2015’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. However, 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 registered nurses, particularly the newly minted of the bunch, lay down roots in areas that are conducive to both personal and professional success. We did so by comparing the 50 U.S. states and the District of Columbia across 15 key metrics that collectively speak to the nursing job opportunities existing in each market. Below, you can check out our findings, the methodology we used to conduct this report as well as expert commentary on the state of the nursing industry.

Main Findings

Embed on your website

 

Overall Rank

State

“Opportunity & Competition” Rank

“Work Environment“ Rank

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

Best-&-Worst-States-for-Nurses-Artwork

Ask the Experts: The State of the Nursing Industry

WalletHub turned to a panel of esteemed nursing industry experts for insight into the future of the profession and how recent entrants into the market can navigate their way to a successful career. You can check out their bios and thoughts below.

  1. What are the biggest issues facing nurses today?
  2. What is the long-term outlook for the field of nursing?
  3. What tips do you have for recent nursing school grads looking for a place to live and work?
  4. What can local governments and health systems do to attract and retain high quality nurses?
  5. What is the impact of the Affordable Care Act (ACA) on nurses?
  6. Are unions beneficial to nurses?
< >

Candace Campbell

Assistant Professor at University of San Francisco, School of Nursing and Health Professions
Candace Campbell
What are the biggest issues facing nurses today?

Nurses today face many of the same and some very different challenges than Florence Nightingale exposed 150 years ago.

The first similar challenge is the work itself. Generally, we interface with people who are in pain, have lost their independence, or just don’t feel well. To say that makes some folks are a bit cranky is an understatement. According to the Bureau of Labor (2007), nurses face the highest on-the-job assault rate (by patients) than any other profession. The reasons for this increased violence is multifactorial. As a result, The Centers for Disease Control and most health care organizations have launched education programs to sharpen nurses’ communication and crisis care skills, so they might recognize behavioral warning signs of violence in individuals.

Another difference/challenge today is that since the 1970’s, medical advancement in treatment and technology has allowed patients to live with acute or chronic debilitating diseases much longer. This means hospitals have an influx of patients whose need for intervention is greater for a longer period of time. In turn, higher acuity patient loads translate into increased nursing care interventions and increased levels of stress for professional caregivers, as well as their patients.

Within the same timeframe of the 70’s, women found other professions besides the previous teacher-secretary-nurse choices available to them. As a result, many women who would have chosen nursing as a profession --- didn’t. I’d venture to say our growth as a profession, as opposed to a vocation, was stalled, in some regard, by that movement (gender equality also became an issue in those years, so that now 6% of all nurses are male). Meanwhile, the economic vagaries of the 21st century have caused those nurses who might have retired mid-life, to keep working. This has a domino effect, because while we, older nurses, comprise the brain trust of the profession, younger nurses, especially in desirable urban areas, find it difficult to secure employment.

Add to that the increased dangers of infection, as world travel increases and infectious agents simultaneously mutate to withstand modern antimicrobials, and we find nursing has become a high-risk profession, even within developed countries.

What is the long term outlook for the field of nursing?

If you are asking if we will be replaced by robotics anytime soon, the answer is no. There will always be a need for nurses to be at the bedside, the classroom, the boardroom, the legislature, etc. At present, the need for nurses is predicted to be growing, with replacements of 1.05 million nurses needed until the year 2022. The American Colleges of Nursing has published an executive summary of these data.

What tips do you have for recent nursing school grads looking for a place to live and work?
  1. Be willing to move to where the opportunities might lie,
  2. Think outside the acute-care box to preventative curative interventions,
  3. Take note of the needs of your community and find a project you might champion to meet that need. [Note: Anything you do that proves you a) understand a healthcare problem, and /or b) can effectively collaborate and create even a partial solution, is very important in terms of advancing or launching your nursing career.
What can local governments and health systems do to attract and retain high quality nurses?
  1. Provide for loan forgiveness! There are some (a few) federal programs now, but many more are needed. The biggest barrier to cultural competency and diversity in the nursing workforce are the financial barriers of entry to nursing school.
  2. Pay nurses the same in acute care as preventative care. A cost-benefit analysis would show the logic of this. To save lives, we need nurse-educators in every clinic to guide, counsel, and inspire patients to avoid the necessity of acute care.
  3. Allow nurses to practice to the full extent of their license.
What is the impact of the Affordable Care Act (ACA) on nurses?

In 2010, the IOM published a report on The Future of Nursing, which outlined several expectations of how nurses, the largest professional healthcare group, can help advance the goal of healthcare as a right, not a privilege. In light of the decrease in numbers of MDs, and increased number of people needing healthcare in this country, the IOM suggested advanced practice RNs should be able to care for about 80% of all the cases and refer about 20% to MDs. In many ways, this has inspired a great push for nurses to take the lead in support of the ACA, in terms of the opportunities.

In other ways, the huge influx of patients on the system causes a predictable bottleneck, when insurance companies decrease payments to secure profits, and PCPs must squeeze in more patients per hour in order to keep organizational revenues afloat. Nurses and patients definitely feel the squeeze.

Are unions beneficial to nurses?

Ah, that is a love-hate relationship if ever there was one. In the public policy arena, our professional nurses association and the nurses unions are on opposite sides of an issue as often as we agree. The difference usually comes down to the issue of “advanced practice.”

Nurses who are able to hang out a shingle and practice independently are primary care providers, and by definition, do not need/want a union to represent them. Conversely, union revenues are impacted when any nurse decides to leave the flock. However, in large organizational hierarchies, unions have historically assisted nurses to have a voice in the marketplace.

Patricia W. Stone

Centennial Professor of Health Policy of Nursing and Director of the Center for Health Policy at Columbia University School of Nursing
Patricia W. Stone
What are the biggest issues facing nurses today?

Nurses are a trusted profession and the rewards of caring for patients and improving health of populations are many. But, increasingly, there are financial constraints in many healthcare work environments (such as hospitals) and the patients being cared for have increased complexity for many reasons. This can result in heavy work load and, in some instances, poor work environments. Each nurse must find the work environment that suits their educational preparation, clinical skills and professional goals.

What is the long term outlook for the field of nursing?

The long term outlook for the nursing field overall is very positive. According to statistics compiled by the U.S. Bureau of Labor Statistics, employment of registered nurses is projected to grow 19 percent from 2012 to 2022. The growth is faster than the average for all occupations. Growth will occur for a number of reasons, including an increased emphasis on preventative care; growing rates of chronic conditions, such as diabetes and obesity; and demand for healthcare services from the baby boomer population, as they live longer and more active lives.

Even more exciting is the expected employment growth for nurse anesthetists, nurse midwives, and nurse practitioners. For these advanced practice nurses, employment growth is expected to grow 31 percent from 2012 to 2022. This is much faster than the average for all occupations. Growth will occur primarily because of the effects of healthcare legislation as well as the reasons cited above.

What tips do you have for recent nursing school grads looking for a place to live and work?

If a recent nursing school graduate is having problems finding the right position, they may want to consider two different options.

First, they may want to extend their education. Registered nurses with a Bachelor’s degree are in higher demand than those with an Associate’s degree. Also, as per above, advanced practice nurses will have even more opportunities than registered nurses.

Second, nurses may want to look into critical shortage areas. They may want to look into the NURSE Corps Loan Repayment Program, which enables dedicated registered nurses committed to caring for underserved people to serve in hospitals and clinics in some of America's neediest communities.

Marilyn Frenn

Professor at Marquette University, College of Nursing
Marilyn Frenn
What are the biggest issues facing nurses today?

Creating and sustaining systems of interprofessional care to foster the highest quality and safety for patients and families is likely the biggest issue. Highly complex care and short lengths of stay make it challenging to help people understand what they need to know to care for themselves at home, recognize early warning signs, and effectively promote their health. Nurses need to evaluate the emerging evidence to provide the best care and accomplishing that within the time they have is a challenge.

What is the long term outlook for the field of nursing?

Well prepared nurses will continue to be the largest component of the health care field. The greatest need for nurses is among those prepared to teach and study more effective ways to provide nursing care. Graduate nursing education for managers also helps them be best prepared to create and sustain effective systems of care delivery. Graduate education is required for advanced practice: nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists. These nurses address health care needs with high quality and cost effectiveness.

What tips do you have for recent nursing school grads looking for a place to live and work?

A bachelor's degree is increasingly becoming the minimum education required in many areas. I have met a number of nurses prepared with associate degrees who are back in school right away in order to get a position. Checking with the state nurses association may be helpful in determining job availability. Some states have nursing workforce centers with even more information. Certainly job postings in types of nursing and locations of interest will continue to be good sources of information.

What can local governments and health systems do to attract and retain high quality nurses?

Support for those seeking to become nurses is essential. Historically, under-represented groups are very needed in nursing as population demographics change. These aspiring nurses need scholarships, internships, and loan forgiveness programs. Rural areas as well as health shortage areas in urban areas may have difficulty recruiting and retaining nurses. Programs to mentor new nurses in these areas to provide high quality care also can help.

What is the impact of the Affordable Care Act (ACA) on nurses?

The Affordable Care Act (ACA) wisely incorporated advanced practice nurses to promote healthcare access and affordability. Understanding the implications of the ACA for patients and families continues to be needed. Sometimes, the amount people need to pay is still quite high, given their income, so nurses continually need to be aware of community resources for referral.

Are unions beneficial to nurses?

Those seeking positions would be well advised to see if nurses in that agency are required to join a union and find out more about the actions the union has taken. Collective action to promote quality of care and safe working conditions is sometimes needed, particularly as healthcare organizations face budget challenges. I tend to favor shared governance approaches to collectively solve problems and advance quality of care.

Christine T. Kovner

Professor at New York University, College of Nursing
Christine T. Kovner
What are the biggest issues facing nurses today?

I think there are two big issues that are of concern to nurses 1) workload - nurses feel overwhelmed with all they have to do. From our research, we were surprised to find that many nurses are asked to work without the supplies that they need to do their job. 2) Their managers - we consistently hear from nurses that the major reason that they switch jobs is because of their manager.

What is the long term outlook for the field of nursing?

Long term outlook for the field of nursing from a nurse’s point of view is very good. While some new nurses may be having trouble finding a job, as nurses my age retire, organizations will be hiring many nurses to replace people such as me.

What tips do you have for recent nursing school grads looking for a place to live and work?

Be flexible about what you expect in a job. Even if you had your heart set on pediatrics, if there are no jobs in pediatrics - take a job in another area. You will get a lot of experience. Community care is where health care is going. You don't need to work a year in a hospital "to get experience." Consider a visiting nurse position.

What can local governments and health systems do to attract and retain high quality nurses?

Improve nurses work environment. Control verbal abuse. Redesign rooms so nurses don't injure their back. Offer professional growth opportunities – this generation of nurses is looking to build new knowledge and skills and do a variety of things.

What is the impact of the Affordable Care Act (ACA) on nurses?

It increases the demand for nurses. Many Americans who had no access to health care, now have access and they will need primary care providers and care managers. Allowing nurses and nurse practitioners to practice to the full scope of their abilities will be really important to meet the increase in demand for health care services. Also, the ACA envisions a health system, which requires collaboration and teamwork among different providers and using data to continuously improve the quality of healthcare. New nurses who are competent in interprofessional teamwork and quality improvement will be in high demand.

Are unions beneficial to nurses?

From our research, we know that if nurses have good work environment and workload, unions don't seem to provide additional benefit.

Nancy M. Short

Associate Professor at the Duke University School of Nursing
Nancy M. Short
What are the biggest issues facing nurses today?

Nursing education/schools requires funding from public sources to maintain the small faculty to student ratio required for clinical education. Legislators to do not understand the importance of changing the entry level for registered nursing to the bachelor's degree level. The entry level must change!

Advanced Practice RNs must be empowered to practice to the full extent of their education and not be limited by so-called "physician supervision". Nurse staffing is so tight in hospitals that nurses are afraid to call in when they are sick... they don't want to place even more burden on their colleagues. Staffing is not tight due to a shortage but due to hospital admin wanting to cut costs.

Nurses in clinical practice must focus on critical thinking rather than tasks.

What is the long term outlook for the field of nursing?

Excellent. Demand will continue to be high. Supply is deeply affected by the shortage of faculty members.

What tips do you have for recent nursing school grads looking for a place to live and work?

Be willing to work unpopular shifts or specialty areas in order to get a foot in the door. Plan! Don't drift. Join your professional organization (ANA affiliate or specialty group) and get involved. Pay attention to legislation affecting your license, practice and vote.

What can local governments and health systems do to attract and retain high quality nurses?

Pay them more! Public health is the ghetto of nursing in terms of pay. It's pitiful.

Health systems should focus on culture. Is the culture physician centric? I know... everyone touts "patient centricity" but this is bull tweed. Most systems are so heavily physician centric they can't see the forest for the trees.

Are unions beneficial to nurses?

Yes - in situations where hospital admin is hostile to nurses or so physician centric that nurses are not listened to. The best question is - are nursing unions beneficial to patients? Again - yes. And I come from and live in a right to work state.

Judith Shindul-Rothschild

Associate Professor at Boston College, Connell School of Nursing
Judith Shindul-Rothschild
What are the biggest issues facing nurses today?

The greatest challenge facing nursing continues to be having sufficient registered nurses to provide safe, high quality care in hospitals. Unlike previous decades, the failure of the health care system to have adequate registered nurse staffing in hospitals is not due to a shortage of registered nurses. As I note in my article in Politics and Policy in Nursing Practice, we found in Massachusetts hospitals after health insurance reform that the demand for hospitals services rose, but there was not a commensurate rise in the numbers of registered nurses hired to care for the influx of newly insured patients. Because of inadequate numbers of primary care providers, the newly insured sought care in emergency rooms, and other new entrants into the health care system sought medical and surgical care for health care needs they had deferred when they were uninsured.

The health care system in Massachusetts did not keep pace and did not hire more registered nurses in hospitals and nurse practitioners in primary care to care for this influx of new patients. I conclude that there is the possibility that as health insurance reform is fully implemented nationwide, similar trends are likely to be experienced by registered nurses across the US.

What is the long term outlook for the field of nursing?

The long term outlook for registered nurses with baccalaureate or higher degrees is very positive. Registered nurses who will face the greatest challenges in finding employment will be those with an associate’s degree. The greatest demand is for registered nurses who are doctorally prepared to educate the next generation of registered nurses in tenure track positions in university baccalaureate and higher degree nursing programs. There is a severe shortage of doctorally prepared registered nurses and we are strongly encouraging our undergraduates at the William F. Connell School of Nursing who are outstanding clinicians and scholars to continue their education and pursue graduate education.

What tips do you have for recent nursing school grads looking for a place to live and work?

We need to reeducate and socialize our undergraduate students to approach their career in the same manner as majors business or law. As undergraduates, after the first clinical experience, nursing students should be seeking health care employment opportunities either as a patient care associate in a hospital or community based setting. Many students, in the summer, pursue voluntary global health experiences in areas of the world where there are profound health disparities. These health related employment experiences build a nursing student's portfolio and resume.

In addition to enhancing their understanding of health care delivery, nursing students develop valuable professional skills that employers ask me about in a reference. For example, many academic health centers send me an online reference to complete that asks: How does the applicant work with others, manage conflict, take direction, adhere to professional standards of conduct such as arriving on time to work and time management? Has the nursing applicant demonstrated the capacity to seek out or speak out to other members of the health care team to advocate for patients in a professional manner; has the nursing student demonstrated the capacity to take criticism, and improve performance without becoming defensive or argumentative? Health care is delivered in interdisciplinary teams. Employers want to know that new nursing graduates are mature and demonstrate these professional skills in addition to having the requisite knowledge and skills to provide safe, high quality nursing care.

From my experience as a faculty member, nursing students and parents need to appreciate that academic performance is one factor weighed in the application process, in addition to health related employment experience. Employers specifically request references from direct supervisors in the clinical setting that can speak authoritatively to the applicant’s professionalism.

What can local governments and health systems do to attract and retain high quality nurses?

The key to attracting and retaining registered nurses has been studied extensively yet remains a tremendous challenge. There is uniform agreement that registered nurses want to have the time and resources to provide safe, high quality care. California is the only state where laws have been enacted limiting the numbers of patients assigned to registered nurses on all hospital units. Massachusetts recently enacted a law limiting the number of patients assigned to registered nurses in all intensive care units in Massachusetts.

I believe there is a role for government to assure that regardless of where a patient is hospitalized, nurse staffing will correspond to the severity and acuity of a patient's illness. My research found wide variation in staffing between 3 states and my testimony before the Massachusetts Health Policy Commission also found variation among Massachusetts hospitals. In primary care, the same principle applies, nurse practitioners will remain in settings where they have sufficient time and resources to provide patients with high quality care.

What is the impact of the Affordable Care Act (ACA) on nurses?

The abstract in the article I authored in Policy, Politics and Nursing Practice succinctly describes the impact of health insurance reform on Massachusetts registered nurses when compared with California and New York. In Massachusetts there was an increase in the numbers of patients seeking hospital care, yet the numbers of registered nurses available to care for these patients did not keep pace with the rise in demand. Subsequently, the Massachusetts Nurses Association was poised to have a ballot question on the November ballot in 2014 limiting the number of patients that could be assigned to registered nurses in hospitals. A law was enacted in Massachusetts limiting the number of patients assigned to registered nurses in intensive care units and regulations will be forthcoming early this summer from the Massachusetts Health Policy Commission mandating public reporting of between 3 and 5 nurse sensitive outcomes in addition to nurse staffing for all hospital units. In addition, the law charged the Health Policy Commission with requiring an acuity scale to be implemented in all Massachusetts hospitals that can guide decisions about nurse staffing on hospital units. I would foresee similar efforts by unions representing nurses would occur in other states if the numbers of registered nurses available to care for patients does not increase commensurate with the rise in demand.

Are unions beneficial to nurses?

I believe there is a strong role for unions in health care not only for registered nurses but for all health care workers. The United States is unique in the developed world in having a health care system that has multiple payers, both private, for-profit and public. The administrative overhead and related costs means that for every dollar spent in the US health care system, about a third goes to profit or indirect administrative costs. Because health care is a labor intensive industry, too often, instead of lowering administrative waste, management uses failed strategies to increase productivity. More patients are assigned to nurses, -- termed a "speedup"; cheaper labor, (e.g., nurses’ aides), are substituted for more educated labor, (e.g. ,registered nurses), -- termed "deskilling", and the process of care is broken up rather than integrated. Unions are a critical force to mediate or counteract these short sighted efforts by advocating for safe staffing and safe working conditions for registered nurses. In states with a high percentage of registered nurses represented for collective bargaining such as California and Massachusetts, nursing turnover is low and there are fewer openings for new graduate nurses.

More specifically, nursing unions, such as National Nurses United, negotiate contracts with management that include: Legal Recognition of the Right of RNs to Advocate for Patients; Whistle-blower protections to protect nurses who uphold their ethical duty to advocate for patients; Unit-specific RN-to-patient ratios for acute-care hospitals; Restrictions on use of unlicensed assistive personnel; Patient classification systems to determine additional nursing staff, based on an acuity tool; Safe workplace standards; Strengthening emergency preparedness capacity with paid leave for volunteers; Establishing a secure retirement; Professional practice committees — Staff RN-controlled committees with the authority to report unsafe practices and the power to make real changes; Mandatory overtime bans; Restrictions on unsafe floating; Enhanced economic security in salary and benefits; and, Occupational health and safety protections, including contract language to prevent latex allergy and needle stick injuries; language to address workplace violence and safe patient handling.

Methodology

WalletHub took 15 key metrics into account in assessing the relative attractiveness of the 50 U.S. states and the District of Columbia to registered 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 available nursing jobs, the amount of current and projected local competition, 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.

Opportunity & Competition – Total Weight: 10

  • Monthly Median Starting Salary for Nurses (Adjusted for Cost of Living): Full Weight
  • Average Annual Salary for Nurses (Adjusted for Cost of Living): Double Weight
  • Number of Health Care Facilities per Capita: Full Weight
  • Medically Underserved Areas: Full Weight
  • Projected Percentage of the Population Older than 65 by Year 2030: Half Weight
  • Educational Opportunities Based on Quality of Nursing Schools: Half Weight
  • Nurses’ Wage Disparity: Full Weight
  • Nursing Job Openings per Capita: Full Weight
  • Number of Nurses per Capita: Half Weight
  • Projected Number of Nurses per Capita by Year 2022: Full Weight

Work Environment – Total Weight: 5

  • Mandatory Overtime Restrictions: Full Weight
  • States with the Largest Share of the Best Nursing Homes: Half Weight
  • WalletHub’s “Best & Worst States for Working Moms” Rank: Half Weight
  • Average Number of Hours Worked: Half Weight
  • Average Commute Time: Half Weight

 
Source: Data used to create these rankings were obtained from the U.S. Census Bureau, the U.S. Bureau of Labor Statistics, Missouri Economic Research & Information Center, Indeed.com, 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

User
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,…
1584 Wallet Points

Discussion

 
By: Jumbonav
May 5, 2015
How much weight for "Best states for working dads"? Interesting study. Just curious why things got weighted the way they did. Thanks!
Reply Delete Flag
 
Feb 6, 2015
I am a Canadian "LPN". In Quebec a LPN is a licensed practical nurse. I took a 2 year class at a vocational school. I want to know what is the difference between a lpn and a lvn in the U.S. and which one am I.
Reply Delete Flag
 
Jul 10, 2014
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.
Reply Delete Flag
 
May 27, 2014
What constitutes a nurse? Is it any level of nurse including LPN, RN, APRN, etc., or just a specific credential? Thanks!
 
By: WalletHub
Jun 5, 2014
Were included the following nurses credentials: Registered Nurses, Licensed Practical and Licensed Vocational Nurses, Nurse Anesthetists, Nurse Midwives and Nurse Practitioners.
Reply Delete Flag