Vol. 18 • Issue 1
• Page 24
Note on survey methods and report: The 2009 National Salary and Workplace Survey of Nurse Practitioners was conducted online through a third-party survey administrator between June 22 and October 5, 2009. More than 6,000 people took the survey, resulting in 5,908 usable responses. Respondents were required to answer every question, but they were not presented with irrelevant questions (e.g., they were not asked, "What's your part-time hourly rate?" if they earlier indicated that they work full time). For the first time, we offer both average and median figures for monetary values. For comparison purposes, we use only averages, because we have no median values from past surveys.
Beginning Jan. 7, you can find a presentation of all survey questions on our Web site, along with the percentage of responses for each answer choice and the number of respondents. The table will also provide average and median salaries for each state and select cities. To read the complete salary report online, click on the Careers tab on our homepage: www.advanceweb.com/NP.
When we set out to collect and tabulate data for the 2009 National Salary and Workplace Survey of Nurse Practitioners, we had more than the typical curiosity about the results. Past surveys showed nurse practitioner compensation steadily growing along with the larger economy. The last survey, in 2007, showed an 8.8% rise in salaries over the previous 2 years.
This time, all bets were off. The Great Recession officially began in December 2007, just 2 months after data collection ended for our last survey. Between that time and October 2009, when data collection for this survey ended, 8.2 million U.S. workers lost their jobs, leaving 15.7 million residents unemployed. The unemployment rate rose to 10.2% from 4.9%, and more than 5.6 million of those unemployed in October 2009 had been out of work for 27 weeks or longer; 2.4 million more had stopped looking for a job. Even more - 9.3 million - managed to hang on to a job but were working less than full time because of cutbacks in hours or inability to find a full-time position. And that was during the so-called recovery. (Statistics are from the U.S. Dept. of Labor Bureau of Labor Statistics, available at www.bls.gov/news.release/pdf/empsit.pdf.)
But while overall employment measures looked bleak, healthcare jobs appeared strong. All other employment categories showed job losses since the beginning of the recession, but healthcare actually added almost 600,000 positions.
This happier job situation in healthcare was borne out by data from the 2009 National Salary and Workplace Survey of Nurse Practitioners. The average annual salary for a nurse practitioner rose by 10% in the past 2 years - to $89,579 (median $85,000) in 2009 from $81,397 at the end of 2007.
Gains in part-time wages were even greater percentagewise: The average part-time hourly wage for an NP rose 13.7%, to $45.85 (median $42.00) in 2009 from $40.32 in 2007 (Table 1 and Table 2).
Still, NPs didn't completely escape the recession. For the first time, we asked a classic question of a bad economy: "Are you better off than you were 2 years ago?" Just over a quarter of respondents (26%) said they were "about the same," and 10% said "no." Some of those responding "no" cited job insecurity, pay freezes and underemployment.
Lynn Schiff, NP, who owns a Minnesota-based recruitment firm specializing in placing NPs in jobs around the country, has noticed the effect of the recession on nurse practitioners. "For the first time in well over 10 years, we began hearing from NPs who were downsized out of their positions," Schiff told ADVANCE.
Still, 64% of respondents indicated that they are better off since our last survey. Of these, 77% indicated that they're making a higher salary, and 30% report receiving more employer benefits. As a reminder that it's not only about money, 67% said they have greater job satisfaction, and 20% said they've benefited from improved NP laws and regulations. Almost unchanged from 2007, 62% of respondents said they believe there are sufficient and appropriate job opportunities for nurse practitioners.
Most Lucrative Settings
An average salary or wage doesn't tell the whole story. For nurse practitioners, practice setting is the biggest determinant of pay - with almost $30,000 separating the annual compensation for the most and least lucrative practice settings (Table 3).
After 10 years in the five highest paying NP practice settings, hospital and surgery settings dropped to places six and eight, respectively. They've been replaced by mental health settings (average salary $100,140; median $92,345) and, new to the survey this year, house calls (average $98,915; median $85,500). Repeating their appearance in the top five are aesthetics/skin care practices (average $105,152; median $100,000), emergency departments (average $104,369; median $100,000) and neonatal units (average $95,280; median $94,000).
Compensation for NPs in aesthetics and mental health settings grew faster than for other settings - each by about 20%. In contrast, nurse practitioners in emergency departments received almost the average 10% raise, and those in neonatal units made a mere 1.3% more than in 2007.
None of the most lucrative settings employs more than 5% of nurse practitioners. Family practice, which employs 23% of NPs, records an average salary increase of about 9%, as does internal medicine, the next most common practice setting.
Schiff noted an increasing number of nurse practitioner positions in subspecialty clinic settings, such as orthopedics, neurosurgery and cardiothoracic surgery. She suspects that the demand for psychiatric-mental health NPs has grown as a result of a shortage of psychiatrists.
"We always have between one and four openings for NPs in this specialty, and the salaries have increased nicely," she commented.
A relatively new setting for NPs is with agencies that contract with health insurance companies. Nurse practitioner duties range from history taking to monthly visits in the patient's home, assisted living facility or nursing home. "NPs are being paid by the case or by the hour, depending on which company they work with," Schiff explained.
As in the past, educational settings were the least lucrative for nurse practitioners. In college health, 12-month positions paid an annual average of $81,981 (median $80,000), while 9-month positions paid $63,452 (median $61,728). Elementary and secondary school NPs made $76,965 on average (median $78,000). And the 3% of NPs whose primary position is teaching made an average of $81,552 (median $76,500), a 19% increase over 2007.
Practice Owners
The wage gap between owners and employees is almost as wide as that between practice settings, with the 3% of nurse practitioners who own their own practices taking home an average of $116,021 (median $100,000) annually, compared with $88,769 (median $85,000) for those who work for someone else.
But practice owners also reported a wide range of salaries: The lowest reported was for a 4-year-old aesthetics practice at $24,000; the highest was for a year-old mental health practice that brought in $340,000 the first year.
Barbara Phillips, NP, a practice owner who operates a network for NP entrepreneurs, notes that many variables can influence take-home pay for business owners: "Is the income gross or net?" she asks. "What type of practice do they have and in what area of the country? Are they still paying off start-up costs and perhaps leases on expensive equipment? Are they in a state that allows direct reimbursement, or are they a cash practice? How many patients or clients are they seeing on a daily basis? Have they been marketing effectively, and have they set up their infrastructure to be able to manage a growing business?"
Twenty-five percent of practice owners responding to the survey said their practice has been open for a year or less. The average length was 5 years, and the median was 3 years - meaning that half of NP-owned practices have been open 3 years or less. Practices open 10 years or longer made up 16% of responses, and three nurse practitioners reported owning their current practice for at least 25 years.
The most popular focus for NP practice owners is family practice (31%), and mental health is the second most popular (21%). Only 4% of nurse practitioners work in mental health, but 16% of them own their own practice. House calls practices represent only 2% of NP practices, and overall less than 1% of NPs work in house calls. But of all the nurse practitioners who exclusively make house calls, 8% of them own their own practice. It makes sense that mental health and housecalls practices might have fewer start-up costs and lower overhead than traditional office-based practices, making them attractive to NPs in those specialties.
The states with the most practice owners per NP population are those you would expect: Practice owners made up 11% of respondents from Montana, Oregon and Washington - where liberal practice laws should make it easier for nurse practitioners to hang out a shingle. But 11% of respondents from Kansas also indicated that they own their own practices. A relatively high percentage of respondents were practice owners in Alaska (9%) and Arizona (8%); other states showed much lower ratios.
Practice owners said they were more satisfied with their work situation than did nurse practitioners overall. Almost 61% of owners reported being very satisfied (compared with 45% overall), and 33% said they were somewhat satisfied (43% overall). And 10% of respondents said they plan to open a practice in the next 5 years.
"Clearly, the number of NP entrepreneurs is increasing," Phillips said. "On a daily basis, I receive e-mails asking for assistance in getting started in business and practice. I see this as a trend for the future role of NPs."
Sex and Salary
The third determinant of NP salaries shows a smaller disparity than setting and practice ownership, but that makes it no less vexing. Once again, nurse practitioners who are women make less than NPs who are men. The shocker is the size of the wage gap: Women make 13% less than men - $88,318 (median $85,000) compared with $101,688 (median $96,000). The gap in median salaries is more than 11%.
For nurse practitioners working part time, the average hourly wage for women ($45.73; median $42.00) is 10% less than that for men ($50.84; median $45.00). Only 5% of male NPs work part time, while 18% of female NPs do.
The gender disparity for nurse practitioners is still less than that for the general population, where women took home only 78% of men's wages in 2008, according to the U.S. Census Bureau (www.census.gov/prod/2009pubs/acsbr08-3.pdf).
Employment setting can account for the NP gender wage gap, at least superficially, with men overrepresented in higher-salary settings. Men make up only 8% of NPs in general, but 25% in emergency departments and 12% in mental health settings; 19% of male NPs own their own practices. Conversely, men are underrepresented in the lowest-paying settings, with only 2% in college health and elementary or secondary school settings and only 0.2% in women's health.
"I was surprised by the gender gap in salaries but figured much of it was due to where men choose to practice," Schiff told ADVANCE. This year her firm has placed only one male NP in a family practice setting. "The rest have all been the higher-paid specialty areas such as ER or surgery," she said.
Education and Experience
As in other professions, nurse practitioner compensation is influenced by education and experience. In general, higher education means higher salary: NPs with a doctoral degree command almost $10,000 more than those with a master's degree (Table 4). Currently, the highest proportion of NPs with some type of doctoral degree work in academia (28%), one of the lowest paying practice settings.
The doctor of nursing practice degree (DNP) is set to become the degree for entry to advanced practice by 2015. While NPs debate the merits of the requirement, one suspicion that keeps arising is that employers won't pay more for the degree.
That suspicion was not borne out by the survey: The nearly 2% of nurse practitioners with a DNP earned $7,688 more annually than NPs with a master's degree. The most popular practice settings for DNP nurse practitioners were family practice (21%) and hospital settings (19%).
As for the influence of experience on compensation, once again we saw salaries leveling off after several years of practice. Those who earn the most have 11 to 15 years' experience. It's unlikely that this peak is tied to pratice setting, because all experience levels were fairly evenly distributed across setting. But NPs in the 11 to 15 years' experience range do hold almost a third of the doctoral degrees, which does influence salary.
Call Duty
The 25% of NPs who take call make higher salaries than those who don't - $91,749 (median $86,000) compared with $88,779 (median $85,000) - even though only 35% of them are paid explicitly for their call duties.
The settings most likely to have a call requirement are house calls and gerontology, where 53% of nurse practitioners take call; corrections, where 49% of NPs take call; and neonatal units, where 47% of NPs take call. About a third of nurse practitioners in mental health, surgery and family practice settings take call.
The most common methods for determining on-call compensation - for those NPs who are paid for it - are to receive a specified amount for unlimited hours of call (29% have this arrangement) and to receive an hourly rate (28%). Other methods include compensation based on a percentage of salary, fee per call, bonus arrangements and stipend. Some nurse practitioners receive comp time for hours spent taking call.
Geography
The state where an NP is employed has a noticeable effect on salary. Two states that were in the top five according to salary in 2007 remained there in 2009: California (No. 1 once again with an average salary of $106,481 and median $104,000) and Arizona (No. 5 with an average of $97,242 and median $91,000). Alaska (average $102,710; median $103,000), New Jersey (average $98,896; median $96,250) and Nevada (average $97,836; median $100,000) round out the top spots.
NPs who reported the lowest salaries work in South Dakota (average $77,192; median $78,000), Alabama (average $79,733; median $80,000) and Nebraska (average $79,782; median $79,650). Except for California and Alaska, the top five states with the highest annual salaries were not the states with the highest part-time hourly rates. A list of the average and median salaries for each state and the largest cities in each state is available with the online posting of this survey report.
The 'Average' NP
The demographics of the average survey respondent haven't changed much from 2007. She has a master's degree and holds a single NP certification, typically in family practice. The average NP is 47 years old, has worked as an NP for 9 years and is employed full time in a family practice or hospital setting. She reports to a physician and does not take call. The average NP sees 64 patients (median 60) and writes 67 (median 40) prescriptions each week and is very satisfied with her job.
Jill Rollet is the editor of our Web site and managing editor of our print edition. Reach her at jrollet@advanceweb.com.
Convenient Care Update
NPs working in convenient care settings have enjoyed a high public profile in the past 2 years. But only 3% of nurse practitioners worked in convenient care at the time of our survey. That's the same percentage as NPs who own their own practices, and that hasn't changed since our 2007 survey. What has changed is the growth in the number of convenient care clinics. As of December 2009, 1,172 of these clinics were in operation, according to Merchant Medicine.
Here's how NPs in convenient care compare with the population of NPs as a whole:
The average full-time salary for NPs working in convenient care is $89,049 (median $88,000). That's up almost 10% from 2 years ago, and it's a mere $500 less than the average annual salary of nurse practitioners overall.
The average part-time convenient care hourly rate is $44.52 ($44.02 median), which is close to the overall average hourly NP rate of $45.85 ($42 median).
About 21% of convenient care NPs work part time, and 29% of those have more than one part-time position. Overall, 17% of NPs work part time, and 35% of those have more than one part-time position.
NPs in convenient care are overwhelmingly master's prepared (93%), 3% have a doctoral degree, and 3% have a bachelor's degree as their highest credential. That's compared with 91% of NPs in general who are master's prepared, 4% with a doctorate, 3% with a bachelor's degree, and 2% still practicing with an associate's degree.
Like NPs overall, convenient care NPs are 47 years old on average (median 49 years), but they have 1 year less experience as nurse practitioners - 8 years on average (median 6).
NPs in convenient care write an average of 43 prescriptions each week (30 median), compared with 67 prescriptions on average (40 median) for NPs in general. They see 56 patients on average each week (50 median), compared with 64 (60 median) for NPs across settings.
NPs in convenient care seem a bit less satisfied with their jobs than do NPs in general: 81% are somewhat or very satisfied in retail health, while 87% are overall. About 17% in convenient care say they are somewhat or very dissatisfied with their job, compared with 12% of NPs in general.
Close to 4% (3.6%) of NPs in convenient care own their own practice.
Specialties and Subspecialties
Nurse practitioners are educated, certified and (often) licensed in specialties - typically, the same specialty. But the services NPs provide are often more specialized than their NP program prepared them for, and many have learned on the job or sought out postgraduate courses. In response, certification bodies and member organizations have added nurse practitioner certification in new specialties. Two newer certifications that weren't reflected in data gathering for this survey are urology and oncology.
Lack of available certification hasn't prevented nurse practitioners from entering specialty practice. Forty-six percent of survey respondents reported working in a subspecialty. These subspecialists sometimes focus on a particular aspect of practice, such as a women's health NP who specializes in bioidentical hormones or infertility, or a psychiatric-mental health NP who focuses on addictions or eating disorders. Sometimes they focus on a specific body system, such as a family or adult NP who specializes in nephrology or neurology.
Basic Benefits
A paycheck isn't the only thing to consider when you're negotiating compensation. Employer-paid benefits can be just as important. We asked only about benefits that can be assigned a dollar value.
The most common benefits offered to NPs by employers are health insurance (offered to 87% of NPs), paid time off (86%) and malpractice insurance (83%).
Health insurance is generally offered across all settings. Paid time off is less available to those in 9-month college health positions (57%) and emergency departments (69%). Malpractice insurance is available to 60% or less of NPs working in mental health settings, house calls, 9-month college health positions and academia.
Other popular benefits include paid continuing education (76%) and a retirement plan (74%).
Almost 9% of NPs indicated that their employer provides no benefits, sometimes because the NP works part time.
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