings of RNs in both inpatient and outpatient hospital-based settings have been especially hard hit. During the 1989-1995 period, earnings of inpatient and outpatient hospital RNs increased by about 3.2 and 2.9 percent annually (in constant 2002 dollars). In the more recent 1995-2002 period, however, RNs in both the inpatient and outpatient hospital sectors began to lose ground to inflation as their inflation-adjusted earnings slipped by one-tenth of one percent annually.
• The HMO/Managed Care/Insurance sector stands out because of its highly positive inflation-adjusted performance during the 1995-2002 period when virtually every other sector was losing ground to inflationary trends. For RNs in this sector inflation-adjusted annual earnings growth during the 1995-2002 period averaged 2.4 percent—a sharp contrast to the erosion in real earnings experienced in most other sectors. Earnings grew the fastest in this sector, despite the fact that it is known for embracing aggressive cost containment measures.
• When we examine earnings by years of work experience, the findings are progressively incremental up to the 20-year experience level, at which point the relationship flattens considerably. Thus, there is less financial return for remaining in the profession after one has worked for more than 20 years.
• There is strong evidence of the investment value of higher educational pursuits. In this study sample, the average workweek adjusted earnings of an RN whose highest educational credential is an associate’s degree were $47,384 in 2002. Those with a higher level nursing degrees (at the bachelor’s, master’s and doctoral levels) had workweek adjusted average earnings of $54,996, $65,760, and $69,228 respectively.

Supply Issues

• Survey results indicate that as of September 2002, 165,640 registered nurses were working in nursing in New York State. The report describes two methods used to translate the 165,640 figure into full-time equivalents (FTEs). The two methods yield an RN workforce of 140,974 or 161,706 FTEs. The first method accords one FTE to RNs whose primary job is full time and 0.5 FTEs to RNs whose primary job is part time. Since the second method used to calculate FTEs is based on RNs’ reports of weekly hours worked in all nursing jobs, including overtime, the discrepancy between the two methods suggests that many health care providers are coping with staffing shortages by "stretching" the existing workforce through extra hours, added part-time jobs, and overtime work.
• HRSA projections indicate that estimated demand for RNs in New York State in September 2002 at 156,394. If we accept this demand estimate, we either have a gap of 15,420 FTEs using the traditional FTE calculation method, or a surplus of 5,312—using the total hours method.
• HRSA has created models to generate long-term state-by-state projections for both the supply of and demand for registered nurses.⁴ The HRSA projections for New York State appear in Figure 7. As the figure shows, HRSA expects the supply/demand gap to diminish slightly from 10.9 percent in 2000 to 8.0 percent in 2005 before rising steadily to 23.6 percent by 2020.
  
  
  
  
  
• We estimate that 37,852 RNs or 22.9 percent of the current New York workforce will be leaving the profession in the next 4.9 years. This means that 127,788 RNs expect to remain in the labor market at least until 2007.
• The projected "leave-taking" rates described in our analysis vary only modestly across Health Service Areas. However, from a risk-appraisal perspective, HSAs with bothrelatively high leave taking percentages and lower existing current supply rates may be faced with substantial supply-demand imbalances in the future. Jamestown and Glens Falls are two HSAs in this situation.
• Projected estimates of nursing supply and demand imbalances for 2007 were made using HRSA's projections for future system demand for nurses in New York State, data from the survey about RNs exit intentions, and trend data on new entrants to nursing. HRSA's own supply and demand projections result in an estimated shortfall of 14,466 RN FTEs in New York State in 2007. SED's high supply estimate (using the "total hours" method of FTE calculation) results in a shortfall of 11,775 FTEs. SED's lower supply estimate, using the traditional FTE calculation method, results in a projected shortfall of 30,858 RN FTEs in 2007.

Nurses' Perceptions of the Shortage

• Over 80 percent of the RNs working in New York State believe that there is a shortage of similarly qualified nurses in their geographic area. Analyses of the "search time" incurred by respondents in finding their first job confirm this view. The average search time was 1.5 months, indicating a very high demand for available nurses and minimal "slack" in the available labor pool.
• On a statewide basis, 45 percent indicated either that it would be very easy or quite easy to find a job as good as their current position in their geographic area. New York City and downstate suburban nurses were especially optimistic in this regard, with 50 percent indicating it would be either "very easy" or "quite easy." Nurses in rural areas were somewhat less optimistic; only 35 percent indicated that finding another job in their area would be "very easy" or "quite easy."
• Nursing homes and hospitals were the two employment settings that stood out in terms of job-finding ease. In these two sectors, 54.1 percent and 51.4 percent of RNs respectively felt that comparable jobs within their geographic area would be “very easy” or “quite easy” to find.

Volume I results support task force recommendations for education and recruitment

Volume I survey findings suggest that health care providers are attempting to deal with the nursing shortage by stretching the existing workforce through extra hours, added part-time jobs and overtime. While this strategy might be effective in the short term, its long-term efficacy is questionable, especially in light of the maturity of the RN population and the projected loss of nearly 38,000 RNs who plan to leave nursing over the next five years. Based on estimates from the survey data, by 2007 the supply-demand gap will be between 11,000 and 31,000 FTEs. Failure to resolve this problem will significantly impact the quality and safety of the entire health care system in New York State.

The survey results of Volume I directly support two major recommendations of the Regents Blue Ribbon Task Force on the Future of Nursing – recruitment and education. The survey data and comments received from survey participants suggest strategies for recruitment and education that may serve as the basis for continued policy discussions and actions by the Board of Regents, members of the Regents Task Force, and other key stakeholders.

Task Force Recommendation: Recruitment - Expand the nursing workforce by recruiting additional numbers of men, minorities, non-practicing nurses, and recent high school graduates.

• Stakeholders should develop and implement strategies to make nursing more attractive to young people. According to survey results, RNs aged 60 and older now outnumber those younger than 30 years of age by a two to one margin. It is recommended that steps be taken to encourage young people to become nurses. For those nurses and prospective entrants into the profession who may be entering the childbearing and child rearing stages of the life cycle, programs of child care, elder care, and more flexible work schedules may be critical in making the profession more staff-friendly.
• Educators, government leaders, employers, associations, Regents Task Force members, and others should work to increase recruitment of members of underrepresented groups. Focused, highly targeted recruitment efforts must be made to attract more minorities and males to the profession. Thus, scholarships, loan-forgiveness programs, and training grants targeted to these groups—and tied to service commitments in approved settings within New York State—should be supported and highly publicized.
• Leaders in the health care community should consider targeting recruitment initiatives to regions with acute shortages. Since our study revealed considerable inter-regional variation in RN staffing availability per 1000 population, and since considerable variation in "leave-taking" rates was also discerned among different Health Service Areas, efforts to more carefully identify HSA labor markets from a "risk appraisal" perspective should be ongoing. Recruitment and incentive strategies should be structured to explicitly recognize these imminent shortage areas and loan-forgiveness commitments tied to service in these higher risk areas. The proposed National Nurse Service Corps, modeled after the National Health Service Corps, is such a model.

Task Force Recommendation: Education - Provide additional academic and financial support systems to increase the pool of nursing school graduates and create career ladders.

Stakeholders should consider providing incentives to encourage associate's degree holders to earn bachelor's degrees. The highest degree held by 30 percent of the RN workforce is an associate’s degree. Yet 37 percent of RNs whose highest credential is an associate's degree plan to further their education. This suggests that many RNs would welcome policies that help them continue their education. Structured programs of credit-bearing course work offered on site—with appropriate preceptor and peer support—represent a significant, cost-effective, and attractive strategy for doing so. The Keuka College work-site based program is a program that may serve as a model for institutions throughout the United States. In addition, despite the growing recognition of the utility of a bachelor's preparation, survey results shows that bachelor's degree recipients now constitute increasingly smaller "shares" of the basic nursing preparation pool as associate's degrees have grown in popularity in recent years. Since the average associate's degree recipient defers the timing of her or his basic education training until the early thirties while the average age of basic credential completion for bachelor's recipients is around 27 years of age, bachelor's degree recipients have potentially greater career longevity than holders of associate's degrees. Based on these results, leaders in the health care community should increase their efforts to promote the bachelor’s degree as the desirable basic preparation for nurses.

Conclusion:

This summary has provided Volume I highlights of the Department’s 2002 survey of registered professional nurses related to basic demographic characteristics, education, employment status, salary, and the nursing supply. The survey results are positioned to serve as a central source of data upon which government leaders, professional association representatives, employers, educators, nurses, and other members of the health care community can base public policy decisions and resource allocation to address the nursing shortage. The full text of Volume I will be available on the Department’s Web site.* We look forward to presenting a summary of Volumes II and III at the November meeting of the Board of Regents.