2014′s Best & Worst States for Nurses

by John S Kiernan

WH-2014-Best-Worst-States-for-NursesThe nursing industry – like most segments of the economy – is in a state of significant transition under the weight of major overarching socioeconomic dynamics, from the aging U.S. population and the Affordable Care Act to the student loan crisis and concerns about the future of key entitlement programs. It’s therefore understandable if recent nursing school grads aren’t sure where to turn once they receive their diploma.

That concern is not unique among recent graduates, regardless of industry, but both the magnitude of the issue – the nursing industry is expected to grow far faster than the average occupation through 2022 – and the various day-to-day demands placed on nursing professionals – from overstaffing and mandatory overtime to unionization and allegations of systematic disrespect – are indeed profession-specific. With that in mind, WalletHub decided to take stock of the nursing industry in order to help nurses, particularly the newly minted of the bunch, lay down roots in areas that are conducive to both personal and professional success.

We compared the 50 states and the District of Columbia in terms of 15 key metrics that collectively speak to the job opportunities that exist for nurses in each market, how much competition there is for each position, differences in the workplace environment, and projections for the future. You can check out our findings as well as the methodology we used to conduct this report and expert commentary on the state of the nursing industry below.

Main Findings

 

Overall Rank

State Name

Opportunity Rank

Competition Rank

Work Environment Rank

1 Oregon 2 5 1
2 Washington 4 6 12
3 South Dakota 1 17 15
4 Arizona 9 4 22
5 New Mexico 20 3 28
6 Alaska 37 1 5
7 Wyoming 22 2 42
8 Minnesota 5 47 1
9 Texas 8 11 36
10 Maryland 30 10 20
11 Nebraska 6 29 13
12 Colorado 24 14 29
13 California 11 25 25
14 North Dakota 23 28 7
15 Maine 28 15 20
16 Idaho 31 19 15
T-17 Kansas 18 24 23
T-17 Montana 21 19 30
19 Massachusetts 29 29 6
20 North Carolina 7 27 39
21 Florida 17 21 39
22 Wisconsin 15 36 11
23 Ohio 3 48 19
24 Oklahoma 32 8 45
25 Connecticut 34 32 4
26 South Carolina 16 26 43
27 Iowa 13 38 24
28 New Hampshire 48 9 9
29 Pennsylvania 14 36 26
30 Virginia 25 18 48
31 Indiana 12 35 34
32 Vermont 49 11 10
33 Michigan 26 34 31
34 Nevada 44 11 38
35 Missouri 10 45 35
36 Hawaii 50 7 32
37 Rhode Island 45 41 3
38 Illinois 35 31 27
39 New York 36 40 17
40 Utah 43 16 44
41 New Jersey 51 22 17
42 District of Columbia 39 39 14
43 Delaware 42 44 8
44 Arkansas 38 33 33
45 Georgia 33 22 51
46 Kentucky 19 51 39
47 West Virginia 27 50 47
48 Tennessee 40 43 46
49 Alabama 46 49 37
50 Louisiana 41 45 50
51 Mississippi 47 42 49

Best_Worst_States_for_Nurses_0525148

Ask the Experts

  • What are the biggest issues facing nurses these days?
  • What can legislators do to make their states more attractive to nurses?
  • Are unions beneficial to nurses?
  • Tips for recent nursing school grads looking for a place to live and work.
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    • Steven G. Ullmann Director, Center for Health Sector Management and Policy, University of Miami, School of Business Administration
    • Pegge Bell Director, Eleanor Mann School of Nursing, College of Education and Health Professions, University of Arkansas
    • Linda H. Aiken Director, Center for Health Outcomes and Policy Research, University of Pennsylvania
    • Robert B. Hackey Professor, Health Policy and Management Program, Providence College
    • Gloria F. Donnelly Dean, College of Nursing and Health Professions, Drexel University
    • Susan B. Sepples Associate Professor, University of Southern Maine School of Nursing
    • Michael S. Sparer Chair & Professor of Health Policy and Management, Mailman School of Public Health, Columbia University
    • Joanne Spetz Professor of Economics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco

    Steven G. Ullmann

    Director, Center for Health Sector Management and Policy, University of Miami, School of Business Administration
    Steven G. Ullmann
    What are the biggest issues facing nurses these days?

    An aging population and therefore a sicker population will put more demands on nurses.

    The growing issue of the overweight and obesity epidemic in this country puts significant physical strain on nurses.

    The rapid growth in high tech requires nurses to keep up to date.

    The increase in cutbacks in reimbursement to health care facilities will put additional stress of workload on nurses.

    What can legislators do to make their states more attractive to nurses?

    Allow higher trained nurses to practice at the level of their training instead of restrictions on their scope of practice.

    Tips for recent nursing school grads looking for a place to live and work.

    Live and work in environments, both professional and lifestyle-wise, that give you joy.

    Pegge Bell

    Director, Eleanor Mann School of Nursing, College of Education and Health Professions, University of Arkansas
    Pegge Bell
    What are the biggest issues facing nurses these days?

    There are so many positives about nursing – the flexibility and mobility of work (you can change clinical settings within your current place of employment and also from an acute care hospital setting to primary care services in the community, clinic, or school-based setting). You can continue your education from almost anywhere by enrolling in a distance learning program, and some of the programs (Master’s degree program with an emphasis on nursing education) will provide federal loans to offset tuition costs. Even so, there continues to be turnover of nurses who find the healthcare setting challenging.

    Under the terms of the Affordable Care Act, federal reimbursement to hospitals for Medicare patients is dependent on patient outcomes: patients must be discharged within a set number of days and stay home (not be readmitted to the hospital) for at least 30 days. The acuity of patients is much higher now for a number of reasons – they’ve delayed seeking necessary primary care because they couldn’t afford it or find it; chronic diseases are on the rise (obesity, hypertension, diabetes) and they are not being managed well by patients, and there is a need for health promotion services that are currently limited. So, the rush to get your patient home can minimize the time they need to learn how to better manage their drugs, treatments, or rehab services. Nurses are taught that their patients are individuals with psychological, sociological, and biological challenges unique to them. Some have support of family and friends along with community resources while other patients do not have these systems in place. A “one size fits all” approach to nursing care has never been well received by nurses.

    While this may sound like nursing is not a great career, nurses themselves are proposing solutions to these challenges. One measure is to continue their education to achieve a Doctor in Nursing Practice degree. This is a terminal practice degree that prepares graduates to take on the challenges of creating new methods of healthcare delivery services that patients need and to make meaningful contributions to improving the health outcomes of patients. The other is to participate in utilizing research-based studies and practices in a specific setting to improve the patient’s situations. Nurses are wonderful problem solvers and if they take the initiative to do this, patient care can be improved. An example of one of our recent graduates is introducing a SPOONS program that uses nursing students to feed the older patient. It takes almost an hour for this process, but the socialization between the patient and student can improve the patient’s nutritional status and speed the recovery time.

    One answer to the need for primary and acute care services is the utilization of Advanced Practice Nurses (certified nurse practitioners, certified nurse midwives, certified nurse anesthetists, and clinical nurse specialists). In some states they function autonomously and in others they either function under the supervision of a physician or in a collaborative practice with a physician. The Institute of Medicine has recommended that they be allowed to function to their full scope of educational preparation, and yet this is continually met with resistance when legislation is proposed that would expand their services and allow for more autonomy.

    One other challenge is the increased reliance on technology – everything is on the computer. While this improves the communication about patients it also requires nurses to be on their guard for the use of social media. They cannot violate patient confidentiality when discussing their work day with others. Older nurses are the most challenged by the move to track all patient data electronically, but the younger nurses are finding it very useful. Nurses need to learn to utilize the data to track the trends on their unit – which patients are the most likely to return within 30 days of discharge? By using the technology they can identify key areas for improvement, but also need to explore more ways to apply technology with patients after discharge.

    What can legislators do to make their states more attractive to nurses?

    Expand and protect the scope of practice for Advanced Practice Nurses.

    Are unions beneficial to nurses?

    I have to say no because nurses are professionals and as such, should belong to their professional organization – The American Nurses Association. There would provide strength in numbers to support and/or oppose the actions of certain companies or states that would make the working environment a negative place.

    Tips for recent nursing school grads looking for a place to live and work.

    They shouldn’t limit themselves to a particular unit or setting; many new graduates want to work in ICUs, but they should take any position to get started in a system. They will get experiences in patient care management that can easily transfer to other settings. Having a good attitude about work and not getting discouraged will help. It is challenging work and nurses have to be alert all day every day. Surrounding yourself with positive co-workers, finding a manager who is supportive of good patient care, and working with patients where you know you’re making a difference is what it’s all about.

    Linda H. Aiken

    Director, Center for Health Outcomes and Policy Research, University of Pennsylvania
    Linda H. Aiken
    What are the biggest issues facing nurses these days?

    Poor work environments that undermine nurse effectiveness and efficiency.

    Lack of evidence based decision making by health care executives that often leads to dangerous reductions in nurse staffing that adversely affect care quality and safety.

    Restrictive state practice act and reimbursement barriers to full scope of nursing practice for nurse practitioners.

    Insufficient access to initial nursing education at the baccalaureate level which requires nurses to repeat their education at high personal costs.

    What can legislators do to make their states more attractive to nurses?

    Adopt the National Council of State Boards of Nursing model nurse practice act.

    Expand access to baccalaureate nursing education by targeting state education funds to schools that enable nursing students to acquire a baccalaureate degree in nursing in their first educational programs. Target state educational loans and scholarships to nursing students who earn a baccalaureate education in nursing. Allow community colleges that meet accreditation standards to offer a baccalaureate degree in nursing to replace the associate degree in nursing programs.

    Are unions beneficial to nurses?

    Many of the best institutions for patient care outcomes and nurse employment do not have unions and their management practices are very supportive to nurses. Many of these best institutions are Magnet hospitals. Some collective bargaining programs also have good records of promoting high quality of care that benefits patients and nurses alike.

    Tips for recent nursing school grads looking for a place to live and work.

    Select a state with a nurse practice act conforming to the National Council of State Boards of Nursing’s model act which allows all registered nurses and nurse practitioners to practice to their full potential

    Investigate the location of Magnet recognized hospitals known as good places for nurses to work and for patients to receive superior care. Every Magnet hospital is listed at www.nursecredentialing.org.

    Select a state with a policy priority on providing health insurance coverage to the poor which would include states that have expanded Medicaid as requested under Obamacare. States that have adequate insurance coverage for all provide significantly greater opportunities for nurses to provide excellent care.

    Select a state with affordable access to baccalaureate and graduate nursing education and an employer whose benefit package includes tuition benefits.

    The Medicare program provides publically available websites to evaluate the performance of hospitals, home care agencies, and nursing homes. Look up a prospective employer to see how their patient outcomes compare to other employers in the community on Medicare.gov.

    Robert B. Hackey

    Professor, Health Policy and Management Program, Providence College
    Robert B. Hackey
    What are the biggest issues facing nurses these days?

    Despite recent improvements in the nursing job market, the profession still faces an uphill battle to recruit and retain new nurses. Nursing still relies disproportionately on women, and although the percentage of men in nursing has crept up, it's not enough to keep up with the demands of an aging society. Women interested in careers in medicine today have many more choices than their predecessors - women now represent a growing proportion of doctors, pharmacists, and other allied health professionals, along with health administrators, lawyers, and other professions. This is a mark of real progress, but it's a challenge for the profession because nursing's salaries and working conditions must now compete with each of these professional careers for new talent.

    The bigger issue facing the profession is cultural. Television medical dramas provide millions of Americans with an up close and personal view of the US health care system, but nurses are often relegated to minor roles in the most popular TV shows such as Grey's Anatomy. The physician centric nature of most TV health dramas provides a misleading impression for viewers, as doctors perform many of the tasks at the bedside usually done by nurses. Although shows like Nurse Jackie have presented audiences with strong nursing characters, they are deeply flawed.

    What can legislators do to make their states more attractive to nurses?

    Regulating working conditions via state legislation that establishes nurse/patient staffing ratios can help in the short run, but it runs the risk of penalizing economically vulnerable institutions that struggle to recruit and retain staff. Hospitals serving more affluent communities may find it easier to meet their staffing goals.

    State colleges and universities could increase the size of their nursing classes, but doing so will require investments in new faculty and facilities. Nursing faculty salaries still lag behind earning opportunities for senior nurses in inpatient settings, so some form of salary support/enhancement is required to encourage more nurses to leave practice for positions in higher education.

    Gloria F. Donnelly

    Dean, College of Nursing and Health Professions, Drexel University
    Gloria F. Donnelly
    What are the biggest issues facing nurses these days?

    The biggest issue facing nurses today is changing the mindset about nursing practice to adjust to the realities and possibilities of the Affordable Care Act, including the shift from hospital-based to ambulatory care, the impact of technology on health care delivery, the delivery of primary care by nurse practitioners, the proliferation of health promotion and disease prevention programs and the rapid graying of the U.S. population.

    There are also many opportunities emerging for nurse entrepreneurs who have hunches about products and services to improve care and care outcomes. The sky is the limit for nurses in this changing health care system, we just need to think and act smarter.

    What can legislators do to make their states more attractive to nurses?

    Legislators can push for state nurse practice acts to grant nurses full scope of practice at whatever level they practice, entry or graduate level, and to reform the rules of practice to emphasize patient-centered, inter-professional collaboration rather than physician control.

    Are unions beneficial to nurses?

    This is not a fair question since the benefit of any advocacy organization depends on the issues at hand. There are “unions” and there are ‘unions,’ some are more effective than others at advocating for nursing professionals who wish and need to expand scope of practice to serve patients more effectively. Some are more adept at the art and science of negotiation; others get much too militant and often send the wrong or a skewed message. I make my judgments issue by issue and union by union.

    Tips for recent nursing school grads looking for a place to live and work.

    If I were graduating from nursing school this year, I would search the states that have granted nurses full scope of practice under the law and look there for employment. At my last count there were approximately 22 states that have made this important revision to legislation. Just visit http://www.nacns.org/docs/toolkit/3A-FAQScope.pdf to learn which states are most progressive with respect to Advanced Practice Nurses and head for those states!

    Susan B. Sepples

    Associate Professor, University of Southern Maine School of Nursing
    Susan B. Sepples
    What are the biggest issues facing nurses these days?

    The issues for nurses at the bedside differ from the issues in terms of workforce planning. At the bedside, the issues are variability in census. Hospitals have low census and are having some trouble finding a staffing mix that works so there are nights where the under-staffing (and the mix of expertise) is scary, and yet hospitals are not hiring because their overall numbers are down.

    Many hospitals and nursing homes are using traveling staff even while new graduates are wanting for jobs. There is a lag in hiring because hospitals need expert staff who can jump in and work right now and the cost of hiring and training new graduates is high. Staff satisfaction in many places is at its nadir. Nurses are working short-staffed, or if per diem, are either working at full tilt or called off and losing hours. A staff mix with travelers, part time or floated staff all has implications for patient safety and nurse satisfaction.

    Add to this that the work is getting harder and more frustrating with documentation becoming the central factor in evaluating performance. Nurses are describing the care they give as no longer patient or family centered but documentation centered. The documentation platforms are riddled with problems and the level of support for the nurse at the bedside or in the home is just not up to speed.

    What can legislators do to make their states more attractive to nurses?

    While I think salary is important it is not the biggest factor in why young nurses stay. They must be supported and nurtured--given real rewards, be able to participate in decision making, and have the opportunity to work with a strong leader. We need to be cultivating these strong leaders.

    Are unions beneficial to nurses?

    In a word, no. I do think the threat of unionization has some beneficial effect. The concerns and issues of staff nurses are taken VERY seriously when there is a threat of unionization and that is when the union is very powerful and the outcomes for the nurse at the point of care do improve (making nurses want to vote in a union).

    It is a case, however, of diminishing returns. I have worked in union hospitals and the us – them mentality that arises is not good for patient care, nurse satisfaction (especially that!) or retention. The work of a union, once in place, is really to foment dissatisfaction. This is how they wield power.

    I think nurses who work in union hospitals are eventually turned off by the oppressive negative environment created by the union. I believe unions create a nurse-versus-nurse situation that is not beneficial to anyone.

    Tips for recent nursing school grads looking for a place to live and work.

    Right now there are jobs in central and northern Maine and in long-term care. We are working at increasing the preceptor programs for long term and critical access hospitals. The salary may be lower but the focus on new graduates and the support for their nurturance is there.

    Look beyond the big medical centers! And start right into graduate school!!! We need leaders and teachers and will need them SOON!

    Michael S. Sparer

    Chair & Professor of Health Policy and Management, Mailman School of Public Health, Columbia University
    Michael S. Sparer
    What are the biggest issues facing nurses these days?

    Seems to me that the biggest issue facing nurses today is their role in the evolving integrated delivery systems. At its core, this is a ‘scope of practice’ issue: who should do what in a reformed health care system? What is the role of the physician, the nurse practitioner, the RN, the Physician Assistant, and so on?

    What can legislators do to make their states more attractive to nurses?

    State's that permit nurses (especially nurse practitioners) greater practice autonomy are likely to be more attractive to nurses with geographic options.

    Joanne Spetz

    Professor of Economics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
    Joanne Spetz
    What are the biggest issues facing nurses these days?

    There are a lot of different perspectives about what the biggest issues might be. In the big picture, I think there is a question of how to ensure that the nursing profession is best positioned to meet the needs of the future. One major area of that is recognizing that we have an aging population that’s having increasing health care needs. So, how do you ensure that the workforce is well prepared to meet those needs?

    It’s also important for the profession to really be in a position to contribute as much as possible to improving the value of health care services. And nurses are actually in a great position to do that because their education is very broad and it tends to be very population-focused.

    What can legislators do to make their states more attractive to nurses?

    Well, from a government standpoint, there are a few things that are pretty obvious but aren’t always in existence. One is continuing support of the educational system. Having a good education system that allows access to education for a broad variety of people from broad economic backgrounds is really important. The Institute of Medicine recommended that a higher share of registered nurses have bachelor’s degree or higher training, so states should really be thinking about growing their bachelor’s degree programs – whether it’s an entry-into-nursing program or an opportunity for a nurse with an associate’s degree to continue on to a bachelor’s degree. That’s kind of a no-brainer but it needs to happen.

    You get a lot of variation among states in terms of occupational health and safety requirements, but I think there is a lot of consensus that there are certain types of injury prevention programs – such as needlestick injury prevention programs – that are pretty evidence-based that have proven to be really valuable in terms of reducing injury and reducing turnover and such. That area is pretty obvious to look at for governments as well.

    There are a lot of other areas that some have advocated states get involved in, such as mandating minimum staffing requirements in various care settings. And my understanding of the evidence in nursing homes is that it’s pretty clear that better staffing in nursing homes and that staffing ratio laws have had benefits for patients.

    For hospitals, there is really not clear evidence at this point that California’s law has had any benefit to patients. So, in the absence of really clear evidence on that, I hesitate to advise other states to go in the path of California from a legislative standpoint. That’s not to say the evidence might not appear in the future, but, at this point, the research that I’ve done and that others have done on staffing ratios hasn’t really found any evidence of a patient benefit.

    Those laws are linked with higher wages for nurses and higher satisfaction levels, so it depends on what your legislature is trying to achieve. If your legislature is trying to achieve lower turnover rates for nurses in hospitals and they’re willing to pay indirectly through rising health care costs for that benefit to nurses, then great. But if the argument is that, ‘Oh, we’re doing this to protect patients,’ well the evidence does not yet support that.

    Are unions beneficial to nurses?

    Unions have a very clear purpose in an economy. The reason unions ever came to be was largely to protect workers where workers were at risk to be exploited. You think about the Industrial Revolution and the original world in which unions came about, and there was a lot of worker exploitation – low wages, poor working conditions, and so on.

    Essentially what unions are doing from an economic theory standpoint is taking some of the profits that might go to shareholders or owners and giving that to workers. This totally makes sense when you’re talking about a private company, but it’s much more ambiguous when you’re talking about a non-profit organization like a hospital. A union may, of course, have a lot of value to try to improve working conditions and increase wages for one group of workers or all groups of workers at hospitals, but at the same time that may also reduce the amount of money that they have available for charity care and other purposes. This is where it gets very localized.

    Some not-for-profit hospitals behave a lot like a for-profit. Some hospitals really are bad places to work, and some are great places to work. Some labor-management partnerships, I think, have been extremely effective both in improving the workplace environment and in improving quality of care.

    Other unions are so much more in the adversarial stage and are still trying to sort out what that relationship is going to really look like in the long-term.

    So, at this point, you can’t really generalize that unions are good or bad. But they do, in theory, serve a really clear role. Given that role that they serve, the question for hospitals or for other employers becomes: how do you harness what unions do bring to the table so you can create as good of an environment as possible for your patient care? This is really fundamentally what you’re trying to do.

    Tips for recent nursing school grads looking for a place to live and work.

    I think you’d look for a lot of the same things that you would look for in any good workplace. Do people seem to get along well here? Is there going to be support for my career development and my continual learning? Is there any indication in terms of objective measures whether this is a good or bad place to work?

    It’s a little tricky right now because in some parts of the country it actually is very hard for new nursing graduates to find jobs. It’s getting better as the economy recovers, but it’s been really challenging for the past four or five years. So nurses may also need to recognize that as they’re graduating they might not get their first-choice job immediately after graduation. The fact is most of us don’t.

    The key is to find a job that will get you where you want to go. If where you really want to go is into geriatric care and you think you’d like to start with a hospital position but your first job is in a nursing home, it may actually be a good fit. Look for something where you can see a pathway for the long-term, but, in general, get yourself employed.

    You don’t want to be too picky when you’re looking for your first job or you might never get a job. If you’ve been out of school for too long, then the perception is – and maybe the reality is – that you lose your skills. So do whatever you can to keep your skills up and get into the workplace as soon as possible or stay in school if your local job market is really bad.

    Methodology

    WalletHub took 15 key metrics into account in assessing the relative activeness of the 50 states and the District of Columbia to nurses. In doing so, we considered trends both short- and long-term related to the employment opportunities that exist in each state, the quality of the jobs that are available, the amount of competition that does and will exist in the local job market, and the nature of the workplace environment in which nurses operate.

    You can check out the metrics as well as the corresponding weights we used to construct our overall rankings below. The three categories under which the metrics are listed were used for organizational purposes only and did not factor in to our overall rankings.

    Opportunity

    • Monthly Median Starting Salary for Nurses, Adjusted for Cost of Living: 0.5
    • Average Annual Salary for Nurses, Adjusted for Cost of Living: 1
    • Number of Health Care Facilities per Capita: 1
    • Medically Underserved Areas: 1
    • Projected Percentage of the Population Over 65 (2030): 0.5
    • Nursing Schools Rank: 1

    Competition

    • Nursing Job Openings per Capita: 1
    • Number of Nurses per Capita: 0.5
    • Projected Number of Nurses per Capita (2020): 1
    • Unemployment Rate: 0.5

    Work Environment

    • Mandatory Overtime Restrictions: 1
    • States with the Largest Share of the Best Nursing Homes: 0.5
    • Best States for Working Moms Rank: 0.5
    • Average Number of Hours Worked: 0.5
    • Average Commute Time: 0.5

    Source: Data used to create these rankings is courtesy of the U.S. Census Bureau, the U.S. Bureau of Labor Statistics, the Missouri Economic Research & Information Center, Indeed.com, the US Department of Health and Human Services Health Resources and Services Administration, U.S. News & World Report, the American Nurses Association and WalletHub research.

    Author
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    John Kiernan is Senior Writer & Editor at Evolution Finance. He graduated from the University of Maryland with a BA in Journalism, a minor in Sport Commerce & Culture,…
    1241 Wallet Points
    With all due respect to the wonderful LVN's, Associate Degree RN's, etc. that have dedicated themselves to our healthcare, the information in this study would be much more useful if it was segmented by higher education degree, in my opinion. Obviously, Nurse Anesthetists and Nurse Practitioners command significantly higher salaries, but do have fewer opportunities, than LVN's and RN's, which may be distorting the data for both groups.
    Jul 10, 2014  •  Reply  •  Flag
    What constitutes a nurse? Is it any level of nurse including LPN, RN, APRN, etc., or just a specific credential? Thanks!
    May 27, 2014  •  Reply (1)  •  Flag
    Were included the following nurses credentials: Registered Nurses, Licensed Practical and Licensed Vocational Nurses, Nurse Anesthetists, Nurse Midwives and Nurse Practitioners.
    Jun 5, 2014  •  Reply  •  Flag