In the journal's first survey of this kind, Nursing Management collected demographic and professional attributes of more than 1,500 nurse leaders representing every U.S. geographical area, in addition to Saudi Arabia, Canada, China, and New Zealand. Uncovering these characteristics is key, especially now: As legislative and industry leaders struggle to find innovative and economical methods to deliver care, they'll also need to carefully consider the makeup of nurse leaders, who represent the largest component of healthcare providers.
As healthcare leaders, we need to actively develop and implement a new care delivery system. And as a new system is being discussed, we need to simultaneously consider how we'll ensure that highly qualified, diverse representatives are recruited and retained into nursing leadership positions. We need to consider a well-articulated succession plan for future generations to lead the nursing profession, as, according to our findings, more than 50% of today's nurse leaders will retire by 2020.
Of the 1,523 survey participants, 7.1% are assistant nurse managers, 47.9% are nurse managers, 36% are directors, 6.3% are vice presidents, and 2.7% fall into the "other" category (case manager, consultant, educator, coordinators).
Greater than 85% of participants work in a hospital or health system as their primary place of employment. Sixty-two percent of participants have greater than 20 years of experience in nursing, 28.9% have been employed in nursing for 11 to 19 years, and 8.8% have 10 years or less experience in the profession.
Over 80% of the participants are parents, and 33.7% have grandchildren. Nurse leaders' self assessment of their health status is very good: Over 93% of respondents reported their health status as either excellent or good. Only 6% reported being in fair health, and less than 1% reporting being in poor health.
Not surprising, 91.5% of nurse leaders are female, while only 8.5% are male. Although males are poorly represented in nursing leadership positions, it appears as though they move into management positions at a younger age than their female counterparts. The men, however, are younger: 40% of male nurse leaders are under the age of 40 while over 80% of female nurse leaders are over the age of 40.
Men earn greater salaries than women, despite no significant difference in the percentage of males holding executive positions within their organization or attaining a higher level of education. Specifically, 30% of men earn greater than $100,000 per year, while only 20% of women earn a six-figure salary. Nearly 70% of women are the sole earner in their household, while only 60% of men are the only family member employed. It's a myth that nursing is a secondary income to supplement a partner's earnings: 70% of those surveyed revealed that they make more than their partners.
The 2000 United States census revealed that 75.1% of the population is Caucasian, 12.3% Black, 3.6% Asian, and 12.5% Hispanic.1 Our survey indicated that the ethnicity of U.S. nurse leaders falls into the following percentages: 82.3% Caucasian, 6.3% Black, 7.8% Asian, and 2.3% Hispanic. Considering these two sets of statistics, Hispanics and Blacks are under represented in nursing leadership positions as compared to the general population, whereas Caucasians and Asians are over represented.
Salaries are primarily based on the level of accountability and responsibility within the organization. In our survey, the majority of vice presidents reported earning greater than $130,000 per year, nursing directors between $100,000 and $119,999, nurse managers between $90,000 and $99,999, supervisors between $75,000 and $79,900, and educators between $60,000 and $64,999. Of those earning greater than $120,000 per year, more than 90% are Caucasian, 4% are Black, and 2% for both Hispanics and Asians.
The older the nurse leader, the greater the salary earned. More than 65% of those ages 50 and above reported an annual income of $120,000. Their younger counterparts earn significantly less, with the majority earning between $90,000 and $99,999 per year. Although the older nurse leader earns more money, there's not a correlation between years of service in the role and salary levels. It's clearly evident that salaries are based on position and not years of experience within the role.
We found that income hinges on geographic location. The highest paid salaries are in the Pacific states, where 40% of you earn greater than $100,000 per year, followed by the New England States, where 28.7% of you earn greater than $100,000 per year. The lowest salaries are in the South Atlantic, where the majority of nurse leaders earn between $80,000 and $84,999.
Education makes a significant difference in compensation. Of those who reported earning greater than $120,000 per year, nearly 75% attained a master's degree; no respondents at the associate degree or diploma level of nursing education reported earning more than $120,000 per year. The majority of those who earned a bachelor's degree made between $80,000 and $89,999 per year.
Those of you who work in Magnet hospitals don't earn greater salaries. In fact, 84% of you earning $120,000 per year come from non-Magnet facilities.
Nearly half of you who responded are at least 50 years old. (And only 13% of you are younger than 40!) More concerning is that the majority (48.2%) of you older than 50 have been in your position for less than five years. We're entering leadership positions at an older age and have limited tenure in our positions. Unfortunately, it looks like we're not paying enough attention to succession planning in our early professional years.
Fifty percent of you age 50 and beyond say that you don't plan on working in your organization 5 years from now. This indicates a 50% turnover rate of nursing leadership positions within healthcare organizations during the next five years.
The highest majority of you older than 50 (57.7%) live in the East North Central portion of the United States, which includes Illinois, Indiana, Michigan, Ohio, and Wisconsin. Younger nurse leaders tend to live in the South Atlantic States of Delaware, Washington, D.C., Florida, Georgia, Maryland, North Carolina, South Carolina, West Virginia, and Virginia.
The older we get, the more education we attain: Greater than 90% of respondents age 55 and beyond have a master's degree or above, while 78% of younger leaders (those less than 40) have a master's degree or above.
How do we like to learn?
Twenty seven percent of you have returned to school for a higher degree. And out of this number, 27% are enrolled in a BSN program, 50% in an MSN program, 8.4% in an MBA program, 9% in a PhD program, and 5.4% in a DNP program.
A majority of the respondents reported that they prefer visual or hands-on learning (see one, do one, and teach one) rather than lecture. Nurses clearly prefer to have an instructor teach them through demonstration or role modeling behavior rather than discussing theoretical concepts. Most of you reported a preference for traditional classroom instruction over electronic distance learning.
Retirement within grasp
It's been long reported that the average age of the professional nurse continues to advance. Forty-nine percent of you told us that you'll retire by 2020. And what's the breakdown? Nearly three-quarters of vice presidents, a little more than half of nursing directors, 45% of nurse managers, 35% of assistant nurse managers, and 70% of case managers will retire from the profession in the next decade. The South and Middle Atlantic States will be most effected by retirements.
Again, succession planning for future nurse leaders is vital. When we fail to ensure a thorough plan, we jeopardize the future success of our organization. What are the exiting plans for all nurse leaders at your facility? Which individuals have high potential for assuming more responsibility? We need to identify and mentor these individuals, providing them with leadership education and coaches so that when a position opens, we can fill it quickly with the correct candidate. We also need plans for recruiting external candidates.
There are many challenges
Those of you responding to our survey expressed a significant amount of discontent with the healthcare industry. The overall tenor of the comments from those of you with executive positions is guarded; you voiced numerous concerns about balancing quality of care and meeting or exceeding financial targets. "I'm sometimes the staunch defender of what's right and clinically appropriate, against forces of business that pressure to grow at all costs. I've made in-roads, and I see a culture shift to quality versus quantity. But it's difficult to implement programs whose benefit is mainly improved quality," shares one vice president.
An executive from a hospital in Florida echoes, "The major challenges are balancing safe staffing and fighting an up-hill battle with declining revenues and intense financial scrutiny."
Another challenge that executive nurse leaders report is contending with increasing regulations from payers, such as the Center for Medicare Services, who are requiring increasingly more public reporting and financial scrutiny.
And the nursing director level is increasingly concerned about fiscal and human resources. "Allocation of resources is always trying during difficult financial times. The current economy coupled with the nursing workforce shortage creates a special challenge in managing patient flow and improving patient outcomes," says one of our respondents.
Many directors are concerned about balancing the regulatory and financial restraints with the quality of care that they provide to patients. The amount of documentation required by regulatory agencies frequently pulls professional staff further away from the bedside, as an increasing amount of time is required for documentation.
Nurse managers express grave concerns regarding the complexity and responsibilities of their position. The following narrative characterizes the frustrations that many middle managers shared with us:
I'm designated as the nurse manager of a large outpatient clinic. There aren't enough staff nurses, so I also function in a staff nurse role. I'm constantly handling patient care issues, nursing issues, and clinic issues—including those from providers (physicians). Our clinic is growing so rapidly, taking on new patients daily and adding new services. We'll soon be offering on-site general radiology and retinal imaging. I'm also asked to supervise a compensated work therapy worker and a radiology technician, and assist with clerical supervision. I'm constantly multi-tasking and usually stressed. Many days I ask myself why I stay in this role. I feel I have a lot to offer the profession...I have creative ideas but they're stifled by the daily grind. I'm tempted to leave middle management and go back to a staff nurse role or look to work from home as a legal nurse consultant.
Who we are may dictate where we're going
So, where are we at? We found that the majority of nurse leaders:
- are female, Caucasian, and older than 50
- are retiring in droves during the next decade
- have been in nursing more than 20 years
- have held their current position for less than 5 years
- work in hospitals and health systems
- are the sole earner or the largest financial contributor to the home
- sustained a flat growth in salary potential
- maintain stressful jobs and still devote their non-work time to children and grandchildren.
Alarmingly, there's growing discontent with nurses who hold leadership positions, as the role has become increasingly more complex and demanding, which requires a significant personal contribution to the work setting. Minimal allocation of material, financial, and human resources—coupled with more regulatory requirements, low staff morale, and the need to profitably grow the business—are taxing the nursing leadership workforce. A cultural shift in role expectations and requirements of the nurse leader will need to take priority as legislative and industry leaders grapple with changing the healthcare provider landscape.
As nurse leaders, it's incumbent upon us to continue to strive for excellence, mentor our reports to take our place, and continue to insist on a high level of care quality and patient services. In the next decade, we must take actionable steps to ensure a clear and distinct pathway for the next generation of nurse leaders to foster creativity and innovation to meet the growing healthcare demands of a rapidly aging population.