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Results of the 2010 AORN Salary and Compensation Survey
Results of the 2010 AORN Salary and Compensation Survey DONALD BACON, PhD
ABSTRACT AORN conducted its eighth annual compensation survey for perioperative nurses in June and July 2010. A multiple regression model was used to examine how a number of variables, including job title, education level, certification, experience, and geographic region, affect nurse compensation. Comparisons between the 2010 data and data from previous years are presented. The effects of other forms of compensation, such as on-call compensation, overtime, bonuses, and shift differentials, on base compensation rates are also examined. Additional analyses explore the effect of the current economic downturn on the perioperative work environment. AORN J 92 (December 2010) 614-630. © AORN, Inc, 2010. doi: 10.1016/j.aorn.2010.11.001 Key words: nurse salaries, compensation, economy.
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n June and July 2010, AORN surveyed its members and some nonmembers to examine the status of perioperative nursing compensation in the United States. This market research study tracks compensation changes on a yearly basis and seeks to identify factors that influence how much perioperative nurses are presently paid. The survey also addressed the perioperative nursing shortage, focusing on perceived changes in staffing-related aspects of the perioperative nursing workplace during the past several years. Additional questions and analyses were conducted to explore the effects of the recent economic downturn on the work environment of perioperative nursing. RESPONDENT PROFILE For the seventh consecutive year, AORN conducted its survey online. In late June, approximately 55,000 potential respondents, including approximately 34,000 AORN members, were sent an e-mail invitation to participate in the survey.
This group of potential respondents is slightly smaller than the 2009 group, but it contains a higher percentage of AORN members. By late July, 6,899 unique responses were received. The focus of this survey is perioperative nursing compensation, so respondents who did not answer any compensation-related questions were excluded. This criterion reduced the usable sample to 4,921 individuals, for an 8.9% net response rate (the 2009 response rate was 5.1%). This sample is substantially larger than the 2009 sample (ie, 3,277). The increase in this year’s response rate is statistically significant. As shown in Figure 1, 44% of the respondents are staff nurses, 24% are managers, 12% are high-level managers (ie, vice presidents [VPs]/ directors/assistant directors and hospital/facility administrators), 7% are educators (ie, faculty members or staff development personnel), 5% are RN first assistants (RNFAs), and 2% are clinical nurse specialists. Forty-seven percent of the respondents are in their 50s, 24% are in their 40s, doi: 10.1016/j.aorn.2010.11.001
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Figure 1. Percentage of survey respondents by job title.
12% are in their 30s, and 5% are younger than 30 years of age. Twelve percent are at least 60 years of age. Approximately 91% of the sample is female, and 9% is male. Hourly-paid employees comprise 65% of the sample; 35% are salaried employees. Most of the respondents work in acute care hospitals (72%), and 24% work in an ambulatory surgery center, whether it be freestanding (12%), hospital based (10%) or office based (1%). Less than 1% of the respondents work in industry, in a school of nursing, or as an independent consultant. Approximately 3% of the sample is employed in other positions. Geographically, the sample is well dispersed across the country. As shown in Table 1, approximately 20% of the respondents live in the upper eastern coastal area (ie, New England and the Mid-Atlantic), 16% reside in the South Atlantic area, and 25% are located in the East and West North Central regions. Approximately 17% reside in the East and West South Central regions, and 21% are located in the western (ie, Mountain) and Pacific states. Approximately 80% work in an
urban or suburban area, and approximately 20% work in a rural location. Approximately 38% of the respondents have a bachelor’s degree in nursing, and 8% have a bachelor’s degree in another field. Approximately 37% of the respondents have a diploma or associate’s degree. Eight percent of respondents have a master’s degree in nursing (MSN), and 7% have a master’s degree in another field. Approximately 2% have a doctorate in nursing or in another field or have some other type of degree (Table 2). Approximately 44% of the respondents have more than 20 years of experience as a perioperative nurse, and approximately 29% have more than 25 years of experience. Approximately 26% of the respondents have 11 to 20 years of experience as a perioperative nurse, and 30% have 10 or fewer years of experience. Overall, the respondents’ demographic profile is similar to samples from the previous four years with one small exception: the respondents have slightly fewer years of experience than did the 2009 sample (eg, a 4% decline among those with more than 20 years of experience and a 4% AORN Journal
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TABLE 1. Geographic Location of Respondents Region New England (New Hampshire, Vermont, Maine, Connecticut, Rhode Island, Massachusetts) Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, New York, Washington, DC) South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida) East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) West North Central (North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, Missouri) East South Central (Kentucky, Tennessee, Mississippi, Alabama) West South Central (Oklahoma, Arkansas, Texas, Louisiana) Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) Pacific (Alaska, Washington, Oregon, California, Hawaii) Outside the United States
Frequency Percent 260
5.6
686
14.8
744
16.0
780
16.8
382
8.2
232
5.0
542
11.7
399
8.6
584
12.6
30
0.6
tive nurse population that statistical tests can provide insight. A summary of the salary findings, categorized by job title and size of facility, is shown in Table 3. This analysis and the salary analyses that follow include only nurses who were employed fulltime in the United States. Facilities are categorized as small or large based on a median split of the number of ORs reported. These findings show the calculated average salary for nurses who spend an average amount of time on direct patient care for their title. As can be seen, nurses generally receive more compensation in larger facilities. On closer examination, the relationship between facility size and compensation may also be influenced by facility type. Table 4 shows how the average number of ORs varies by facility type and how the number of ORs is related to staff nurse compensation. Taking facility size into account, the university or academic facilities tend to be larger than other facility types. The ambulatory care facilities pay somewhat less than the acute care facilities. The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. I used multiple regression as the primary analytical tool in this study because so many variables are involved.
TABLE 2. Respondents’ Education Levels Education
increase among those with 10 years of experience or less). Figure 2 represents some of the demographic information from the sample.
BASE COMPENSATION I performed statistical analyses to identify which factors have the most influence on perioperative nursing compensation. It should be noted that the sample is not perfectly random, because the net response rate was modest (8.9%). Still, the sample is sufficiently representative of the periopera616
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Diploma Associate’s degree Bachelor of science degree in nursing Bachelor’s degree in another field Master of science degree in nursing Master’s degree in another field Doctorate in nursing Doctorate in another field Other
Frequency Percent 583 1249 1853
11.9 25.5 37.8
374
7.6
394
8.0
339
6.9
4 15 85
0.1 0.3 1.7
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Figure 2. Profile of survey respondents.
The multiple regression model makes it possible to estimate the effects of one variable on compensation while statistically holding the other variables constant. The influence of each variable can then be identified, independent of the others. For this analysis, I used hierarchical regression by entering the variables expected to explain the most variance in the model first and then entering less important variables. I entered several variables with related effects initially and simultaneously. These variables are
job title, facility size, facility type, population setting (ie, urban, suburban, rural), region, and percentage of time spent in direct patient care.
I then entered other variables one at a time. These secondary variables are
years of work experience, compensation basis, certification, education level, participation in a collective bargaining unit, household status, and gender.
To obtain the most reliable results, I limited the sample for the regression analyses to respondents who are full-time employees and who work in the United States. I also eliminated statistical outliers (eg, unusually high or low pay reported by a very small number of nurses) to avoid skewing the results. I conducted checks to ensure that the statistical assumptions behind the regression AORN Journal
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TABLE 3. Estimate of Average Base Compensation by Job Title and Facility Size
Job title
Average percentage of time spent on direct patient care
Small facility (< 10 ORs)
Large facility (> 10 ORs)
89.0 19.9 17.3
$65,400 $93,700 $92,000
$67,100 ⴱ $121,900
36.1
$78,200
$84,900
19.2 47.7
$74,600 ⴱ
$76,900 $85,600
86.8 38.6 56.3
$70,900 $82,100 $76,500
$76,300 $80,900 $78,600
Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/ team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other Total
The small net subsample sizes for educators/faculty members, nurse practitioners, and consultants resulted in their exclusion from the regression analysis. Other samples with fewer than 30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred.
model were met (eg, linear relationships and normally distributed errors). The final model explains 57% of the variation in base compensation. What follows is an overview of the results concerning each variable included in the regression analysis that was found to be significantly related to base compensation level. All variables were significant at the P ⱕ .05 level. Readers can easily obtain the estimates of compensation for any particular nursing position by using the compensation calculator on the AORN web site at http://www.aorn.org/CareerCenter/SalarySurvey. Job Title More than any other variable, differences in job title are linked to differences in compensation. The average staff nurse, for example, earns
$66,400 ($2,000 more than in 2009), and the average VP/director/assistant director of nursing makes $102,900 ($1,100 more than in 2009). Part of the difference in salary across titles is explained by the difference in the percentage of time spent in direct patient care versus the percentage of time spent on other tasks such as management or administration. To explore the trends in salary for nurses and nurse managers over time, I combined data from eight years of AORN salary surveys. Figure 3 shows that staff nurses and VPs/directors/assistant directors of nursing have seen increases in average compensation during this eight-year period. The rate of growth appears to be slightly higher for staff nurses (averaging 3.9% a year) than for
TABLE 4. Size and Compensation by Facility Type
Facility type
Size (average number of ORs)
Average staff nurse base compensation
Count
Acute care hospital, general/community Acute care hospital, specialty Acute care hospital, university/academic Ambulatory surgery center, general/community Ambulatory surgery center, university/academic
14 18 27 13 23
$64,700 $69,000 $72,400 $60,100 $70,500
750 86 298 103 50
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Figure 3. Trends in base compensation.
VPs/directors/assistant directors of nursing (averaging 2.7% a year) over eight years. For comparison, the average inflation rate during this period was 2.5%. On average, staff nurses spend 89% of their time providing direct patient care and nurse managers spend 36% of their time providing direct care. As expected, high-level managers spend a relatively small amount of time in patient care (20% for facility/hospital administrators and 17% for VPs/directors/assistant directors). Facility and hospital administrators spend approximately 2% more time in direct patient care than was reported by the 2009 sample. The percentage of time spent in direct patient care varies among nurses with the same title. For example, some nurse managers spend as much time on direct patient care as does the average staff nurse, whereas other nurse managers spend as little time on patient care as the typical director or VP. Facility Type The regression model indicates several differences in compensation related to facility type. Hospitalbased nurses often receive more compensation, especially in an acute care hospital, where compensation is $7,300 higher than in many other
settings. Ambulatory care nurses generally receive less compensation, especially if the setting is office based ($8,600 less). Managers employed in any type of ambulatory setting also receive less compensation, averaging $11,300 less. Facility Size The facility size is an important differentiator in nursing compensation. This difference is particularly pronounced for those who work in higherlevel management positions. After controlling for facility type, hospital/facility administrators and VPs/directors/assistant directors of nursing earn, on average, $1,300 more per OR in the facility (compared with $1,500 in 2009). This difference may be a result of the greater number and range of responsibilities that these upper-level positions entail. In 2009, a much smaller size differential was noticed for staff nurses ($200 more per OR), but this year, there was not a statistically significant relationship between staff nurse compensation and facility size. Different types of facilities (ie, acute care hospitals compared with ambulatory care centers) also differ in size, and so for staff nurses, after facility type is considered, the size of the facility makes little difference. AORN Journal
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Facility Ownership Approximately 57% of the sample is employed by nongovernment, nonprofit organizations. The findings indicate that nurses in these facilities earn $1,600 more than nurses in facilities with different ownership structures (eg, private for profit). Those few respondents (4%) working in government or federally owned facilities (eg, Veterans Administration hospitals) earn $9,700 more, on average, than do other nurses. Population Setting The location of the facility, in an urban, suburban, or rural area, substantially influences compensation. Nurses in rural settings earn an estimated $8,900 less per year ($9,000 less in 2009) than they would if employed in a suburban or urban setting. Geographic Region Controlling for all variables previously discussed, geographic region explains significant differences in compensation levels across the United States. Although nurses in the South Atlantic, West North Central, West South Central, and East North Central regions all earn approximately the same income, nurses working in the Pacific region receive $23,200 more. The other regions with higher incomes are New England ($15,100 more), Mid-Atlantic ($7,700 more), and Mountain ($5,000 more). Nurses in the East South Central region earn approximately $2,500 less. Time Spent on Direct Patient Care Nurses in a particular position who spend more or less time than the average for direct patient care in that position should expect to receive different compensation than the estimated average compensation. On average, staff nurses earn approximately $400 more per year than the average staff nurse compensation for each 10% decrease in time spent on direct patient care per week and correspondingly for each 10% increase in time spent doing managerial tasks. This relationship is the same for nurse managers, educators, RNFAs, nurse practitioners, private scrub nurses, and other nurses. Hospital/facility administrators and VPs/ 620
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BACON directors/assistant directors of nursing earn $300 more per year for every 10% decrease in time spent on direct patient care. Work Experience The polynomial regression model suggests that nurses generally see large increases related to experience early in their careers but much smaller increases later. For example, the increase in compensation from the first to the second year is close to $1,100, but the increase from the 25th to the 26th year is only approximately $100. In this sample, the average nurse has 18 years of experience (compared with 19 years in 2009). Nurses with more or fewer years of experience should add or subtract some amount per year of experience to estimate their base compensation. Interestingly, hospital/facility administrators and VPs/ directors/assistant directors of nursing earn approximately $460 per year of experience, and this relationship continues through 30 years of experience. On average, these individuals reported 22 years of work experience (identical to the 2009 sample). Compensation Basis Whether a nurse is paid on an hourly basis or salaried is related to base compensation level, even after all of the factors mentioned previously are controlled for in the regression model. Salaried employees earn $2,400 more per year than do hourly employees. This amount is approximately the same as the $2,300 additional compensation reported in the 2009 survey. Certification Eleven types of certification were examined: BC (board certified), C (certified), CNOR (certified operating room nurse), CRNFA (certified RNFA), CPAN (certified perianesthesia nurse) and/or CAPA (certified ambulatory perianesthesia nurse), CPSN (certified plastic surgical nurse), CNA (certified in nursing administration), CNAA (certified in nursing administration advanced), ONC (certified orthopedic nurse), CNS (clinical nurse specialist), and NP (certified nurse practitioner). This year, only one of these certifications, CNOR, is
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TABLE 5. Education by Selected Job Titles
Education
Staff nurse (n ⴝ 1,540)
Nurse manager (n ⴝ 986)
Director/administrator (n ⴝ 447)
Diploma Associate’s degree Bachelor of science degree in nursing Bachelor’s degree in another field Master of science degree in nursing Master’s degree in another field
14% 32% 39% 7% 2% 3%
11% 27% 39% 9% 8% 7%
6% 18% 28% 10% 14% 20%
related to significant differences in compensation. Nurses with CNOR certification receive $860 more per year in compensation than do nurses without CNOR certification. Of particular note, these findings are qualified by the small number of nurses in the sample who hold other types of certification. Although 58% of respondents are CNOR certified, only a small percentage holds BC, C, CPAN or CAPA, CPSN, CNA, CNAA, ONC, CNS, or NP certifications. Only CRNFA and BC are held by more than 1% of respondents (3% and 2% of the sample, respectively). Thus, the number of some certifications was too small to render a statistically significant effect in regression analysis. In this regard, however, 37% of the respondents said that their facility pays more for holding a nursing certification (the same percentage as in 2009). In response to a follow-up question, of those who said their hospital offers more compensation for some certifications, 93% of the respondents said they receive extra compensation for CNOR, 24% said their facility offers more for CRNFA or CPAN and/or CAPA, 12% mentioned ONC or NP, 10% mentioned CPSN or CNS, 8% mentioned CNAA or CNA, and 6% mentioned BC or C. All of these percentages are higher than in the 2009 report, indicating that facilities may be gaining interest in certifications. Although it appears that some nurses receive extra compensation for a variety of certifications, this compensation may vary by hospital. Also, nurses with some certifications such as CNOR may find work in facilities
that offer more compensation, or they may spend more time on management tasks. After controlling for the variables of facility type and time spent on direct patient care, the effect of certification by itself is less pronounced. Education Level Nurses with an MSN add an additional $2,100 in annual base compensation, which this year is the same as nurses holding a master’s degree in another field. Nurses with only an associate’s degree make approximately $1,000 less than the average. When asked directly, only 27% of the respondents said that their facility pays more for having a degree in nursing. It may seem surprising that education has so little effect on compensation in this analysis, but it should be noted that I already controlled for job title, and a nurse’s education level may well affect the level of responsibility to which he or she may rise. Table 5 provides an analysis of education by selected job titles, including staff nurses, nurse managers, and higher-level directors and hospital administrators. The nurses in higherpaying positions, especially director and administrator, are less likely to have only a diploma or an associate’s degree and are more likely than others to have an MSN or a master’s degree in another field. Thus, although level of education does not always have a strong direct effect on compensation for nurses with the same title, education may well affect the title each nurse holds. AORN Journal
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TABLE 6. Mean Pay Raises by Job Title
Job title
Percentage of pay Percentage of pay Percentage of pay raise 2008 raise 2009 raise 2010
Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other
3.4 5.8 4.3 4.0
3.1 5.3 3.8 3.4
2.7 3.7 3.3 3.0
3.5 4.6
3.0 3.0
2.7 2.8
3.3 3.9
2.8 3.2
2.8 3.1
Nurse practitioners, educators/faculty members, and consultants were excluded because of a small sample size.
Collective Bargaining Unit Approximately 11% of respondents reported working in an environment with a union or collective bargaining unit (compared with 10.3% in 2009 and 9.4% in 2008). Nurses working in a unionized setting earn an average of $8,700 more in annual base compensation ($7,100 in 2009) than do nurses employed in a nonunion workplace. Working in a unionized environment does not appear to affect the compensation of managers. The percentage of nurses in unions appears to be rising slightly, perhaps because of the improved compensation of union members. Household Status and Gender Being married, single, or divorced is not significantly linked to base compensation. Having children younger than 18 years living at home is related to compensation. Nurses with children at home earn, on average, $1,200 less per year. This year, like some previous years, I found gender to be significant after controlling for all of the variables mentioned previously. Men earned, on average, $2,700 more than women. The varying results across the last few years of studies suggest that there may be a gender effect, but the effect is inconsistent and small relative to all of the other factors that influence perioperative nursing compensation. 622
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Other Variables As a cautionary note, the results from the regression analysis represent general patterns and do not address several variables that can affect compensation, such as the unique needs of facilities, interpersonal skills, and leadership ability. The results are generally accurate enough that two-thirds of nurses or managers who fit a particular profile will see an annual base compensation within $14,900 of base compensation estimated by the model. In questions unrelated to the base compensation model, 65% of the respondents reported receiving a raise this year, which is a 19% decline since 2008. For those receiving raises, the mean pay raise for staff nurses is 2.9% (3.1% in 2009). As shown in Table 6, raises are slightly higher for those with greater management responsibilities. Hospital/facility administrators received an average 3.7% pay raise (5.3% in 2009 and 5.8% in 2008); VPs/directors/assistant directors averaged a 3.3% raise (3.8% in 2009 and 4.3% in 2008). Nurse managers averaged a 3.0% pay raise (3.4% in 2009 and 4.0% in 2008). Notably, the pay raise percentages have declined in 2009 and in 2010 for every job title category except RNFA (the same in 2009 and 2010).
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Figure 4. Additional compensation by job title.
OTHER FORMS OF COMPENSATION The regression analysis previously described applies to base compensation. In the present sample, 65% of the respondents receive additional compensation from a variety of sources, including overtime, shift differential, on-call compensation, and bonuses (the percentage was 68% for the previous three years). The amount of additional pay differs substantially by title. The average percentage of additional compensation, by title, is shown in Figure 4. As shown, RNFAs received the largest compensation relative to base pay (19.1% compared with 16.4% in 2009) followed by staff nurses (11.1% compared with 12.1% in 2009). Educational/staff development employees received the smallest additional compensation relative to base pay (4.1% compared with 5.4% in 2009). On-call Compensation More than half of the respondents (56%) reported that they take call (55% in 2009). The median number of hours per week on call is 16 (the same
number of hours as reported in the previous five surveys). Among the on-call respondents, 67% receive a dollar-per-hour amount for being on call (compared with 68% in 2009), 6% receive a percentage of their base pay (same as in 2009), and 20% receive no compensation (same as in 2009). Among those who receive dollar-per-hour pay, the median pay is $3 per hour (same as in 2009). If called in, 59% receive time-and-a-half pay (same as in 2009), 14% receive no additional pay, and 7% get straight-time pay (compared with 5% in 2009 and 2008). Instead of pay, 4% of the oncall respondents receive comp time (3% in 2009). Overall, findings on the methods of on-call compensation are quite similar for the past three years. Overtime Compensation A large majority of respondents work overtime (76% in 2010 and 2009), totaling an average of 6.2 hours each week (identical to 2009). Approximately 62% of those who work overtime receive time-and-a-half pay (same as in 2009), but 29% AORN Journal
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TABLE 7. Average Overtime Hours Per Week and Percentage of Respondents Who Are Salaried
Job title Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other
Average number of overtime hours per week
Percentage salaried
4.1 5.6 6.4 5.1
3.8 93.5 95.1 52.3
3.3 4.3 6.6 4.2
57.8 53.6 19.2 44.4
Educators/faculty members, nurse practitioners, and consultants were excluded because of a small sample size.
receive no additional compensation (30% in 2009). Almost all of those who are not compensated for overtime are salaried (97% compared with 98% in 2009). As shown in Table 7, RNFAs average the most overtime (6.6 hours per week compared with 5.6 hours in 2009), followed by VPs/directors/assistant directors of nursing (6.4 hours compared with 6.8 hours in 2009) and hospital/facility administrators (5.6 hours compared with 4.8 hours in 2009). Respondents working the least amount of overtime are educator/staff development employees (3.3 hours per week compared with 3.7 hours in 2009). Hiring Bonuses Relatively few of the respondents received a hiring bonus when they were hired (13% compared with 14% in 2009), and only 9% reported that their employer now offers a hiring bonus for their position; this percentage has declined in each of the past three years. Half of the bonuses are in the $1,000 to $5,000 range (identical to the 2009 findings). The employees who are most likely to receive a hiring bonus are RNFAs (13%), clinical nurse specialists (12% compared with 20% in 2009), and staff nurses (10%). Hospital/facility administrators are least likely to receive a hiring bonus, with 1% reporting receiving hiring bonuses this year (0% in 2009). 624
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Shift and Other Differentials Among the respondents, 91% work the day shift and 4% work afternoons/evenings. Very few respondents work nights, weekend days, or weekend nights (less than 5% for the three categories combined). For those working the afternoon/ evening shift, the median differential is $2.75 per hour or 10% of base pay (compared with $2.72 per hour or 10% of base pay in 2009). Benefits Almost all of the respondents receive benefits as part of their compensation. As shown in Table 8, the most frequently received benefit in 2010 is health insurance (94%), followed by earned time or paid time off and dental insurance (both at 88%), life insurance (85%), and bereavement leave (76%). This year, the percentage of recipients declined in 14 of 24 benefit categories, although the declines typically were small. The most notable decreases occurred in employee referral bonuses (a 17% decline since 2008) and in bereavement leave, jury duty compensation, and tax-sheltered annuity plans (a 7% decline since 2008). Written comments revealed that a number of nurses were particularly concerned with retirement benefits. I combined data from the last several years of salary surveys to explore trends in
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TABLE 8. Percentage of Respondents Receiving Benefits
Benefit
Percentage receiving benefit in 2008
Percentage receiving benefit in 2009
Percentage receiving benefit in 2010
Health insurance Earned time or paid time off Dental insurance Life insurance Bereavement leave 401(k) contributions Jury duty compensation Long-term disability Free/discounted parking Short-term disability Tuition reimbursement Pension plan Paid certification examinations Pharmacy discounts Paid conference travel Tax-sheltered annuity plan Flexible scheduling Employee referral bonus Incentive bonuses Malpractice insurance Relocation assistance Retention bonuses Life quality service (eg, dry cleaning) Subsidized child or elder care
94 87 90 85 83 74 75 66 63 63 67 45 40 34 44 31 25 37 17 15 10 6 4 6
92 89 87 85 78 70 70 61 62 59 56 44 36 32 29 27 23 23 15 12 7 4 4 4
94 88 88 85 76 71 68 60 60 58 56 43 35 31 29 24 23 20 15 12 6 4 3 3
this benefit over time. As shown in Figure 5, the trends are mixed. There has been a slight uptick in the percentage of nurses receiving 401(k) contributions in the last year, whereas the percentage of nurses receiving a pension plan declined slightly, continuing a six-year negative trend. THE EFFECT OF THE ECONOMIC DOWNTURN ON THE PERIOPERATIVE NURSING WORK ENVIRONMENT The economic downturn that started in the fall of 2008 has had widespread effects on the perioperative nursing environment, but the negative effects appear to have lessened according to the latest survey. We asked respondents if they had seen any change in activity at their facilities. Although more than half (53%) of respondents in 2009 reported that activity had declined, 38% of the respondents in the current survey reported a
decrease in activity. Notably, 43% reported an increase in activity, which is significantly more than the 14% that reported an increase in activity in 2009. Approximately 19% reported no change compared with 33% in 2009. We asked the respondents what steps, if any, their employers had taken to deal with the current economic situation. The results, shown in Figure 6, indicate that a hiring freeze was the most frequent step taken (43% compared with 50% in 2009), followed by reduced or eliminated conference travel (36% compared with 37% in 2009) and reduced hours for nurses still employed (30% compared with 31% in 2009). We also wondered how the economic downturn affected each respondent’s own position. Approximately 46% of the respondents reported no change in their positions (51% in 2009), but AORN Journal
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Figure 5. Changes in retirement benefits.
22% experienced reduced or eliminated conference travel reimbursement (Figure 7). To a slightly greater extent, employers turned to reducing health care contributions/coverage (a 4% increase since 2009), extending hours (a 3% increase), and reducing or eliminating 401(k) contributions (a 3% increase) as ways of coping with adverse economic conditions. UPDATE ON THE PERIOPERATIVE NURSING SHORTAGE One finding stands out in the results related to the perioperative nursing shortage. In the latest survey, the median percentage of vacant full-time nursing positions decreased from 4.5% in 2009 to 0.9%. The decline is statistically significant. The decline may be the result of a cutback in the number of full-time positions and the resulting increase in the number of unemployed perioperative nurses, making it easier to staff vacant positions. Adequate staffing remains a priority for respondents, but this may be due in part to the perceived need for more staffing positions given position cutbacks. This year, 32% of high-level managers reported that the shortage has had a moderate-to-crisis 626
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level of effect on their working environment compared with 30% last year and 46% in 2008. Among nurses in this year’s sample, 53% reported a moderate-to-crisis effect, down from 56% in 2009, 66% in 2008, and 72% in 2007. As expected, the effect of the shortage on patient care tends to be rated more severely by those with the most patient contact. Approximately 57% of staff nurses rate the shortage as having a moderate-to-crisis level effect compared with 45% of nurse managers, 34% of VPs/directors/assistant directors of nursing, and 20% of facility/hospital administrators. Respondents rated their agreement with several statements about their work environment. Some of these statements were phrased as satisfaction measures. The results are shown in Figure 8. Overall, managers are more satisfied with their jobs than are nurses, with one exception. Both groups were the same in the rating of not feeling pressured to work more hours than they want to work. Overall satisfaction ratings are similar to last year, with managers rating their satisfaction as 5.1 on a 6-point scale (5.2 in 2009) and nurses rating their satisfaction as 4.8 (same as 2009 and
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Figure 6. Changes made by employers to deal with the economic downturn.
2008). The largest gaps in satisfaction between the two groups concern support from hospital management and adequate number of staff. Nurses are least satisfied with management support, the number of nursing staff, pay, and the education/training for their coworkers. Managers are least satisfied with the pressure they feel to work more hours than they prefer to work, pay, and education/training for their coworkers. The respondents were also asked to identify their top three priorities for improving the workplace. Nurses who are not in management rate their top priorities as more pay (42% rated this as one of three top priorities), more support from management (35%), and adequate number of staff (28%). Managers rate their top priorities as more education and training for coworkers (36%), more pay (36%), and more available equipment (30%).
OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION Respondents were asked to provide any comments about compensation that they would like to express. More than 650 nurses offered their views. A plurality of respondents said they are underpaid. Concerning the reasons for this view, many respondents focused on the lack of compensation for certifications and advanced degrees. One nurse explained, My patients always question me about CNOR when they read my badge, and they tell me that they feel extra safe knowing that they are in the hands of a highly skilled nurse. Despite not being paid for the certification, I am constantly recruiting and encouraging staff to take the CNOR course, but it seems that compensation is always the biggest issue. AORN Journal
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Figure 7. Ways the current economy has affected the respondent’s position.
Another nurse commented, “If the hospital doesn’t pay for our certification, nurses will not get certified. The cost of getting it and keeping it is too high.” Another nurse wrote, “My facility only compensates 50 cents per hour for certification. This is an insult to any nurse who has achieved that level of professional practice.” A number of respondents noted that experience is not adequately compensated, especially when compared with pay for new OR nurses. One nurse commented, The starting salary of new nurses in my pay grade is more than my salary, and I have been a nurse for almost 20 years with CNOR, RNFA, BSN and three classes short of my master’s degree. Nursing starts off strong in salary and then levels off and stays there. This makes it difficult to strive for more because you end up 628
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in debt with no extra money to pay for it. It all seems counterintuitive. Others noted that pay is inadequate given the amount of responsibility, physical work, stress, and increasing knowledge required for the job given the growing use of technology in perioperative nursing. One nurse wrote, “For what we do, for what we are responsible for, and given the revenue that we generate for the institution, the pay is quite low.” Several respondents asserted that OR nursing should be provided the compensation, benefits, and respect of a professional specialty given the unique skills and requirements of the job. One nurse manager wrote, In perioperative nursing, it takes time to train nurses and it’s difficult to find experienced
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Figure 8. Nurses’ and managers’ satisfaction with aspects of the work environment.
ones. Other nursing areas can call an agency to get immediate help. But if I need staffing tomorrow, it’s not going to happen by calling a local agency. For this reason, perioperative nursing should be a specialty and paid at a higher rate. A nurse added, “Nurses can be pulled out of the OR to work on the floor, but floor nurses cannot be pulled out of their department to work in the OR. Doesn’t this make what we do a specialty?” A number of respondents were dissatisfied with call compensation and scheduling, especially when they must work their regular shift shortly after completing call work. This practice raised concerns about patient safety. One nurse wrote, How can we be assured that when we are on call, we will not have eight hours or less be-
tween the time we leave and when we have to return to our regular shift? It is scary to be sleepy when you are on the job! Others expressed concerns about call requirements for older nurses. One nurse commented, “Not being required to take call after 25 or 30 years of service would be a huge recruiting and retention tool. I need to work until I’m 65, but I don’t plan to be on call at 65.” Related to compensation issues are concerns about employers reducing the type and quality of benefits and cutting employer contributions to benefit premiums, especially health insurance. A number of nurses expressed concern about the lack of benefits for retirees. A nurse wrote, “As I am getting older, I worry about health care for myself and my husband. If I don’t work, I have AORN Journal
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no coverage. Can I physically keep up and work until I’m 65?” A number of nurses described the workplace changes that have occurred because of the economic downturn, including freezes on pay and hiring, loss of bonuses, and increased workloads to compensate for position cuts. This year, more respondents commented on managers’ practice of sending nurses home when activity is low and requiring extended time when needed while keeping total hours worked to 40 or less to avoid paying overtime. One nurse wrote, “We are currently not allowed to have any overtime, and this is not likely to change.” Another stated, “This is the first time that I have seen nurses not be able to work as much as they want to.” Some nurses who said they have witnessed the hardships that others are experiencing wrote that they are thankful to have a job. One nurse said, I feel that if the CEO, COO, and CFO can get yearly bonuses—the nurses should get a yearly raise no matter how many years they have worked in the field. Nursing salaries do not grow as they do in the business world. But at least there is still a need for nurses in this present economy, and for that, I am grateful. Another nurse commented, “I am very fortunate in my present position. Jobs are few out there.” Another nurse wrote, “I feel darned fortunate to have a job.” Again this year, there were positive comments about the effects of unionization on compensation and benefits from those who are union members
BACON or work in a unionized workplace. One nurse manager wrote, “As a manager, I am not a union member, but the union takes care of its nurses with a 5%-6% yearly pay increase.” Commented a nurse, “Having a union has helped keep us competitive and has allowed us to attract qualified nurses.” Another wrote, “I don’t think we would have the salary or benefits that we do without the union.” As with last year’s results, commenters expressed thanks to AORN for the compensation survey and for the organization’s services. “Thank you for doing this survey,” one nurse wrote. “It’s nice to know what other nurses across the country make.” Said another nurse, “Thanks for all you are doing!” Despite concerns about compensation and other workplace issues, a number of respondents expressed their pride in the nursing profession and in its value. One nurse wrote, “I have enjoyed working in the perioperative arena for 40 years. The changes in technology and in the approach to patient care have been phenomenal. I am very proud to have chosen a fulfilling profession. I am proud to declare: I AM A NURSE!” Donald Bacon, PhD, is a professor of marketing at the University of Denver, CO, and a research associate at Rocky Mountain Market Research, Denver. Dr Bacon has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN thanks Baxter Healthcare Corporation, exclusive sponsor of the 2010 Salary Survey and online AORN Compensation Calculator.
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ABSTRACT AORN conducted its eighth annual compensation survey for perioperative nurses in June and July 2010. A multiple regression model was used to examine how a number of variables, including job title, education level, certification, experience, and geographic region, affect nurse compensation. Comparisons between the 2010 data and data from previous years are presented. The effects of other forms of compensation, such as on-call compensation, overtime, bonuses, and shift differentials, on base compensation rates are also examined. Additional analyses explore the effect of the current economic downturn on the perioperative work environment. AORN J 92 (December 2010) 614-630. © AORN, Inc, 2010. doi: 10.1016/j.aorn.2010.11.001 Key words: nurse salaries, compensation, economy.
I
n June and July 2010, AORN surveyed its members and some nonmembers to examine the status of perioperative nursing compensation in the United States. This market research study tracks compensation changes on a yearly basis and seeks to identify factors that influence how much perioperative nurses are presently paid. The survey also addressed the perioperative nursing shortage, focusing on perceived changes in staffing-related aspects of the perioperative nursing workplace during the past several years. Additional questions and analyses were conducted to explore the effects of the recent economic downturn on the work environment of perioperative nursing. RESPONDENT PROFILE For the seventh consecutive year, AORN conducted its survey online. In late June, approximately 55,000 potential respondents, including approximately 34,000 AORN members, were sent an e-mail invitation to participate in the survey.
This group of potential respondents is slightly smaller than the 2009 group, but it contains a higher percentage of AORN members. By late July, 6,899 unique responses were received. The focus of this survey is perioperative nursing compensation, so respondents who did not answer any compensation-related questions were excluded. This criterion reduced the usable sample to 4,921 individuals, for an 8.9% net response rate (the 2009 response rate was 5.1%). This sample is substantially larger than the 2009 sample (ie, 3,277). The increase in this year’s response rate is statistically significant. As shown in Figure 1, 44% of the respondents are staff nurses, 24% are managers, 12% are high-level managers (ie, vice presidents [VPs]/ directors/assistant directors and hospital/facility administrators), 7% are educators (ie, faculty members or staff development personnel), 5% are RN first assistants (RNFAs), and 2% are clinical nurse specialists. Forty-seven percent of the respondents are in their 50s, 24% are in their 40s, doi: 10.1016/j.aorn.2010.11.001
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© AORN, Inc, 2010
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Figure 1. Percentage of survey respondents by job title.
12% are in their 30s, and 5% are younger than 30 years of age. Twelve percent are at least 60 years of age. Approximately 91% of the sample is female, and 9% is male. Hourly-paid employees comprise 65% of the sample; 35% are salaried employees. Most of the respondents work in acute care hospitals (72%), and 24% work in an ambulatory surgery center, whether it be freestanding (12%), hospital based (10%) or office based (1%). Less than 1% of the respondents work in industry, in a school of nursing, or as an independent consultant. Approximately 3% of the sample is employed in other positions. Geographically, the sample is well dispersed across the country. As shown in Table 1, approximately 20% of the respondents live in the upper eastern coastal area (ie, New England and the Mid-Atlantic), 16% reside in the South Atlantic area, and 25% are located in the East and West North Central regions. Approximately 17% reside in the East and West South Central regions, and 21% are located in the western (ie, Mountain) and Pacific states. Approximately 80% work in an
urban or suburban area, and approximately 20% work in a rural location. Approximately 38% of the respondents have a bachelor’s degree in nursing, and 8% have a bachelor’s degree in another field. Approximately 37% of the respondents have a diploma or associate’s degree. Eight percent of respondents have a master’s degree in nursing (MSN), and 7% have a master’s degree in another field. Approximately 2% have a doctorate in nursing or in another field or have some other type of degree (Table 2). Approximately 44% of the respondents have more than 20 years of experience as a perioperative nurse, and approximately 29% have more than 25 years of experience. Approximately 26% of the respondents have 11 to 20 years of experience as a perioperative nurse, and 30% have 10 or fewer years of experience. Overall, the respondents’ demographic profile is similar to samples from the previous four years with one small exception: the respondents have slightly fewer years of experience than did the 2009 sample (eg, a 4% decline among those with more than 20 years of experience and a 4% AORN Journal
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TABLE 1. Geographic Location of Respondents Region New England (New Hampshire, Vermont, Maine, Connecticut, Rhode Island, Massachusetts) Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, New York, Washington, DC) South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida) East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) West North Central (North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, Missouri) East South Central (Kentucky, Tennessee, Mississippi, Alabama) West South Central (Oklahoma, Arkansas, Texas, Louisiana) Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) Pacific (Alaska, Washington, Oregon, California, Hawaii) Outside the United States
Frequency Percent 260
5.6
686
14.8
744
16.0
780
16.8
382
8.2
232
5.0
542
11.7
399
8.6
584
12.6
30
0.6
tive nurse population that statistical tests can provide insight. A summary of the salary findings, categorized by job title and size of facility, is shown in Table 3. This analysis and the salary analyses that follow include only nurses who were employed fulltime in the United States. Facilities are categorized as small or large based on a median split of the number of ORs reported. These findings show the calculated average salary for nurses who spend an average amount of time on direct patient care for their title. As can be seen, nurses generally receive more compensation in larger facilities. On closer examination, the relationship between facility size and compensation may also be influenced by facility type. Table 4 shows how the average number of ORs varies by facility type and how the number of ORs is related to staff nurse compensation. Taking facility size into account, the university or academic facilities tend to be larger than other facility types. The ambulatory care facilities pay somewhat less than the acute care facilities. The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. I used multiple regression as the primary analytical tool in this study because so many variables are involved.
TABLE 2. Respondents’ Education Levels Education
increase among those with 10 years of experience or less). Figure 2 represents some of the demographic information from the sample.
BASE COMPENSATION I performed statistical analyses to identify which factors have the most influence on perioperative nursing compensation. It should be noted that the sample is not perfectly random, because the net response rate was modest (8.9%). Still, the sample is sufficiently representative of the periopera616
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Diploma Associate’s degree Bachelor of science degree in nursing Bachelor’s degree in another field Master of science degree in nursing Master’s degree in another field Doctorate in nursing Doctorate in another field Other
Frequency Percent 583 1249 1853
11.9 25.5 37.8
374
7.6
394
8.0
339
6.9
4 15 85
0.1 0.3 1.7
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Figure 2. Profile of survey respondents.
The multiple regression model makes it possible to estimate the effects of one variable on compensation while statistically holding the other variables constant. The influence of each variable can then be identified, independent of the others. For this analysis, I used hierarchical regression by entering the variables expected to explain the most variance in the model first and then entering less important variables. I entered several variables with related effects initially and simultaneously. These variables are
job title, facility size, facility type, population setting (ie, urban, suburban, rural), region, and percentage of time spent in direct patient care.
I then entered other variables one at a time. These secondary variables are
years of work experience, compensation basis, certification, education level, participation in a collective bargaining unit, household status, and gender.
To obtain the most reliable results, I limited the sample for the regression analyses to respondents who are full-time employees and who work in the United States. I also eliminated statistical outliers (eg, unusually high or low pay reported by a very small number of nurses) to avoid skewing the results. I conducted checks to ensure that the statistical assumptions behind the regression AORN Journal
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TABLE 3. Estimate of Average Base Compensation by Job Title and Facility Size
Job title
Average percentage of time spent on direct patient care
Small facility (< 10 ORs)
Large facility (> 10 ORs)
89.0 19.9 17.3
$65,400 $93,700 $92,000
$67,100 ⴱ $121,900
36.1
$78,200
$84,900
19.2 47.7
$74,600 ⴱ
$76,900 $85,600
86.8 38.6 56.3
$70,900 $82,100 $76,500
$76,300 $80,900 $78,600
Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/ team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other Total
The small net subsample sizes for educators/faculty members, nurse practitioners, and consultants resulted in their exclusion from the regression analysis. Other samples with fewer than 30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred.
model were met (eg, linear relationships and normally distributed errors). The final model explains 57% of the variation in base compensation. What follows is an overview of the results concerning each variable included in the regression analysis that was found to be significantly related to base compensation level. All variables were significant at the P ⱕ .05 level. Readers can easily obtain the estimates of compensation for any particular nursing position by using the compensation calculator on the AORN web site at http://www.aorn.org/CareerCenter/SalarySurvey. Job Title More than any other variable, differences in job title are linked to differences in compensation. The average staff nurse, for example, earns
$66,400 ($2,000 more than in 2009), and the average VP/director/assistant director of nursing makes $102,900 ($1,100 more than in 2009). Part of the difference in salary across titles is explained by the difference in the percentage of time spent in direct patient care versus the percentage of time spent on other tasks such as management or administration. To explore the trends in salary for nurses and nurse managers over time, I combined data from eight years of AORN salary surveys. Figure 3 shows that staff nurses and VPs/directors/assistant directors of nursing have seen increases in average compensation during this eight-year period. The rate of growth appears to be slightly higher for staff nurses (averaging 3.9% a year) than for
TABLE 4. Size and Compensation by Facility Type
Facility type
Size (average number of ORs)
Average staff nurse base compensation
Count
Acute care hospital, general/community Acute care hospital, specialty Acute care hospital, university/academic Ambulatory surgery center, general/community Ambulatory surgery center, university/academic
14 18 27 13 23
$64,700 $69,000 $72,400 $60,100 $70,500
750 86 298 103 50
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Figure 3. Trends in base compensation.
VPs/directors/assistant directors of nursing (averaging 2.7% a year) over eight years. For comparison, the average inflation rate during this period was 2.5%. On average, staff nurses spend 89% of their time providing direct patient care and nurse managers spend 36% of their time providing direct care. As expected, high-level managers spend a relatively small amount of time in patient care (20% for facility/hospital administrators and 17% for VPs/directors/assistant directors). Facility and hospital administrators spend approximately 2% more time in direct patient care than was reported by the 2009 sample. The percentage of time spent in direct patient care varies among nurses with the same title. For example, some nurse managers spend as much time on direct patient care as does the average staff nurse, whereas other nurse managers spend as little time on patient care as the typical director or VP. Facility Type The regression model indicates several differences in compensation related to facility type. Hospitalbased nurses often receive more compensation, especially in an acute care hospital, where compensation is $7,300 higher than in many other
settings. Ambulatory care nurses generally receive less compensation, especially if the setting is office based ($8,600 less). Managers employed in any type of ambulatory setting also receive less compensation, averaging $11,300 less. Facility Size The facility size is an important differentiator in nursing compensation. This difference is particularly pronounced for those who work in higherlevel management positions. After controlling for facility type, hospital/facility administrators and VPs/directors/assistant directors of nursing earn, on average, $1,300 more per OR in the facility (compared with $1,500 in 2009). This difference may be a result of the greater number and range of responsibilities that these upper-level positions entail. In 2009, a much smaller size differential was noticed for staff nurses ($200 more per OR), but this year, there was not a statistically significant relationship between staff nurse compensation and facility size. Different types of facilities (ie, acute care hospitals compared with ambulatory care centers) also differ in size, and so for staff nurses, after facility type is considered, the size of the facility makes little difference. AORN Journal
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Facility Ownership Approximately 57% of the sample is employed by nongovernment, nonprofit organizations. The findings indicate that nurses in these facilities earn $1,600 more than nurses in facilities with different ownership structures (eg, private for profit). Those few respondents (4%) working in government or federally owned facilities (eg, Veterans Administration hospitals) earn $9,700 more, on average, than do other nurses. Population Setting The location of the facility, in an urban, suburban, or rural area, substantially influences compensation. Nurses in rural settings earn an estimated $8,900 less per year ($9,000 less in 2009) than they would if employed in a suburban or urban setting. Geographic Region Controlling for all variables previously discussed, geographic region explains significant differences in compensation levels across the United States. Although nurses in the South Atlantic, West North Central, West South Central, and East North Central regions all earn approximately the same income, nurses working in the Pacific region receive $23,200 more. The other regions with higher incomes are New England ($15,100 more), Mid-Atlantic ($7,700 more), and Mountain ($5,000 more). Nurses in the East South Central region earn approximately $2,500 less. Time Spent on Direct Patient Care Nurses in a particular position who spend more or less time than the average for direct patient care in that position should expect to receive different compensation than the estimated average compensation. On average, staff nurses earn approximately $400 more per year than the average staff nurse compensation for each 10% decrease in time spent on direct patient care per week and correspondingly for each 10% increase in time spent doing managerial tasks. This relationship is the same for nurse managers, educators, RNFAs, nurse practitioners, private scrub nurses, and other nurses. Hospital/facility administrators and VPs/ 620
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BACON directors/assistant directors of nursing earn $300 more per year for every 10% decrease in time spent on direct patient care. Work Experience The polynomial regression model suggests that nurses generally see large increases related to experience early in their careers but much smaller increases later. For example, the increase in compensation from the first to the second year is close to $1,100, but the increase from the 25th to the 26th year is only approximately $100. In this sample, the average nurse has 18 years of experience (compared with 19 years in 2009). Nurses with more or fewer years of experience should add or subtract some amount per year of experience to estimate their base compensation. Interestingly, hospital/facility administrators and VPs/ directors/assistant directors of nursing earn approximately $460 per year of experience, and this relationship continues through 30 years of experience. On average, these individuals reported 22 years of work experience (identical to the 2009 sample). Compensation Basis Whether a nurse is paid on an hourly basis or salaried is related to base compensation level, even after all of the factors mentioned previously are controlled for in the regression model. Salaried employees earn $2,400 more per year than do hourly employees. This amount is approximately the same as the $2,300 additional compensation reported in the 2009 survey. Certification Eleven types of certification were examined: BC (board certified), C (certified), CNOR (certified operating room nurse), CRNFA (certified RNFA), CPAN (certified perianesthesia nurse) and/or CAPA (certified ambulatory perianesthesia nurse), CPSN (certified plastic surgical nurse), CNA (certified in nursing administration), CNAA (certified in nursing administration advanced), ONC (certified orthopedic nurse), CNS (clinical nurse specialist), and NP (certified nurse practitioner). This year, only one of these certifications, CNOR, is
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TABLE 5. Education by Selected Job Titles
Education
Staff nurse (n ⴝ 1,540)
Nurse manager (n ⴝ 986)
Director/administrator (n ⴝ 447)
Diploma Associate’s degree Bachelor of science degree in nursing Bachelor’s degree in another field Master of science degree in nursing Master’s degree in another field
14% 32% 39% 7% 2% 3%
11% 27% 39% 9% 8% 7%
6% 18% 28% 10% 14% 20%
related to significant differences in compensation. Nurses with CNOR certification receive $860 more per year in compensation than do nurses without CNOR certification. Of particular note, these findings are qualified by the small number of nurses in the sample who hold other types of certification. Although 58% of respondents are CNOR certified, only a small percentage holds BC, C, CPAN or CAPA, CPSN, CNA, CNAA, ONC, CNS, or NP certifications. Only CRNFA and BC are held by more than 1% of respondents (3% and 2% of the sample, respectively). Thus, the number of some certifications was too small to render a statistically significant effect in regression analysis. In this regard, however, 37% of the respondents said that their facility pays more for holding a nursing certification (the same percentage as in 2009). In response to a follow-up question, of those who said their hospital offers more compensation for some certifications, 93% of the respondents said they receive extra compensation for CNOR, 24% said their facility offers more for CRNFA or CPAN and/or CAPA, 12% mentioned ONC or NP, 10% mentioned CPSN or CNS, 8% mentioned CNAA or CNA, and 6% mentioned BC or C. All of these percentages are higher than in the 2009 report, indicating that facilities may be gaining interest in certifications. Although it appears that some nurses receive extra compensation for a variety of certifications, this compensation may vary by hospital. Also, nurses with some certifications such as CNOR may find work in facilities
that offer more compensation, or they may spend more time on management tasks. After controlling for the variables of facility type and time spent on direct patient care, the effect of certification by itself is less pronounced. Education Level Nurses with an MSN add an additional $2,100 in annual base compensation, which this year is the same as nurses holding a master’s degree in another field. Nurses with only an associate’s degree make approximately $1,000 less than the average. When asked directly, only 27% of the respondents said that their facility pays more for having a degree in nursing. It may seem surprising that education has so little effect on compensation in this analysis, but it should be noted that I already controlled for job title, and a nurse’s education level may well affect the level of responsibility to which he or she may rise. Table 5 provides an analysis of education by selected job titles, including staff nurses, nurse managers, and higher-level directors and hospital administrators. The nurses in higherpaying positions, especially director and administrator, are less likely to have only a diploma or an associate’s degree and are more likely than others to have an MSN or a master’s degree in another field. Thus, although level of education does not always have a strong direct effect on compensation for nurses with the same title, education may well affect the title each nurse holds. AORN Journal
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TABLE 6. Mean Pay Raises by Job Title
Job title
Percentage of pay Percentage of pay Percentage of pay raise 2008 raise 2009 raise 2010
Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other
3.4 5.8 4.3 4.0
3.1 5.3 3.8 3.4
2.7 3.7 3.3 3.0
3.5 4.6
3.0 3.0
2.7 2.8
3.3 3.9
2.8 3.2
2.8 3.1
Nurse practitioners, educators/faculty members, and consultants were excluded because of a small sample size.
Collective Bargaining Unit Approximately 11% of respondents reported working in an environment with a union or collective bargaining unit (compared with 10.3% in 2009 and 9.4% in 2008). Nurses working in a unionized setting earn an average of $8,700 more in annual base compensation ($7,100 in 2009) than do nurses employed in a nonunion workplace. Working in a unionized environment does not appear to affect the compensation of managers. The percentage of nurses in unions appears to be rising slightly, perhaps because of the improved compensation of union members. Household Status and Gender Being married, single, or divorced is not significantly linked to base compensation. Having children younger than 18 years living at home is related to compensation. Nurses with children at home earn, on average, $1,200 less per year. This year, like some previous years, I found gender to be significant after controlling for all of the variables mentioned previously. Men earned, on average, $2,700 more than women. The varying results across the last few years of studies suggest that there may be a gender effect, but the effect is inconsistent and small relative to all of the other factors that influence perioperative nursing compensation. 622
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Other Variables As a cautionary note, the results from the regression analysis represent general patterns and do not address several variables that can affect compensation, such as the unique needs of facilities, interpersonal skills, and leadership ability. The results are generally accurate enough that two-thirds of nurses or managers who fit a particular profile will see an annual base compensation within $14,900 of base compensation estimated by the model. In questions unrelated to the base compensation model, 65% of the respondents reported receiving a raise this year, which is a 19% decline since 2008. For those receiving raises, the mean pay raise for staff nurses is 2.9% (3.1% in 2009). As shown in Table 6, raises are slightly higher for those with greater management responsibilities. Hospital/facility administrators received an average 3.7% pay raise (5.3% in 2009 and 5.8% in 2008); VPs/directors/assistant directors averaged a 3.3% raise (3.8% in 2009 and 4.3% in 2008). Nurse managers averaged a 3.0% pay raise (3.4% in 2009 and 4.0% in 2008). Notably, the pay raise percentages have declined in 2009 and in 2010 for every job title category except RNFA (the same in 2009 and 2010).
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Figure 4. Additional compensation by job title.
OTHER FORMS OF COMPENSATION The regression analysis previously described applies to base compensation. In the present sample, 65% of the respondents receive additional compensation from a variety of sources, including overtime, shift differential, on-call compensation, and bonuses (the percentage was 68% for the previous three years). The amount of additional pay differs substantially by title. The average percentage of additional compensation, by title, is shown in Figure 4. As shown, RNFAs received the largest compensation relative to base pay (19.1% compared with 16.4% in 2009) followed by staff nurses (11.1% compared with 12.1% in 2009). Educational/staff development employees received the smallest additional compensation relative to base pay (4.1% compared with 5.4% in 2009). On-call Compensation More than half of the respondents (56%) reported that they take call (55% in 2009). The median number of hours per week on call is 16 (the same
number of hours as reported in the previous five surveys). Among the on-call respondents, 67% receive a dollar-per-hour amount for being on call (compared with 68% in 2009), 6% receive a percentage of their base pay (same as in 2009), and 20% receive no compensation (same as in 2009). Among those who receive dollar-per-hour pay, the median pay is $3 per hour (same as in 2009). If called in, 59% receive time-and-a-half pay (same as in 2009), 14% receive no additional pay, and 7% get straight-time pay (compared with 5% in 2009 and 2008). Instead of pay, 4% of the oncall respondents receive comp time (3% in 2009). Overall, findings on the methods of on-call compensation are quite similar for the past three years. Overtime Compensation A large majority of respondents work overtime (76% in 2010 and 2009), totaling an average of 6.2 hours each week (identical to 2009). Approximately 62% of those who work overtime receive time-and-a-half pay (same as in 2009), but 29% AORN Journal
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TABLE 7. Average Overtime Hours Per Week and Percentage of Respondents Who Are Salaried
Job title Staff nurse Hospital/facility administrator Vice president/director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master of science degree or higher) RN first assistant Other
Average number of overtime hours per week
Percentage salaried
4.1 5.6 6.4 5.1
3.8 93.5 95.1 52.3
3.3 4.3 6.6 4.2
57.8 53.6 19.2 44.4
Educators/faculty members, nurse practitioners, and consultants were excluded because of a small sample size.
receive no additional compensation (30% in 2009). Almost all of those who are not compensated for overtime are salaried (97% compared with 98% in 2009). As shown in Table 7, RNFAs average the most overtime (6.6 hours per week compared with 5.6 hours in 2009), followed by VPs/directors/assistant directors of nursing (6.4 hours compared with 6.8 hours in 2009) and hospital/facility administrators (5.6 hours compared with 4.8 hours in 2009). Respondents working the least amount of overtime are educator/staff development employees (3.3 hours per week compared with 3.7 hours in 2009). Hiring Bonuses Relatively few of the respondents received a hiring bonus when they were hired (13% compared with 14% in 2009), and only 9% reported that their employer now offers a hiring bonus for their position; this percentage has declined in each of the past three years. Half of the bonuses are in the $1,000 to $5,000 range (identical to the 2009 findings). The employees who are most likely to receive a hiring bonus are RNFAs (13%), clinical nurse specialists (12% compared with 20% in 2009), and staff nurses (10%). Hospital/facility administrators are least likely to receive a hiring bonus, with 1% reporting receiving hiring bonuses this year (0% in 2009). 624
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Shift and Other Differentials Among the respondents, 91% work the day shift and 4% work afternoons/evenings. Very few respondents work nights, weekend days, or weekend nights (less than 5% for the three categories combined). For those working the afternoon/ evening shift, the median differential is $2.75 per hour or 10% of base pay (compared with $2.72 per hour or 10% of base pay in 2009). Benefits Almost all of the respondents receive benefits as part of their compensation. As shown in Table 8, the most frequently received benefit in 2010 is health insurance (94%), followed by earned time or paid time off and dental insurance (both at 88%), life insurance (85%), and bereavement leave (76%). This year, the percentage of recipients declined in 14 of 24 benefit categories, although the declines typically were small. The most notable decreases occurred in employee referral bonuses (a 17% decline since 2008) and in bereavement leave, jury duty compensation, and tax-sheltered annuity plans (a 7% decline since 2008). Written comments revealed that a number of nurses were particularly concerned with retirement benefits. I combined data from the last several years of salary surveys to explore trends in
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TABLE 8. Percentage of Respondents Receiving Benefits
Benefit
Percentage receiving benefit in 2008
Percentage receiving benefit in 2009
Percentage receiving benefit in 2010
Health insurance Earned time or paid time off Dental insurance Life insurance Bereavement leave 401(k) contributions Jury duty compensation Long-term disability Free/discounted parking Short-term disability Tuition reimbursement Pension plan Paid certification examinations Pharmacy discounts Paid conference travel Tax-sheltered annuity plan Flexible scheduling Employee referral bonus Incentive bonuses Malpractice insurance Relocation assistance Retention bonuses Life quality service (eg, dry cleaning) Subsidized child or elder care
94 87 90 85 83 74 75 66 63 63 67 45 40 34 44 31 25 37 17 15 10 6 4 6
92 89 87 85 78 70 70 61 62 59 56 44 36 32 29 27 23 23 15 12 7 4 4 4
94 88 88 85 76 71 68 60 60 58 56 43 35 31 29 24 23 20 15 12 6 4 3 3
this benefit over time. As shown in Figure 5, the trends are mixed. There has been a slight uptick in the percentage of nurses receiving 401(k) contributions in the last year, whereas the percentage of nurses receiving a pension plan declined slightly, continuing a six-year negative trend. THE EFFECT OF THE ECONOMIC DOWNTURN ON THE PERIOPERATIVE NURSING WORK ENVIRONMENT The economic downturn that started in the fall of 2008 has had widespread effects on the perioperative nursing environment, but the negative effects appear to have lessened according to the latest survey. We asked respondents if they had seen any change in activity at their facilities. Although more than half (53%) of respondents in 2009 reported that activity had declined, 38% of the respondents in the current survey reported a
decrease in activity. Notably, 43% reported an increase in activity, which is significantly more than the 14% that reported an increase in activity in 2009. Approximately 19% reported no change compared with 33% in 2009. We asked the respondents what steps, if any, their employers had taken to deal with the current economic situation. The results, shown in Figure 6, indicate that a hiring freeze was the most frequent step taken (43% compared with 50% in 2009), followed by reduced or eliminated conference travel (36% compared with 37% in 2009) and reduced hours for nurses still employed (30% compared with 31% in 2009). We also wondered how the economic downturn affected each respondent’s own position. Approximately 46% of the respondents reported no change in their positions (51% in 2009), but AORN Journal
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Figure 5. Changes in retirement benefits.
22% experienced reduced or eliminated conference travel reimbursement (Figure 7). To a slightly greater extent, employers turned to reducing health care contributions/coverage (a 4% increase since 2009), extending hours (a 3% increase), and reducing or eliminating 401(k) contributions (a 3% increase) as ways of coping with adverse economic conditions. UPDATE ON THE PERIOPERATIVE NURSING SHORTAGE One finding stands out in the results related to the perioperative nursing shortage. In the latest survey, the median percentage of vacant full-time nursing positions decreased from 4.5% in 2009 to 0.9%. The decline is statistically significant. The decline may be the result of a cutback in the number of full-time positions and the resulting increase in the number of unemployed perioperative nurses, making it easier to staff vacant positions. Adequate staffing remains a priority for respondents, but this may be due in part to the perceived need for more staffing positions given position cutbacks. This year, 32% of high-level managers reported that the shortage has had a moderate-to-crisis 626
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level of effect on their working environment compared with 30% last year and 46% in 2008. Among nurses in this year’s sample, 53% reported a moderate-to-crisis effect, down from 56% in 2009, 66% in 2008, and 72% in 2007. As expected, the effect of the shortage on patient care tends to be rated more severely by those with the most patient contact. Approximately 57% of staff nurses rate the shortage as having a moderate-to-crisis level effect compared with 45% of nurse managers, 34% of VPs/directors/assistant directors of nursing, and 20% of facility/hospital administrators. Respondents rated their agreement with several statements about their work environment. Some of these statements were phrased as satisfaction measures. The results are shown in Figure 8. Overall, managers are more satisfied with their jobs than are nurses, with one exception. Both groups were the same in the rating of not feeling pressured to work more hours than they want to work. Overall satisfaction ratings are similar to last year, with managers rating their satisfaction as 5.1 on a 6-point scale (5.2 in 2009) and nurses rating their satisfaction as 4.8 (same as 2009 and
2010 SALARY SURVEY
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Figure 6. Changes made by employers to deal with the economic downturn.
2008). The largest gaps in satisfaction between the two groups concern support from hospital management and adequate number of staff. Nurses are least satisfied with management support, the number of nursing staff, pay, and the education/training for their coworkers. Managers are least satisfied with the pressure they feel to work more hours than they prefer to work, pay, and education/training for their coworkers. The respondents were also asked to identify their top three priorities for improving the workplace. Nurses who are not in management rate their top priorities as more pay (42% rated this as one of three top priorities), more support from management (35%), and adequate number of staff (28%). Managers rate their top priorities as more education and training for coworkers (36%), more pay (36%), and more available equipment (30%).
OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION Respondents were asked to provide any comments about compensation that they would like to express. More than 650 nurses offered their views. A plurality of respondents said they are underpaid. Concerning the reasons for this view, many respondents focused on the lack of compensation for certifications and advanced degrees. One nurse explained, My patients always question me about CNOR when they read my badge, and they tell me that they feel extra safe knowing that they are in the hands of a highly skilled nurse. Despite not being paid for the certification, I am constantly recruiting and encouraging staff to take the CNOR course, but it seems that compensation is always the biggest issue. AORN Journal
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Figure 7. Ways the current economy has affected the respondent’s position.
Another nurse commented, “If the hospital doesn’t pay for our certification, nurses will not get certified. The cost of getting it and keeping it is too high.” Another nurse wrote, “My facility only compensates 50 cents per hour for certification. This is an insult to any nurse who has achieved that level of professional practice.” A number of respondents noted that experience is not adequately compensated, especially when compared with pay for new OR nurses. One nurse commented, The starting salary of new nurses in my pay grade is more than my salary, and I have been a nurse for almost 20 years with CNOR, RNFA, BSN and three classes short of my master’s degree. Nursing starts off strong in salary and then levels off and stays there. This makes it difficult to strive for more because you end up 628
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in debt with no extra money to pay for it. It all seems counterintuitive. Others noted that pay is inadequate given the amount of responsibility, physical work, stress, and increasing knowledge required for the job given the growing use of technology in perioperative nursing. One nurse wrote, “For what we do, for what we are responsible for, and given the revenue that we generate for the institution, the pay is quite low.” Several respondents asserted that OR nursing should be provided the compensation, benefits, and respect of a professional specialty given the unique skills and requirements of the job. One nurse manager wrote, In perioperative nursing, it takes time to train nurses and it’s difficult to find experienced
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Figure 8. Nurses’ and managers’ satisfaction with aspects of the work environment.
ones. Other nursing areas can call an agency to get immediate help. But if I need staffing tomorrow, it’s not going to happen by calling a local agency. For this reason, perioperative nursing should be a specialty and paid at a higher rate. A nurse added, “Nurses can be pulled out of the OR to work on the floor, but floor nurses cannot be pulled out of their department to work in the OR. Doesn’t this make what we do a specialty?” A number of respondents were dissatisfied with call compensation and scheduling, especially when they must work their regular shift shortly after completing call work. This practice raised concerns about patient safety. One nurse wrote, How can we be assured that when we are on call, we will not have eight hours or less be-
tween the time we leave and when we have to return to our regular shift? It is scary to be sleepy when you are on the job! Others expressed concerns about call requirements for older nurses. One nurse commented, “Not being required to take call after 25 or 30 years of service would be a huge recruiting and retention tool. I need to work until I’m 65, but I don’t plan to be on call at 65.” Related to compensation issues are concerns about employers reducing the type and quality of benefits and cutting employer contributions to benefit premiums, especially health insurance. A number of nurses expressed concern about the lack of benefits for retirees. A nurse wrote, “As I am getting older, I worry about health care for myself and my husband. If I don’t work, I have AORN Journal
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no coverage. Can I physically keep up and work until I’m 65?” A number of nurses described the workplace changes that have occurred because of the economic downturn, including freezes on pay and hiring, loss of bonuses, and increased workloads to compensate for position cuts. This year, more respondents commented on managers’ practice of sending nurses home when activity is low and requiring extended time when needed while keeping total hours worked to 40 or less to avoid paying overtime. One nurse wrote, “We are currently not allowed to have any overtime, and this is not likely to change.” Another stated, “This is the first time that I have seen nurses not be able to work as much as they want to.” Some nurses who said they have witnessed the hardships that others are experiencing wrote that they are thankful to have a job. One nurse said, I feel that if the CEO, COO, and CFO can get yearly bonuses—the nurses should get a yearly raise no matter how many years they have worked in the field. Nursing salaries do not grow as they do in the business world. But at least there is still a need for nurses in this present economy, and for that, I am grateful. Another nurse commented, “I am very fortunate in my present position. Jobs are few out there.” Another nurse wrote, “I feel darned fortunate to have a job.” Again this year, there were positive comments about the effects of unionization on compensation and benefits from those who are union members
BACON or work in a unionized workplace. One nurse manager wrote, “As a manager, I am not a union member, but the union takes care of its nurses with a 5%-6% yearly pay increase.” Commented a nurse, “Having a union has helped keep us competitive and has allowed us to attract qualified nurses.” Another wrote, “I don’t think we would have the salary or benefits that we do without the union.” As with last year’s results, commenters expressed thanks to AORN for the compensation survey and for the organization’s services. “Thank you for doing this survey,” one nurse wrote. “It’s nice to know what other nurses across the country make.” Said another nurse, “Thanks for all you are doing!” Despite concerns about compensation and other workplace issues, a number of respondents expressed their pride in the nursing profession and in its value. One nurse wrote, “I have enjoyed working in the perioperative arena for 40 years. The changes in technology and in the approach to patient care have been phenomenal. I am very proud to have chosen a fulfilling profession. I am proud to declare: I AM A NURSE!” Donald Bacon, PhD, is a professor of marketing at the University of Denver, CO, and a research associate at Rocky Mountain Market Research, Denver. Dr Bacon has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN thanks Baxter Healthcare Corporation, exclusive sponsor of the 2010 Salary Survey and online AORN Compensation Calculator.
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