Results of the 2014 AORN Salary and Compensation Survey DONALD R. BACON, PhD; KIM A. STEWART, PhD
ABSTRACT AORN conducted its 12th annual compensation survey for perioperative nurses in June and July 2014. 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 data from 2014 and data from previous years are presented. The effects of other forms of compensation (eg, oncall compensation, overtime, bonuses, shift differentials) on base compensation rates also are examined. Additional analyses explore the effect of the economic downturn on the perioperative work environment. AORN J 100 (December 2014) 570-585. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.09.010 Key words: nurse salaries, compensation, economy.
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rom late June to early July 2014, 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 potential nursing turnover and the reasons why some nurses are actively considering leaving their jobs. RESPONDENT PROFILE For the 11th consecutive year, AORN conducted its survey online. In mid-June, 88,320 potential respondents (including 36,550 AORN members) received an invitation to participate in the survey. This group of potential respondents is substantially larger than last year’s group (50,850). As an incentive, participants were eligible to enter a raffle for a free iPadÒ mini. By mid-July, 4,709 unique responses were received. Because the focus of this
survey is perioperative nursing compensation, respondents who did not answer any compensationrelated questions were excluded. This criterion reduced the usable sample to 3,437 individuals, for a 3.9% net response rate. The final sample is 15% larger than the 2013 sample. As shown in Figure 1, 44% of the respondents are staff nurses, 24% are managers (ie, nurse manager, supervisor, coordinator, team leader, business manager), 10% are high-level managers (ie, director, vice president [VP], assistant director of nursing), 7% are educators, 4% are RN first assistants (RNFAs), and 1% are clinical nurse specialists. Less than 1% are nurse practitioners or consultants. Some of the demographic information from the sample is represented in Figure 2. Approximately 38% of the respondents are in their 50s, 27% are in their 40s, 17% are in their 30s, 6% are younger than 30 years of age, and 13% are at least 60 years of age. Approximately 90% of the sample is female. http://dx.doi.org/10.1016/j.aorn.2014.09.010
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Ó AORN, Inc, 2014
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and West North Central regions, 17% reside in the East South Central and West South Central regions, and 19% are located in the Mountain and Pacific regions. Additionally, approximately 80% work in an urban or suburban area and approximately 20% work in a rural location. Forty-three percent of the respondents have a bachelor’s degree in nursing, and approximately 6% have a bachelor’s degree in another field. Approximately 33% of the respondents have a diploma or associate degree. Approximately 11% of respondents have a master’s degree in nursing, and approximately 5% hold a master’s degree in another field. Two percent have a doctorate in nursing or in another field or hold some other type of degree (Table 2).
Figure 1. Percentage of survey respondents by job title.
Hourly-paid employees comprise 65% of the sample, and 35% are salaried employees. Most of the respondents work in acute care hospitals (73%), and 27% work in an ambulatory surgery center (ASC), whether it be freestanding (13%), hospital based (12%), or office based (2%). Approximately 40% of respondents have more than 20 years of experience as a perioperative nurse, with 28% having more than 25 years of experience. Approximately 26% of the respondents have 11 to 20 years of experience as a perioperative nurse, and 34% have 10 or fewer years of experience. Overall, the respondents’ demographic profile is quite similar to the 2013 sample. Geographically, the sample is well dispersed across the country. As shown in Table 1, approximately 21% of the respondents live in the upper eastern coastal region (ie, New England and the Mid-Atlantic), 17% reside in the South Atlantic region, 26% are located in the East North Central
BASE COMPENSATION We 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 (3.9%). Still, the sample is sufficiently representative of the perioperative 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 full time in the United States. Facilities are categorized as small or large based on a median split of the number of ORs reported, with small defined as 10 or fewer ORs and large defined as more than 10 ORs. 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 also may 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, AORN Journal j 571
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Figure 2. Profile of survey respondents.
university or academic facilities tend to be larger than other facility types. There are instances, however, in which compensation is higher in smaller facilities than in larger ones, indicating that facility size and type have simultaneous effects on compensation. The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. We used multiple regression as the primary analytical tool in this study because so many variables are involved. The multiple regression model makes it possible to estimate the effects of one variable on compensation 572 j AORN Journal
while statistically holding the other variables constant. The influence of each variable then can be identified independent of the others. For the analysis, we used hierarchical regression by entering the variables expected to explain the most variance into the model first and then entering the less important variables. We entered several variables with related effects initially and simultaneously. These variables are n
job title, n facility size, n facility type, n population setting (ie, urban, suburban, rural),
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TABLE 1. Geographic Location of Respondents
Region
Frequency
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) Total
n
region, n state, and n percentage of time spent in direct patient care. State was only entered for states with 50 or more respondents. We then entered other variables one at a time. These secondary variables are n n n n n n n
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, we limited the sample for the regression analysis to respondents who are full-time employees and who work in the United States. We eliminated statistical outliers (eg, unusually high or low pay reported by a very small number of nurses) to avoid skewing the results. We conducted checks to ensure that the statistical assumptions behind the regression model were met (eg, linear relationships and normally distributed errors). The final model explains 62% 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
Percentage (%)
178 529 582 585 311
5.2 15.4 16.9 17.0 9.0
211 374 250 417 3,437
6.1 10.9 7.3 12.1 100.0
significant at the P .05 level. Readers can 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 (accessed August 22, 2014). Job Title More than any variable, differences in job title are linked to differences in annual compensation. The average staff nurse, for example, earns $67,800 ($400 more than in 2013), and the average director/ VP/assistant director of nursing earns $110,700
TABLE 2. Respondents’ Education Levels
Education
Frequency
Percentage (%)
Diploma Associate degree Bachelor’s degree in nursing Bachelor’s degree in another field Master’s degree in nursing Master’s degree in another field Doctorate in nursing Doctorate in another field Other Total
263 873 1,475 200
7.7 25.4 43.0 5.8
368 187
10.7 5.4
13 10 44 3,433
0.4 0.3 1.3 100.0
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TABLE 3. Estimate of Average Base Compensation by Job Title and Facility Size
Job title
Average percentage (%) of time in direct patient care
Small facility ( 10 ORs)
Large facility (> 10 ORs)
87.8 16.4 16.1 37.6
$65,800 $104,600 $97,900 $80,300
$69,100 * $130,200 $87,200
16.7 35.6 85.2 37.7 57.6
$79,900 * $74,300 $75,000 $77,700
$82,500 $85,800 $79,800 $81,600 $80,700
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other Total
The small net subsample sizes for nurse practitioners and consultants resulted in their exclusion from the regression analysis. Other samples with less than 30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred.
($1,200 more than in 2013, but $1,200 less than 2012). 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, we combined data from 11 years of AORN salary surveys. Figure 3 shows that staff nurses and directors/VPs/assistant directors of nursing generally have seen increases in average compensation during this 11-year period. In 11 years, the average annual growth rate has been similar for staff nurses (2.68%) and for directors/VPs/assistant directors of nursing (2.41%). For comparison, the average annual inflation rate is 2.38% for the past 11 years. On average, staff nurses spend 88% of their time delivering direct patient care, and nurse managers spend 38% of their time providing direct care. As expected, high-level managers average a relatively small amount of time on patient care (16% for facility/hospital administrators, unchanged since 2013, and 16% for directors/VPs/assistant directors of nursing, a 1% decline from 2013). The percentage of time spent on direct patient care varies among nurses with the same title. For 574 j AORN Journal
example, some nurse managers spend as much time on direct patient care as 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 annual compensation related to facility type. Hospital-based nurses often receive more compensation, especially in an acute care hospital, whereas nurses in ASCs receive less compensation. This year, nurses in acute care hospitals received $2,900 more than other nurses in general, whereas nurses in office-based ASCs received $9,400 less and nurses in freestanding ASCs received $5,800 less. Nurses in general/ community hospitals received $3,700 less than nurses in specialty hospitals or in university/ academic medical centers. Facility Size The size of the facility is an important differentiator in annual nursing compensation. This difference is particularly pronounced for those who work in higher-level management positions. After controlling for facility type, hospital/facility administrators and directors/VPs/assistant directors of nursing
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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
15 16 30 12 22
$66,600 $75,100 $69,900 $61,800 $71,300
681 105 273 138 57
earn on average $1,300 more per OR in the facility. This difference may be because of the greater number and range of responsibilities that these upper-level positions entail. No statistically significant relationship was found between staff nursing compensation and facility size. Different types of facilities (eg, acute care hospitals compared with ambulatory care facilities) also differ in size; thus, after facility type is considered, facility size makes little difference for nurses. Facility Ownership Approximately 32% of the respondents are employed by private, for-profit organizations. The findings indicate that nurses in these facilities earn $3,400 per year less than nurses in facilities with
different ownership structures (eg, nongovernment, nonprofit). The few respondents (9%) working in government facilities but not federal facilities (eg, county hospitals) earn an average of $2,800 less per year than other nurses. Population Setting The location of the facility (ie, urban, suburban, rural) substantially influences compensation. Nurses in rural settings earn an estimated $7,300 less per year than if they were employed in a suburban or urban setting. Geographic Region Controlling for all variables previously discussed, geographic region explains significant differences
Figure 3. Trends in base compensation over time.
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in annual compensation across the United States. Nurses in the Pacific region receive $18,000 more than the average staff nurse. The other regions with higher incomes are New England ($10,600 more), Mid-Atlantic ($14,800 more), and Mountain ($5,100 more). A region with significantly below average compensation is East South Central ($4,300 less). This year, nurses reported the specific state where they reside. Our total sample is large enough that meaningful estimates for state differences could be made for many states. Only states with more than 50 respondents were examined for statespecific effects. Of the 26 states studied, six states showed significantly different effects than their region would otherwise suggest. After adjusting for region, these states should be adjusted again. Table 5 shows the states requiring specific adjustments and the adjusted amounts. All adjustments are additions or subtractions to base compensation. 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 amounts, as shown in Table 3. On average, staff nurses earn approximately $700 more per year than the average staff nurse 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 (a $100 increase from 2013). This relationship is the same for nurse managers, educators, RNFAs, nurse practitioners, private scrub nurses, and other nurses. Hospital/facility administrators and directors/VPs/assistant directors of nursing earn approximately $500 more per year for each 10% increase in time spent on managerial tasks and, correspondingly, $500 less per year for each 10% increase in time spent on direct patient care. Work Experience The polynomial regression model suggests that nurses generally see large increases related to 576 j AORN Journal
TABLE 5. States With Adjustments Different From Their Regions State
Adjustment
Massachusetts California Minnesota Texas Maryland Pennsylvania
$25,800 $18,200 $14,400 $9,700 e$6,700 e$13,100
experience early in their careers compared with later in their careers. For example, the increase from the first to the second year is close to $1,200, but the jump from the 25th to the 26th year is only approximately $200. In this sample, the average nurse has 17 years of experience (one year less than the 2013 sample). Nurses with more or less than this amount of experience should add or subtract some amount per year of experience to estimate their base compensation. Of interest is that hospital/facility administrators and directors/VPs/assistant directors of nursing earn approximately $500 per year of experience, and this positive relationship continues through 30 years of experience. On average, these individuals reported 22 years of work experience, which is one year less than reported in 2013. Compensation Basis The salary survey generally finds that whether a nurse is paid an hourly rate or salary is related to base compensation, with salaried nurses earning as much as $3,000 per year more than hourlypaid nurses (unchanged since 2013). For 2014, the average difference between salaried and hourly compensation was $2,300 per year. Certification Ten types of certification were examined: n
BC (board certified), CNORÒ (certified OR nurse), n CRNFAÒ (certified RNFA), n
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n n n n n n
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).
Of all these, only four were held by more than 50 respondents: CNOR (1,794 nurses), CRNFA (77 nurses), BC (65 nurses), and CPAN and/or CAPA (54 nurses). The other certification counts were considered too small to provide reliable results. This year, two of these three certifications were significantly associated with higher annual compensation. Nurses with a CNOR earned $2,200 more and BC nurses earned $6,900 more than other nurses. In 2013, CRNFA nurses were found to earn significantly more compensation ($5,300), but this year the average difference was less ($4,300); this difference was not statistically significant. Approximately 39% of the respondents said that their facility pays more for holding a nursing certification (down from 40% in 2013). Of those who said their hospital offers more compensation for some certifications, 91% of the respondents said they receive extra compensation for CNOR, 27% mentioned CPAN and/or CAPA, 25% mentioned CRNFA, 15% mentioned NP, 15% mentioned ONC, 14% mentioned CNS, 12% mentioned CPSN, and 10% or less respondents mentioned BC, CNAA, or CNA. Most of these percentages are approximately the same as reported last year. Thus, while the regression model did not show large differences in pay related to certification, a substantial number of nurses reported that their facility pays for certification. To gain more insight, we asked nurses whether they receive the compensation as an addition to their base pay or as a one-time bonus. More than half (61%) of the nurses
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in the sample reported that the pay was an addition to their base pay, and 23% reported that the pay was a one-time bonus. The remainder of our sample (16%) provided a variety of responses, including no additional pay, an annual bonus, or better opportunities for promotion. Although it appears that some nurses receive extra compensation for a variety of certifications, this compensation can 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 managerial tasks. Once we control for facility type and time spent on direct patient care, the effect of certification on base pay by itself is less pronounced. Education Level Nurses with a master’s degree in nursing receive an additional $3,200 in annual base compensation. No other significant differences in compensation related to education were found in this year’s sample. When asked directly, 28% of the respondents said that their facility pays more for having a degree in nursing, compared with 29% in 2013, 27% in 2012, and 26% in 2011. It may seem surprising that education has little effect on compensation in this analysis, but it should be noted that the analysis has already been 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 6 provides an analysis of education by selected job titles, including staff nurse, nurse manager, and director/ administrator. Nurses in higher-paying positions, especially directors and administrators, are less likely to have a diploma or associate degree as their highest level of education and are more likely than others to have a master’s degree in nursing or 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.
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TABLE 6. Education by Selected Job Titles Job title (sample size) Education
Staff nurse, % (n ¼ 1,521)
Nurse manager, % (n ¼ 833)
Director/administrator, % (n ¼ 355)
Diploma Associate degree Bachelor’s degree in nursing Bachelor’s degree in another field Master’s degree in nursing Master’s degree in another field
8.6 31.7 46.9 5.5 4.1 1.8
7.1 25.6 43.5 5.3 12.1 5.8
6.2 11.8 34.1 8.5 15.5 19.7
The small net subsample sizes for those with DNP and PhD degrees resulted in their exclusion from analysis.
Collective Bargaining Unit Approximately 12% of respondents reported working in an environment with a union or collective bargaining unit. Nurses working in a unionized setting earn an average $9,200 more in annual base compensation than nurses employed in a nonunion workplace (compared with $7,000 in 2013 and $6,100 in 2012). Working in a unionized environment does not appear to affect the compensation of managers. Household Status and Gender In several past years, nurses with fewer commitments outside of work received a higher base wage. This year, respondents who are parents with children younger than 18 years of age living at home were paid $2,300 less per year than other respondents. This difference is statistically significant. Although not always a significant variable in predicting compensation, gender was a significant influence this year. In several past years, but not all, men received approximately $3,000 more per year than women. This year, men were paid $3,200 more per year. The varying results across the past several years of studies suggest that there may be a gender effect, but the effect is inconsistent and small relative to the other factors that influence perioperative nursing compensation. Other Variables As a cautionary note, the results from the regression analysis represent general patterns and do not 578 j AORN Journal
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 $15,700 of base compensation estimated by the model. In questions unrelated to the regression model, 70% of the respondents reported receiving a raise this year compared with 71% in 2013. The mean year-over-year pay raise for staff nurses is 2.3%. Raises are higher for those who have greater management responsibilities. Hospital/facility administrators received an average 4.1% pay raise. Directors/VPs/assistant directors of nursing averaged a 3.0% raise. Table 7 shows the average pay raises during a seven-year period (2008-2014) by job title. Of the eight employee groups, staff nurses and nurse managers are the two groups in which pay raises have declined every year since 2008, with one small exception in each case (ie, unchanged percentages for 2012-2013). OTHER FORMS OF COMPENSATION The regression analysis previously described applies to base compensation. In the present sample, 63% of the respondents received additional compensation from a variety of sources, including overtime, shift differential, on-call compensation,
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TABLE 7. Mean Pay Raises by Job Title Percentage (%) of pay raise Job title
2008 2009 2010 2011 2012 2013 2014
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other
3.4 5.8 4.3 4.0 3.5 4.6 3.3 3.9
3.1 5.3 3.8 3.4 3.0 3.0 2.8 3.2
2.7 3.7 3.3 3.0 2.7 2.8 2.8 3.1
2.6 3.9 3.3 2.9 2.7 2.8 2.5 4.0
2.4 3.6 3.4 2.8 2.5 2.7 3.1 2.6
2.4 4.0 2.9 2.8 2.6 2.2 2.6 2.6
2.3 4.1 3.0 2.7 2.7 2.7 2.3 2.4
Nurse practitioners were excluded due to small sample size.
and bonuses (the percentage was 62% in 2013 and in 2012). 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 additional compensation relative to base pay (14.9%), followed by staff nurses (9.9%). Educators and staff development personnel received the smallest additional compensation relative to base pay (3.2%). On-Call Compensation More than half of the respondents (56%) reported that they are on call compared with 54% in 2013. The median number of hours per week on call is 16 (the same number of hours reported in the previous nine surveys). Among the on-call respondents, 65% receive a dollar-per-hour amount for being on call (64% in 2013), 6% receive a percentage of their base pay (5% in 2013), and 22% receive no compensation (21% in 2013). Among those who receive dollar-per-hour pay, the median pay is $3 per hour (unchanged from 2013). If called in, 57% receive time-and-a-half pay (compared with 55% in 2013), 18% receive no compensation at all (17% in 2013, 23% in 2012), 1% receive no additional compensation beyond the pay for being on call (2.5% in 2013), and 6% get straight-time pay (unchanged from
2013). Instead of pay, 5% of the on-call respondents receive compensation time (4% in 2013). Overall, findings on the methods of on-call compensation are quite similar for the past five years. Overtime Compensation A large majority of respondents work overtime (81% this year and in 2013), totaling an average of 5.2 hours each week (unchanged from 2013). Approximately 61% of those who work overtime receive time-and-a-half pay (59% last year), but 31% receive no additional compensation (32% in 2013). Almost all of those not compensated for overtime are salaried (97%, unchanged from 2013). As shown in Table 8, directors/VPs/assistant directors of nursing average the most overtime at 8.5 hours (8.8 hours in 2013), followed by hospital/ facility administrators (6.9 hours, compared with 5.9 hours in 2013), RNFAs (6.1 hours, compared with 6.5 hours in 2013), and nurse managers (6 hours, unchanged from 2013). Staff nurses work the least overtime (4.0 hours per week, unchanged from 2013). Overall, the group with the highest percentage of salaried employeesdtop-level managers and administratorsdexperienced the largest increases in weekly overtime hours since 2011, and staff nurses (the least likely to be salaried) experienced the smallest number of weekly overtime
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Figure 4. Mean percentage of additional compensation by job title.
hours this year, in 2013, and in 2012, with only a 12-minute increase in weekly overtime since 2011. Hiring Bonuses Relatively few of the respondents received a hiring bonus when they were hired (10%, unchanged since 2013), and only 8% are certain that their employer now offers a hiring bonus for their position (7% in 2013). Of these bonuses, 15% were in the $1,000 to $2,499 range, 26% were in the $2,500 to $4,999 range, and 26% were in the $5,000 to $7,499 range. Clinical nurse specialists and staff nurses are the most likely to receive a hiring bonus (9%). Approximately 8% of RNFAs, 6% of nurse managers, and 5% of nurse educators reported a hiring bonus. Although hospital and facility administrators are least likely to receive the bonus (2% this year, 4% in 2013), 10% of directors/VPs/assistant directors of nursing reported that their facility provides a hiring bonus for their positions. 580 j AORN Journal
Shift and Other Differentials Among the respondents, 92% work the day shift and 4% work afternoons/evenings. Very few respondents work nights, weekend days, or weekend nights (less than 3% for the three categories combined). For those working the afternoon/evening shift, the median differential is $2.25 per hour or 10% of base pay (compared with $2.50 per hour or 10% in 2013). Of note is that the dollar amounts differ across years but the percentages do not; the dollar differences may be because of sampling error. Benefits Almost all of the respondents receive benefits as part of their compensation. As shown in Table 9, the most frequently received benefit in 2014 is health insurance (94%), followed by dental insurance (90%), earned time or paid time off (88%), life insurance (83%), and 401(k) contributions (77%). The median number of paid time off days
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TABLE 8. Average Overtime Hours per Week and Percentage of Respondents Who Are Salaried
Job title
Average number of overtime hours
Percentage (%) salaried
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other
4.0 6.9 8.5 6.0 4.4 4.9 6.1 4.1
3.8 96.9 93.2 50.9 66.7 52.2 16.7 45.8
Nurse practitioners and consultants were excluded due to small sample size.
per year was 20, excluding national holidays. This year, we calculated a three-year average of respondents receiving each respective benefit for 2008 to 2010 and for 2011 to 2013. The percentage of recipients declined in 13 of 24 benefit categories in 2014 compared with the respective average for 2011 to 2013, and seven benefit categories were unchanged in the percentage of recipients. Only four benefit categories experienced an increase in the percentage of recipients, and only two benefit categoriesd401(k) contributions (Figure 5) and short-term disabilityd experienced an increase in recipients in 2011 to 2013 compared with 2008 to 2010. The 2014 benefits with the largest declines compared with the average for 2011 to 2013 are pension plans (6% decrease), pharmacy discounts (4% decrease), and tax-sheltered annuity plans (4% decrease). Since 2008 to 2010, pension plans have declined 12%, tax-sheltered annuity plans have declined 9%, and flexible scheduling and free or discounted parking each have declined 8%. Overall, the conclusion drawn from the analysis is clear: most employers are reducing the number of benefits provided to study respondents. ECONOMIC TRENDS IN THE PERIOPERATIVE NURSING WORK ENVIRONMENT The negative effects of the economic downturn on the perioperative work environment lessened from
2009 to 2012; this year, some ground lost in 2013 was recovered. For each of the past six years, we asked respondents whether they had seen any change in activity at their facilities. The percentage of respondents reporting a decrease in activity in 2013 jumped from 31% to 42%, and the percentage reporting an increase in activity in 2013 decreased from 51% to 41% of respondents. However, this year, the percentage of respondents reporting an increase in activity grew from 41% to 46% and those reporting a decrease in activity declined from 42% to 37% (Figure 6). To explore changes in perioperative nursing activity, we asked nurses whether they have seen a shift from inpatient surgery to ambulatory/ hybrid/interventional treatments. This year, twothirds (67%) reported a shift in procedure volumes away from inpatient treatments, a slight increase from 66% reported in 2013. Specifically, 37% saw a shift to ambulatory treatments, 25% saw a shift to either ambulatory or hybrid/interventional treatments, and 5% saw a shift primarily to hybrid/ interventional treatments. UPDATE ON THE PERIOPERATIVE NURSING SHORTAGE In the latest survey, the median percentage of vacant full-time nursing positions was low at 3.6%, an increase of half a percent from 2013. This year, 40% of top-level managers reported a moderate- to crisis-level effect of the shortage on their working AORN Journal j 581
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TABLE 9. Percentage of Respondents Receiving Benefits Percentage (%) receiving benefit Benefit type
2008-2010 average
2011-2013 average
2014
Health insurance Dental insurance Earned time or paid time off Life insurance 401(k) contributions Bereavement leave Jury duty compensation Short-term disability Long-term disability Tuition reimbursement Free/discounted parking Paid certification exams Pension plan Paid conference travel Pharmacy discounts Employee referral bonus Flexible scheduling Tax-sheltered annuity Incentive bonuses Malpractice insurance Relocation assistance Retention bonuses Subsidized child/elder care Life quality service (eg, dry cleaning)
93 88 88 85 72 79 71 60 62 60 62 37 44 34 32 24 27 27 16 13 8 5 4 4
93 87 88 84 73 76 68 62 61 56 57 37 38 30 30 22 19 22 15 12 6 3 3 3
94 90 88 83 77 75 65 62 60 58 54 36 32 28 26 20 19 18 15 10 5 3 3 3
environment compared with 37% last year and 38% in 2012. Among nurses in this year’s sample, 60% share this view, a notable increase over the generally flat trend in the previous four years (53% in 2013 and 2012, 54% in 2011, and 53% in 2010). As expected, the effect of the shortage on patient care tended to be rated more severely by those who have the most patient contact. Approximately 66% of staff nurses rated the shortage as having a moderate- to crisis-level effect, an 8% increase from 2013. In comparison, 49% of nurse managers, 44% of directors/VPs/ assistant directors of nursing, and 20% of facility/ hospital administrators shared this view. The survey asked respondents whether they were thinking of quitting their job in the next year. Approximately 14% of our sample indicated they probably would or definitely would quit (compared 582 j AORN Journal
with 11% in 2013). We then probed about what the nurses planned to do after they quit. Among the nurses who were seriously considering quitting, 61% said they were thinking of changing employers and 18% said they were planning to change careers but remain in health care. Approximately 2% of the total sample (16% of those likely to quit their jobs) planned to retire. Less than half a percent of the sample (3% of those likely to quit their jobs) were planning to change careers and leave health care. A few respondents (2% of those likely to quit) said they were leaving their jobs for personal reasons, including family, and might return later. We asked specifically why the nurses were considering leaving their jobs. Of those who were not retiring, 58% indicated dissatisfaction with their work environment and 18% mentioned
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Figure 5. Changes in retirement benefits.
dissatisfaction with compensation. The remaining respondents mentioned other reasons, including family reasons. OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION Respondents were asked to provide any comments about perioperative nursing that they would like to express. In total, 599 respondents provided comments containing information or opinions (17% of the entire sample). Several themes have consistently emerged in comment analysis during the past several years, and they again are present in this year’s results. Dissatisfaction with compensation is again the predominant theme, expressed this year by more than half of the commenters. A plurality of these commenters said that their pay does not reflect the amount of responsibility, increasing knowledge requirements, physical and psychological stress, and specialty nature of their jobs. One nurse wrote, Based on the acuity of care, our years of service and experience, our knowledge and expertise
base, we as nurses sell ourselves short. We deserve better and, more importantly, so do our patients. Another nurse commented, Our pay should be much higher for the highly technical and stressful work that we do. We often face life-and-death situations. Shouldn’t this matter? Another nurse wrote, We need to be paid more for caring for a much heavier and unhealthy population. We recover patients from every area in the hospital and every age from the newborn to 104. At the same time, we pay more for our insurance, including co-pays and scripts. Heaven help us, we need a raise! Another nurse wrote, There should be compensation for the strenuous physical work that has a long-term effect on our bodies. Lifting and pushing heavy equipment AORN Journal j 583
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Figure 6. Trends in perceived changes in activity (2009 to 2014).
[and] patients and repetitive movements wreak havoc on the body over time. Again this year, a notable number of nurses believe that perioperative nursing should be recognized as a specialization and be compensated accordingly. One commenter wrote, “It’s hard to find others trained in this specialty [that] doesn’t seem to be valued as it should be, given the long period of time it takes to achieve competency.” Another wrote, “We work in the most technically advanced area in nursing.” Echoing a point made by several nurses, a commenter said, “NO ONE floats to us. That alone means our work is a specialty.” This year, some nurses expressed concern that inadequate pay was reaching the point where turnover in the OR is increasing as nurses move to jobs that offer more pay. One nurse wrote, There is a tendency in the market to use the national employment crisis to keep the wages/raises down, or even no raises. I just left my employer after 21 years because of this problem (the corporate leaders were taking multi-million dollar bonuses at the same time). The only real way to get any increase in pay is to change employers. 584 j AORN Journal
Shorter tenures on the job and higher turnover are affecting recruitment and retention of experienced OR nurses, wrote some nurses. One nurse wrote, It is very difficult to find and keep experienced OR nurses. The younger generation works for a year and then moves on to another hospital that offers better compensation. Another nurse explained, “We don’t have so much a nursing shortage as a shortage of nurses with perioperative experience.” Another nurse said, “It’s very difficult to recruit new nurses to the OR. We’ve had many good nurses quit when they find better paying [jobs] and [jobs with] better hours.” Another nurse said, “We have not received more than a 1% raise in four years. At least seven of the younger nurses in our unit have left for more money.” Concerns were expressed about four other issues: inadequate compensation for certifications and advanced degrees, pay compression, the demands and amount of on-call pay, and the present state of nursing benefits. Concerning pay compression, one nurse wrote, “I truly love what I do. However, my pay is sad, even more so when
2014 SALARY SURVEY new nurses start out at a higher hourly rate than I make with all my years of experience in the OR.” One nurse wrote, The on-call compensation is lacking where I work, and we are required to be at the hospital within 30 minutes after being called. I live more than 30 minutes away so I must stay somewhere near the hospital. The facility does not have any accommodations for on-call staff. I find this very upsetting at times and very inconvenient. Concerning employee benefits, several nurses noted that benefits are declining in the types and amount of support provided, which is a concern that is consistent with the overall benefit reductions shown by the survey. “Nurses should be offered lifetime health insurance benefits commensurate with the number of years they have served, like in the [Veterans Affairs] system,” said one nurse. “We spend our lives serving others and then are left to fend for ourselves in the end.” The concerns about compensation raise the question: How should the compensation problem be addressed? One nurse proposed the development of a formula that bases an OR nurse’s hourly rate on the complexity of a procedure that could include, among other variables, the length of the procedure, the surgery support required, and the destination of the patient postoperatively. A nursing manager suggested that compensation should be based on the nurse’s skill set: “I appreciate
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nurses who are able to work in a variety of areas. Those who are able to work [in preoperative, intraoperative, and postoperative areas] should be compensated for those abilities.” Although the large majority of commenters stated their concerns about compensation, benefits, and the present nursing environment, a number of nurses expressed satisfaction with their pay and jobs. A nurse commented, “I love being an OR nurse and I am fortunate to make a living at it!” Another nurse wrote, “This is the best career in the world.” Editor’s notes: iPad is a registered trademark of Apple, Inc, Cupertino, CA. CNOR and CRNFA are registered trademarks of the Competency and Credentialing Institute, Denver, CO. Donald R. 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. Kim A. Stewart, PhD, is an independent scholar in Denver, CO. Dr Stewart has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT AORN conducted its 12th annual compensation survey for perioperative nurses in June and July 2014. 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 data from 2014 and data from previous years are presented. The effects of other forms of compensation (eg, oncall compensation, overtime, bonuses, shift differentials) on base compensation rates also are examined. Additional analyses explore the effect of the economic downturn on the perioperative work environment. AORN J 100 (December 2014) 570-585. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.09.010 Key words: nurse salaries, compensation, economy.
F
rom late June to early July 2014, 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 potential nursing turnover and the reasons why some nurses are actively considering leaving their jobs. RESPONDENT PROFILE For the 11th consecutive year, AORN conducted its survey online. In mid-June, 88,320 potential respondents (including 36,550 AORN members) received an invitation to participate in the survey. This group of potential respondents is substantially larger than last year’s group (50,850). As an incentive, participants were eligible to enter a raffle for a free iPadÒ mini. By mid-July, 4,709 unique responses were received. Because the focus of this
survey is perioperative nursing compensation, respondents who did not answer any compensationrelated questions were excluded. This criterion reduced the usable sample to 3,437 individuals, for a 3.9% net response rate. The final sample is 15% larger than the 2013 sample. As shown in Figure 1, 44% of the respondents are staff nurses, 24% are managers (ie, nurse manager, supervisor, coordinator, team leader, business manager), 10% are high-level managers (ie, director, vice president [VP], assistant director of nursing), 7% are educators, 4% are RN first assistants (RNFAs), and 1% are clinical nurse specialists. Less than 1% are nurse practitioners or consultants. Some of the demographic information from the sample is represented in Figure 2. Approximately 38% of the respondents are in their 50s, 27% are in their 40s, 17% are in their 30s, 6% are younger than 30 years of age, and 13% are at least 60 years of age. Approximately 90% of the sample is female. http://dx.doi.org/10.1016/j.aorn.2014.09.010
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Ó AORN, Inc, 2014
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and West North Central regions, 17% reside in the East South Central and West South Central regions, and 19% are located in the Mountain and Pacific regions. Additionally, approximately 80% work in an urban or suburban area and approximately 20% work in a rural location. Forty-three percent of the respondents have a bachelor’s degree in nursing, and approximately 6% have a bachelor’s degree in another field. Approximately 33% of the respondents have a diploma or associate degree. Approximately 11% of respondents have a master’s degree in nursing, and approximately 5% hold a master’s degree in another field. Two percent have a doctorate in nursing or in another field or hold some other type of degree (Table 2).
Figure 1. Percentage of survey respondents by job title.
Hourly-paid employees comprise 65% of the sample, and 35% are salaried employees. Most of the respondents work in acute care hospitals (73%), and 27% work in an ambulatory surgery center (ASC), whether it be freestanding (13%), hospital based (12%), or office based (2%). Approximately 40% of respondents have more than 20 years of experience as a perioperative nurse, with 28% having more than 25 years of experience. Approximately 26% of the respondents have 11 to 20 years of experience as a perioperative nurse, and 34% have 10 or fewer years of experience. Overall, the respondents’ demographic profile is quite similar to the 2013 sample. Geographically, the sample is well dispersed across the country. As shown in Table 1, approximately 21% of the respondents live in the upper eastern coastal region (ie, New England and the Mid-Atlantic), 17% reside in the South Atlantic region, 26% are located in the East North Central
BASE COMPENSATION We 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 (3.9%). Still, the sample is sufficiently representative of the perioperative 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 full time in the United States. Facilities are categorized as small or large based on a median split of the number of ORs reported, with small defined as 10 or fewer ORs and large defined as more than 10 ORs. 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 also may 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, AORN Journal j 571
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Figure 2. Profile of survey respondents.
university or academic facilities tend to be larger than other facility types. There are instances, however, in which compensation is higher in smaller facilities than in larger ones, indicating that facility size and type have simultaneous effects on compensation. The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. We used multiple regression as the primary analytical tool in this study because so many variables are involved. The multiple regression model makes it possible to estimate the effects of one variable on compensation 572 j AORN Journal
while statistically holding the other variables constant. The influence of each variable then can be identified independent of the others. For the analysis, we used hierarchical regression by entering the variables expected to explain the most variance into the model first and then entering the less important variables. We entered several variables with related effects initially and simultaneously. These variables are n
job title, n facility size, n facility type, n population setting (ie, urban, suburban, rural),
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TABLE 1. Geographic Location of Respondents
Region
Frequency
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) Total
n
region, n state, and n percentage of time spent in direct patient care. State was only entered for states with 50 or more respondents. We then entered other variables one at a time. These secondary variables are n n n n n n n
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, we limited the sample for the regression analysis to respondents who are full-time employees and who work in the United States. We eliminated statistical outliers (eg, unusually high or low pay reported by a very small number of nurses) to avoid skewing the results. We conducted checks to ensure that the statistical assumptions behind the regression model were met (eg, linear relationships and normally distributed errors). The final model explains 62% 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
Percentage (%)
178 529 582 585 311
5.2 15.4 16.9 17.0 9.0
211 374 250 417 3,437
6.1 10.9 7.3 12.1 100.0
significant at the P .05 level. Readers can 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 (accessed August 22, 2014). Job Title More than any variable, differences in job title are linked to differences in annual compensation. The average staff nurse, for example, earns $67,800 ($400 more than in 2013), and the average director/ VP/assistant director of nursing earns $110,700
TABLE 2. Respondents’ Education Levels
Education
Frequency
Percentage (%)
Diploma Associate degree Bachelor’s degree in nursing Bachelor’s degree in another field Master’s degree in nursing Master’s degree in another field Doctorate in nursing Doctorate in another field Other Total
263 873 1,475 200
7.7 25.4 43.0 5.8
368 187
10.7 5.4
13 10 44 3,433
0.4 0.3 1.3 100.0
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TABLE 3. Estimate of Average Base Compensation by Job Title and Facility Size
Job title
Average percentage (%) of time in direct patient care
Small facility ( 10 ORs)
Large facility (> 10 ORs)
87.8 16.4 16.1 37.6
$65,800 $104,600 $97,900 $80,300
$69,100 * $130,200 $87,200
16.7 35.6 85.2 37.7 57.6
$79,900 * $74,300 $75,000 $77,700
$82,500 $85,800 $79,800 $81,600 $80,700
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other Total
The small net subsample sizes for nurse practitioners and consultants resulted in their exclusion from the regression analysis. Other samples with less than 30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred.
($1,200 more than in 2013, but $1,200 less than 2012). 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, we combined data from 11 years of AORN salary surveys. Figure 3 shows that staff nurses and directors/VPs/assistant directors of nursing generally have seen increases in average compensation during this 11-year period. In 11 years, the average annual growth rate has been similar for staff nurses (2.68%) and for directors/VPs/assistant directors of nursing (2.41%). For comparison, the average annual inflation rate is 2.38% for the past 11 years. On average, staff nurses spend 88% of their time delivering direct patient care, and nurse managers spend 38% of their time providing direct care. As expected, high-level managers average a relatively small amount of time on patient care (16% for facility/hospital administrators, unchanged since 2013, and 16% for directors/VPs/assistant directors of nursing, a 1% decline from 2013). The percentage of time spent on direct patient care varies among nurses with the same title. For 574 j AORN Journal
example, some nurse managers spend as much time on direct patient care as 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 annual compensation related to facility type. Hospital-based nurses often receive more compensation, especially in an acute care hospital, whereas nurses in ASCs receive less compensation. This year, nurses in acute care hospitals received $2,900 more than other nurses in general, whereas nurses in office-based ASCs received $9,400 less and nurses in freestanding ASCs received $5,800 less. Nurses in general/ community hospitals received $3,700 less than nurses in specialty hospitals or in university/ academic medical centers. Facility Size The size of the facility is an important differentiator in annual nursing compensation. This difference is particularly pronounced for those who work in higher-level management positions. After controlling for facility type, hospital/facility administrators and directors/VPs/assistant directors of nursing
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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
15 16 30 12 22
$66,600 $75,100 $69,900 $61,800 $71,300
681 105 273 138 57
earn on average $1,300 more per OR in the facility. This difference may be because of the greater number and range of responsibilities that these upper-level positions entail. No statistically significant relationship was found between staff nursing compensation and facility size. Different types of facilities (eg, acute care hospitals compared with ambulatory care facilities) also differ in size; thus, after facility type is considered, facility size makes little difference for nurses. Facility Ownership Approximately 32% of the respondents are employed by private, for-profit organizations. The findings indicate that nurses in these facilities earn $3,400 per year less than nurses in facilities with
different ownership structures (eg, nongovernment, nonprofit). The few respondents (9%) working in government facilities but not federal facilities (eg, county hospitals) earn an average of $2,800 less per year than other nurses. Population Setting The location of the facility (ie, urban, suburban, rural) substantially influences compensation. Nurses in rural settings earn an estimated $7,300 less per year than if they were employed in a suburban or urban setting. Geographic Region Controlling for all variables previously discussed, geographic region explains significant differences
Figure 3. Trends in base compensation over time.
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in annual compensation across the United States. Nurses in the Pacific region receive $18,000 more than the average staff nurse. The other regions with higher incomes are New England ($10,600 more), Mid-Atlantic ($14,800 more), and Mountain ($5,100 more). A region with significantly below average compensation is East South Central ($4,300 less). This year, nurses reported the specific state where they reside. Our total sample is large enough that meaningful estimates for state differences could be made for many states. Only states with more than 50 respondents were examined for statespecific effects. Of the 26 states studied, six states showed significantly different effects than their region would otherwise suggest. After adjusting for region, these states should be adjusted again. Table 5 shows the states requiring specific adjustments and the adjusted amounts. All adjustments are additions or subtractions to base compensation. 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 amounts, as shown in Table 3. On average, staff nurses earn approximately $700 more per year than the average staff nurse 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 (a $100 increase from 2013). This relationship is the same for nurse managers, educators, RNFAs, nurse practitioners, private scrub nurses, and other nurses. Hospital/facility administrators and directors/VPs/assistant directors of nursing earn approximately $500 more per year for each 10% increase in time spent on managerial tasks and, correspondingly, $500 less per year for each 10% increase in time spent on direct patient care. Work Experience The polynomial regression model suggests that nurses generally see large increases related to 576 j AORN Journal
TABLE 5. States With Adjustments Different From Their Regions State
Adjustment
Massachusetts California Minnesota Texas Maryland Pennsylvania
$25,800 $18,200 $14,400 $9,700 e$6,700 e$13,100
experience early in their careers compared with later in their careers. For example, the increase from the first to the second year is close to $1,200, but the jump from the 25th to the 26th year is only approximately $200. In this sample, the average nurse has 17 years of experience (one year less than the 2013 sample). Nurses with more or less than this amount of experience should add or subtract some amount per year of experience to estimate their base compensation. Of interest is that hospital/facility administrators and directors/VPs/assistant directors of nursing earn approximately $500 per year of experience, and this positive relationship continues through 30 years of experience. On average, these individuals reported 22 years of work experience, which is one year less than reported in 2013. Compensation Basis The salary survey generally finds that whether a nurse is paid an hourly rate or salary is related to base compensation, with salaried nurses earning as much as $3,000 per year more than hourlypaid nurses (unchanged since 2013). For 2014, the average difference between salaried and hourly compensation was $2,300 per year. Certification Ten types of certification were examined: n
BC (board certified), CNORÒ (certified OR nurse), n CRNFAÒ (certified RNFA), n
2014 SALARY SURVEY n
n n n n n n
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).
Of all these, only four were held by more than 50 respondents: CNOR (1,794 nurses), CRNFA (77 nurses), BC (65 nurses), and CPAN and/or CAPA (54 nurses). The other certification counts were considered too small to provide reliable results. This year, two of these three certifications were significantly associated with higher annual compensation. Nurses with a CNOR earned $2,200 more and BC nurses earned $6,900 more than other nurses. In 2013, CRNFA nurses were found to earn significantly more compensation ($5,300), but this year the average difference was less ($4,300); this difference was not statistically significant. Approximately 39% of the respondents said that their facility pays more for holding a nursing certification (down from 40% in 2013). Of those who said their hospital offers more compensation for some certifications, 91% of the respondents said they receive extra compensation for CNOR, 27% mentioned CPAN and/or CAPA, 25% mentioned CRNFA, 15% mentioned NP, 15% mentioned ONC, 14% mentioned CNS, 12% mentioned CPSN, and 10% or less respondents mentioned BC, CNAA, or CNA. Most of these percentages are approximately the same as reported last year. Thus, while the regression model did not show large differences in pay related to certification, a substantial number of nurses reported that their facility pays for certification. To gain more insight, we asked nurses whether they receive the compensation as an addition to their base pay or as a one-time bonus. More than half (61%) of the nurses
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in the sample reported that the pay was an addition to their base pay, and 23% reported that the pay was a one-time bonus. The remainder of our sample (16%) provided a variety of responses, including no additional pay, an annual bonus, or better opportunities for promotion. Although it appears that some nurses receive extra compensation for a variety of certifications, this compensation can 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 managerial tasks. Once we control for facility type and time spent on direct patient care, the effect of certification on base pay by itself is less pronounced. Education Level Nurses with a master’s degree in nursing receive an additional $3,200 in annual base compensation. No other significant differences in compensation related to education were found in this year’s sample. When asked directly, 28% of the respondents said that their facility pays more for having a degree in nursing, compared with 29% in 2013, 27% in 2012, and 26% in 2011. It may seem surprising that education has little effect on compensation in this analysis, but it should be noted that the analysis has already been 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 6 provides an analysis of education by selected job titles, including staff nurse, nurse manager, and director/ administrator. Nurses in higher-paying positions, especially directors and administrators, are less likely to have a diploma or associate degree as their highest level of education and are more likely than others to have a master’s degree in nursing or 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.
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TABLE 6. Education by Selected Job Titles Job title (sample size) Education
Staff nurse, % (n ¼ 1,521)
Nurse manager, % (n ¼ 833)
Director/administrator, % (n ¼ 355)
Diploma Associate degree Bachelor’s degree in nursing Bachelor’s degree in another field Master’s degree in nursing Master’s degree in another field
8.6 31.7 46.9 5.5 4.1 1.8
7.1 25.6 43.5 5.3 12.1 5.8
6.2 11.8 34.1 8.5 15.5 19.7
The small net subsample sizes for those with DNP and PhD degrees resulted in their exclusion from analysis.
Collective Bargaining Unit Approximately 12% of respondents reported working in an environment with a union or collective bargaining unit. Nurses working in a unionized setting earn an average $9,200 more in annual base compensation than nurses employed in a nonunion workplace (compared with $7,000 in 2013 and $6,100 in 2012). Working in a unionized environment does not appear to affect the compensation of managers. Household Status and Gender In several past years, nurses with fewer commitments outside of work received a higher base wage. This year, respondents who are parents with children younger than 18 years of age living at home were paid $2,300 less per year than other respondents. This difference is statistically significant. Although not always a significant variable in predicting compensation, gender was a significant influence this year. In several past years, but not all, men received approximately $3,000 more per year than women. This year, men were paid $3,200 more per year. The varying results across the past several years of studies suggest that there may be a gender effect, but the effect is inconsistent and small relative to the other factors that influence perioperative nursing compensation. Other Variables As a cautionary note, the results from the regression analysis represent general patterns and do not 578 j AORN Journal
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 $15,700 of base compensation estimated by the model. In questions unrelated to the regression model, 70% of the respondents reported receiving a raise this year compared with 71% in 2013. The mean year-over-year pay raise for staff nurses is 2.3%. Raises are higher for those who have greater management responsibilities. Hospital/facility administrators received an average 4.1% pay raise. Directors/VPs/assistant directors of nursing averaged a 3.0% raise. Table 7 shows the average pay raises during a seven-year period (2008-2014) by job title. Of the eight employee groups, staff nurses and nurse managers are the two groups in which pay raises have declined every year since 2008, with one small exception in each case (ie, unchanged percentages for 2012-2013). OTHER FORMS OF COMPENSATION The regression analysis previously described applies to base compensation. In the present sample, 63% of the respondents received additional compensation from a variety of sources, including overtime, shift differential, on-call compensation,
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TABLE 7. Mean Pay Raises by Job Title Percentage (%) of pay raise Job title
2008 2009 2010 2011 2012 2013 2014
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other
3.4 5.8 4.3 4.0 3.5 4.6 3.3 3.9
3.1 5.3 3.8 3.4 3.0 3.0 2.8 3.2
2.7 3.7 3.3 3.0 2.7 2.8 2.8 3.1
2.6 3.9 3.3 2.9 2.7 2.8 2.5 4.0
2.4 3.6 3.4 2.8 2.5 2.7 3.1 2.6
2.4 4.0 2.9 2.8 2.6 2.2 2.6 2.6
2.3 4.1 3.0 2.7 2.7 2.7 2.3 2.4
Nurse practitioners were excluded due to small sample size.
and bonuses (the percentage was 62% in 2013 and in 2012). 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 additional compensation relative to base pay (14.9%), followed by staff nurses (9.9%). Educators and staff development personnel received the smallest additional compensation relative to base pay (3.2%). On-Call Compensation More than half of the respondents (56%) reported that they are on call compared with 54% in 2013. The median number of hours per week on call is 16 (the same number of hours reported in the previous nine surveys). Among the on-call respondents, 65% receive a dollar-per-hour amount for being on call (64% in 2013), 6% receive a percentage of their base pay (5% in 2013), and 22% receive no compensation (21% in 2013). Among those who receive dollar-per-hour pay, the median pay is $3 per hour (unchanged from 2013). If called in, 57% receive time-and-a-half pay (compared with 55% in 2013), 18% receive no compensation at all (17% in 2013, 23% in 2012), 1% receive no additional compensation beyond the pay for being on call (2.5% in 2013), and 6% get straight-time pay (unchanged from
2013). Instead of pay, 5% of the on-call respondents receive compensation time (4% in 2013). Overall, findings on the methods of on-call compensation are quite similar for the past five years. Overtime Compensation A large majority of respondents work overtime (81% this year and in 2013), totaling an average of 5.2 hours each week (unchanged from 2013). Approximately 61% of those who work overtime receive time-and-a-half pay (59% last year), but 31% receive no additional compensation (32% in 2013). Almost all of those not compensated for overtime are salaried (97%, unchanged from 2013). As shown in Table 8, directors/VPs/assistant directors of nursing average the most overtime at 8.5 hours (8.8 hours in 2013), followed by hospital/ facility administrators (6.9 hours, compared with 5.9 hours in 2013), RNFAs (6.1 hours, compared with 6.5 hours in 2013), and nurse managers (6 hours, unchanged from 2013). Staff nurses work the least overtime (4.0 hours per week, unchanged from 2013). Overall, the group with the highest percentage of salaried employeesdtop-level managers and administratorsdexperienced the largest increases in weekly overtime hours since 2011, and staff nurses (the least likely to be salaried) experienced the smallest number of weekly overtime
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Figure 4. Mean percentage of additional compensation by job title.
hours this year, in 2013, and in 2012, with only a 12-minute increase in weekly overtime since 2011. Hiring Bonuses Relatively few of the respondents received a hiring bonus when they were hired (10%, unchanged since 2013), and only 8% are certain that their employer now offers a hiring bonus for their position (7% in 2013). Of these bonuses, 15% were in the $1,000 to $2,499 range, 26% were in the $2,500 to $4,999 range, and 26% were in the $5,000 to $7,499 range. Clinical nurse specialists and staff nurses are the most likely to receive a hiring bonus (9%). Approximately 8% of RNFAs, 6% of nurse managers, and 5% of nurse educators reported a hiring bonus. Although hospital and facility administrators are least likely to receive the bonus (2% this year, 4% in 2013), 10% of directors/VPs/assistant directors of nursing reported that their facility provides a hiring bonus for their positions. 580 j AORN Journal
Shift and Other Differentials Among the respondents, 92% work the day shift and 4% work afternoons/evenings. Very few respondents work nights, weekend days, or weekend nights (less than 3% for the three categories combined). For those working the afternoon/evening shift, the median differential is $2.25 per hour or 10% of base pay (compared with $2.50 per hour or 10% in 2013). Of note is that the dollar amounts differ across years but the percentages do not; the dollar differences may be because of sampling error. Benefits Almost all of the respondents receive benefits as part of their compensation. As shown in Table 9, the most frequently received benefit in 2014 is health insurance (94%), followed by dental insurance (90%), earned time or paid time off (88%), life insurance (83%), and 401(k) contributions (77%). The median number of paid time off days
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TABLE 8. Average Overtime Hours per Week and Percentage of Respondents Who Are Salaried
Job title
Average number of overtime hours
Percentage (%) salaried
Staff nurse Hospital/facility administrator Director/vice president/assistant director of nursing Nurse manager/supervisor/coordinator/team leader/business manager Educator/staff development Clinical nurse specialist (master’s degree or higher) RN first assistant Other
4.0 6.9 8.5 6.0 4.4 4.9 6.1 4.1
3.8 96.9 93.2 50.9 66.7 52.2 16.7 45.8
Nurse practitioners and consultants were excluded due to small sample size.
per year was 20, excluding national holidays. This year, we calculated a three-year average of respondents receiving each respective benefit for 2008 to 2010 and for 2011 to 2013. The percentage of recipients declined in 13 of 24 benefit categories in 2014 compared with the respective average for 2011 to 2013, and seven benefit categories were unchanged in the percentage of recipients. Only four benefit categories experienced an increase in the percentage of recipients, and only two benefit categoriesd401(k) contributions (Figure 5) and short-term disabilityd experienced an increase in recipients in 2011 to 2013 compared with 2008 to 2010. The 2014 benefits with the largest declines compared with the average for 2011 to 2013 are pension plans (6% decrease), pharmacy discounts (4% decrease), and tax-sheltered annuity plans (4% decrease). Since 2008 to 2010, pension plans have declined 12%, tax-sheltered annuity plans have declined 9%, and flexible scheduling and free or discounted parking each have declined 8%. Overall, the conclusion drawn from the analysis is clear: most employers are reducing the number of benefits provided to study respondents. ECONOMIC TRENDS IN THE PERIOPERATIVE NURSING WORK ENVIRONMENT The negative effects of the economic downturn on the perioperative work environment lessened from
2009 to 2012; this year, some ground lost in 2013 was recovered. For each of the past six years, we asked respondents whether they had seen any change in activity at their facilities. The percentage of respondents reporting a decrease in activity in 2013 jumped from 31% to 42%, and the percentage reporting an increase in activity in 2013 decreased from 51% to 41% of respondents. However, this year, the percentage of respondents reporting an increase in activity grew from 41% to 46% and those reporting a decrease in activity declined from 42% to 37% (Figure 6). To explore changes in perioperative nursing activity, we asked nurses whether they have seen a shift from inpatient surgery to ambulatory/ hybrid/interventional treatments. This year, twothirds (67%) reported a shift in procedure volumes away from inpatient treatments, a slight increase from 66% reported in 2013. Specifically, 37% saw a shift to ambulatory treatments, 25% saw a shift to either ambulatory or hybrid/interventional treatments, and 5% saw a shift primarily to hybrid/ interventional treatments. UPDATE ON THE PERIOPERATIVE NURSING SHORTAGE In the latest survey, the median percentage of vacant full-time nursing positions was low at 3.6%, an increase of half a percent from 2013. This year, 40% of top-level managers reported a moderate- to crisis-level effect of the shortage on their working AORN Journal j 581
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TABLE 9. Percentage of Respondents Receiving Benefits Percentage (%) receiving benefit Benefit type
2008-2010 average
2011-2013 average
2014
Health insurance Dental insurance Earned time or paid time off Life insurance 401(k) contributions Bereavement leave Jury duty compensation Short-term disability Long-term disability Tuition reimbursement Free/discounted parking Paid certification exams Pension plan Paid conference travel Pharmacy discounts Employee referral bonus Flexible scheduling Tax-sheltered annuity Incentive bonuses Malpractice insurance Relocation assistance Retention bonuses Subsidized child/elder care Life quality service (eg, dry cleaning)
93 88 88 85 72 79 71 60 62 60 62 37 44 34 32 24 27 27 16 13 8 5 4 4
93 87 88 84 73 76 68 62 61 56 57 37 38 30 30 22 19 22 15 12 6 3 3 3
94 90 88 83 77 75 65 62 60 58 54 36 32 28 26 20 19 18 15 10 5 3 3 3
environment compared with 37% last year and 38% in 2012. Among nurses in this year’s sample, 60% share this view, a notable increase over the generally flat trend in the previous four years (53% in 2013 and 2012, 54% in 2011, and 53% in 2010). As expected, the effect of the shortage on patient care tended to be rated more severely by those who have the most patient contact. Approximately 66% of staff nurses rated the shortage as having a moderate- to crisis-level effect, an 8% increase from 2013. In comparison, 49% of nurse managers, 44% of directors/VPs/ assistant directors of nursing, and 20% of facility/ hospital administrators shared this view. The survey asked respondents whether they were thinking of quitting their job in the next year. Approximately 14% of our sample indicated they probably would or definitely would quit (compared 582 j AORN Journal
with 11% in 2013). We then probed about what the nurses planned to do after they quit. Among the nurses who were seriously considering quitting, 61% said they were thinking of changing employers and 18% said they were planning to change careers but remain in health care. Approximately 2% of the total sample (16% of those likely to quit their jobs) planned to retire. Less than half a percent of the sample (3% of those likely to quit their jobs) were planning to change careers and leave health care. A few respondents (2% of those likely to quit) said they were leaving their jobs for personal reasons, including family, and might return later. We asked specifically why the nurses were considering leaving their jobs. Of those who were not retiring, 58% indicated dissatisfaction with their work environment and 18% mentioned
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Figure 5. Changes in retirement benefits.
dissatisfaction with compensation. The remaining respondents mentioned other reasons, including family reasons. OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION Respondents were asked to provide any comments about perioperative nursing that they would like to express. In total, 599 respondents provided comments containing information or opinions (17% of the entire sample). Several themes have consistently emerged in comment analysis during the past several years, and they again are present in this year’s results. Dissatisfaction with compensation is again the predominant theme, expressed this year by more than half of the commenters. A plurality of these commenters said that their pay does not reflect the amount of responsibility, increasing knowledge requirements, physical and psychological stress, and specialty nature of their jobs. One nurse wrote, Based on the acuity of care, our years of service and experience, our knowledge and expertise
base, we as nurses sell ourselves short. We deserve better and, more importantly, so do our patients. Another nurse commented, Our pay should be much higher for the highly technical and stressful work that we do. We often face life-and-death situations. Shouldn’t this matter? Another nurse wrote, We need to be paid more for caring for a much heavier and unhealthy population. We recover patients from every area in the hospital and every age from the newborn to 104. At the same time, we pay more for our insurance, including co-pays and scripts. Heaven help us, we need a raise! Another nurse wrote, There should be compensation for the strenuous physical work that has a long-term effect on our bodies. Lifting and pushing heavy equipment AORN Journal j 583
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Figure 6. Trends in perceived changes in activity (2009 to 2014).
[and] patients and repetitive movements wreak havoc on the body over time. Again this year, a notable number of nurses believe that perioperative nursing should be recognized as a specialization and be compensated accordingly. One commenter wrote, “It’s hard to find others trained in this specialty [that] doesn’t seem to be valued as it should be, given the long period of time it takes to achieve competency.” Another wrote, “We work in the most technically advanced area in nursing.” Echoing a point made by several nurses, a commenter said, “NO ONE floats to us. That alone means our work is a specialty.” This year, some nurses expressed concern that inadequate pay was reaching the point where turnover in the OR is increasing as nurses move to jobs that offer more pay. One nurse wrote, There is a tendency in the market to use the national employment crisis to keep the wages/raises down, or even no raises. I just left my employer after 21 years because of this problem (the corporate leaders were taking multi-million dollar bonuses at the same time). The only real way to get any increase in pay is to change employers. 584 j AORN Journal
Shorter tenures on the job and higher turnover are affecting recruitment and retention of experienced OR nurses, wrote some nurses. One nurse wrote, It is very difficult to find and keep experienced OR nurses. The younger generation works for a year and then moves on to another hospital that offers better compensation. Another nurse explained, “We don’t have so much a nursing shortage as a shortage of nurses with perioperative experience.” Another nurse said, “It’s very difficult to recruit new nurses to the OR. We’ve had many good nurses quit when they find better paying [jobs] and [jobs with] better hours.” Another nurse said, “We have not received more than a 1% raise in four years. At least seven of the younger nurses in our unit have left for more money.” Concerns were expressed about four other issues: inadequate compensation for certifications and advanced degrees, pay compression, the demands and amount of on-call pay, and the present state of nursing benefits. Concerning pay compression, one nurse wrote, “I truly love what I do. However, my pay is sad, even more so when
2014 SALARY SURVEY new nurses start out at a higher hourly rate than I make with all my years of experience in the OR.” One nurse wrote, The on-call compensation is lacking where I work, and we are required to be at the hospital within 30 minutes after being called. I live more than 30 minutes away so I must stay somewhere near the hospital. The facility does not have any accommodations for on-call staff. I find this very upsetting at times and very inconvenient. Concerning employee benefits, several nurses noted that benefits are declining in the types and amount of support provided, which is a concern that is consistent with the overall benefit reductions shown by the survey. “Nurses should be offered lifetime health insurance benefits commensurate with the number of years they have served, like in the [Veterans Affairs] system,” said one nurse. “We spend our lives serving others and then are left to fend for ourselves in the end.” The concerns about compensation raise the question: How should the compensation problem be addressed? One nurse proposed the development of a formula that bases an OR nurse’s hourly rate on the complexity of a procedure that could include, among other variables, the length of the procedure, the surgery support required, and the destination of the patient postoperatively. A nursing manager suggested that compensation should be based on the nurse’s skill set: “I appreciate
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nurses who are able to work in a variety of areas. Those who are able to work [in preoperative, intraoperative, and postoperative areas] should be compensated for those abilities.” Although the large majority of commenters stated their concerns about compensation, benefits, and the present nursing environment, a number of nurses expressed satisfaction with their pay and jobs. A nurse commented, “I love being an OR nurse and I am fortunate to make a living at it!” Another nurse wrote, “This is the best career in the world.” Editor’s notes: iPad is a registered trademark of Apple, Inc, Cupertino, CA. CNOR and CRNFA are registered trademarks of the Competency and Credentialing Institute, Denver, CO. Donald R. 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. Kim A. Stewart, PhD, is an independent scholar in Denver, CO. Dr Stewart has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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