NURSE PRACTITIONER SALARIES: WHERE ARE THEY NOW?

NURSE PRACTITIONER SALARIES: WHERE ARE THEY NOW? By Cassandra Whittington, BSN, RN A clinical project paper submitted in partial fulfillment ofthe requirements for the degree of: MASTER OF NURSING WASHINGTON STATE UNIVERSITY-VANCOUVER Intercollegiate College ofnursing Spring, 2008 ".. p,"" 1

2 To the faculty of Washington State University: The members of the committee appointed to examine the clinical project of CASSANDRA WHITTINGTON find it satisfactory and recommend that it be accepted. ot~jl: Chair: Louise Kaplan, PhD, ARNP Melody Rasmor,,ARNP Tracy Klein, MS, FNP

3 TABLE OF CONTENTS ABSTRACT LIST OF TABLES INTRODUCTION LITERATURE REVIEW National and state NP salary data RN salaries Limitations of data Washington State ARNP Survey Purpose Method Presentation of Data Average state salary Average salary by education, gender, years of practice Employment location Type of practice Salary by workforce development areas and cities Salary satisfaction Discussion and Implications References 3 5 6 6 6 8 9 10 10 10 11 11 11 12 12 13 14 14 16

4 NURSE PRACTITIONER SALARIES: WHERE ARE THEY NOW? Abstract By Cassandra Whittington, RN, BSN Spring 2008 Chair: Louise Kaplan Appropriate financial compensation is essential for nurse practitioners. Several national salary surveys have been presented in the last few years. Until recently there has been little nurse practitioner salary data that is state, regional or city specific. This article reports on Washington State nurse practitioner (NP) salaries. Washington NPs are legally autonomous professionals who assume demanding roles and provide high quality care to hundreds of thousands of people. Salary data was analyzed using factors such as level of education, place of employment, type of practice and by regional and local areas. This study supports the value of having local state and city salary data in order to negotiate for fair salary practices.

5 Tables Table 1: Salary by education Table 2 : Salary by years of practice Table 3 : Salary by enlployment location Table 4 : Salary by type of practice Table 5 : Average salary by workforce development area Table 6 : Average salary by city 18 18 18 19 19 19 Figures Figure 1 : Map of workforce development areas 17

6 Introduction In the past decades, roles for nurse practitioners (NPs) have grown markedly. As legally autonomous professionals, they play an integral role in providing health care to both the insured and the underserved uninsured individuals. Annual salaries and practice characteristics are topics that most employed professionals are interested in and nurse practitioners are no exception. Most NP salary surveys report data from a national or regional perspective. While this is useful, most NPs may be interested in data that reflects salaries that are more local since employers typically recruit from their own locale, especially if there is a nurse practitioner program in the area. This article presents results from a 2006 Washington State ARNP (Advanced Registered Nurse Practitioner) survey which had a strong response rate of 65%. Salary variants were based on practice characteristics such as practice location, type of employer, type ofnp practice, and gender. NPs who are entering the profession as well as NPs who are seasoned providers can benefit from a salary survey which provides data necessary to negotiate for appropriate financial compensation. The Washington State survey can also serve as a model for NPs in other states who may wish to conduct a salary survey. State and local data is more representative of and more useful than national data. National and State Salary Data Currently, there are three major sources of national salary data. Surveys were conducted by the American Academy ofnurse Practitioners (AANP) in 2007 and the journals Advance for Nurse Practitioners in 2007 and The Nurse Practitioner in 2005. Survey data is reported as national and regional figures, with the exception ofadvance for Nurse Practitioners which also presented state average salaries.

7 The most recent of these three reports on NP salaries is the 2007 survey conducted by Advance for Nurse Practitioners (Rolet & Lebo, 2008). They published their questionnaire in the 2007 July through October issues, as well as online. Respondents submitted their replies by fax or mail. The survey respondent numbers totaled 6,162. In order for them to ensure the accuracy and validity of their data, they did not tabulate responses from advanced practice nurses other than NPs. Further, salaries were separately averaged for part-time (less than 35 hours per week) and full-time (35 or more hours per week) NPs. The 2007average national salary from this survey for full-time NPs was $81,397. The average hourly wage for part-time NPs was $40.32. This salary data indicated that over the past two years the average nurse practitioner salary rose 8.8%. ADVANCE attributed this pay hike to public relations gains as the public reflected on NP capabilities and their contributions to the health care system or contribution to physician income. The top earners, who reported an average income of$95,157 were emergency department NPs while the lowest incomes of $68,624 were from NPs who focused on teaching. ADVANCE briefly reported geographic salary variants among two to three cities within a randomly selected five states. For California, Oakland salaries were $88,143, much lower than the salaries of San Fral1cisco, $112,551 and Los Angeles, $102,599. For the east coast, New York salaries varied from the $96,955 earnings within New York City to the $75,762 earnings in Buffalo. The American Academy National Practitioner (AANP) NP Compensation Survey (www.aanp.org) was conducted in 2007 during the month of April. The survey was sent by e mail to a national random sample of 32,869 NPs of which slightly more than half were AANP members. The response rate was 24%. The average national base salary for full-time NPs, defined as working 35 hours per week for more tllan 47 weeks per year was $81,486. The

8 average hourly wage based on the income of the entire sample was $42.58. The highest paid full time NPs were those certified in acute care with a salary of $86,460 with the lowest paid being women's health NPs at $77,460. The Nurse Practitioner collected data in 2005 using a convenience sample by placing a salary and practice survey in its August through December 2005 issues with an option to reply online (Newland, 2006). There were 549 respondents. The average income for this nationwide sample was $70,960 for NPs who self reported working full-time. However, NPs who reported working 35 or more hours per week had an average annual salary of $72,060. An hourly wage of $35.10 was reported for NPs who self-reported working part-time. National average salaries may not reflect state or local salaries. This realization prompted the Northeast Tennessee Nurse Practitioner Association (NTNPA) to conduct a local/regional salary survey in 2005. NTNPA compared the average full time NP salary of $69,316 in northeast Tennessee to the Tennessee average of $71,068 and the national average of $74,812 as reported by Advance for Nurse Practitioners the prior year (Sharp, 2006). From the 441 response surveys, a response rate of 41 %, it was concluded that the average annual NP salary in northeast Tennessee was $1,752 lower than the state average and $5,496 lower than the national average. RN Salaries While NP salary surveys provide rich data for negotiations, it is also important to review the salaries earned by registered nurses (RNs). The nursing shortage has strengthened salaries for RNs which can create an opportunity cost that may be factored into the decision about whether to enroll in NP education. NP salaries that are comparable to or even less than those of RNs may serve as a disincentive to seeking NP education. Salary ranges for RNs are affected by factors such as employment setting and location, degree earned, union membership and overtime

9 worked. According to the Bureau of Labor Statistics, the 2006 national average salaries for RNs was $57,280 (ww-w.bls.gov, 2008). The highest 10 percent ofrns in 2006 earned mean wages of $83,440. However, as was found with the NP salaries, there are large variations in state average salaries compared to national average salaries. For instance, South Dakota and California average RN salaries are $49,560 and $75,130, respectively. Further, if average salaries are accounted for within a state's region there are even higher salary variants from the national average: RNs working in the California metropolitan areas of San lose-sunnyvale-santa Clara are earning, on average, $92,400. Over 1,100 registered nurses responded to a salary survey conducted by Nursing 2006. The average national RN salary was $51,000 (Mee, 2006). Interestingly, this was a decline from the 2005 average RN wages of$58,600. This was attributed to a change in the profile of the respondents with a higher percentage of the respondents working in nursing for less than five years. Fewer respondents worked in hospital settings or as staff nurses where higher salaries were usually earned. Limitations of the data There are nlajor differences among the national surveys which limit their generalizability and result in wide variances. Methodologies vary. The American Academy ofnurse Practitioners surveyed members and non-members. Advance for Nurse Practitioners and The Nurse Practitioner surveyed the readership of the journal. Response rates varied from 549 responses with the Nurse Practitioner to 7,832 responses with the AANP. There is no way of determining how respondents compare among the surveys nor is there a way to determine how they vary from non-respondents. National or even regional data may not reflect state or local salaries.

10 Washington State ARNP Salary Survey Until recently there has been little data about the salaries of Washington State nurse practitioners. NP Central, a web based resource center, has collected salary data since 1993 however the number of respondents varies each year ranging from a low 78 to a high of 505 between 1997 and 2007 with differing methodologies for data collection by year (NP Central 2007). A statewide survey of all licensed advanced practice nurses in 2003 obtained salary data using ranges rather than asking for a specific amount earned (Kaplal1 & Brown 2004). Appropriate financial compensation is essential for Washington State NPs. As legally autonomous professionals with full prescriptive authority and third party reimbursement, Washington State NPs assume demanding roles and provide high quality care to hundreds of thousands of people in the state. The salary data presented in this article was obtained as part of a statewide survey ofnps conducted to evaluate the impact of a 2005 law that authorized fully autonomous practice. Those practicing independently are also asked to assume more risk of liability and assume more financial responsibility for their practice than those employed by a practice or hospital. Methods This quantitative study utilized survey methodology. The study instrument was developed based on a review of the literature and results of two prior statewide NP surveys conducted by the investigators. After obtaining institutional review board approval, questionnaires were mailed to all NPs licensed in Washington with addresses in Washington, Oregon and Idaho. People not responding to the initial mailing were sent up to two additional mailings. A response rate of 65% was obtained. Respondents were included in the study if they

11 were practicing in Washington. Certified registered nurse anesthetists (CRNAs) were surveyed separately and the data presented here does not include CRNAs. Study participants were asked to indicate their NP related income for 2005. Unless otherwise specified, the data reported is for NPs practicing in Washington State and working full-time, defined as 30 or more hours per week. Data for respondents who were more than two standard deviations from the mean were eliminated so that 894 respondents were included in the analysis ofthe salary data. Results The average annual salary was $78,845 with 10% ofnps making over $100,000 and 2% ofnps making over $150,000. The average hollrly wage was $36.23. A gender gap was identified with males earning more per than females and urban NPs earned more than rural NPs. The highest average salaries were reported by NPs working in a hospitalist role. Salaries varied among the state's 12 workforce development areas, regional subdivisions of the state created to be used for economic development pllrposes. Salaries also varied among cities. Overall, the variance in salaries between the regions and cities and the state average salary confirms the importance of more refined data. Education Education was rewarded at the doctorate level but not at the master's level (Table 1). NPs who possessed a master's degree reported an average income that was $1,585 lower than the salaries earned by NPs with a bachelor's degree at $78,354 and $79,939 respectively. At the doctorate level, the average salary was reported at $90,206, providing more than an $11,000 increase in salary compensation over a master's degree.

12 Gender The salary data revealed a gender gap with men reporting higher full-time salaries. Male NPs reported average incomes of $84,440 while their female counterparts reported average incomes of $78,172, a difference of $6,268. Years of practice Experience was rewarded financially (Table 2). NPs with 0-5 years of experience earned an average income of$75,340. Interestingly, respondents who have practiced within the 11-15 year range earned roughly the same compensation as the 26-30 year experience range. NPs with 16-20 years of experience had average incomes of $82,482. However, this is a financial reward of less than $10,000 for nearly two decades of experience. At the experience level of 31 plus years, the average salary peaked at $96,125, although there were only 8 respondents in this group. Salary by Employment Setting Salaries for NPs varied by employment settings (Table 3). The highest financial compensation by employment setting were NPs in the hospitalist role with their average salaries reported at $94,784. Other NPs earning more than $90,000 per year by location were NPs practicing in hospital operating rooms and neonatal NPs. Employers that compensated NPs with the lowest average state salaries were Planned Parenthood clinics and school/college health clinics at $61,860 and $60,289 respectively. Type of Practice NP practice trends are moving to treating select patient populations within specialty settings such as orthopedics, neurology or cardiology. All general specialties were represented in the survey. Financial compensation by type of practice varied widely (Table 4.) With the state

13 average salary at $78,845, NPs specializing in endocrinology earned the least with an average salary of $68,325 while hospitalist NPs earned the most at $94,944. Salary by Workforce Development Areas and Cities Analysis of the survey data included difference according to workforce development areas (WDA) (Table 5). Washington is divided into 12 WDAs (Figure 1) which represent counties within sub-state workforce regions (WWAMI Center for Health Workforce Studies, 2007). Reporting the data by these areas allows for comparison by county or region. NPs in WDA #11, Benton/Franklin, which is in central Washington and includes the state's Hanford Nuclear Site, earned the highest average salaries of $82,444. The lowest average salary was in WDA # 10, Eastern Partnership, which includes several large rural counties in eastern Washington with an average salary of$68,745. These salaries varied from the state average by $3,599 more than the average to $10,100 less than the average. Average hourly salaries were calculated by dividing the average annual salary by the average nun1ber of hours worked per year. Salary averages by city are the most focused data (Table 6). Respondents practicing in Seattle, the largest city in western Washington reported an average annual salary of $79,280 which was just $435 more than the state average. This is also $11,697 less than Bellevue, a city a few miles east of Seattle where NPs reported the highest average salary of $90,978. Bellevue's annual average salary was $12,133 more than the state average. NPs in Spokane, the largest city in eastern Washington near the Idaho border, reported the lowest average salary of$71,278 which was $7,567 less than the state average. Average hourly salaries were also calculated for each city using by dividing the average annual salary by the average number of hours worked per year.

14 Salary Satisfaction The survey questioned respondents on the level of satisfaction of the specific characteristics of their job, one of which was salary. Respondents chose from category of "very dissatisfied", "dissatisfied", "satisfied" to "very satisfied" The overall ARNP salary satisfaction range revealed that 52% percent of respondents were "satisfied" with their salary while 20.6% were "very satisfied". Only 4.6% were very dissatisfied but nearly one quarter (22.7%) were dissatisfied with their salary. Salary satisfaction by WDAs shows that respondents in WDA #1 and #8 reported the highest number ofnps who were "very satisfied". These are two of the more rural areas of the state with WDA #1, Olympic Peninsula in western Washington and WDA #8, Olympic Peninsula in north central Washington. WDA #7, SOllthwest Washington, which includes three counties in southwest Washington, including the region's largest city of Vancouver, had respondents who most often reported being "very dissatisfied" with salary practices. Discussion and Implications An unexpected finding was that NPs with a baccalaureate degree as their highest level of educational attainment reported higher salaries than those with a master's degree. This suggests that those without a master's degree began practicing prior to 1995 when Washington first required a graduate degree to practice. The baccalaureate educated NPs likely possessed more years of experience, an advantage to earning a higher salary. NPs who earned the highest salaries were the hospitalists. This may be accounted for by the increases in RN salaries related to the nursing shortage giving rise to the opportunity for NPs to negotiate higher salaries. In addition, while hospital based NPs were paid higher salaries than NPs in community settings,

15 they were still paid salaries less than those of physicians, saving the hospital money in overall salary expenditures. It is interesting to note the salary dip observed for NPs with 26-30 years of practice experience. It is possible that some of these NPs may have worked fewer hours as they came closer to retirement, which would have accounted for the dip. The salary range reported from the NPs in the 31 + years range of experience ranged from 65,000 to 135,000. However, there were only eight respondents in this group which may account for the higher mean. The identification of a gender gap is consistent with data from national studies. In the 2005 Advance survey female NPs experienced an 11.7% shortfall with 2007 respondents reporting incomes 8.7% less than their male counterparts (Rollet &Lebo, 2008). The Nurse Practitioner reported that male NP salaries were $4,760 higher than female NP salaries. This is also consistent with a gender-related wage gap identified in other professions that are predominantly female (Boraas & Rodgers III, 2003). Higher earnings are associated with more experience, and women tend to have less continuous experience than men due to childrearing. However, in the current marketplace, delayed marriages and lower fertility rates should discount this theory. Further research of this gender gap among NPs is warranted rather than assunling what is the root cause. Conclusion This study highlights the inlportance of analyzing NP salary data at state, regional and city levels both given the variations that occur and to be more relevant when engaging in salary negotiations. This data can then be shared with employers, potential employers and colleagues to assure that NPs receive the salaries they deserve in commensurate with the skills, knowledge and abilities necessary to provide high quality care.

16 References AANP (2007, June). Preliminary Report: 2007 AANP National NP Compensation Survey. American Academy ofnurse Practitioners Boraas, S., & Rodgers III, W. M. (2003). How does gender playa role in the gender gap? An update. Retrieved from www.bls.gov Center for Health Workforce Studies - Washington Center for Nursing (2007, October). Washington State Data Snapshot. Retrieved January 20, 2008, from www.wacenterfomursing.org Kaplan, L., & Brown, M. (2004). Washington State ARNP Practice Survey. Mee, C. L. (2006). Nllrsing 2006 Salary Survey. Nursing2006, 36(10), pp. 46-51. NP Central. (2007) NP Salary Summary. Available at: http://www.nurse.net/cgibin/start.cgi/salary/index.html. Accessed February 19, 2008. Newland, J. A. (2006). Salary and Practice Survey. The Nurse Practitioner, 31(5), pp. 39-43. Rollet, J., & Lebo, S. (2008). A decade of growth. ADVANCE FOR NURSE PRACTITIONERS, pp.29-35. Sharp, K. (2006). Salary Survey Results from the Northeast Tennessee Nurse Practitioner Association. The Tennessee Nurse, 69(1), pp. 1-4.

17 Figure 1 Workforce Development Areas., V'iDA 12. 86.1 ~.

18 Table 1 Salary By Education $79,939 $78,354 $90,206 Table 2 Sib a ary ~y Years 0 rae IC 0-5 years $75,340 6-10 years $77,730 11-15 years $80,555 16-20 years $82,482 21-25 years $84,057 26-30 years $80,336 31 + years $96,125 Table 3 Sib a ary ~y Empoymen oca Ion Hospital operating room $94,784 Long term care facility $78,258 Hospital based inpatient unit $83,983 Other $74,509 Hospital obstetrics $83,753 Rural health clinic $72,194 Veterans Administration facility $83,450 Urgent care center $71,875 Private office $82,866 Surgery center $71,714 Hospital emergency department $82,642 Community clinic $71,597 Health maintenance Hospital (other) $82,403 organization $71,162 Tribal clinic/indian Health Military facility $82,352 Service $68,094 Mental health center $80,891 Health department clinic $66,297 Correctional center $80,821 Home care service $65,779 Hospital based outpatient clinic $78,079 School/college health service $61,860 Occupational/employee health center $76,419 Planned Parenthood clinic $60,289

19 Table 4 Sib a ary ty Type 0 rac Ice Hospitalist $94,944 Other $78,697 Neonatal $91,346 Orthopedics $78,250 Psychiatry/mental health $85,337 Geriatric $78,116 Midwifery $84,453 Oncology $77,630 Dermatology $82,436 Family $76,901 Emergency care $81,976 Gastroenterology $76,556 Rehabilitation $80,000 Ob/Gyn women's health $76,063 Research $79,773 Cardiology $76,047 Long term care $78,999 Occupational health $75,753 Neurology $78,954 Pediatric $73,479 Adult $78,880 Urgent care $72,908 Pain management $78,758 Endocrinology $68,325 Table 5 AverageSib~y a ary WorIdorce Deve opmen tarea WDA WDA Number Annual Salary Hourly Salary Benton/Franklin 11 $82,444 $36.10 Tacoma/Pierce County 6 $81,414 $38.16 North Central 8 $80,986 $35.89 Seattle/King County 5 $80,956 $37.95 Pacific Mountain 2 $79,237 $36.65 Southwest Washington 7 $78,148 $35.00 Snohomish County 4 $77,855 $34.96 Olympic Peninsula 1 $76,642 $34.33 Central 9 $76,401 $35.97 Spokane County 12 $71,189 $32.54 Northwest 3 $69,476 $31.48 Eastern Partnership 10 $68,744 $32.10 Table 6 Average Salary by City City Annual Salary Hourly Salary Bellevue $90,977 $42.64 Tri-Citi~s $82,566 $36.05 Tacoma $82,066 $38.12 Vancouver $81,346 $35.23 Everett $79,889 $35.88 Seattle $79,280 $37.07 Bellingham $76,094 $32.92 Olympia $73,107 $34.80 Spokane $71,277 $32.25