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

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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?
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  • Linda L. Lazure Associate Dean for External Relations and Associate Professor at Creighton University College of Nursing
  • Candace Campbell Assistant Professor at University of San Francisco, School of Nursing and Health Professions
  • Sean P. Clarke Associate Dean for Undergraduate Programs and Professor at Boston College, Connell School of Nursing
  • Patricia W. Stone Centennial Professor of Health Policy of Nursing and Director of the Center for Health Policy at Columbia University School of Nursing
  • Marilyn Frenn Professor at Marquette University, College of Nursing
  • Christine T. Kovner Professor at New York University, College of Nursing
  • Nancy M. Short Associate Professor at the Duke University School of Nursing
  • Judith Shindul-Rothschild Associate Professor at Boston College, Connell School of Nursing
  • Angela P. Clark Associate Professor Emerita, and Clinical Nurse Specialist in Cardiopulmonary and Diabetes Care at University of Texas at Austin
  • Ronda Hughes Associate Professor at Marquette University, College of Nursing
  • Eileen Sullivan-Marx Erline Perkins McGriff Professor, and Dean of the School of Nursing at New York University
  • Phyllis P. Wright Clinical Associate Professor at Emory University, Nell Hodgson Woodruff School of Nursing
  • Lori Lioce Clinical Associate Professor at University of Alabama Huntsville College of Nursing
  • G. Rumay Alexander Clinical Professor & Director of the Office of Multicultural Affairs at University of North Carolina at Chapel Hill, School of Nursing and a Member of the Board of Governors of the National League for Nursing.
  • Stephen Cavanagh Professor and Dean of the School of Nursing at University of Massachusetts, Amherst
  • Patricia M. Davidson Professor and Dean of the School of Nursing at Johns Hopkins University
  • Constance Dallas Associate Professor at University of Illinois College of Nursing

Linda L. Lazure

Associate Dean for External Relations and Associate Professor at Creighton University College of Nursing
Linda L. Lazure
What are the biggest issues facing nurses today?

I have been very involved in the Nebraska Action Coalition (NAC) which, like action coalitions in every state, is dedicated to implementing the recommendations from the landmark 2010 Institute of Medicine (IOM) Report, The Future of Nursing: Leading Change, Advancing Health. I would agree with Susan Hassmiller, PhD, RN, FAAN:
  • Nurses can help build a culture of health;
  • Nurses can increase access to health care;
  • Nurses can lead change by getting on boards;
  • Nurses can engage in Interprofessional collaboration;
  • Nurses can advance their education.
I also think the nursing profession is challenged to reflect the population. We really need to be more diverse to truly meet the needs of the communities we serve.

While there may be statutory and regulatory obstacles to increasing access to our services, I think nursing has been able to overcome them. All health professions need to be able to practice “at the top of their licenses”.

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

I am very optimistic. Nurses have always been resourceful and resolute in their abilities to meet challenges. Career opportunities abound for bright, upwardly mobile people who are strong in the sciences, can be academically successful, and are emotionally intelligent.

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

I have been giving out advice a lot – be led by your gut and your heart. Where is your passion? Don’t expect to get your dream job right away. Be prepared to learn something new every day. Work with folks who truly care about you as a developing nurse. Consider working in rural and underserved areas – much can be learned and many can be served there.

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

Support the five things Dr. Hassmiller suggested (first question). Provide opportunities for novice and experienced nurses to participate in community and health initiatives – from personal involvement to policy development. Decrease barriers to practice – whether it’s a nurse practitioner (NP) seeking hospital or community center privileges or being able to freely prescribe durable medical equipment or reordering medications (under their own name) through the local pharmacy.

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

I think the ACA is a wonderful opportunity for nurses. Again, with the five Hassmiller issues: Finally, the emphasis can be on keeping people healthy! Why have we been focused on the “medical model” for so long? Hopefully the system can get away from an antiquated payment system and look toward reimbursing by outcomes (this will take a lot of work but change is good). If barriers to practice can be surmounted, nurses can make great improvements in the health care system (which really is not a system). I propose that “Medical Home” name be changed to “Health Care Home” and make sure any health care professional can be considered the leader – not just the physician. Nurses receive actual education regarding working with groups and facilitating behavior change. Nurses should not be shut out of the “home” concept – Florence thought of it a long time ago and now it is being “discovered” again. The most successful “medical homes” seem to be those that have nurses playing key roles.

Are unions beneficial to nurses?

I used to think so. There is a place for workplace/workforce advocacy in any environment. I just cringe at the “one size fits all” and the acrimony that can be produced if situations get out of hand. I have seen some unfortunate behavior in my lifetime.

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.

Sean P. Clarke

Associate Dean for Undergraduate Programs and Professor at Boston College, Connell School of Nursing
Sean P. Clarke
What are the biggest issues facing nurses today?

I’ve been involved in teaching nursing school for about 20 years now and about half of my career has been in Canada where I was originally trained and half has been here in the US. I was in Philadelphia for about 10 years. I’ve been teaching nursing school, but I also do research on the work force and on trends going on in hospital nursing.

For graduates who are coming out now it’s a bright career, there are lots of possibilities that are out there right now, possibilities that are going to be open in the future. Finding first jobs I think is an issue for nursing school graduates, finding that first place to park in terms of developing the career. For experienced nurses, the question is “How to wind down their careers?” I think what we’re seeing is people who have entered nursing or stayed in the work force longer than we’ve seen historically for a bunch of reasons.

The work is generally well-paying in most of regions of the country; the economy hasn’t been all that kind in other sectors, so folks are hanging around longer. It’s great in the sense that we have lots of experienced nurses but in a few years we’re going to see those folks retire and for those nurses themselves they’re seeing how physically demanding especially, the work can be (in some settings where you’re working multiple shifts, different hours all the time). I wouldn’t say those are necessarily insurmountable challenges, those are the personal ones.

I think lots of people have a picture in their head about what nursing is going to involve. There is a great article in The New York Times talking about how nursing is one of those occupations out there you might think of it as a “sure bet”. Most people who graduate from nursing school do find work relatively soon, but a lot of people go to nursing school hoping to work in the same areas where they’ve been educated and it’s a very different picture labor market wise in different areas of the country.

For instance, in Boston, where we have a lot of hospitals, a lot of nurses, a lot of doctors, and nurses are relatively well paid, right now we can’t necessarily absorb all of the nurses coming out of our schools in the greater Boston area necessarily; but there are other places, maybe outside hospitals or other areas of the state or the country where those folks can go and get their initial experience. But it’s sort of a settling out time I guess, it’s not clearly a shortage and it’s definitely not a surplus and we’re expecting opportunities to be good in the future. I think on the two coasts, West Coast and East Coast, in general in places where a lot of nurses live and a lot of nurses want to work, because of slow down retirement rates, we’re not seeing new opportunities opening up in the most desirable places to practice quite as quickly as I think some people might have thought. But that doesn’t mean it’s shut down or it’s going to be shut down forever; it just means it’s going to be a little different than maybe what people were thinking.

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

Long term outlook for the field, just given the essential nature of the services, basically anywhere where healthcare is delivered, you’ll see nurses and you’ll see especially registered nurses, because they’re so versatile in terms of the things they can do in the system. With the aging of the population that we’re always talking about, with all these new technologies that are coming online and so forth, in many cases technologies might change where we get healthcare, but they don’t eliminate the need for the human touch.

I think that we’re going to continue to see very high employment rates for nurses, but the exact locations in the sectors where nurses work are probably going to shift a little bit. At one time, hospitals were the place where we saw 80% or more of nurses working; these days it’s around 60% of licensed registered nurses. In the future I’m not sure what that number is going to look like as more and more service goes out to the community and to short term and day clinics and so forth. There’s still going to be a need for hospitals and hospital nurses, it’s just they’re going to probably see the sickest of the sick patients, like we see going on right now. The short answer is very bright long term outlook, but the exact configuration of the demand for nurses is going to evolve over the next years.

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

There are absolutely opportunities, always have been in nursing, for people who are willing to be flexible on at least one of several points. With real estate they say “location, location, location” or “location, condition and size” and depending on what your budget is you might have to compromise on one or more than one; for nursing jobs it’s all about location, it’s about specialty sometimes, and it’s also about region of the country and location and also the specialty.

I think there are jobs available right now in places that are not as heavily sought out by nurses. I think for instance there are great opportunities in the South West, in the South East, but there are still good opportunities in New England, in the Midwest and so forth. Like with a lot of jobs, there don’t have to be hundreds of jobs for somebody in exactly your situation, or in exactly the specialty where you want to work, there just has to be one.

You might need as a new grad to do a little more leg work to find that first job and be a little flexible about where that first job happens. After you’ve worked for at least a year or couple of years, you’re kind of a tested entity then, people know that you can actually do the job out in the field, and lots more employers are willing to take you on, and even see you change specialties. Because that first year in practice, like with a lot of other fields, it’s really a time where there’s a lot of testing out of all that theoretical knowledge you get in school, and actually showing that you can do the job out in a field. There’s a lot of investment of the employer and they know a lot of people tend to move on and so some employers, especially right now with a lot of experienced nurses being in the market and willing to work, employers are preferring experienced folks. Once a young nurse or somebody fresh out of school, young in the profession has gotten that experience, opportunities sort of crack open really wide.

So if you come from an area of the country and you went to nursing school somewhere where you absolutely love, like one of the big cities on the coasts, maybe it might mean taking a job in a different specialty in that city or even in a different sector, and then working your way back to the city and the specialty that you want.

Not to say that it’s not possible. We do have students from Boston College who are getting jobs in major Boston teaching hospitals right away. That’s actually happening; it’s just that with our graduating class of a hundred, if there are thirty or forty that want to do that, it’s not thirty of forty jobs that are out there. So people are finding other first places to start and then moving forward.

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

It’s a really interesting thing. The local government part I find kind of interesting. After my PhD, I started teaching at the end of the 90’s - the beginning of the 2000’s, when a lot of organizations and states had declared that there was a nursing shortage, they were worried we’ll never come back from, and a notable prominent example that’s been talked a lot about, how they thought about the problem has been Texas. The Texas economy has been growing, one of the things that you need to grow in economy is a great work force.

One of the things you need to draw in a work force is good public services, like good schools, good healthcare and so forth. I know that there were definitely communities in Texas that were thinking about what they were going to do to make sure that their hospitals had critical masses of nurses out there that were willing to stay. It’s very interesting as the economy has shifted around a bit, sometimes in predictable ways, sometimes in not predictable ways, what it’s meant for how much demand is out there.

Right now you don’t hear too much, especially in particular geographical regions, it’s a jurisdiction thing. How do we make Texas or how do we make North Carolina an attractive place for nurses? Actually, right now you don’t hear a lot of hospitals or homecare agencies saying that but I think we all realize that even though there is a little bit of playing the label market for nurses that relates to what’s going on in the broader economy, we know that in the end we really want people to stay put, we don’t want tons and tons of turnover and we want people to be happy in their work. Salary isn’t the only thing; of course a salary that’s in line with the cost of living in a region is really important and some regions have really discovered that; especially places where the cost of living is much higher than the average nurses salary is.

You ask, what can local government and health systems do? I think, especially if you’re talking about recruiting people who are fresh out of school and making your region seem like an interesting place to come, nurses are really looking for career opportunities, room to grow, a chance to use their skills, a chance to do interesting things and a chance to grow because they have a sense that there’s not just one job out there for them, there’s a bunch of jobs. I think paying attention to what’s going to retain people in the long term, like a sense of challenge and a sense of opportunities, I think that’s a pretty critical thing.

Recruiting nurses is going to be an issue. In the next few years; there’s a lot of nurses in their late 50’s, early 60’s, even late 60’s who are getting to the point where they’re probably going to retire pretty soon, we believe that a lot of them are waiting for their retirement investments to come back up and the question is, what will happen when all those folks leave the work place? Will hospitals be short-staffed or will they feel the pain or the pinch of having far fewer experienced staff than they’re use to having? We just don’t know and it doesn’t seem to be what people are talking at the moment.

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

If you’d bring 10 healthcare policy people into a room and ask them what’s their opinion of this, you’d get 10 different answers and essentially the answer underneath it all would come down to “we’re not exactly sure where things are going to go”. We know that the ACA is going to inject a lot more insured Americans into being consumers of healthcare. We know from the Massachusetts experiment that, the minute that people had health insurance they started to go see the primary care providers; they started to go to the emergency room and other kinds of healthcare use sort of went up.

There are also some big changes that are coming in terms of the way hospital care and healthcare more broadly are financed. There is money coming of Medicare reimbursements to hospitals for instance. There are going to be changes in incentives, in terms of what hospitals and health systems do to try to either prevent complications or maximize their reimbursements under pay for performance schemes where happier patients, in order to stay out of the hospital longer, have to pay the hospital more money. I think the short answer is that we expect that demand for healthcare is going to continue to grow; we’re not sure if it’s just going to be in hospitals or whether it might be in places like urgent care and primary care settings, I think the future is especially bright for nurses who are interested in using their skills outside hospital settings.

I think that the push for hospitals to make sure that they are getting as much value as possible for their reimbursements is going to go up, so a lot of hospitals and healthcare agencies under ACA are going to be looking for nurses who have some awareness of how costs fit into the equation. Historically, we sort of said; okay, we graduate you from nursing school and you know how to look after patients with different conditions and you know how to do these “things” with patients as part of the healthcare and you don’t have to worry about what these services cost.

These days we’re realizing we need to have nurses who also are willing to work with their manager, are willing to work in teams that will improve the quality and the efficiency of service delivery and have an interest in being part of that discussion. We know that there are a lot of changes that are coming fast that the ACA is kind of accelerating a bit, but there were probably in the works for a long time, that are going to mean the healthcare has to be delivered differently and more effectively, with more attention to the safety and quality of care. It’s clear that everything from preventable readmissions to complications and so forth are going to end up costing hospitals money and anything that employees like nurses can do to slow that down is going to be recognized.

Do you think that will vary, state by state?

I think it will, to a certain extent. Like I was saying, the labor market for nurses is different all over the country. I think there are places that the ACA will be felt more dramatically. Massachusetts is an interesting state because we have so many teaching hospitals, we have some of the most expensive healthcare in the country, but we also have very high rates of health insurance, we don’t have a lot of uninsured here relative to some other states.

I think it’s going to be a little bit different from place to place but I think the keyword is: keep an eye out for changes and shifts, and new opportunities that might emerge either because of increase in demand or a shift in the way that services are provided. I think having a good education as a nurse, like a good base to go from, is going to be a really useful thing because it’s going to make nurses more employable in new opportunities and even being involved in the setup of new kinds of services and I think we’re definitely going to see that in the next years.

Are unions beneficial to nurses?

I came from a place that is basically 100% unionized, nurses all work in unions in hospitals in Canada to a place where from state to state there is variation. Pennsylvania wasn’t a particularly unionized nurse state; Massachusetts is a very unionized nurse state, I think that we’re seeing all permutations and combinations. We see hospitals that don’t have a union presence, that don’t have collective bargaining, that have pretty decent working conditions for nurses. I think we see hospitals where unions and management collaborate really well together and they get really good outcomes and we see situations that are just dreadful - even though unions are present, the working conditions aren’t good.

I think that in a lot of cases there is sort of an attitude of managers in healthcare in the U.S. to sort of be leery of unions because it’s one more set of constraints that operates when you’re trying to manage a big expensive work force in a complicated system that’s always changing, but I know a lot of nurse leaders who would say that they have really good collegial relationships with union leaders and that the union seems to do a good job of maintaining a good practice environment and promoting positive careers. Some communities and some hospitals manage to have quite good working conditions and high job satisfaction among nurses, without having unions or collective bargaining.

I know that a lot of unions that include nurses as well as other professionals like teachers and so forth, see healthcare as a very right area to build in, or an important area to maintain, because there’s a lot of change going on in healthcare and if there is ground to be secured, in terms of representing a large group of workers like nurses, it’s now because there’s going to be a lot of change in the years to come and probably less and less maneuvering room for folks that haven’t secured concessions and so forth now.

It’s very interesting as things shake out, as the business of healthcare sorts itself out all of the changes that have happened over time. Right now, with the ACA, everybody is wondering what is going to happen when the music stops and they’re trying to position themselves so they have as much market as possible. Nurses historically haven’t really thought about that side of things but it is going to ultimately affect where nurses work and how they work.

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.

Angela P. Clark

Associate Professor Emerita, and Clinical Nurse Specialist in Cardiopulmonary and Diabetes Care at University of Texas at Austin
Angela P. Clark
What are the biggest issues facing nurses today?

Ethical issues surrounding increased technology use.

Maintaining lifelong learning by continuing ones professional education.

Seeking opportunities to develop and exercise leadership skills.

Becoming a team player in the healthcare field—there is a major focus nationally on IPE — interprofessional education, where teams are formed to provide care and consultation for patient care issues — disciplines as nursing, pharmacy, medicine, social work are the most common. At our university (University of Texas at Austin), we have this in place where students are learning team building together — we anticipate that they will be better prepared to integrate this into clinical settings after graduation. The potential for this is incredible for the future, given the knowledge explosion.

Keeping a focus on a culture of health, health promotion, and prevention of illness and disease. These areas have long been stressed by the nursing profession. Given the chronic medical conditions that are in our society, nurses need to provide leadership in advancing health, even in the presence of disease.

Keeping current and developing expertise with the knowledge explosion.

Legislative barriers to practicing nursing to the full extent of education and training, especially for advanced practice nurses.

Promoting the baccalaureate degree as the entry into practice for the nursing field — in 2010, approximately 50% of nurses had a BSN degree minimum; the goal is 80% by 2020.

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

Excellent! Year after year, nurses are continually rated as the most trusted professionals by consumers. I don’t see a time that nurses will not be part of the matrix of healthcare with the goal of advancing health. The profession offers an amazing variety of choices in job settings, as well as areas of specialization.

Job settings include areas such as hospitals, clinics, physician offices, community health, occupational health. Areas of specialization can include acute and critical care, pediatrics, obstetrics, women’s health, community health, health education, gerontology.

In addition, there are several advanced practice nursing roles (clinical nurse specialists; nurse practitioners; nurse anesthetists; nurse midwives) that provide exciting opportunities for even higher levels of patient, family, and community care and responsibility. Clinical nurse specialists and nurse practitioners are eligible for prescriptive authority in many states and add significant value to patient and family care, especially for people in underserved populations.

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

Think about what you will need over the next few years or decade to be happy and look for it. Proximity to family is important to many, while others want to be able to develop personal interests (art, outdoor activities, music). Look beyond the job itself to see what the community has to offer and how you could be part of it.

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

Marketing the benefits of joining an organization is helpful to nurses who are choosing where to work. Why should a person join your organization? What is unique about it? I recently read about the efforts of all organizations in my city to provide a focus on improved personal health for its employees — some very unique with good outcomes.

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

There are positive and negative impacts on nurses and nursing care. The ACA is complex and I doubt many healthcare leaders are aware of the entire scope. One of the major benefits is better access to healthcare for millions of americans, as well as insuring those with preexisting conditions — both of these have been longstanding goals by most nurses.

Ronda Hughes

Associate Professor at Marquette University, College of Nursing
Ronda Hughes
What are the biggest issues facing nurses today?

Nursing is an incredible profession with tremendous opportunities to make a difference. I continue to be energized by all the smart, compassionate, and incredible nurses I have met over the years. Heavy workloads, unrealistic expectations, lack of respect, and the ongoing misunderstanding of what nurses do and can do continue to be challenges.

While efforts continue to increase the number of nurses with baccalaureate and graduate degrees, remove scope of practice barriers faced by advanced nurse practitioners, and use and improve data to inform decision-making from the bedside to national policy, nursing must work together and across the health professions; a slow but necessary process.

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

There are tremendous opportunities for nursing. In some respects, we are entering the next dimension of health care where there will be emerging opportunities and transformations in how care is delivered, organized, and utilized. Nurses are critical members of all healthcare teams that provide patient care and improve the quality and effectiveness of healthcare. While there will continue to be challenges with meeting patient needs, healthcare teams need to work together. Part of being able to accomplish this as we move forward is the need for interprofessional collaboration focused on patient-centered care. Patient-centered care is at the heart of nursing, so nurses should be leading healthcare teams in both hospital and community settings. If you take the provisions of the ACA, the "greying" of the population (e.g., an aging population), and the skills that nursing bring to patient care, the demand for nurses will continue to increase.

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

I have seen nurses really thrive when they enjoy their job, can balance work and personal activities/interests. Think of nursing as career, not a job. If you find yourself in a situation where you just have a job, it is most likely time to find another position. A mentor I had years ago told me that the best thing I could do with my career was love the work, enjoy the people you work with and always do your best. To do that, you need to find the place and people that will support you reaching your career goals. The importance of friends, family, and colleagues cannot be emphasized enough. As recent grads select where they want to work and live, they need to really understand what they are passionate about, what are their strengths and weaknesses, and the pros and cons about where they are thinking of living.

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

Health systems can focus on developing work environments that empower nurses to perform their jobs to the best of their abilities. There are two aspects of this that health systems can facilitate.

First, management and leadership need to fully support and understand the work of nurses. When nurses do not feel supported and/or burnout from heavy workloads, they become dissatisfied and either leave their positions or even leave the profession. We cannot assume that managers and leaders have the skills and knowledge necessary to understand and support the work of nurses. There are many opportunities to gain the knowledge and skills to enable nursing practice.

Second, health systems need to ensure that managers and leaders really understand how to bring skill-mix, staffing, and patient needs together. When these three areas are not matched well, there is inadequate nurse staffing and staffing that does not meet patient care needs; placing nursing in difficult situations and potentially jeopardizing patient care.

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

The Patient Protection and Affordable Care Act (ACA) is transforming U.S. healthcare. Several provisions under the ACA act together to shift the emphasis from acute care/hospital care to primary care. You could say that this is the backbone of the ACA's transformation of healthcare.

There are several provisions that focus on nursing education of the next generation of the nursing workforce, and on emphasizing the importance of nursing in healthcare. Yet to transform healthcare, there needs to be an adequate workforce to meet the healthcare needs of a growing elderly population and that of the newly insured (under other provisions of ACA). One area of particular importance is the scholarships and loan repayments for investing in primary care nurses in underserved areas throughout the nation. The ACA also includes provisions that give nurses the ability to lead Primary Care Medical Homes. While the ACA does improve the role that nurses can have as primary care providers, specifically nurse practitioners (NPs, also referred to as Advanced Practice Registered Nurses - APRNs) and certified nurse midwives (CNMs), there are some historic hurdles that remain. For example, NPs and CNMs are considered 0.75 FTE of a primary care physician, even though they can provide similar quality care.

Are unions beneficial to nurses?

This is a complex question with no simple answer. It is also a question that is associated with strong, often polarizing opinions that either favor or oppose unions. The important question is what is it that facilitates high-quality nursing care that meets the needs of the patient? Patient outcomes can be optimized when nurses work within positive working conditions, that support nursing care and both value and empower nursing staff. When nurses do not feel supported by management, or feel that they are not able to provide the quality care than patients need, nurses can be dissatisfied with their jobs.

Generally speaking, the amount that hospitals pay for nursing is the largest cost center within a hospital. At times, hospitals have used some of those funds to cover shortfalls, potentially resulting in fewer nursing positions or salary/benefit cuts. The right amount for a salary for any healthcare professional varies across the country and some will feel that the salaries are too high, but often these judgments are made without much thought. While it has been argued that unionized nurses may have had some success with gaining increased salary and benefits, others have argued that because of the demand for nurses, some have had success with seeking employment elsewhere.

Eileen Sullivan-Marx

Erline Perkins McGriff Professor, and Dean of the School of Nursing at New York University
Eileen Sullivan-Marx
What are the biggest issues facing nurses today?

Health care in the US and also the world over is increasingly provided where people live, work, learn, and play. For the US, hospital stays are steadily shortened, so nurses are more and more prepared and responding to providing preventive care where people are and providing illness care across service settings from short hospital stays to office areas, to rehabilitation, to nursing homes, and/or homes. Nurses are flexible and are prepared to provide their assessment plans, critical thinking, and implementation with patients and families. How nurses will stretch this new way of nursing is evolving but is exciting. We must provide our students with the imagination and skills to engage with people and their families and caregivers to make a difference in a new world of preventive and illness care.

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

Very good; we are attracting more and more people into the field of nursing who see the rewards of making a difference in people’s lives and in the world. The challenges of science, critical thinking, engineering systems, and caring come together in nursing thus our fastest growing group of students in the US are those who have completed basic four years of college and now want to enter the profession of nursing. We have articulation programs where these bright and engaged students can complete the clinical nursing courses and move continuously through to graduate degrees.

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

Nursing graduates find work that they choose within six months of graduation. At NYU, our nursing graduates earn $75,000 annual salary in their first year.

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

Nurse Faculty Loan Programs foster graduate education for nurses to enter into academic careers and teach and research, particularly working on clinical research issues. Local governments can incentivize loan repayment options to work in their areas and offer scholarships, particularly for those students who are earning a nursing baccalaureate degree after completing college in another major.

Nurses need to be given the benefits and salary commensurate with the responsibility and accountability of their profession. The best way to retain nurses is to promote an environment that is positive, where nurses are valued for their input and critical thinking. The ANCC Magnet Program certifies hospitals, nursing homes, and other areas of service that has shown improved retention and good patient outcomes so encourage local facilities to do the Magnet journey. I think local communities and regions should support that all of the health systems in their area have achieved Magnet status! That would truly change the community for the better!

Finally, put nurses on all decision making boards of hospitals and governing boards. We have the best and most cogent knowledge during this time of health care change.

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

Nurses are thrilled to participate in all of the missions of the ACA – Better Access, Improved Cost and Quality. Opportunities for advanced practice nurses to practice to the full extent of their license and education is promoted in several ways in the ACA and that will continue to lead to improved care.

Phyllis P. Wright

Clinical Associate Professor at Emory University, Nell Hodgson Woodruff School of Nursing
Phyllis P. Wright
What are the biggest issues facing nurses today?

Rapid pace of change for health care delivery to improve outcomes.

Clarification and acceptance of new roles and expanded responsibilities for nurse practitioners to relieve primary care shortages.

Different levels of educational preparation for nurses: conflict between on line, on campus, use of simulation, state board exams that may not be reflective of nursing roles.

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

Excellent, as there will always be those who need the compassion, broad system thinking and intelligence of nurses.

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

Do not be afraid to go outside of clinical care to make a difference.

Think like an entrepreneur as health care delivery is not static; make your own slot.

Sell yourself as a professional with unique gifts, talents and leadership.

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

Local governments: Offer incentives for novel practice ideas by nurses, and remove barriers to practice by nurses through barriers by the medical boards in various states.

Standardize scopes of practice among the states for NPs.

Increase data support to capture nurses’ work — currently, nurses practicing in hospitals are covered under the bed rate, therefore it is not easy to see what they do not to develop data analytics.

Decrease the incentive for physician practices to have NP’s practice under a physicians’ license by removing the 20% less reimbursement if NPs file under their own provider number.

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

For the most part it adds burden on those in ERs and family practice but in a clinical setting there hasn’t been that much difference. There are always people to be seen and people who have needs that need to be nurtured.

Hopefully, future modifications in ACA will change some of the care delivery models reimbursement mechanisms so that more care is delivered within the environmental setting. Matching the outcomes to the payment system is key for delivering new models of care that will heavily rely on nurses. Gaining pay for performance for nurse related standards of care is something that was totally ignored by ACA and could drive nursing care models that reward excellent nursing care outcomes.

Are unions beneficial to nurses?

No, they simply take the power away from the individual and give it to someone else.

Lori Lioce

Clinical Associate Professor at University of Alabama Huntsville College of Nursing
Lori Lioce
What are the biggest issues facing nurses today?

Workload and artificial barriers put in place which ultimately prevent nurses at all levels from practicing at their full scope of practice. Also, not being included at the decision making tables.

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

Positive, as more nurses are pursing additional education and being placed in leadership positions.

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

Network while you are in school, you get an inside look at the culture of those units and the people. Always be professional in all of your experiences and communication.

Join the American Nurses Association (ANA); you will find a wealth of information on many pertinent topics which affect practice everyday. ANA also allows you to explore connections and networking beyond school. and outside your city and state to find a place to live and practice where you love. The most satisfying jobs are found through the relationships you forge during your clinical experiences so keep contact information on those administrators whom you would like to follow up with prior to graduation and make contact three months prior to graduation to begin interviews -- most interviewing and hiring is done well before graduation.

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

Place nurses on committees, local, state, and national healthcare boards. They are highly educated and are the closest to the patient. Nurses are problem solvers and will have variety of ideas to bring solutions to the table.

Government can limit the influence of others, repeal outdated legislation limiting scope of practice. Artificial barriers to providing care such as limitations on how many nurse practitioners are "allowed" to work with a physician in a state are ludicrous. Both providers are nationally board certified to provide care. I have experienced and seen many restraint of trade issues, especially in advanced practice nursing, which makes me question our healthcare system and limit the care nurse practitioners may provide to the patient. Legislators must become more familiar with the impact of the "policies" professional boards create which impact other professions. There is real trend in the industry of using private policies to limit access to care.

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

Originally I thought this was going to be very positive in empowering nurse practitioners to practice. It has been more difficult to measure the impact on nurses and states have found ways to still limit practice.

Are unions beneficial to nurses?

We do not have unions in the state in which I work, but I have seen them be very effective.

One of our greatest barriers inside and outside of nursing is voting together on professional issues when they may effect someone differently in their personal life. This seems to be a common issue for the current culture in America. Sometimes we must sacrifice what we need personally for the good of the profession and others. This may mean taking the time out of our busy schedules to explore the impact of our vote, legislation, polices, and seek new solutions to problems.

Being a part of our professional organization, ANA, renews our inspiration, provides mentor, enhances our education in both the clinical and political arenas which affect practice everyday.

G. Rumay Alexander

Clinical Professor & Director of the Office of Multicultural Affairs at University of North Carolina at Chapel Hill, School of Nursing and a Member of the Board of Governors of the National League for Nursing.
G. Rumay Alexander
What are the biggest issues facing nurses today?
  1. Faculty shortage;
  2. We want to advance the nation’s health but are not being supported in many cases to practice to their full scope of capability;
  3. Anticipated retirements of the boomers and with that will go knowledge and expertise;
  4. Lack of nurses on boards of health systems of all types;
  5. Diversity of faculty and practicing nurses is not in alignment with demographic changes of the nation’s demographics;
What is the long term outlook for the field of nursing?

As always, nurses are and continue to be the surveillance system for patients. Here’s a metaphor to make my point. For homes protected by an alarm system, you know that you have to set it to keep uninvited harm from violating your personhood and property. If you fail to set it, your safety is threatened. The same holds true for the health care system. Not having enough nurses and the capability to educate enough nurses is like failing to set the nation’s alarm system. It’s dangerous, unsafe and a threat to the nation! So nurses are and continue to be in demand and the outlook is terrific and the places to impact others continues to grow in the healthcare field, legal field, research fields, long term care or transitional care field, military, sports medicine, media production, journalism and I can just go on and on!

What tips do you have for recent nursing school grads looking for a place to live and work?
  1. Be willing to go where the needs are the greatest to practice such as the non-urban areas.
  2. Seek places that are compatible with your passions and hobbies; surroundings that give you life and joy.
  3. Get as much educational preparation as you can…it enhances your probabilities!
  4. Get in touch with your contacts. Who you know matters.
  5. Hone your negotiating skills. You are your best advocate!
  6. Do not be picky about the shifts you work. Each has its own culture and much to teach you.
  7. Go where you will be stretched to grow!
What can local governments and health systems do to attract and retain high quality nurses?
  1. Place nurses on the governing boards of hospital and health systems, school boards, municipal boards.
  2. Advocate for legislation that supports Title VII and Title VIII funding requests.
  3. At every governing board meeting ask for information about recruitment and retention rates of nurses, reports with disaggregated data about who was hired, who was not, who was promoted, where was advertisement placed, the diversity of the top leadership, disaggregated patient satisfaction data (it is related to who works in the place)!
  4. Support and insist on Diversity Training for everyone!
  5. Create and nurture healthy workplace environments so human flourishing can happen.
  6. Support efforts to diversify the workforce…people of color, men, veterans.
  7. Provide same sex benefits.
  8. Provide childcare.
What is the impact of the Affordable Care Act (ACA) on nurses?

The increase in patient populations makes the case for efficiency of scales and using all providers to the fullest scope of practice. The evidence on nurse managed health clinics and the satisfaction of patients served by advanced practice nurses makes the case for using nurses in meeting and advancing the health care needs of the nation.

Stephen Cavanagh

Professor and Dean of the School of Nursing at University of Massachusetts, Amherst
Stephen Cavanagh
What are the biggest issues facing nurses today?

Some of the major challenges facing nursing today center around the extent to which individual nurses can practice to the fullest extent of their license. If nurses are to be a full and active member of healthcare teams, we need to be able to use our education and training to its fullest extent. Maintaining quality will remain a challenge as our healthcare system transitions into a model based on prevention, community and populations. Ensuring nursing’s identity and practice authority does not become blurred will be a major issue.

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

There is a very strong and vibrant outlook for nurses and the profession of nursing in general. Not just the employment issues — though these are very important — as a result of an aging population, but about expanding nursing opportunities to improve care, influence policy and develop new healthcare delivery models. The exciting developments in nursing science and clinical interventions will ensure that nursing remains at the forefront of improving health care outcomes. The expansion of Doctor of Nursing Practice (DNP) and PhD programs will ensure patients have access to nursing care that is both evidence-based and supportive of their needs. Nurses will be at the center of transforming healthcare and improving the quality of care.

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

It is increasingly important for recent graduates to secure a place in a nursing residency program. This is important because it will enable students to develop their nursing skill, judgment and confidence. It will also provide an opportunity for students to show their patient care skills to a potential employer. New graduates should consider the opportunity for travel to work in other parts of the United States as part of a process of finding an employer or client group that they would like to work with as they gain increasingly more nursing experience.

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

Nurses are in great demand. All employers are faced with the challenges of recruiting and retaining high quality, caring and motivated nurses. Opportunities for continuing clinical and academic education will be essential for an employer to successfully attract and develop a long-term relationship with its nurses. But this is not enough. A clinical environment must exist where nurses are fully participating members of the healthcare team, are listened to, and given every opportunity to use their considerable skills and knowledge to improve the quality of their patient’s life and outcomes of care.

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

The Affordable Care Act (ACA) will have a major impact on nurses because of the focus on a model of preventative health care. This will, out of necessity, result in an expanding role for nurses with primary care qualifications, including those with a Doctor of Nursing Practice degree. For the ACA to indelibly transform healthcare it will be essential that nurses practice to the fullest extent of their nursing licenses as part of a collaborative team. I would expect to see nurses involved far more in the planning and delivery of health care in the community and the homes of patients. Nurses will be at the center of delivering evidence-based healthcare, as well as evidence-based communication strategies.

Patricia M. Davidson

Professor and Dean of the School of Nursing at Johns Hopkins University
Patricia M. Davidson
What are the biggest issues facing nurses today?

It’s workforce. There is a well-documented nursing shortage, with the Health Resources and Services Administration estimating that by 2020, the U.S. will need over one million more nurses than it is expected to produce. This issue is being felt in varying degrees by most countries around the world.

And the challenge starts with higher education. According to the American Association of Colleges of Nursing, U.S. nursing schools turned away almost 80,000 qualified applicants from baccalaureate and graduate nursing programs in 2013 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. The onus is on us in the sector to come up with new and innovative strategies for rapid but sustainable growth.

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

Because of the shortage, employment prospects for nursing school graduates in teaching, research and advocacy, as well as practice, are extremely strong. Changes in health care delivery, advances in technology and an increasing aging population have created unprecedented career opportunities for nurses. Nurses today are full partners and leaders on interdisciplinary healthcare teams in a wide variety of venues.

But these opportunities require higher levels of education and training than in the past, and this is really the future of nursing; research shows that master’s and doctorally-prepared nurses can significantly improve the quality of healthcare. Again, however, we face the workforce shortage issue; the Health Resources and Services Administration predicted that the demand for nurse practitioners and other advanced practice nurses will likely outpace supply by more than 25 per cent by 2025.

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

Seek enabling and supportive environments. Choose places that will help you to achieve your career goals.

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

The American Association of Colleges of Nursing is a proponent of nurse residency programs in nursing education, and governments and health systems can work in collaboration with educational institutions to use these programs to build a pipeline for quality nurses to join their workforce.

More generally, while burnout is an issue for nurses due to the demanding nature of the job and the workforce shortage, employers can improve retention by increasing employee benefits like compensation, tuition support and health and wellness programs.

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

As we expected, by increasing the number of Americans with health insurance, the ACA has also increased the number of new patients. Many new patients are presenting with chronic illnesses that have not been adequately cared for in the past, and that requires more care now as a result. All of this means an increased workload, and demand, for nurses.

The ACA also aims to keep patients out of hospital and in their communities, so there are increasing opportunities for nurses specializing in home care, care management, case management and community health care.

Are unions beneficial to nurses?

Both professional organization and unions can help provide a unified voice for nurses, advocate for practice standards and the needs of patients and their families, as well as professional values.

Constance Dallas

Associate Professor at University of Illinois College of Nursing
Constance Dallas
What are the biggest issues facing nurses today?

There are two major issues facing nurses today. The first is the challenge of providing quality nursing care to patients in an era of severely restricted resources. The second is determining scope of practice boundaries in a rapidly changing health service delivery environment and educating nurses with skills to practice appropriately.

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

The long term outlook for the nursing profession is excellent because of the aging population and nursing’s historical adaptability to changing health service delivery environments. Professional nursing began with nurses delivering care on battlefields and in homes. Nurses moved their focus to acute care in response to the dramatic growth in hospitals. Presently, nurses provide care in an impressive variety of settings that range from in-hospital acute care, to public health, to home health, to schools, to hospice care, to frontier nursing, to nurse-managed clinics.

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

Be flexible about shifts, particularly if you have selected an agency that has other important qualities that you want. Sometimes you might have to take a less desirable shift to get your foot in the door and get experience. You can always make changes later.

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

Treat nurses with respect. Most nurses don’t admit patients, but we do generate revenue for agencies. We have significant impact on cost and quality of care. Agencies that focus only on admission do themselves and nurses a great disservice. Make sure that nurses serve on influential committees and boards. We are the largest body of health service providers and spend the most time with patients. Our voice should be heard in discussion about quality and costs of patient care and delivery of health services.

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

It is still too early to determine how ACA will affect nurses. The American Nursing Association (ANA) supported passage of the ACA in the belief that it would improve health care coverage to U.S. citizens and facilitate appropriate scope of practice for nursing. It’s still too early to judge how well ACA has met those goals.

Are unions beneficial to nurses?

Unions, and any agency that improves the ability of nurses to be heard and to improve health care and health service delivery, are beneficial to nurses and to the patients we care for.

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

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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,…
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Discussion

 
May 28, 2015
Coming from the District of Columbia and Maryland, and now working in Kansas, I have to say that I disagree with your results. Kansas is working off of a 1939 Authoritarian model of administration. They claim to be a Matrix, but this is inaccurate and a mockery. They will terminate anyone who utters the word Union and have a very abusive Totalitarian governing system. They grant promotions based on who they know not what they read more
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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!
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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.
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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.
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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.
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