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Volume 110, Issue 6 p. 578-595
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Results of the 2019 AORN Salary and Compensation Survey

First published: 27 November 2019
Citations: 10

ABSTRACT

AORN conducted its 17th annual compensation survey for perioperative nurses in June 2019. A multiple regression model was used to examine how several variables, including job title, education level, certification, experience, and geographic region, affect perioperative nurse compensation. Comparisons between the 2019 data and data from previous years are presented. The effects of other forms of compensation (eg, on-call compensation, overtime, bonuses, shift differentials, benefits) on total compensation also are examined. Additional analyses explore the current state of the nursing shortage and the sources of job satisfaction and dissatisfaction.

In June 2019, AORN surveyed its members and some nonmembers to examine the status of perioperative nursing compensation in the United States. This survey was part of a continuing market research study that tracks compensation changes on a yearly basis and seeks to identify factors that influence how much perioperative nurses are paid. The survey also addressed job satisfaction, potential nursing turnover, and the reasons why some nurses are actively considering leaving their jobs.

RESPONDENT PROFILE

In mid-June, 81,712 potential respondents (including 39,207 AORN members) received an electronic invitation to participate in the survey (AORN has more than 39,207 members, but not all members opt to receive e-mail communications or have e-mail addresses). As an incentive, participants were eligible to enter a raffle to win any one of three $100 gift cards, two $250 gift cards, or one $500 gift card. By July 9, 5,708 unique responses had been received. Because the primary focus of this study is perioperative nursing compensation, respondents who did not answer key compensation-related questions were excluded. This criterion reduced the usable sample to 3,712 individuals, for a 4.5% net response rate. The final sample size is slightly smaller (−0.2%) than the 2018 sample.

As shown in Figure 1, 53% of the respondents were staff nurses, 17% were managers (ie, nurse manager, supervisor, coordinator, team leader), 10% were high-level managers (ie, director, assistant director of nursing) or hospital/facility administrators, 6% were educators (ie, faculty or staff development), 7% were charge nurses, 4% were RN first assistants, and 1% were clinical nurse specialists and nurse practitioners. Nurse informaticists, consultants, business managers, faculty, researchers, safety officers, chief nursing officers, vice presidents (VPs), and assistant VPs each comprised less than 1% of the sample.

Details are in the caption following the image
Percentage of survey respondents by job title.

Some of the demographic information from the sample is presented in Figure 2. The average age of the respondents was 46 years (unchanged from 2018), and 77% (76% in 2018) were between 30 and 60 years old. As in last year's survey, 11% of the respondents were male. Hourly-paid employees comprised 73% of the sample (72% in 2018); 27% were salaried employees (28% in 2018). Approximately 76% of the respondents worked in an acute care hospital, 13% worked in a freestanding ambulatory surgery center, 6% worked in a hospital outpatient department, and less than 1% were employed in a physician's office. Less than 1% of the sample worked in industry, a mobile surgical unit, a school of nursing, as an independent consultant, or at system headquarters. Approximately 44% of the respondents worked in an urban area, 38% in a suburban area, and 18% in a rural area.

Details are in the caption following the image
Profile of survey respondents. Numbers in parentheses indicate the respective change from the 2018 survey. NC = no change.

Geographically, the respondents were well dispersed across the country. As shown in Table 1, 20% of the respondents lived in the Upper Eastern coastal area (ie, New England and the mid-Atlantic), 16% resided in the South Atlantic area, 24% were located in the East and West North Central regions, 16% resided in the East and West South Central regions, and 23% were located in the Mountain and Pacific regions.

Table 1. Geographic Location of Respondents
Region Respondents, n Percent
New England (New Hampshire, Vermont, Maine, Connecticut, Rhode Island, Massachusetts) 176 5.1
Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, New York, District of Columbia) 515 15.0
South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida) 566 16.5
East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) 547 15.9
West North Central (North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, Missouri) 281 8.2
East South Central (Kentucky, Tennessee, Mississippi, Alabama) 161 4.7
West South Central (Oklahoma, Arkansas, Texas, Louisiana) 395 11.5
Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) 291 8.5
Pacific (Alaska, Washington, Oregon, California, Hawaii) 499 14.5
Total 3,431 99.9

NOTE

  • Percentages do not total to 100 because of rounding.

BASE COMPENSATION

We performed statistical analyses to identify the factors that have the most influence on perioperative nursing compensation. It should be noted that the sample is not perfectly random because the net response rate was modest (4.5%). Still, the sample is sufficiently representative of the perioperative nurse population that statistical tests can provide insight.

A summary of the base compensation findings categorized by job title and facility size is shown in Table 2. This analysis and the compensation analyses that follow include only perioperative nurses who were employed full-time in the United States when they took the survey. Facilities are categorized as small or large based on a median split of the number of ORs reported, where “small” is defined as 10 or fewer ORs and “large” is defined as more than 10 ORs. These findings show the calculated average compensation for nurses who spend an average amount of time on direct patient care for their title. Nurses generally receive more compensation in larger facilities.

Table 2. Estimate of Average Base Compensation by Job Title and Facility Size
Job Title Average Percent Time in Direct Patient Care Small (≤10 ORs) Large (>10 ORs)
Staff nurse 90.7 $73,100 $73,400
Hospital/facility administrator 15.3 $114,400 *
Director/assistant director of nursing 16.1 $113,500 $138,800
Nurse manager/supervisor/coordinator/team leader 37.1 $92,400 $97,900
Charge nurse 60.9 $78,200 $82,000
Educator/staff development 16.0 $82,700 $91,000
Clinical nurse specialist 54.9 * $93,700
RN first assistant 87.0 $82,800 $90,000

NOTE

  • Samples with fewer than 30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred.

The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. We used multiple regression as the primary analytical tool in this study because so many variables are involved. The multiple regression model makes it possible to estimate the effects of one variable on compensation while statistically holding the other variables constant. The influence of each variable then can be identified independently of the other variables. For the analysis, we used hierarchical regression by first entering into the model the variables expected to explain the most variance and then entering the less important variables.

We entered several variables with related effects initially and simultaneously. These variables were

  • job title,
  • facility type,
  • facility size,
  • facility ownership,
  • travel versus staff nurse,
  • percentage of time spent in direct patient care,
  • number of staff members the respondent oversees,
  • population setting (ie, urban, suburban, rural),
  • geographic region, and
  • state.

State was entered into the model only for states with 50 or more respondents. We then entered other variables one at a time. These secondary variables were

  • years of work experience,
  • compensation basis,
  • certification,
  • education level,
  • participation in a collective bargaining unit,
  • household status, and
  • gender.

To obtain the most reliable results, we eliminated statistical outliers (eg, unusually high or low pay reported by a very small number of nurses) to avoid skewing the results. We conducted checks to ensure that the statistical assumptions behind the regression model were met (eg, linear relationships, normally distributed errors). The final model explains 65% of the variation in base compensation.

What follows is an overview of the results concerning each variable included in the regression analysis that was found to be significantly related to the base compensation level. All variables were significant at the P ≤ .05 level. Readers may obtain the estimates of compensation for any particular nursing position by using the compensation calculator on the AORN web site at https​://www.aorn.org/salar​ysurvey.

Job Title

More than any other variable, differences in job title were linked to differences in base compensation. As shown in Table 3, the average staff nurse, for example, earned $73,200 ($1,100 more than in 2018), and the average VP/director of nursing earned $125,600 ($5,300 more than in 2018). Note that we combined VPs, assistant VPs, directors, and assistant directors for this longitudinal analysis to allow comparisons with past years.

Table 3. Base Compensation, 2003–2019
2003 2006 2009 2012 2015 2019
Vice president/director of nursing $85,200 $91,000 $101,800 $111,900 $112,800 $125,600
Staff nurse $50,700 $59,200 $64,400 $66,800 $68,600 $73,200

To explore the trends in compensation for staff nurses and for VPs/directors of nursing over time, we combined data from 16 years of AORN salary surveys. Figure 3 shows that staff nurses and VPs/directors of nursing have generally seen increases in average base compensation during this period. The compound annual rate of growth has been similar for staff nurses (2.3%) and for VPs/directors (2.4%). For comparison, the average compound annual inflation rate was 2.1% during this period. Thus, staff nurses’ base compensation averaged a 0.2% raise above inflation and VPs/directors of nursing averaged a 0.1% raise above inflation during this period.

Details are in the caption following the image
Trends in base compensation over time.

On average, staff nurses spent 90.7% of their time delivering direct patient care (a 0.2% decrease from 2018) and nurse managers spent 37.1% of their time providing direct patient care (a 0.5% increase from 2018). As expected, high-level managers averaged a relatively small amount of time on direct patient care—15.3% for hospital/facility administrators (a 1.5% decrease from 2018) and 16.1% for directors/assistant directors of nursing (a 2.0% decline from 2018). Lastly, the percentage of time spent on direct patient care varied among nurses with the same title. For example, some nurse managers spent as much time on direct patient care as the average staff nurse, while some other nurse managers spent as little time on direct patient care as the typical director of nursing or VP. We suspect that differences in time spent on direct patient care versus management tasks are largely related to the number of staff members a manager oversees.

Facility Type

The regression model indicates a few differences in base compensation related to facility type.

  • Nurses in freestanding ambulatory surgery centers received $2,800 less in base compensation than nurses in acute care hospitals or hospital outpatient departments.
  • Nurses in university/academic medical centers earned $5,900 more than nurses in general/community hospitals or critical access hospitals. Nurses in specialty hospitals earned approximately $2,900 more than nurses in general/community hospitals or critical access hospitals.

We found that 29% of respondents were employed in Magnet facilities, 19% were employed in facilities with the Pathway to Excellence Program designation, and 15% were employed in facilities with American Nurses Credentialing Center continuing education accreditation. However, none of these variables was significant in explaining base compensation.

Facility Size and Staff Members Overseen

Nursing compensation differs by facility size. This difference was particularly pronounced for those working in higher-level management positions. In the past, we have used the number of ORs in a facility as a metric of size. This year, we found that the number of staff members that a manager oversees, including RN and non-RN staff members, was a better predictor of salary. While controlling for facility type, we found that hospital/facility administrators, chief nursing officers, directors/assistant directors of nursing, and VPs/assistant VPs earned, on average, more per staff member they oversaw ($155 more for non-RN staff members, $133 more for RN staff members). No statistically significant relationship was found between staff nursing compensation and facility size.

Facility Ownership

Most of the respondents (54%) were employed by nongovernment, nonprofit facilities. Nurses in these facilities earned $1,900 more than nurses in private, for-profit facilities and $4,200 more than nurses in nonfederal government facilities (eg, a county hospital). Only 3% of the respondents worked in government-owned federal facilities, and these nurses earned $4,300 more than nurses working in nongovernment, nonprofit facilities. More than two-thirds (70%) of the nurses in the sample were employed in facilities that were part of a larger network; these nurses received $3,500 more per year than nurses in nonnetwork facilities.

Travel Nurse Compensation Versus Staff Nurse Compensation

This year, we attempted to determine whether travel nurses earned more compensation than staff (ie, longer-term contract) nurses. The travel nurse variable was not significant in the regression; however, the number of travel nurses in the sample was small (34), and thus any conclusions about travel nurses are tentative.

Population Setting

The location of the facility (ie, urban, suburban, rural) substantially influenced base compensation. Nurses in rural settings earned an estimated $5,800 less per year than nurses in suburban or urban settings.

Geographic Region

Controlling for all variables previously discussed, geographic region explained significant differences in base compensation across the United States. Compensation for nurses working in the Pacific region was $22,300 higher than the average base compensation for nurses. The other regions with higher incomes were the mid-Atlantic (+$14,900), New England (+$8,400), and the Mountain regions (+$5,000). Two regions that were associated with lower compensation were the East South Central region (−$7,400) and the West North Central region (−$6,800). Nurses in other regions showed no significant difference in compensation.

We integrated cost-of-living-by-region information with compensation data as shown in Table 4. The cost-of-living information for 2019 was collected from the Missouri Economic Research and Information Center,1 which computes state-level estimates of cost of living by aggregating indices of cities and metropolitan areas participating in a Council for Community and Economic Research survey. These indices were aggregated to the region level for our analysis. The national average of these indices is 100. The differences in compensation closely parallel differences in the cost of living, indicating that the differences in compensation in some regions may be offset by the differences in the cost of living.

Table 4. Compensation and Cost-of-Living Differences by Region
Region Compensation Difference Cost-of-Living Index
New England (New Hampshire, Vermont, Maine, Connecticut, Rhode Island, Massachusetts) +$8,400 123
Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, New York, District of Columbia) +$14,900 123
South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida) NS 96
East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) NS 92
West North Central (North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, Missouri) −$6,800 92
East South Central (Kentucky, Tennessee, Mississippi, Alabama) −$7,400 89
West South Central (Oklahoma, Arkansas, Texas, Louisiana) NS 91
Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) +$5,000 99
Pacific (Alaska, Washington, Oregon, California, Hawaii) +$22,300 143
NS = not significant.

Nurses also reported the specific state where they resided at the time of the survey. Our total sample is large enough that meaningful estimates for state differences could be made for many states. We examined only the states with more than 50 respondents for state-specific effects. Of the 26 states with sufficient sample sizes, eight states showed significantly different effects from what their region would otherwise suggest. The states requiring specific adjustments and those adjustments are shown in Table 5. For these states, the listed adjustment should be used instead of the regional adjustment. For example, nurses in California made $40,500 more than the model estimate and nurses in Massachusetts made $28,600 more. Interestingly, nurses in Texas appear to be in an attractive financial position, with an average compensation level $5,400 higher than the base model, but a cost of living eight points below the national average.

Table 5. States With Adjustments Different From That of Their Region
State Adjustment State Cost-of-Living Index
California $40,500 152
Massachusetts $28,600 132
Washington $16,300 111
Minnesota $7,700 102
Texas $5,400 92
Pennsylvania $3,900 102
Ohio −$3,700 91
Oklahoma −$6,300 87

Time Spent on Direct Patient Care

The more time that nurse managers spent on management tasks, the higher their salaries tended to be. For each 10% increase in time spent on managerial tasks, the average manager earned $215 more in annual compensation.

Work Experience

The regression model suggests that nurses generally see larger increases related to experience early in their careers and smaller increases later in their careers. For example, the increase in compensation from the first to the second year is close to $1,500, but the jump from the 25th to the 26th year is only approximately $200. In this sample, the average nurse had 13 years of experience (unchanged from 2018). Nurses with more or less than this amount of experience should add or subtract some compensation amount per year of experience to estimate their base compensation. Interestingly, hospital/facility administrators, chief nursing officers, directors/assistant directors of nursing, and VPs/assistant VPs earned approximately $660 more per year of experience, and this positive relationship continued through 30 years of experience. On average, individuals in such positions reported 18 years of work experience, one year less than in 2018.

Certification

We expanded our analysis of certifications this year to include 163 of the 181 certifications listed on Nurse.org.2 We selected certifications that were considered relevant to perioperative nursing. To ensure reliable results, we included in the regression analysis certifications that were held by at least 50 respondents. Only two certifications met this criterion: CNOR (44% of the sample) and CRNFA (1.7% of the sample). This year, neither certification was found to be significantly associated with compensation.

Approximately 44% of the respondents said that their facility pays more to employees who hold a nursing certification (unchanged from 2018). Of these respondents, 43% said that the pay adjustment was an addition to base pay (52% in 2018), and the median of those additions was either $1 per hour or 2.5% of base compensation. Another 25% of the respondents said that the compensation is an annual bonus, and the median bonus was approximately $600. Finally, 13% said there was an adjustment to the nurse's position on the clinical ladder. Among those reporting facility rewards for specific certifications, 63% of the respondents said that their facility rewarded nurses with CNORs; however, many nurses mentioned in the qualitative comments that any recognized and relevant certification may be rewarded.

Although it appears that some nurses received extra compensation for a variety of certifications, this compensation typically varied by hospital. In addition, nurses with some certifications (eg, CNOR) may find work in facilities that offer more compensation, or they may be promoted into management. For example, 35% of staff nurses, 43% of nurse managers, and 67% of directors/assistant directors of nursing have the CNOR certification. After we controlled for all the preceding variables, including facility type and job title, the effect of certification on compensation alone was less pronounced.

Education Level

As in many past years, several degrees were significantly related to compensation. Using nurses with a diploma as a compensation baseline, nurses with an associate's degree earned $700 more; nurses with a bachelor's degree earned $3,800 more; nurses with a master's degree in any field earned $5,300 more; and nurses with a doctorate earned $12,800 more in base compensation. We asked respondents if they had obtained a master of business administration (MBA) degree, recognizing that some nurses could have a master of science in nursing and an MBA, or a doctorate and an MBA. We found that nurses with an MBA earned $7,700 more in base compensation, in addition to the aforementioned education premiums.

It may seem surprising that the level of education does not have a more profound effect on base compensation. However, the analysis has already controlled for job title, and a nurse's education level may well affect the level of responsibility attained. Table 6 provides an analysis of education level for the positions of staff nurse, nurse manager, and director/assistant director of nursing. Those with higher-paying jobs, especially the directors, are less likely to have only a diploma or associate's degree and are more likely than staff nurses to have a master's degree in nursing, business administration, or another field. Thus, education level may have direct and indirect effects on base compensation for nurses because it is associated with differences in the same title and may well affect the title that each nurse holds.

Table 6. Level of Education by Selected Title
Education Job Title (Sample Size)
Staff Nurse (n = 1,958) Nurse Manager (n = 637) Director/Assistant Director of Nursing (n = 316)
Percent Percent Percent
Diploma 3.2 2.8 1.6
Associate's degree 22.5 17.9 11.4
Bachelor's degree in nursing 59.9 51.3 32.6
Bachelor's degree in another field 5.0 3.7 3.2
Master's degree in nursing 5.0 17.9 30.7
Master's degree in another field 1.8 1.3 2.9
Master's degree in business administration 0.7 3.1 11.7
Doctorate in any field 0.3 0.9 3.8

Collective Bargaining Unit

Approximately 14% of respondents reported working in an environment with a union or collective bargaining unit (13% in 2018). Staff nurses working in a unionized setting earned an average of $4,100 more in annual base compensation than nurses employed in a nonunion workplace ($5,500 in 2018 and $8,200 in 2017). Our analysis suggests that this increase in pay may not hold for all job titles (eg, nurse managers, directors), but the data did not include enough respondents of each title in union and nonunion settings to form firm conclusions.

Household Status and Gender

In several past years, nurses with fewer commitments outside work received a higher base wage. This year, a nurse with one or more children in the home was found to earn $1,600 less on average than other nurses.

Gender has not always been significantly related to nursing compensation in our AORN research conducted in the last 17 years. Men often, but not always, receive more compensation than women. This year, the relationship was statistically significant, with a $3,700 gender-based wage gap. Including this result, gender has been significant in 8 of the last 10 analyses that included wage gaps ($2,700 in 2010; $3,300 in 2011; $2,800 in 2012; $3,200 in 2014; $4,200 in 2015; $3,700 in 2017; $4,700 in 2018). The patterns we have seen over the years led us to conclude in our 2016 report that gender differences are related to the base compensation that perioperative nurses receive. The significant finding for 2019 is yet another result that reaffirms our conclusion.

Interestingly, the American Association of University Women (AAUW) reports a pay ratio of 0.92 for RNs,3 indicating that female nurses earn 92% of the pay of male nurses. This ratio was the highest reported among the 10 professions that the AAUW included in their 2018 analysis (financial managers exhibited the lowest ratio at 0.65). In our sample of staff nurses, and likely controlling for more variables than the AAUW report, we found a ratio of 0.95 for staff nurses. Thus, although a pay gap exists, women in nursing appear to be treated more fairly concerning compensation than they are in some other professions.

Other Variables

On a cautionary note, the results from the complete regression analysis represent general patterns and do not address several variables that can affect base compensation, such as the unique needs of facilities, interpersonal skills, and leadership ability. The results are sufficiently accurate to conclude that two-thirds of nurses or managers who fit a particular profile will see an annual base compensation within $17,300 of the base compensation estimated by the model.

In questions unrelated to the regression model, 78% of the respondents said they received a raise this year, compared with 75% in 2018 and 2017, 74% in 2016, 72% in 2015, and 70% in 2014. When asked for the reasons for their raise, 92% of the respondents indicated that the raise was an annual pay increase (85% in 2018); 10% were promoted, 8% changed jobs or responsibilities under the same employer; and 4% changed employers. Respondents could select multiple responses to this question as well as write in specific factors affecting their raises. Other specific responses included a change in union contract, cost-of-living adjustment, system-wide adjustment, market adjustment, and obtaining a certification. The mean pay raise for staff nurses was 2.5% (unchanged from 2018), and the mean raise for other job titles was not substantially different.

OTHER FORMS OF COMPENSATION

The regression analysis previously described applies to base compensation. In the present sample, 67% of the respondents received additional compensation from a variety of sources, including overtime, shift differential, on-call compensation, and bonuses (64% in 2018). The amount of additional pay differed substantially by title. The average percentage of additional compensation by job title is shown in Figure 4.

Details are in the caption following the image
Compensation beyond base by title.

Registered nurse first assistants received the most additional compensation relative to base pay (18%), followed by charge nurses (13%) and staff nurses (10%). Educators and staff development employees received the smallest additional compensation relative to base pay (3%), followed by directors/assistant directors of nursing (5%), clinical nurse specialists (6%), nurse managers (7%), and hospital and facility administrators (8%).

On-Call Compensation

Almost two-thirds of the respondents (63%) reported that they worked on call. In our sample, 56% reported that they were required to work on call, and 7% reported that they volunteered to work on call as needed. The median number of on-call hours per week was 12, unchanged from 2018 and 2017. The median number of on-call hours per week has declined over the years: the median was 14 hours in 2016, 15 hours in 2015, and 16 hours reported in the previous 10 surveys. Most of the on-call respondents received a dollar-per-hour amount for being on call (ie, standby).

Among those who received dollar-per-hour pay, the median pay was $3.50 per hour (unchanged from the previous three years). If called in, 53% received time-and-a-half pay, 8% received no additional compensation beyond pay for being on standby call, and 13% received straight-time pay if they worked less than 40 hours that week and time-and-a-half pay if they worked more than 40 hours. Instead of pay, 5% of the on-call respondents received compensation time. These compensation arrangements are very similar to last year's results.

Overtime Compensation

A large majority of respondents (79%) worked overtime, and the median number of hours worked was four. Of those who worked overtime, 70% received time-and-a-half pay for hours greater than 40 per week; 23% received no additional compensation. Salaried employees comprised 95% of those who were not compensated (unchanged from 2018).

As shown in Table 7, directors/assistant directors of nursing averaged the most overtime per week at 8.3 hours, followed by RNFAs at 6.8 hours, hospital/facility administrators at 6.7 hours, and nurse managers at 6.6 hours. Clinical nurse specialists worked the least amount of overtime at 3.9 hours per week, followed by staff nurses at 4.2 hours, educator/staff development employees at 4.4 hours, and charge nurses at 4.8 hours. Nurse practitioners were excluded from the analysis because the group comprised fewer than 30 respondents.

Table 7. Average Overtime Hours per Week and Percent of Respondents Who Are Salaried
Job Title Average Number of Overtime Hours Percent Salaried
Staff nurse 4.2 (4.0) 3.2
Hospital/facility administrator 6.7 (5.8) 100
Director/assistant director of nursing 8.3 (7.9) 93.3
Nurse manager/supervisor/coordinator/team leader 6.6 (6.1) 53.9
Charge nurse 4.8 (4.7) 5.7
Educator/staff development 4.4 (4.0) 63.1
Clinical nurse specialist 3.9 (4.7) 38.8
RN first assistant 6.8 (5.8) 12.7

NOTE

  • Job titles with fewer than 30 respondents are not shown. Numbers in parentheses are from 2018.

Hiring Bonuses

Eleven percent of the respondents received a hiring bonus when they were hired (unchanged from 2018). Of those who received bonuses, 13% ranged from $1,000 to $2,499 (9% in 2018), 18% ranged from $2,500 to $4,999 (22% in 2018), and 27% ranged from $5,000 to $7,499 (29% in 2018).

Shift and Other Differentials

Among the respondents, 89% worked the day shift and 6% worked afternoons/evenings. Very few respondents worked nights, weekend days, or weekend nights (less than 3% for the three categories combined). For those working the afternoon/evening shift, the median differential was $2.25 per hour or 8% of base pay. For those working weekends, the median differential was $3.00 per hour or 10% of base pay.

Benefits

Almost all of the respondents receive benefits as part of their compensation. Table 8 provides the percentage of respondents receiving each of 32 benefits in 2019. The table also provides a three-year average of respondents receiving each benefit for the 2013 to 2015 and 2016 to 2018 periods. The far-right column shows increases, decreases, and no changes in the percentage of respondents receiving each 2019 benefit compared with the percent average for the 2016 to 2018 period. Data are not available for eight benefits in the 2013 to 2015 period because data were not collected for those benefits at some point during that three-year period.

Table 8. Percent of Respondents Receiving Benefits
Benefit Type 2013–2015 Percent Average 2016–2018 Percent Average 2019 Percent Average Change From 2016–2018
Health insurance 93 93 93 NC
Dental insurance 89 90 90 NC
Life insurance 84 83 84 +1
Vision insurance 82 83 +1
Earned time off or paid time off 86 85 82 −3
Bereavement leave 73 66 62 −4
Short-term disability 63 63 61 −2
Tuition reimbursement 58 58 59 +1
Long-term disability 60 59 57 −2
401(k) contributions 67 53 57 +4
Health spending accounts 55 55 NC
Jury duty compensation 65 56 49 −7
Free or discounted parking 54 49 42 −7
403(b) contributions 43 41 −2
Paid certification exams 37 34 34 NC
Employee referral bonus 20 25 28 +3
Paid conference travel 29 26 23 −3
Pension plan 33 26 22 −4
Reimbursement for continuing education contact hours 20 19 −1
Flexible scheduling 22 19 18 –1
Reimbursement for professional association member fees 17 17 NC
Pharmacy discounts 27 22 17 –5
Other bonuses (eg, holiday, quarterly) 17 16 –1
Incentive bonuses 15 17 16 –1
Health/fitness center membership 16 15 –1
Tax-sheltered annuity plan 17 8 6 –2
Malpractice insurance 11 8 6 –2
Relocation assistance 6 5 5 NC
Meals 4 5 +1
Retention bonuses 3 4 4 NC
Subsidized child/elder care 3 3 3 NC
Life quality service (eg, dry cleaning) 3 1 2 +1
  • NC = no change.

The five most frequently received benefits in 2019 were health insurance (93%), dental insurance (90%), life insurance (84%), vision insurance (83%), and earned time or paid time off (PTO) (82%). Concerning changes in benefits in the last four years (2019 compared with the 2016 to 2018 period), there were reductions in 17 benefits, with a lower average percentage of respondents receiving the respective benefit in 2019. The reductions were jury duty compensation and free/discounted parking (−7%); pharmacy discounts (−5%); bereavement leave and pension plans (−4%); earned time or PTO and paid conference travel (−3%); short-term disability, long-term disability, 403(b) contributions, and tax-sheltered annuity and malpractice insurance (−2%); and reimbursement for continuing education, flexible scheduling, other bonuses, incentive bonuses, and health/fitness center memberships (−1%). The seven increases in benefits were 401(k) contributions (+4%); employee referral bonuses (+3%); and life insurance, vision insurance, tuition reimbursement, meals, and life quality services (+1%). Eight benefits were unchanged.

In the 2019 versus the 2013 to 2015 comparison, there were reductions in 16 benefits, with a lower average percentage of respondents receiving the benefit in 2019: jury duty compensation (−16%); free/discounted parking (−12%); bereavement leave, pension plans, and tax-sheltered annuity plans (−11%); 401(k) contributions and pharmacy discounts (−10%); paid conference travel (−6%); malpractice insurance (−5%); earned time or PTO and flexible scheduling (−4%); long-term disability and paid certification exams (−3%); short-term disability (−2%); and relocation assistance and quality life services (−1%).

Five benefits increased in coverage in 2019 relative to 2013 to 2015: employee referral bonuses (+8%) and dental insurance, tuition reimbursement, incentive bonuses, and retention bonuses (+1%). Three benefits were unchanged: health insurance, life insurance, and subsidized child/elder care. In summary, from 2013 to 2019, employers decreased a substantially higher number of benefits than they increased or left unchanged.

Respondents were asked whether their employer contributions had increased, decreased, or remained unchanged for four widely held benefits in the respondent sample: health insurance, dental insurance, life insurance, and PTO. Nurses who did not receive a respective benefit were excluded from the analysis of that benefit. The net change was computed as the percentage of respondents who reported an increase in employer contributions for a respective benefit minus the percentage of respondents with a decrease in employer contributions for the benefit.

The net change in employers contributing to health insurance was +7.6% (+8.3% in 2018). The net change in employers contributing to dental insurance was +6.1% (+9.1% in 2018), and the net change in employers contributing to life insurance was +3.9% (+3.7% in 2018). It appears that although employer contributions may be increasing for a small number of benefits, the total number of benefits offered is decreasing.

The net change for employer contributions to earned time off or PTO is +0.1% (−0.4% in 2018), which was likely not noticeable to most nurses. The median number of PTO days (excluding national holidays) was 20 (unchanged from 2018, 19 days in 2017 and 2016). The median number of PTO days was 16 for staff nurses, 20 for charge nurses, 21 for nurse managers, and 21 for directors/assistant directors of nursing. The number of PTO days was related to years of experience. For example, staff nurses with less than four years of experience had a median PTO benefit of 15 days, while those with 16 or more years of experience had a median PTO benefit of 20 days.

Some benefits are more valued than others. In this regard, we asked respondents to identify the five benefits that they most valued. Health insurance and dental insurance ranked first and second as the most frequently included in the top five most-valued group; they also ranked first and second as the most frequently provided benefit to respondents.

In an open-ended response question, we asked nurses how their overall benefits package could be improved to provide more value to them as employees. Comments that focused solely on improvements in compensation rather than benefits (eg, increases in salary, on-call wage, hourly wage) were removed from the analysis.

As in 2018, suggested improvements focused on improving health insurance benefits by a considerable margin. Overall, 47% of the 1,803 comments about benefits focused on this subject. In this group, reducing health insurance costs comprised the plurality of comments. By far, the most popular cost-cutting method was to increase employer contributions to premiums or lower the deductibles. Some respondents suggested lowering costs by providing an insurance discount if insured health care services are provided at the employer's facility or by negotiating with another insurer. Other suggestions included providing more comprehensive benefits and expanding choices for health care providers that are outside the insurer's network, continuing health insurance coverage in retirement, compensating employees who decline the employer's health insurance, providing a discount for healthy employees who demonstrate a healthy lifestyle, and extending health insurance coverage to part-time employees.

Respondents also frequently suggested improving benefits related to certification and advanced degree programs. Comments focused on reimbursing certification costs (eg, tuition, materials, certification exams), rewarding certified employees with a bonus or pay increase, and providing incentives to encourage perioperative nurses to advance their education. Several respondents suggested reimbursements for attending educational conferences and for professional memberships. Some respondents suggested financial assistance with covering tuition and other costs to obtain an associate's, bachelor of science, or master of science degree in nursing.

Many respondents suggested improvements to PTO, including increasing the accrual rate (eg, increases based on years of service), improving the flexibility of using PTO, and providing a 100% cash-out value if an employee is unable to take time off.

A notable number of respondents wanted to see improvements in employee retention, most frequently suggesting retention bonuses along with various ways to encourage nurses to remain in their jobs. Several respondents also mentioned raising employer contributions or matching employee payments to 401(k) and 403(b) plans.

COMPENSATION AND JOB SATISFACTION

After controlling for all of the variables in the regression equation, a small but significant correlation was found between base compensation and job satisfaction. Nurses appear to earn an additional $1,400 per year for every step up in satisfaction on our 5-point scale (1 = very dissatisfied; 2 = somewhat dissatisfied; 3 = neither satisfied nor dissatisfied; 4 = somewhat satisfied; and 5 = very satisfied). For example, a nurse who was very satisfied would be likely to see $1,400 more in compensation than a nurse who is only somewhat satisfied. The average job satisfaction rating in our sample was 3.9 (median = 4.0), unchanged from 2018 and 2017.

We then analyzed the reasons why nurses were satisfied or dissatisfied with their jobs. We focused on a subsample of respondents: those who were satisfied with their jobs (ie, they selected 4 or 5 on the scale) and nurses who were dissatisfied (ie, they selected 1 or 2 on the scale). We asked each group, respectively, to indicate the reasons why they were satisfied or dissatisfied with their jobs. Respondents could select multiple workplace characteristics.

As shown in Figure 5, the job itself and the respondents’ coworkers (excluding managers and the surgical team) ranked as the first and second most frequently cited sources of satisfaction for satisfied nurses. Benefits and compensation also played a role in satisfaction, ranking as the third and fourth most frequently cited sources. Satisfaction with other members of the surgical team was the fifth most frequently cited source of satisfaction. Job scheduling and management ranked as the sixth and seventh sources, and workload and organizational structure ranked eighth and ninth of the nine sources of satisfaction. Notably, these rankings are identical to the 2018 survey results.

Details are in the caption following the image
Reasons for job satisfaction.

Figure 6 shows the reasons for dissatisfaction among dissatisfied respondents, management was the most frequently cited source of dissatisfaction, and by a considerable margin. Compensation was the second ranked reason; however, it lags behind management by a substantial amount (24%). Organizational structure and workload ranked third and fourth as reasons for dissatisfaction among dissatisfied employees and, as previously noted, these ranked ninth and eighth of the nine sources of satisfaction among the satisfied respondents. These results suggest that these two factors and management merit attention by employers seeking to improve satisfaction in the workplace. With the exception of organizational structure and workload (ranked fourth and third last year), these rankings are identical to those in the 2018 survey.

Details are in the caption following the image
Reasons for job dissatisfaction.

ECONOMIC TRENDS IN THE PERIOPERATIVE NURSING WORK ENVIRONMENT

In each of the past 10 years, we asked respondents if they had seen any change in the level of activity at their facilities. As shown in Figure 7, the reported level of activity in the perioperative nursing environment increased in the past year. The percentage of respondents reporting an increase in activity rose 5%, from 54% in 2018 to 59% in 2019. Those reporting a decline in activity decreased 3%, from 21% in 2018 to 18% in 2019.

Details are in the caption following the image
Trends in perceived changes in perioperative nursing activity (eg, procedure volumes) (2010–2019).

To explore changes in perioperative nursing activity, nurses were asked whether they have seen a shift in procedure volumes. Approximately 75% of respondents reported a shift in procedure volumes away from inpatient treatments to ambulatory or same-day surgery (75% in 2018 and 72% in 2017). Approximately 19% reported a shift from inpatient surgery to hybrid or interventional procedures (18% in 2018 and 2017), and 39% reported a shift from ambulatory to inpatient surgery (36% in 2018 and 35% in 2017). Approximately 12% saw a shift from ambulatory to hybrid or interventional procedures (11% in 2018 and 12% in 2017). Percentages do not sum to 100 because of multiple responses.

UPDATE ON THE PERIOPERATIVE NURSING SHORTAGE

In the latest survey, the median percentage of vacant full-time nursing positions was 9%, rising from a 3% level six years ago. Although the percentage of vacant positions is not large, the number of facilities affected is. Among managers in our sample, 68% (63% in 2018) reported having at least one open position, and the median time that the positions have been open is six months. Nearly all managers with openings reported open clinical positions (98%), but only 19% of managers reported openings for management positions (many managers reported openings for both).

This year, we asked more specific questions about how the nursing shortage is affecting the quality of patient care. Nearly half of the respondents (46%) have not seen a substantial effect on patient care, but a similar percentage (48%) reported having to cancel or delay procedures. For respondents experiencing a shortage, we also asked questions about critical or sentinel events (eg, patient injuries, nerve damage, wrong-site or wrong-side surgery, retained surgical items, medication errors). Although the incidence is fairly low, some facilities did report near misses of critical events and, in some cases, critical events themselves as a result of the nursing shortage at their facilities.

Respondents were asked to indicate the reasons for the nursing shortage at their facilities. As shown in Table 9, the top five reasons for the shortage are insufficient compensation and benefits (46%); employees leaving the facility or industry (45%); workload (40%); a lack of qualified, experienced nurses (40%); and retirements (37%). The ordering of the reasons is almost identical to the 2018 results. Only one reason changed: workload moved up from fourth place in 2018 to a third-place tie with lack of qualified, experienced nurses.

Table 9. Reasons for Nursing Shortage
Reasons Percent
Job compensation/benefits 46
Staff members changed employers or industry 45
Workload 40
Lack of qualified, experienced nurses 40
Nurses retired 37
Job-related stress (psychological) 35
Job-related stress (physical) 34
Hours 34
Shifts 26
Facility budget constraints or timing 24
Staff members left the perioperative specialty 22
Facility added positions 14
Lack of BSN-prepared nurses 7
  • BSN = bachelor of science in nursing.
  • NOTE. Percentages total to more than 100 because of multiple responses.

In an open-ended question, respondents were asked what steps their employers were taking to manage the nursing shortage. Hiring replacement nurses topped the list of actions by a considerable margin. Hiring traveling nurses was mentioned specifically by approximately 28% of the 2,639 respondents to this question (26% in 2018); hiring agency, contract, or temporary nurses was mentioned by an additional 12% of the respondents and is unchanged from 2018 (many respondents simply wrote “hiring”). Approximately 10% of the respondents mentioned recruiting efforts that included forming a recruitment team, holding open houses and nursing fairs, advertising, and using a recruiting agency. In many cases, the facility pursued nursing students, graduates, and experienced perioperative nurses.

Bonuses were a particularly popular approach for managing the shortage. Sign-on bonuses comprised 60% of the types of bonuses that were specified. Other mentioned bonuses were for overtime and extra shifts, referral and recruiting, and retention. Many bonuses were unspecified.

Increased training was mentioned frequently. Training focused on new nursing graduates and cross-training nurses from other departments. Compared with the 2018 results, more respondents said their facilities were creating or using their own training programs or AORN's Periop 101 program. In facilities where the nursing shortage was acute, some ORs were closed.

A notable number of the respondents wrote that their facility was not adding resources or personnel to eliminate the shortage, but instead was making changes in managing the present workforce and resources. These reported changes included increasing the amount of overtime and on-call time and, in some cases, having managers provide more direct patient care.

Respondents were asked how new perioperative nurses enter the field. Most respondents (59%) said that they transitioned into perioperative nursing after working as an RN in a different specialty. One-third (33%) of the respondents entered perioperative nursing from a non-RN field, and 3% said they entered perioperative nursing directly out of school (5% mentioned other paths).

We also asked respondents whether they were thinking of quitting their job in the next year. Approximately 28% of the sample indicated they were somewhat likely or very likely to quit (unchanged from 2018). Among the nurses who were seriously considering quitting, 67% were thinking of changing employers (unchanged since 2018 and 65% in 2017), and 12% were planning to change careers but remain in health care (13% in 2018). Approximately 10% of those likely to quit were planning to retire (3% of the total sample). Three percent of those likely to quit were planning to change careers and leave health care. Another 2% might leave for personal reasons, including family, and may return later, and 1% were leaving their jobs to attend school full time. Five percent of the respondents preferred not to answer this question.

We asked respondents why they were considering leaving their jobs. As shown in Table 10, four reasons were closely clustered: dissatisfaction with the work environment/culture (46%), their supervisor/manager (42%), their pay (38%), or their employer (35%). These top four reasons for quitting their job and the ranking of these items are identical to the 2018 results.

Table 10. Reasons for Quitting Job
Reasons Percent
Dissatisfaction with work environment/culture 46
Dissatisfaction with supervisor/manager 42
Dissatisfaction with salary 38
Dissatisfaction with employer 35
New opportunity for career advancement 28
Dissatisfaction with hours 19
Desire to work in a different facility 16
Dissatisfaction with physical demands of job 14
Family reasons 12
Retirement 11
Dissatisfaction with commute 9
To pursue an education degree 7
Tired of this career 6
Prefer not to answer 1
Not thinking about quitting my job 1

NOTE

  • Percentages total more than 100 because of multiple responses.

OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION

We asked respondents to provide any comments they would like to express about perioperative nursing compensation. In total, 527 respondents provided comments containing information or opinions that comprised 14% of the total sample.

As with every previous survey that included an open-ended question about compensation, dissatisfaction with compensation emerged as the dominant theme, comprising a plurality of the comments. Many respondents asserted that their compensation does not sufficiently reflect the amount of responsibility, increasing knowledge and physical demands, stress, and unique requirements of their jobs.

“Over the last 20 years, the job has become harder due to patient acuity, patient size, difficulty of the procedures, the technically challenging equipment, and less staff to do more work,” commented one nurse. Another nurse agreed. “Surgery constantly changes. We must stay on top of the amount of technology changes, and compensation should reflect that demand.”

Some nurses commented about the intensity of nursing in the OR. “The operating room is a different world,” a nurse wrote. “We are not compensated nearly enough considering the physical and mental intensity of the job.” Some respondents compared the job's demands and pay with those of other occupations. “[Heating, ventilation, and air conditioning] technicians and electrical journeymen make more than we do and with less skills,” one nurse commented. “And they have no loans to pay back.”

In the compensation comments from previous years, some respondents asserted that perioperative nursing should be formally recognized as a specialization, and compensation should be increased to reflect that designation. This year, we saw a notable increase in the number of perioperative nurses calling for this change.

“We should be paid more because we are so specialized,” said one nurse. “Most nurses have no training in the OR during nursing school, and so when you finally achieve the level of becoming an OR nurse, you should be compensated for your specialized area.”

“Hospitals have always traditionally lumped all nursing together,” a nurse commented. “However, perioperative nurses truly need to have their own specialty requirements and ladders. We do not fit the everyday nursing models.” Another nurse agreed, “All nursing is special, but what we deal with every day, every hour, every minute, every second is completely different.”

According to one nurse:

Our hospital recently restructured the pay so that RN compensation is based on years of experience. A nurse in the clinic with ten years of experience makes the same base pay as a nurse in the OR with ten years of experience. That is super frustrating for specialized areas of care where so much additional training and education are required. Consequently, we have seen people leave for ‘easier’ jobs physically and mentally.

Another nurse affirmed this view, writing that without the increased pay that comes with specialization, new RN graduates are not motivated to pursue the more demanding perioperative nursing profession, which contributes to the present shortage of perioperative nurses.

As has been the case in several previous years, some respondents again provided a particular argument for specialty status: Nurses outside the OR cannot effectively do the work of nurses inside the OR. “They cannot float a nurse from any other area to our area to do the job when we are short staffed,” said one nurse. “But we can float to other areas and jump right in if needed.”

Dissatisfaction with on-call requirements was again voiced by a notable number of respondents. Concerns were raised about the amount of pay when called in and about the amount of standby compensation given the limitations that standby call places on free time, especially on weekends. “The compensation does not correlate with the manner in which call alters personal time,” a nurse commented.

“We cannot keep younger employees because they do not believe that $4 an hour for being on call and being limited in what and where they can go is worth it,” a nurse asserted. “They don't consider $200 for a 50-hour call weekend to be worth it to be available for the weekend. It cuts into their lifestyle. There should be an increase in call pay and pay when called in to make it attractive to younger employees.” Another nurse suggested, “Standby pay should match the respective state's minimum wage because minimum wage is state law.”

A particular concern was raised by respondents about the requirement that, when on call, they be able to report to work with 30 minutes’ notice. They work for hospitals in expensive cities and live outside the city where housing is less expensive. Consequently, it is difficult to meet the employer's requirement.

Frustration was expressed in some comments about on-call pay and requirements. “As I am filling out this survey, I am being texted about covering a call that is vacant,” a nurse wrote. “This is my first weekend in eight weekends, and I'm doing my best to ignore it. For once, management can step up.”

Respondents expressed concerns about training because of what some of them view as a revolving door: Perioperative nurses train new nurses for several months and then the nurses leave for jobs at better-paying facilities. One nurse wrote, “Our more senior staff are facing burnout from constantly training and picking up shifts from people who leave.” Given the training demands, another nurse asserted, “Perioperative RNs should be paid for precepting and orienting new employees. It should not be an expectation. And they should be trained in the proper way to precept and orient.”

Nurses expressed the need to provide compensation for more experienced nurses given the positive effect that they have on nursing quality and the fact that the higher their retention, the lower the demand on nurses to train newcomers. Some respondents asserted that requirements for training new hires are considerable and frustrating. A nurse explained, “Our new nurses with perioperative experience don't seem to stay long. So, our staff has to work so much which makes it hard. You can only take so much call and stay late so many times before you reach a breaking point.”

Although concerns about compensation dominated the comments, some nurses expressed their passion and fulfillment as a perioperative nurse. “Yes, there are shortcomings, but I have a passion for perioperative nursing,” a nurse commented. “I love it and it is very much my life calling.” Wrote another nurse, “I love being an OR nurse!”

Some respondents also expressed thanks to AORN for conducting the survey and publishing the results. “I appreciate AORN doing the annual salary survey,” one nurse commented. “I use the information to ensure my staff wages, my assistant director's wages, and my wages are appropriate. If they fall behind, I use the information to negotiate appropriate wage increases. I look at it every year!”

Editor's notes: Magnet and Pathway to Excellence are registered trademarks of the American Nurses Credentialing Center, Silver Spring, MD. CNOR/CRNFA are registered trademarks of the Competency & Credentialing Institute, Denver, CO. Periop 101 is a registered trademark of AORN, Inc, Denver, CO.

Biographies

  • Donald Bacon, PhD, is a professor of marketing at the University of Denver, CO. Dr Bacon has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

  • Kim A. Stewart, PhD, is a research scholar at the University of Denver, CO. Dr Stewart has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.