In June 2017, AORN surveyed its members and some

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1 Results of the 2017 AORN Salary and Compensation Survey DONALD R. BACON, PhD; KIM A. STEWART, PhD ABSTRACT AORN conducted its 15th annual compensation survey for perioperative nurses in June A multiple regression model was used to examine how several variables, including job title, educational level, certification, experience, and geographic region, affect nurse compensation. Comparisons between the 2017 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 base compensation rates are examined. Additional analyses explore the current state of the nursing shortage and the sources of job satisfaction and dissatisfaction. AORN J 106 (December 2017) ª AORN, Inc, Key words: nurse salaries, compensation, economy. In June 2017, 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. As shown in Figure 1, 45% of the respondents were staff nurses, 19% were managers (ie, nurse manager, supervisor, coordinator, team leader), 11% were high-level managers (ie, director, vice president [VP], assistant director of nursing, chief nursing officer, assistant VP) or hospital/facility administrators, 7% were educators (ie, faculty or staff development), 6% were charge nurses, 3% were RN first assistants (RNFAs), and 2% were clinical nurse specialists. Nurse practitioners, consultants, and business managers comprised 1% of the sample. RESPONDENT PROFILE In early June, 63,834 potential respondents (including 37,996 AORN members) received an electronic invitation to participate in the survey (AORN has more than 37,996 members, but not all members opt to receive communications or have addresses). As an incentive, participants were eligible to enter a raffle to win a $100 gift card. By June 30, 5,141 unique responses had been received. The focus of this study is perioperative nursing compensation, so respondents who did not answer key compensation-related questions were excluded. This criterion reduced the usable sample to 3,331 individuals, for a 5.2% net response rate. The final sample size is 16% larger than the 2016 sample. Some of the demographic information from the sample is represented in Figure 2. Approximately 9% of the respondents were younger than 30 years of age, 22% were in their 30s, 24% were in their 40s, 31% were in their 50s, and 14% were at least 60 years of age. Approximately 89% of the respondents were female. Hourly paid employees comprised 68% of the sample; 32% were salaried employees. Most of the respondents (78%) worked in acute care hospitals, 14% worked in freestanding ambulatory surgery centers, 7% worked in a hospital outpatient department, and less than 1% were employed in a physician s office. Approximately 32% of the respondents had more than 20 years of experience as a perioperative nurse (24% had more than 25 years of experience), 24% had 11 to 20 years of experience, and 45% ª AORN, Inc, j AORN Journal

2 December 2017, Vol. 106, No Salary Survey Figure 1. Percentage of survey respondents by job title. had 10 or fewer years of experience as perioperative nurses. Approximately 80% worked in an urban or suburban area, and 20% worked in a rural location. Approximately 6% of the respondents were veterans of the US armed services. Geographically, the sample was well dispersed across the country. As shown in Table 1, approximately 22% of the respondents lived in the Upper Eastern Coastal area (ie, New England and the mid-atlantic), 16% resided in the South Atlantic area, 27% were in the East and West North Central regions, 16% resided in the East and West South Central regions, and 19% were in the Mountain and Pacific regions. Approximately 49% of the respondents hold a bachelor s degree in nursing, 5% have a bachelor s degree in another field, and 25% have a diploma or associate degree. Approximately 12% of respondents have a master s degree in nursing, 2% hold a master s degree in business administration, and 4% hold a master s degree in another field. Approximately 2% have a doctorate in nursing or in another field or hold some other type of degree (Table 2). BASE COMPENSATION We performed statistical analyses to identify which factors 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 (5.2%). 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 3. This analysis and the compensation analyses that follow include only 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. As can be seen, nurses generally receive more compensation in larger facilities. On closer examination, the relationship between facility size and compensation may also be influenced by facility type. Table 4 shows how the average number of ORs varies by facility type and how the number of ORs is related to staff nurse compensation. Taking into account facility size, university or academic facilities tend to be larger than other facility types. The challenge in understanding perioperative nursing compensation is in estimating the simultaneous influence of the many different variables that can affect compensation. We used AORN Journal j 477

3 BacondStewart December 2017, Vol. 106, No. 6 Figure 2. Profile of survey respondents. 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 can then be identified independently of the others. For the analysis, we used Table 1. Geographic Location of Respondents Region Respondents, n Percent New England (New Hampshire, Vermont, Maine, Connecticut, Rhode Island, Massachusetts) Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, New York, District of Columbia) South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida) East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) West North Central (North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, Missouri) East South Central (Kentucky, Tennessee, Mississippi, Alabama) West South Central (Oklahoma, Arkansas, Texas, Louisiana) Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) Pacific (Alaska, Washington, Oregon, California, Hawaii) Total 3, NOTE. Percentages do not add to 100% because of rounding. 478 j AORN Journal

4 December 2017, Vol. 106, No Salary Survey Table 2. Respondents Educational Levels Educational Level Respondents, n Percent Diploma Associate degree Bachelor s degree in nursing 1, Bachelor s degree in another field Master s degree in nursing Master s degree in another field Master s degree in business administration Doctorate in nursing Doctorate in another field Other Total 3, NOTE. Percentages do not add to 100% because of rounding. 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 size, facility type, 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 intraoperative roles, percentage of time spent in direct patient care, years of work experience, compensation basis, certification, educational level, participation in a collective bargaining unit, household status, and gender. To obtain the most reliable results, we limited the sample for the regression analyses to respondents who were full-time employees and working in the United States. 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 61% 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 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 Table 3. 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 88.7 $69,400 $69,000 Hospital/facility administrator 15.7 $110,200 * Director/assistant director of nursing 16.7 $105,500 $134,600 Nurse manager/supervisor/coordinator/team leader 35.5 $84,100 $93,700 Charge nurse 53.7 $76,200 $80,700 Educator/staff development 15.0 $81,800 $88,200 Clinical nurse specialist 34.7 * $95,800 RN first assistant 89.4 $79,700 $87,300 Sample mean 58.4 $82,200 $83,000 NOTE. The small net subsample sizes for chief nursing officers, vice presidents, business managers, nurse practitioners, and consultants resulted in their exclusion from the regression analysis. Other samples with <30 observations are noted with an asterisk. Dollar amounts are rounded to the nearest hundred. AORN Journal j 479

5 BacondStewart December 2017, Vol. 106, No. 6 Table 4. Size and Compensation by Facility Type Facility Type Facility Size (Average Number of ORs) Average Staff Nurse Base Compensation Respondents, n Acute care hospital, general/community 16 $68, Acute care hospital, specialty 17 $72, Acute care hospital, university/academic 31 $75, Job Title More than any variable, differences in job title were linked to differences in base compensation. The average staff nurse, for example, earned $70,300 ($1,200 more than in 2016), and the average VP/director of nursing earned $117,000 ($3,400 more than in 2016). Note that we combined VPs, assistant VPs, directors, and assistant directors for this longitudinal analysis to allow comparisons with prior years. Part of the difference in salary across titles is explained by the difference in the percentage of time spent in direct patient care versus the percentage of time spent on other tasks, such as management or administration. To explore the trends in compensation for staff nurses and for VPs/directors of nursing over time, we combined data from 14 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 (2.4%) and for VPs/directors (2.3%). For comparison, the average compound annual inflation rate was 2.1% during this period. Thus, during this time, staff nurses base compensation averaged a 0.3% raise above inflation, and VPs/directors of nursing averaged a 0.2% raise above inflation. On average, staff nurses spent 88.7% of their time delivering direct patient care (a 0.9% decrease from 2016), and nurse managers spent 35.5% of their time providing direct care (a 0.5% decrease from 2016). As expected, high-level managers averaged a relatively small amount of time on patient care (15.7% for facility/hospital administrators [a 1.9% decline from 2016] and 16.7% for directors/assistant directors of nursing [a 0.1% decline from 2016]). 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, whereas some other nurse managers spent as little time on patient care as the typical director of nursing or VP. Figure 3. Trends in base compensation over time. 480 j AORN Journal

6 December 2017, Vol. 106, No Salary Survey Facility Type The regression model indicates several differences in base compensation related to facility type. This year, on average, nurses in acute care hospitals received $3,000 more in base compensation and nurses at freestanding ambulatory surgery centers received $6,000 less in base compensation than nurses in other facilities. Nurses in general/community hospitals received $4,300 less than nurses in specialty hospitals or university/academic medical centers. We found that 28% (versus 30% in 2016) of respondents were employed in Magnet facilities. However, a facility s Magnet status was not a statistically significant variable for explaining differences in compensation. Facility Size The size of a facility was an important differentiator in nursing compensation. This difference was particularly pronounced for those working in higher-level management positions. After 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 $400 more per OR in the facility (compared with $1,200 more in 2016). This difference may be a result of the greater number and range of responsibilities that these upper-level positions entail. Last year, no statistically significant relationship was found between staff nursing compensation and facility size. This year, staff nurses earned slightly less money in larger hospitals ($200 less per year per OR). Facility Ownership A majority of the respondents (56%) were employed by nongovernment, nonprofit facilities. These nurses earned $2,700 more than other nurses. Only approximately 3% of the respondents worked in government-owned federal facilities, and these nurses earned $8,600 more than nurses working in nongovernment facilities. More than two-thirds (69%) were employed in facilities that were a part of a larger network; these nurses received $3,100 more per year than nurses in nonnetwork facilities. Population Setting The location of the facility (ie, urban, suburban, rural) substantially influenced base compensation. Nurses in rural settings earned an estimated $6,700 less per year than they would have earned if they were employed in a suburban or urban setting. 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 $20,400 higher than the average base compensation for staff nurses. The other regions with higher incomes were New England (þ$7,600), the mid-atlantic (þ$14,300), and the mountain region (þ$6,500). Two regions that were associated with lower compensation were the East South Central region ( $5,600) and the West South Central region ( $5,000). Nurses in other regions showed no significant difference in compensation. This year, we integrated cost-of-living-by-region information with compensation data as shown in Table 5. The costof-living information 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 regional 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. Nurses also reported the specific state in which 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 25 states with sufficient sample sizes, seven states showed significantly different effects from what their region would otherwise suggest. The states requiring specific adjustments and those adjustments are shown in Table 6. For these states, the adjustment listed should be used instead of the regional adjustment. For example, nurses in California made $43,200 more than the model estimate and nurses in Massachusetts made $32,900 more. The cost-of-living index is higher in Massachusetts than in California, suggesting that many California nurses may be better off financially because the cost of living is lower compared with that of Massachusetts. Interestingly, nurses in Texas appear to be in an attractive financial position, with an average compensation level $8,500 higher than the base model but a cost of living nine points below the national average. Intraoperative Roles: RN Circulators, Scrub Persons, and RNFAs Approximately 78% of the respondents worked on intraoperative procedures. This year, we asked these respondents about the roles they typically filled. Among these nurses, many AORN Journal j 481

7 BacondStewart December 2017, Vol. 106, No. 6 Table 5. Compensation and Cost of Living Differences by Region Region Compensation Difference Cost-of-Living Index New England (New Hampshire, Vermont, Maine, Connecticut, þ$7, Rhode Island, Massachusetts) Mid-Atlantic (New Jersey, Delaware, Maryland, Pennsylvania, þ$14, New York, District of Columbia) South Atlantic (West Virginia, Virginia, North Carolina, South Carolina, NS 97 Georgia, Florida) East North Central (Wisconsin, Michigan, Illinois, Indiana, Ohio) NS 93 West North Central (North Dakota, South Dakota, Minnesota, Nebraska, NS 95 Iowa, Kansas, Missouri) East South Central (Kentucky, Tennessee, Mississippi, Alabama) $5, West South Central (Oklahoma, Arkansas, Texas, Louisiana) $5, Mountain (Montana, Idaho, Wyoming, Nevada, Utah, Colorado, þ$6, Arizona, New Mexico) Pacific (Alaska, Washington, Oregon, California, Hawaii) þ$20, NS ¼ not significant. assumed multiple roles; for example, 95% worked as RN circulators, 40% worked as scrub persons, and 9% worked as RNFAs. Of those who worked as scrub persons, 50% spent less than one-quarter of their time in that role each week. The average time spent in the scrub person role among nurses who spent any time in that role was approximately 29% of the workweek. Our preliminary analysis indicates that the relationship between time spent in various intraoperative roles and compensation is complex. We will use this year s insights to refine next year s survey, when we hope to report in more detail on the relationship between intraoperative roles and compensation. Time Spent on Direct Patient Care For certain job titles, nurses who spend more time on management tasks and less time on direct patient care should Table 6. States With Adjustments Different From That of Their Region State Adjustment State Cost-of-Living Index California $43, Massachusetts $32, New Jersey $19, Minnesota $14, Texas $8, Georgia $6, Pennsylvania $3, expect to receive different base compensation than nurses who spend more time on direct patient care and less time on management tasks. Nurse managers, hospital/facility administrators, chief nursing officers, VPs/assistant VPs, and directors/assistant directors of nursing earned approximately $300 more per year for each 10% increase in time spent on managerial tasks and, correspondingly, $300 less per year for each 10% increase in time spent on direct patient care. No significant difference in compensation was found among staff nurses, educators, clinical nurse specialists, RNFAs, and nurse practitioners who spent more or less time on managerial tasks. Differences in pay related to direct patient care were lower this year than in 2016, when the pay difference for each 10% decrease in direct patient care was $600 for managers and $300 for other nurses. Work Experience The regression model suggests that nurses generally see larger increases related to experience early in their careers compared with later in their careers. For example, the increase in compensation from the first to the second year is close to $1,400, but the jump from the 25th to the 26th year is only approximately $300. In this sample, the average nurse had 14 years of experience (two years less than last year s sample). 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, and VPs/assistant VPs earn approximately $500 more per year of experience, and 482 j AORN Journal

8 December 2017, Vol. 106, No Salary Survey this positive relationship continues through 30 years of experience. On average, individuals in such positions reported 19 years of work experience (down from 22 years in 2014e2016). Compensation Basis Generally, we found that whether a nurse is paid by hourly rate or salary is related to base compensation level, with salaried nurses earning approximately $1,800 more than hourly nurses. Certification We asked about 17 types of certification in the survey: board certified (BC); certified administrator surgery center (CASC); critical care RN (CCRN); certification in infection prevention and control (CIC); certified OR nurse (CNOR); certified RNFA (CRNFA); certified perianesthesia nurse (CPAN) or certified ambulatory perianesthesia nurse (CAPA); certified plastic surgical nurse (CPSN); certified in nursing administration (CNA); certified in nursing administration, advanced (CNAA); certified pediatric nurse (CPN); certified surgical technologist (CST); nurse executive, board certified (NE-BC); certified orthopedic nurse (ONC); clinical nurse specialist (CNS); and nurse practitioner (NP). Of all these certifications, only two were held by more than 50 respondents: CNOR (47% of the sample) and CPAN or CAPA (2% of the sample). The other certification counts were too small to provide reliable results. Although staff nurses with CNOR certification earned more than other nurses in the past several years, neither the CNOR nor the CPAN or CAPA certifications had a statistically significant effect on base compensation this year. Approximately 41% of the respondents said that their facility pays more to employees who hold a nursing certification (approximately the same percentage as in the past four years). Of these respondents, 45% said that the pay adjustment was an addition to base pay, 17% said it was an annual bonus, and 13% said it was a one-time bonus. Another 16% of respondents said there was an adjustment to the nurse s position on the clinical ladder. Among those reporting facility rewards for specific certifications, approximately 91% of the respondents said that their facility rewarded nurses with CNOR, 42% reported rewards for CCRN, 36% reported rewards for CPAN or CAPA, 23% reported rewards for CST, 22% reported rewards for CRNFA, 16% reported rewards for ONC, and 11% reported rewards for CNS or NP. Ten percent or fewer respondents mentioned other certifications. These percentages are similar to those reported in 2014e2016. Thus, 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, 36% of staff nurses, 56% of nurse managers, and 47% of directors or 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. Educational Level This year, several educational degrees were significantly related to compensation. Using nurses with a diploma as a compensation baseline, nurses with an associate degree earned $4,600 more, nurses with a bachelor of science degree in a nonnursing field made $2,700 more, nurses with a bachelor of science degree in nursing made $6,600 more, and nurses with a master s degree or higher in any field earned $13,900 more than nurses with only diplomas. When asked directly, 29% of the respondents said that their facility pays nurses more for having a degree in nursing, such as a bachelor s, master s, or doctoral degree in nursing or a doctoral degree in nursing practice (1% higher than in 2014e2016). It may seem surprising that level of education does not have a more profound effect on base compensation in this analysis, but it should be noted that the analysis has already controlled for job title, and a nurse s educational level may well affect the level of responsibility attained. Table 7 provides an analysis of educational level for the positions of nurse, nurse manager, and director or assistant director of nursing. Those with higher-paying jobs, especially the directors, are less likely to have only a diploma or associate degree and are more likely than staff nurses to have a master s degree in nursing, a master s degree in business administration, or a master s degree in another field. Thus, level of education 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. Collective Bargaining Unit Approximately 14% of respondents reported working in an environment with a union or collective bargaining unit AORN Journal j 483

9 BacondStewart December 2017, Vol. 106, No. 6 Table 7. Level of Education by Selected Title Educational Level Job Title (Sample Size) Staff Nurse (n ¼ 1,510) Nurse Manager (n ¼ 642) Director/Assistant Director of Nursing (n ¼ 293) Percent Percent Percent Diploma Associate degree Bachelor s degree in nursing Bachelor s degree in another field Master s degree in nursing Master s degree in another field Master s degree in business administration (the same as 2016 but up slightly from 12% in 2013 through 2015). Staff nurses working in a unionized setting earned an average of $8,200 more in annual base compensation than nurses employed in a nonunion workplace (compared with $10,300 in 2016, $8,600 in 2015, $9,200 in 2014, $7,000 in 2013, and $6,100 in 2012). 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. In some years, any nurse with one or more children in the home was found to earn less money than other nurses. This year, no significant difference was found related to the presence of children in the home. In past years, gender was not always significantly related to nursing compensation, and we concluded that the effect was inconsistent and small relative to all other factors that influence perioperative nursing compensation. However, this year, the gender wage gap was $3,700 and was statistically significant. Men have significantly out-earned women in five of the past seven years (by an average gap of $4,200 in 2015, $3,200 in 2014, $2,800 in 2012, $3,300 in 2011, and $2,700 in 2010). 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 2017 affirms our conclusion. 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 generally accurate enough that two-thirds of nurses or managers who fit a particular profile will see an annual base compensation within $17,100 of the base compensation estimated by the model. In questions unrelated to the regression model, 75% of the respondents said they received a raise this year, compared with 74% in 2016, 72% in 2015, and 70% in When asked about the factors that best explain their raises, most respondents (84%) indicated an annual pay increase, 8% indicated they were promoted, 6% indicated they had changed jobs or responsibilities with the same employer, and 2% indicated that they had changed employers. Respondents could select multiple responses to this question, and 14% selected other. The other responses included a change in union contract, cost-of-living adjustment, systemwide adjustment, market adjustment, retention adjustment, and obtaining a degree or certification. Table 8 shows average pay raises for job titles with 30 or more respondents. The mean pay raise for staff nurses was 3.1%, and the mean raise for other titles was not substantially different. Nurse managers received the largest average raise (3.5%) across all job titles, and RNFAs received the smallest raise (2.6%). OTHER FORMS OF COMPENSATION The regression analysis previously described applies to base compensation. In the present sample, 64% of the respondents 484 j AORN Journal

10 December 2017, Vol. 106, No Salary Survey Table 8. Mean Pay Raises by Job Title Job Title Percent Pay Raise Staff nurse Hospital/facility administrator NA NA 3.2 Director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader Educator/staff development Clinical nurse specialist (master s degree or higher) NA NA RN first assistant NOTE. Results are shown only for job titles with 30 respondents. Vice presidents and business managers were excluded in the 2015 and 2016 analyses because of small sample sizes. NA ¼ not available. received additional compensation from a variety of sources, including overtime, shift differential, on-call compensation, and bonuses (compared with 65% in 2016 and 63% in 2015 and 2014). The amount of additional pay differed substantially by title. The average percentage of additional compensation by job title is shown in Figure 4. As shown, RNFAs (12.9%) received the largest additional compensation relative to base pay, followed by charge nurses (11.4%) and staff nurses (9.7%). Educators and staff development employees received the smallest additional compensation relative to base pay (3.3%), followed by directors and assistant directors of nursing (3.7%). Figure 4. Mean percentage of additional compensation by job title. AORN Journal j 485

11 BacondStewart December 2017, Vol. 106, No. 6 Table 9. Average Overtime Hours per Week and Percentage of Respondents Who Are Salaried Job Title Average Number of Overtime Hours Percent Salaried Staff nurse Hospital/facility administrator Director/assistant director of nursing Nurse manager/supervisor/coordinator/team leader Charge nurse Educator/staff development Clinical nurse specialist RN first assistant NOTE. Job titles with <30 respondents are not shown. On-Call Compensation Slightly more than half of the respondents (51%) reported that they work on call (53% in 2016 and 56% in 2015 and 2014). The median number of on-call hours per week was 12, slightly lower than the 14 hours last year, the 15 hours in 2015, and the 16 hours that were reported in the previous 10 surveys. Among the on-call respondents, most received a dollar-perhour amount for being on call (standby). Among those who received dollar-per-hour pay, the median pay was $3.50 per hour (no change from 2016). If called in, 55% received time-and-a-half pay (58% in 2016, 60% in 2015, and 57% in 2014). When called in, 9% of the respondents received no additional compensation beyond what they receive for being on call, and 14% received straight-time pay if they worked 40 hours or less that week and time-and-ahalf pay if they worked more than 40 hours. Instead of pay, 4% of the on-call respondents received compensatory time (5% in 2016). Overtime Compensation A large majority of respondents (77%) worked overtime (compared with 81% in 2016 and 87% in 2015), and they averaged 2.8 overtime hours each week (5.3 hours in 2016). Approximately 61% of those who worked overtime received time-and-a-half pay; 28% received no additional compensation. Approximately 96% of those not compensated were salaried employees (unchanged since 2016). As shown in Table 9, directors/assistant directors of nursing averaged the most overtime per week at 7.7 hours (compared with 8.5 hours in 2016 and 9.9 hours in 2015), followed closely by hospital/facility administrators at 7.6 hours (6.7 in 2016 and 6.2 in 2015), nurse managers at 5.7 hours (6.2 in 2016 and 7.4 in 2015), and RNFAs at 5.4 hours (5.4 in 2016 and 7.0 in 2015). Educators and staff development employees worked the least amount of overtime at 3.8 hours per week (4.2 in 2016 and 3.7 in 2015), followed closely by staff nurses at 3.9 hours. Hiring Bonuses Relatively few of the respondents (10%) received a hiring bonus when they were hired (9% in 2016). Only 17% of the respondents were certain that their employer provided a hiring bonus for their position (15% in 2016). For positions with bonuses, 16% (18% in 2016) were in the $1,000 to $2,499 range, 22% (28% in 2016) were in the $2,500 to $4,999 range, and 24% (22% in 2016) were in the $5,000 to $7,499 range. At facilities that currently provide hiring bonuses, charge nurses were the most likely to receive a hiring bonus (26%), followed by staff nurses and RNFAs (20%). Approximately 16% of nurse managers reported that their facility provided a hiring bonus for their positions. Approximately 14% of clinical nurse specialists and 13% of nurse educators received a hiring bonus. Only 8% of directors/assistant directors of nursing reported that their facility provided a hiring bonus for their positions. Shift and Other Differentials Among the respondents, 90% worked the day shift and 5% 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 10% of base pay. For those working weekends, the median differential was $3.00 per hour or 10% of base pay. 486 j AORN Journal

12 December 2017, Vol. 106, No Salary Survey Table 10. Percentage of Respondents Receiving Benefits Benefit Type 2011e2013 Percent Average 2014e2016 Percent Average 2017 Percent Average Change From 2014e2016 to 2017 Health insurance Dental insurance þ1 Earned time or paid time off Life insurance Vision insurance þ1 Bereavement leave Short-term disability þ2 Jury duty compensation Long-term disability Tuition reimbursement Health spending accounts (k) contributions Free or discounted parking (b) contributions þ1 Paid certification exams Pension plans Paid conference travel Pharmacy discounts Employee referral bonuses þ2 Flexible scheduling Reimbursement for continuing þ1 education contact hours Health/fitness center memberships þ2 Other bonuses (eg, holiday, quarterly) þ2 Incentive bonuses þ1 Reimbursement for professional association membership fees Tax-sheltered annuity plans Malpractice insurance Relocation assistance Meals Retention bonuses þ1 Subsidized child/elder care Life quality services (eg, dry cleaning) NOTE. A dash appears in a percentage cell if, during the respective period, data were not collected for the benefit or the benefit was not provided to any respondents. Benefits Almost all the respondents receive benefits as part of their compensation. As shown in Table 10, the most frequently received benefit in 2017 was health insurance (93%), followed by dental insurance (90%), earned time or paid time off (85%), life insurance (83%), and vision insurance (81%). Compared with the 2014 through 2016 averages, 16 benefits were decreased in 2017: earned time or paid time off ( 1%), life AORN Journal j 487

13 BacondStewart December 2017, Vol. 106, No. 6 insurance ( 1%), bereavement leave ( 3%), jury duty compensation ( 2%), tuition reimbursement ( 2%), 401(k) contributions ( 7%), free/discounted parking ( 1%), paid certification exams ( 2%), pension plans ( 3%), pharmacy discounts ( 2%), flexible scheduling ( 2%), reimbursement for professional association membership fees ( 2%), taxsheltered annuity plans ( 4%), malpractice insurance ( 1%), relocation assistance ( 1%), and life quality services ( 1%). Ten benefits increased in 2017 compared with 2014 through 2016 averages: dental insurance (þ1%), vision insurance (þ1%), short-term disability (þ2%), 403(b) contributions (þ1%), employee referral bonuses (þ2%), reimbursement for continuing education contact hours (þ1%), health/fitness center memberships (þ2%), other bonuses (þ2%), incentive bonuses (þ1%), and retention bonuses (þ1%). Six benefits were unchanged: health insurance, long-term disability, health spending accounts, paid conference travel, meals, and subsidized child/elder care. Compared with 2011 through 2013 averages, 16 benefits decreased in 2017: earned time or paid time off ( 3%), life insurance ( 1%), bereavement leave ( 9%), jury duty compensation ( 9%), long-term disability ( 1%), 401(k) contributions ( 20%), free/discounted parking ( 6%), paid certification exams ( 3%), pension plans ( 11%), paid conference travel ( 3%), pharmacy discounts ( 7%), flexible scheduling ( 3%), tax-sheltered annuity plans ( 13%), malpractice insurance ( 3%), relocation assistance ( 1%), and life quality services ( 2%). Five benefits increased in 2017 compared with 2011 through 2013 averages: dental insurance (þ3%), short-term disability (þ3%), employee referral bonuses (þ4%), incentive bonuses (þ2%), and retention bonuses (þ1%). Three benefits were unchanged: health insurance, tuition reimbursement, and subsidized child/elder care. Respondents were asked whether their employer contributions had increased, decreased, or remained unchanged for the four most widely held benefits in the respondent sampledhealth insurance, dental insurance, earned time or paid time off, and life insurance. 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 who reported a decrease in employer contributions for the benefit. For example, 27.3% of the sample reported an increase in health insurance contributions, whereas 20.4% reported a decrease (45.1% reported no change), for a net change of þ6.9% in health insurance coverage (the net change was þ3.2% in 2016). The results across several benefits reveal that for employers offering these benefits, the net gain was small but positive except for earned time or paid time off, for which the change was slightly negative. The change in paid time off is probably not noticeable to most nurses. The median number of days of paid time off in this year s sample (not counting national holidays) was 19, unchanged from the 2016 survey results. Although a nurse may receive many benefits, some benefits are more valued than others. We asked respondents to identify the five benefits that they most valued. As expected, health insurance and dental insurance ranked first and second as the most frequently included in the top five most-valued group, and they also ranked first and second as the most frequently provided benefits to respondents. Three interesting findings that emerged from the analysis concerned the employee referral bonus, earned time or paid time off, and vision insurance. More than half of the respondents (54%) placed the employee referral bonus in their top five mostvalued group. However, only 23% of the respondents at present receive this benefit. Earned time or paid time off ranked as the third-most frequently provided benefit, currently provided to 85% of the respondents. However, only 15% of the respondents placed the benefit intheirtop five most-valued group. Vision insurance ranked fifth in atpresent provided benefits and is currently received by 81% of respondents; however, only 35% of respondents placed it in their top five most-valued group. For these three benefits, there appears to be a disconnect of varying degrees between the benefits that employers provide and the ones that respondents most value. 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. Approximately 63% of the respondents suggested specific improvements that would increase the value of their benefits package. Comments focusing solely on improvements in compensation (eg, increases in salary, on-call wage, hourly wage) rather than benefits were removed from analysis. By a considerable margin, suggested improvements focused on health insurance benefits. The plurality of the health insurance comments suggested lowering the overall cost of the benefit by increasing employer contributions to premiums or lowering 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 that 488 j AORN Journal

14 December 2017, Vol. 106, No Salary Survey comprised a substantial number of responses included providing more comprehensive benefits and expanding choices for health care providers beyond those at the employer s facility, continuing health insurance benefits in retirement, providing a discount for healthy employees who demonstrate a healthy lifestyle, compensating employees who decline the employer s health insurance, adding dental and vision insurance, and providing health insurance for PRNs and part-time employees. Many respondents focused on improving benefits related to certification and advanced degree programs. Comments focused on reimbursements for certification costs (eg, tuition, materials, certification exams), financial recognition for achieving certificationssuchasabonusorpayincrease,andincentives to encourage perioperative nurses to advance their education. Several respondents suggested financial assistance with tuition and other costs required to obtain an associate, bachelor of science, or master of science in nursing degree. To a lesser degree, some respondents suggested reimbursements for attending educational conferences and for professional memberships. A notable number of respondents also suggested improvements for paid time off benefits. These suggestions included increasing the amount of paid time off, increasing the flexibility of obtaining and using paid time off, providing a cash-in paid time off program, and providing a higher paid time off accrual for long-term employees. A notable number of respondents also wanted improvements in employee retention. Retention bonuses were most frequently suggested, along with various ways to encourage nurses to remain in their jobs. COMPENSATION AND JOB SATISFACTION Are perioperative nurses more satisfied in their jobs when they achieve higher pay, or do nurses accept less-satisfying work to achieve higher pay? After controlling for all the previously mentioned variables, no significant correlation was found between base compensation and job satisfaction. The average satisfaction rating in our sample was 3.9 (median ¼ 4.0), where 1 ¼ very dissatisfied, 2 ¼ somewhat dissatisfied, 3 ¼ neither satisfied nor dissatisfied, 4 ¼ somewhat satisfied, and 5 ¼ very satisfied. In a comment question, respondents were asked to identify the the primary reason you are satisfied/dissatisfied in your job. To analyze responses, we separated respondents into two groups: those who were very or somewhat dissatisfied (ie, answered the previous question with a 1 or 2) and those who were somewhat or very satisfied (ie, answered the previous question with a 4 or 5). The dissatisfied group comprised 587 respondents (113 very dissatisfied and 474 somewhat dissatisfied), and the satisfied group comprised 1,452 respondents (913 very satisfied and 539 somewhat satisfied). We analyzed the content of the 2,039 comments to identify each group s most frequently cited sources of satisfaction or dissatisfaction. Note that many respondents in each group provided more than one source. Coworkers emerged as the most frequently cited source of satisfaction. Approximately 36% of the satisfied respondents cited their coworkers as a primary source of their satisfaction. The job itself was the runner-up, with 28% of respondents selecting it. Effective management was the third-most cited source of satisfaction, selected by 19% of respondents. Job scheduling (eg, flexibility) ranked fourth, cited by 17% of satisfied respondents, and compensation ranked fifth, cited by 11% of respondents in this group. Physicians (ie, surgeons or other physicians) and the culture of the respondent s group or organization ranked very closely, just outside the top five group; 10% of the respondents in the satisfied group identified each of these sources. An important caveat exists concerning management and surgeons or physicians in this analysis. Many respondents cited fellow employees as a source of satisfaction in a way that was impossible to accurately determine whether the group included their direct manager, managers, or surgeons and other physicians (eg, the people I work with, my colleagues ). Consequently, it is likely that managers and physicians are underrepresented as sources of satisfaction in the satisfied sample. By a substantial margin, management was the most frequently cited source of dissatisfaction. Approximately 44% of the respondents attributed their dissatisfaction to poor management. Inadequate compensation was the second-most cited source, identified by 28% of respondents. An excessive workload ranked third, cited by 18% of respondents. Inadequate staffing ranked fourth, as cited by 15% of dissatisfied respondents; the lack of demonstrated respect from the administration, physicians, or colleagues was the fifth-most cited source of dissatisfaction, selected by 10% of respondents in this group. Dissatisfaction with job scheduling (eg, lack of flexibility) and benefits ranked just outside the top five group, at 9% for each of these two sources of dissatisfaction. Inourview,theresultsofouranalysisofthissamplesuggest three insights. First, compensation, when inadequate, can be a substantial source of dissatisfaction. When compensation is AORN Journal j 489

15 BacondStewart December 2017, Vol. 106, No. 6 Figure 5. Trends in perceived changes in perioperative nursing activity (eg, procedure volumes) (2009e2017). adequate or better, however, it does not emerge as a significant satisfier. Pay ranked fifth among satisfied respondents (cited by 11% of respondents), and in many of these comments, pay was not listed as the only source and was not listed first among multiple sources of satisfaction. Second, the quality of management matters a great deal in influencing job satisfaction. Poor management was clearly the driving factor for almost half (44%) of the dissatisfied respondents; effective management placed in the top three sources of satisfaction, and that ranking is probably understated. Third, coworkers play an important role in job satisfaction. They ranked first among satisfied respondents by a large degree, and many of these commenters spoke warmly about their colleagues (eg, amazing, dedicated, committed to patients, like family ). Coworkers were cited as a source of dissatisfaction by only 6% of dissatisfied respondents. ECONOMIC TRENDS IN THE PERIOPERATIVE NURSING WORK ENVIRONMENT In each of the past nine years, we asked respondents whether they had seen any change in the level of activity at their facilities. The reported level of activity in the perioperative nursing environment declined slightly in the past year (Figure 5). The percentage of respondents reporting an increase in activity fell 5% from 55% in 2016 to 50% in 2017, and those reporting a decline in activity increased 2% from 20% in 2016 to 22% in To explore changes in perioperative nursing activity, nurses were asked whether they have seen a shift in procedure volumes. Approximately 72% of respondents reported a shift in procedure volumes away from inpatient treatments to ambulatory or same-day surgery (compared with 70% in 2016). Approximately 18% reported a shift from inpatient surgery to hybrid or interventional procedures (no change from 2016), and 35% reported a shift from ambulatory to inpatient surgery (compared with 36% in 2016). Approximately 12% saw a shift from ambulatory to hybrid or interventional procedures (compared with 13% in 2016). 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 5.9%, reflecting the first decrease in the percentage of vacant positions in four years. Since 2013, the median percentage had increased year by year: 3.1% in 2013, 3.6% in 2014, 4.7% in 2015, and 7.1% in Approximately 62% of high-level managers reported a moderate-to-crisis level effect that the shortage has had on their working environment (38% in 2012, 37% in 2013, 40% in 2014, and 55% in 2016). Among nurses in this year s sample, 73% shared this view, which continues the increase of the past several years (53% in 2010, 54% in 2011, 53% in 2012 and 2013, 60% in 2014, and 72% in 2016). These respondents were then asked to indicate the reasons for the nursing shortage at their facilities. The lack of qualified, experienced nurses was the most frequently cited reason (50%). Insufficient compensation and benefits were cited by 41% of the respondents, job-related psychological stress was indicated by 31%, and workload was the fourth-most 490 j AORN Journal

16 December 2017, Vol. 106, No Salary Survey commonly cited reason (29%). Besides entering retirement (28%), nurses are leaving because of the hours (27%) and facility budget constraints or timing (24%). Some concerns have been raised about the possibility that the nursing shortage may increase in the near future because too few nurses are entering perioperative nursing to replace those who are approaching retirement. To explore this possibility, we collected data from the past 11 years of AORN salary surveys and looked for trends. Although the approximate average age of our perioperative nurse respondents has remained within a narrow range of 47 to 50 years during this period, some shifts have occurred among the age groups. Since 2009, the number of nurses in the 50- to 59-year-old group has declined substantially, and the 40- to 49-year-old group has declined slightly; however, increases have occurred in the 25- to 29-year-old, 30- to 39-year-old, and 60- to 69-year-old groups. Given the increases in the younger groups, we do not expect the perioperative nursing shortage to be exacerbated by a general aging of these nurses. To understand how new perioperative nurses enter the field, we asked respondents directly. Most respondents (58%) said that they transitioned into perioperative nursing after working as an RN in a different specialty. Approximately one-third (31%) entered perioperative nursing from a non-rn field, and 7% said they entered perioperative nursing directly out of school. We asked respondents whether they were thinking of quitting their job in the next year. Approximately 26% (28% in 2016) of the sample indicated they were somewhat likely or very likely to quit. We then asked about the nurses plans after they quit. Among the nurses who were seriously considering quitting, 65% were thinking of changing employers (versus 63% in 2016) and 13% were planning to change careers but remain in health care (versus 14% in 2016). Approximately 12% of those likely to quit were planning to retire (3% of the total sample). Approximately 3% of those likely to quit were planning to change careers and leave health care. Approximately 2% might leave for personal reasons, including family, and might return later; 1% said they were leaving their jobs to attend school full-time. We asked respondents why they were considering leaving their jobs and then analyzed the reasons in three age groups: younger than 30 years old, 30 to 49 years old, and 50 years of age and older. Interestingly, the percentage of nurses who were somewhat likely or very likely to quit was similar across the three groups (29%, 25%, and 27% respectively). Dissatisfaction with the work environment or culture was the most frequently cited reason for respondents at least 30 years of age; this reason tied with compensation dissatisfaction as the top reason respondents less than 30 years old were considering leaving their jobs. For this youngest age group, a new opportunity for career advancement was the secondmost commonly cited reason. Compensation dissatisfaction ranked second for respondents in their 30s and 40s but was less of a factor for respondents at least 50 years of age. For these older respondents, dissatisfaction with their supervisor or manager was a more prominent factor and the secondmost frequently cited reason; retirement ranked third in frequency for this group. OPEN-ENDED COMMENTS ABOUT PERIOPERATIVE NURSE COMPENSATION In years past, we have asked respondents to provide any comments about perioperative nursing that they would like to express. This year, we narrowed the request to comments about perioperative nursing compensation. In total, 602 respondents provided comments containing information or opinions. As in previous years, dissatisfaction with compensation emerged as the predominant theme in the comments. This year, 79% of the commenters expressed dissatisfaction. Many respondents said that their pay does not reflect the amount of responsibility, increasing knowledge requirements, continually changing technology, physical and psychological stress, or the unique requirements of their jobs. As a general rule, most perioperative nurses are underpaid for the knowledge they are required to have, wrote one nurse. The OR is a constantly changing environment that requires a vast knowledge base, critical thinking skills, communication skills, a high energy level, and the ability to effectively deal with stressdall capabilities that are worth much more than an entry-level nurse. For the amount of work and time that we put into our profession, we are not compensated enough, explained a nurse. We are the silent heroes. Patients don t remember how well they were treated because of the medication they receive and so we are never praised or thanked during patient surveys. Another nurse agreed: I honestly feel that perioperative nurses are undervalued as a whole by health care. We work behind closed doors, we aren t easily visible to administrators, and we re rarely remembered by AORN Journal j 491

17 BacondStewart December 2017, Vol. 106, No. 6 patients and families. These factors combine to make us underrecognized and, therefore, undervalued. She continued: We are so valuable to hospitals. Operating rooms are the profit generator for most hospitals and they could not function without us, yet we are rarely recognized and compensated for our contributions and the amount of training we must have to do our jobs. As in previous surveys, several nurses asserted that OR nursing should be recognized as a specialization and compensated as such. Consistent with comments provided in the past years, several nurses provided perhaps the primary argument for obtaining specialty status: nurses outside the OR cannot effectively do the work of nurses inside the OR. The second point that some nurses provided about perioperative nursing as a specialty is the amount of training required to work effectively in the OR. A nurse commented, It requires at least six months of specialized training in the OR to become a qualified OR nurse. Another nurse added, It takes years to foster a new nurse. The comments about the profession as a specialization and the need for experienced nurses arguably are related to the following concern among respondents: the need to improve nursing retention because of the effect that experience has on nursing quality and, consequently, the need to provide retention-based compensation so that experienced nurses do not leave the hospital. Some nurses expressed frustration with training newly hired perioperative nurses who leave the hospital thereafter for better compensation. This situation may be linked to expressed concerns that perioperative nursing is not sufficiently covered in the curricula of nursing schools and other educational nursing programs. One nurse explained: Our facility spends so much money on orientation and training of new staff. Then they stay here for a year or two after getting the sign-on bonus completed, and they leave to make more money. Wouldn t it make sense to pay our staff better and make the signing bonus for more than two years so people put down roots? And don t hire new graduates for the OR, which many facilities in our city don t do. Another nurse wrote: Nurses mainly get raises when they change jobs. We should focus on the retention of our seasoned nurses. It s demoralizing for all of our staff when someone leaves for higher pay. Few want to precept when they see their hard work go out the door to a surgery center. One perioperative nurse suggested considering acuity of care in setting compensation for perioperative nurses: There is a difference in an OR nurse who has worked in ambulatory or L&D [labor and delivery department] and a nurse who has done complex neuro, robotics, cardiac, and hybrid cases. When hiring experienced employees, recruitment mainly looks at years of experience and not acuity of experience. It s difficult to recruit experienced staff who may not have lots of years of experience but their experience is from an advanced center. Several nurses expressed concerns with on-call policies that centered on the amount of call required, compensation, and the limits that on-call duty places on the lives of nurses away from the job. Said one nurse: As time goes by, it is much more difficult to recover from call where, for day nurses, the hours are long or in the middle of the night. Having a weekend shift team would save money by having less overtime compensation. Although the large majority of commenters stated concerns about compensation, approximately 9% of commenters expressed their satisfaction with their compensation; one nurse asserted, It s not all about the money. Another nurse wrote, We want to be paid for our work, knowledge, expertise, and experience, but money doesn t help us sleep at night. The respect and acknowledgments from supervisors for our individual and team accomplishments are more valuable. I ve worked at places where there was no recognition, and the morale was horrible. The increased pay is great, but being part of something important and that is appreciated is the real benefit. Another nurse said, We are not appreciated or compensated for all the work we do and the stress that we face on a daily basis. However, I stay in nursing because I love fixing people, which is what the operating room is all about. Editor s notes: Magnet is a trademark of the American Nurses Credentialing Center, Silver Spring, MD. CNOR and CRNFA are registered trademarks of the Competency & Credentialing Institute, Denver, CO. 492 j AORN Journal

18 December 2017, Vol. 106, No Salary Survey Reference 1. Cost of living data series: second quarter Missouri Economic Research and Information Center. Accessed August 14, Donald R. Bacon, PhD, is a professor of marketing at the University of Denver, CO, and a research associate at Rocky Mountain Market Research, Denver. 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. WRITE FOR THE AORN JOURNAL The award-winning, peer-reviewed AORN Journal is always looking for new authors to contribute their perioperative knowledge and expertise. Authorship provides a means to improve patient care, educate your colleagues, and continue your professional and personal growth. Transform what you do every day into a published AORN Journal article. Consider submitting an article today! The AORN Journal publishes the following article types: Clinical Management Research Quality Improvement Education Literature Review Concept Analysis For more information on author guidelines, visit For editorial assistance, please contact us at aornjournal@aorn.org. AORN Journal j 493