Posted by: John S Kiernan

Like most segments of the economy, the nursing industry is in a state of significant transition under the weight of major socioeconomic dynamics — from the aging U.S. population to the student-loan crisis to concerns about the future of key entitlement programs. But such concerns are not unique among recent graduates, regardless of industry.

More specific to nursing professionals are the various day-to-day demands placed on them, such as mandatory overtime, overstaffing, unionization and allegations of systemic disrespect. Despite those challenges, however, aspiring nurses have much to look forward to upon certification. Nursing occupations are some of the most lucrative careers with the lowest unemployment rates in the U.S. In fact, the industry is expected to grow at more than double the rate of the average occupation through 2024.

With such bright projections, WalletHub’s analysts took stock of the nursing industry to help registered nurses, particularly the newly minted of the bunch, lay down roots in areas that are conducive to both personal and professional success. We did so by comparing the 50 states and the District of Columbia across 18 key metrics that collectively speak to the nursing-job opportunities in each market. Below, you can check out our findings, expert commentary on the state of the nursing industry as well as the methodology we used to conduct this report.

1. Main Findings
2. Ask the Experts: The State of the Nursing Industry
3. Methodology

Main Findings

Embed on your website<iframe src="//d2e70e9yced57e.cloudfront.net/wallethub/embed/4041/nurses-geochart1.html" width="556" height="347" frameBorder="0" scrolling="no"></iframe> <div style="width:556px;font-size:12px;color:#888;">Source: <a href="http://ift.tt/2pvGkrV;  

Overall Rank	State	Total Score	‘Opportunity & Competition’ Rank	‘Work Environment’ Rank
49	Hawaii	39.54	50	20
50	Louisiana	33.27	49	51
51	District of Columbia	27.41	51	33

Ask the Experts: The State of the Nursing Industry

WalletHub turned to a panel of nursing-industry experts for insight into the future of the profession and how recent entrants into the market can navigate their way to a successful career. You can check out their bios and thoughts below.

1. What are the biggest issues facing nurses today?
2. What is the long-term outlook for the field of nursing?
3. What tips do you have for recent nursing school grads looking for a place to live and work?
4. What can local governments and health systems do to attract and retain high quality nurses?
5. Has the Affordable Care Act, or ACA, been a net positive or net negative for the work life of nurses?
6. Are unions beneficial to nurses?

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• Glenn Melnick Professor and Chair in Health Care Finance at University of Southern California, Sol Price School of Public Policy
• Deborah A. Raines Associate Professor in the School of Nursing at University at Buffalo
• Jagdish Khubchandani Associate Professor of Community Health Education at Ball State University
• Karen Cotter, PhD, RN Assistant Professor of Nursing at Oklahoma Baptist University
• Patricia Abbott Associate Professor in the School of Nursing, and Director of the Hillman Scholars in Innovation Program at University of Michigan
• Christopher Friese Assistant Professor in the School of Nursing at University of Michigan
• Bobbie Berkowitz Dean, Columbia University School of Nursing and Senior Vice President, Columbia University Medical Center
• Patric Schine Assistant Professor in the Marybelle and S. Paul Musco School of Nursing and Health Professions, and Interim Director of the Post Master's Doctor of Nursing Practice Program at Brandman University
• Norma A. Metheny Dorothy A Votsmier Endowed Chair in Nursing, and Associate Dean of Research at Saint Louis University
• Leslie Neal-Boylan Professor and Dean of the College of Nursing at University of Wisconsin-Oshkosh
• Cynthia Anderson Assistant Professor in the School of Nursing, and Coordinator of the CNS Program at California Baptist University
• Mary Elizabeth Mancini Senior Associate Dean for Education Innovation in the College of Nursing and Health Innovation at The University of Texas at Arlington
• Christina Melvin Clinical Associate Professor of Nursing at University of Vermont, College of Nursing and Health Sciences
• Erin Poe Ferranti Research Assistant Professor in the Nell Hodgson Woodruff School of Nursing at Emory University

Glenn Melnick Professor and Chair in Health Care Finance at University of Southern California, Sol Price School of Public Policy What are the biggest issues facing nurses today? Hospitals are big employers of nurses in the US. There is a shift in the hospital sector away from AA nurses to BSN (4 year). This may be due to increased complexity of the patient population. AA nurses are moving out of hospitals to nursing homes and other settings. A recent study found: Roughly 40% of the nearly 3 million registered nurses (RNs) in the United States have an associate’s degree (ADN) as their highest level of nursing education. Yet even before the recent Institute of Medicine report on The Future of Nursing, employers of RNs have increasingly preferred baccalaureate-prepared RNs (BSNs). The data reveal a divergence in employment setting: the percentage of ADN-prepared RNs employed in hospitals dropped from 65% to 60% while the percentage of BSN-prepared RNs employed in hospitals grew from 67% to 72% over this period. Many ADNs (Associate) who would have otherwise been employed in hospitals seem to have shifted to long-term care settings. What is the long term outlook for the field of nursing? The baby boomers will retire, creating opportunities. A recent study found that annual retirements from the nursing workforce will accelerate from 20,000, a decade ago, to near 80,000 in the next decade, as baby boomer RNs continue to age. We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce. Overall, we project that the registered nursing workforce will increase from roughly 2.7 million FTE RNs in 2013 to 3.3 million in 2030. But supply is also increasing. A recent study found: The total number of graduates with a baccalaureate or associate degree in nursing declined from 100,000 in 1996 to 77,000 by 2002, but then increased sharply, reaching approximately 184,000 in 2012. What tips do you have for recent nursing school grads looking for a place to live and work? Look at the supply and demand data and projections. There will be places where demand will outgrow supply and places without a lot of nursing programs, but aging/growing populations. Try not to go into big debt for education. Look for hospitals that have subsidized programs. What can local governments and health systems do to attract and retain high quality nurses? Wages and work conditions matter to nurses. Some states have mandated increased nursing ratios. This leads to increased wages and less work stress. What is the impact of the Affordable Care Act (ACA) on nurses? It should have a modest sustained increase on the demand for nurses. Are unions beneficial to nurses? Wages are higher in places with strong unions. No Cal is a good example. Deborah A. Raines Associate Professor in the School of Nursing at University at Buffalo What are the biggest issues facing nurses today? There are a number of issues facing nurses today. The issues I see as the biggest challenges are work environments and education.

• Work environments include issues such as work place violence, lack of resources – both equipment and short staffing and nurses working long hours. All of these issues compromise the safety and well-being of both the nurse and the patients. They also result in nurses leaving positions and at times leaving the profession.
• Education. Nursing continue to have multiple entry point for practice. While the population of learners seeking a degree in nursing has changed over the years, much of nursing education is still in a very traditional-hospital based model. In today’s complex healthcare environment, nurses are making critical decisions that impact patient well-being. Nursing education, both in preparing students for a career in nursing and in advancing the nurse’s professional growth as a nurse needs to use innovative teaching strategies and experience that build on the existing skills of the learner and build new skills and behaviors to facilitate the transition to the complex nursing practice environment. Nurses need to be educated and continually seeking new knowledge and the best evidence on which to base practice decisions and nursing care to promote the best outcomes for the patient, family and community.

What is the long term outlook for the field of nursing? Nurses are the largest single group of clinical healthcare professions in our healthcare system. RNs are educated to practice holistically and to view persons, families and communities as interrelated systems that keep people healthy and help people to heal. A number of sources predict continued job growth for nurses, but there are also predictions that the field of nursing may look different in the future. As a society, we need nurses; therefore it is important that we find new ways to bring the best and brightest into the profession and to continue to explore strategies to retain nurses in the workforce. As educators, we also need to explore ways to better prepare new nurses for the challenges of a complex and changing healthcare environment and the expectations of the practicing nurse. What tips do you have for recent nursing school grads looking for a place to live and work? Choose a nursing position that you are passionate about. Don’t take the job that pays the most or looks best on your resume. Accept the position where you want to be involved in the care of the patients, are valued as a member of the healthcare team and where you can see yourself making a difference. Nursing is hard work, both physically and emotionally. It is important that you love what you do – both for your own happiness and for the well-being of the patients you are caring for. What can local governments and health systems do to attract and retain high quality nurses? Recognize that nurses are educated professionals and valuable members of the healthcare team and make a significant contribution to patient outcomes. What is the impact of the Affordable Care Act (ACA) on nurses? Nurses need to be leaders in healthcare reform as the ACA transforms the focus of care from the treating of diseases to the promoting of health of individuals and populations. This will change the places nurses work, the tasks being performed and their role in patient care. Nurses currently in the work force need to prepare themselves for these changes and Schools of Nursing need to adapt their models of nursing education to prepare students for the evolving role of the nurse and the changes in the healthcare system. Jagdish Khubchandani Associate Professor of Community Health Education at Ball State University What are the biggest issues facing nurses today? Even though the number of nurses has generally increased in the US, there is still a shortage of nurses. In addition, there are vast geographic disparities in availability of nurses. Coupled with shortage of nurses, the existing nursing workforce has a large proportion of nurses who are above the age of 50 and may not remain active in the workforce for long. This has led to increase in the cost of nursing education and increase in the cost of professional nursing care for healthcare facilities and patients. Also, shortage of nurses leads to increased workload and burden on working nurses. As the US is becoming increasingly diverse in relation to population demographics, disease variety, and lifestyle issues of patients, nurses need to be acclimatized to such population changes and acquire a reasonable amount of cultural competence to function in diverse environments for patients with diverse needs. However, there is still a shortage of minority nurses and cultural competence training is highly lacking, which poses challenges for nurses. The health of nurses in the US should be better than the average US population due to education and better knowledge of health. However, recent studies have pointed out the high burden of lifestyle related diseases and unhealthy behaviors in nurses. This in part, could be due to heavy workload and stress. I see that as another challenge to maintaining a healthy nursing workforce. What is the long term outlook for the field of nursing? The long term outlook for the field of nursing is very promising. For all types of nurses, the number of jobs will grow from 10-20% in the next decade. What tips do you have for recent nursing school grads looking for a place to live and work? Recent graduates in the healthcare workforce should look at best places to live, high salaries, and good benefits (e.g., healthcare, retirement, and education). However, this has led to further shortage of healthcare professionals in the rural and underserved areas as these places do not offer the most attractive work and life benefits. I would recommend that recent graduates look at areas of high demand and provide service in these areas. Rural and underserved America has high healthcare needs and new graduates can certainly have good exposure to patients and great opportunities for learning in such areas. Also, recent graduates can bring a lot of current knowledge and innovative practices to the rural and underserved areas, where they are needed the most. Recent graduates should also look for continuing education opportunities and opportunities to develop leadership skills. Engaging in the local community is another way to contribute to healthcare by providing expertise and education. Finally, nursing is a very stressful profession. New graduates should remember that their career is not supposed to be a sprint, but a marathon. Therefore, maintaining a good work-life balance, acquiring a healthy lifestyle, and pursuing their own creative and leisure time interests is of paramount importance. What can local governments and health systems do to attract and retain high quality nurses? There are several initiatives required to recruit and retain nurses at the local level. First, always hire the best, even if the cost is higher. Second, provide good work-life benefits and flexibility (e.g., good health insurance, life insurance, retirement, opportunities to buy cheap cinema tickets, car insurance, local store discounts, etc.). Third, provide continuing education and continuous professional development (e.g., training on newer technology). Fourth, engage nurses as stakeholders in management issues. Fifth, constant support from management helps retention (e.g., addressing issues such as emotional demands, role ambiguity and conflicts, work-family conflicts, effort-reward imbalance). Sixth, build a culture of trust, appreciation, collaboration, and respect. Finally, organization and industrial psychology literature provides numerous examples on how to recruit, retain, and maintain a healthy and productive nursing workforce. What is the impact of the Affordable Care Act (ACA) on nurses? There are many independent and intertwined impacts of ACA on nurses. Some key facts to consider:

• American population is ageing and life expectancy has grown.
• American population has more chronic diseases than ever.
• ACA has provided insurance to 15-20 million Americans who did not have it earlier.
• The number of people with insurance is projected to grow.
• The healthcare costs are increasing, but the quality is not increasing as much.

Overall, these facts pose a heavy demand on the healthcare workforce because more individuals will seek access to healthcare and that too, high quality care. As of now, this would make nurses deal with more patients and sicker patients. So, they will have greater demands. In the long run, this can be addressed by increasing nurses in the workforce and recruiting and retaining high quality nurses. Are unions beneficial to nurses? Yes and no. Hospital managements have to look at profits. Therefore, for them, every employee can sometimes be just a number. Practices such as employee layoffs, fewer salary raises, and increasing workloads for employees are used by hospital managements to make profits. If there are unions, nurses can certainly advocate for themselves and demand salary raises and better social protection in their jobs. The bad side is that most unions will not be or are not effective. Most of the times, hospital and healthcare facility management will do as they prefer. In addition, unions need heavy dues and fees, which may not be well appreciated by nurses. Finally, the moral argument may go against nurses if they demand something by forming unions - aren’t nurses supposed to help? Care? Serve? Why would they make a union for example, for greater rewards? Karen Cotter, PhD, RN Assistant Professor of Nursing at Oklahoma Baptist University What are the biggest issues facing nurses today? I think the biggest issue facing nurses today is the shortage which results in difficult working conditions and high stress. There are also issues of workplace violence which are well documented, with hospitals being high on the list of places that assault and battery are likely to occur. This is attributed to the stress of the patient/family dealing with an illness, and the nurses dealing with workloads that are at times, unreasonable. Compounding the shortage is that new nurses entering the profession frequently do not receive adequate support and will leave the practice of nursing within the first 12 months after completing their licensure. What is the long term outlook for the field of nursing? The long term outlook for nursing is good, if nurses can learn to work to their full educational preparation. Registered Nurses with a Bachelor of Science should be working in units and in communities where they can impact health outcomes in measureable ways. Nurses who are in advanced practice roles, with masters or doctoral degrees need to be working for legislative changes to give them full authority as care providers. With the Affordable Care Act and the increase in people who have access to the health care delivery system, we need a corresponding increase in the number of providers to give that care. What tips do you have for recent nursing school grads looking for a place to live and work? Nursing school graduates should seek positions that offer support to the new graduates. Oftentimes these programs are called residency programs. These programs provide education/emotional support/ and extended work alongside a more experienced nurse as they progress through their first year of practice. What can local governments and health systems do to attract and retain high quality nurses? I think that you could attract high quality nurses by offering loan repayment programs to nursing graduates. Many nursing students have to take out student loans to pay the expense of the professional program. Loan repayment programs could also lead to retention of those nurses, in terms of requiring a commitment of time to the agency giving the loan repayment assistance. What is the impact of the Affordable Care Act (ACA) on nurses? The Affordable Care Act, increased access to the health care system by making health insurance mandatory, and therefore increasing the number of individuals who can utilize the health care delivery system. This cascades to an increased number of nurses who are needed to care for those individuals (those nurses are not in abundant supply), therefore contributing to difficult workloads. Along with the ACA are new measures that impact health care systems reimbursement based upon patient satisfaction scores. This element is difficult for some nurses because the interventions that must be completed at times, to promote recovery of the client, are difficult and unpleasant to patients. Therefore they leave dissatisfied, even if the interventions were given to promote recovery and were in their best interest. Nurses feel they have to balance doing the right thing for the client, and working to increase patient satisfaction scores for the financial solvency of their employing health care system. Are unions beneficial to nurses? Unions can be beneficial to nurses if they are unions that understand nursing practice. Unions try to unite nurses and speak for nurses, and can allow their voices to be heard. However, if they are represented by a company that does not understand nursing or nursing practice, then the union is not a fair representation of the issues and needs of those health care professionals that they are being paid to represent. A number of years ago, a generic labor union approached nurses in the Tulsa, OK area, and I am not sure that they ever came to represent the nurses or group because a contract could not be completed for labor relations between the hospital and the union. There are other states that the nurses are unionized and it works well for them - in terms of having their voice heard, but these groups have nurses speaking for them, not just generic labor unions. Patricia Abbott Associate Professor in the School of Nursing, and Director of the Hillman Scholars in Innovation Program at University of Michigan What are the biggest issues facing nurses today? This depends on your practice area. For nurses working with vulnerable populations in low-resource areas (or in conflict zones), the most pressing issues could be resources and safety. Working in the Ebola wards is extremely dangerous – and when compounded with limited resources and supplies, the job of the nurse can become one of a martyr. In conflict zones, the Red Cross or Red Crescent insignias can serve as a bull’s-eye or a target. For nurses working in states that prohibit advanced practice registered nurses (APRNs) from practicing at their full level of training and education - the inconsistency in state regulations for practice is both frustrating and disheartening. The ability to access high quality care is a looming problem in the US, and States that impose barriers to the provision of this care by restricting the practices of APRNs flies in the face of the evidence. No studies show that the quality of care deteriorates in those states that have broader scope of practice for APRNs – in fact the Institute of Medicine provides overwhelming evidence to the contrary. As the US population ages, and fewer and fewer physicians choose primary care, family medicine, or gerontology as a practice area – where does that leave all of us boomers? Apathy after the honeymoon. Getting stuck in a rut or mired in the mundane. Of course, I guess we all face that – right? Funding for advanced education, particularly doctoral study, is a major challenge for nurses. The US is suffering badly from a dearth of nurse scientists who are needed to help understand and drive the new models of care that our changing society and healthcare system requires. The compression of NIH funding for nursing & healthcare sciences (I am not talking about narrow disease specific funding portfolios) is impacting our higher education system in unexpected ways. Without extramural funding to help support the education of nurse scientists (larger grants often have “slots” for trainees who work on the research while funding their tuition), the production of new nurse scientists is falling. Nursing Schools on University campuses are often an afterthought of the Boards and Presidents who allocate campus-wide funding. Unlike Schools of Medicine who supplement University funding with revenue affiliated faculty practices and clinics, Schools of Nursing (who do generate practice revenue in large part) are more reliant on grants, contracts, gifts, and tuition – increasing the dependence on extramural funding. Schools of Nursing need corporate and industrial partners with interest in the areas of science that nursing excels in. What is the long term outlook for the field of nursing? Terrific. Every day in the US, 10,000 people turn 65. We have a Silver Tsunami on the horizon. Our population is aging, has an increasing rate of obesity and chronic diseases, and families are often separated by hundreds or thousands of miles. The US needs a team of dedicated providers and family partners (coupled with innovative technology) to help us manage what is already upon us – and projected to reach crisis stage in short order. I believe we have 4 Million +/- residential care beds in the US and 77 Million Baby Boomers. These people will all need care, and it will not be in an acute care facility or in a nursing home. It will be in their community or in their homes – and I believe that nursing (who has always been in the homes and communities) will be critical to the management of patients outside of brick and mortar. I am a nurse informatician – so of course I see huge opportunity for nurses who are also technically savvy. What tips do you have for recent nursing school grads looking for a place to live and work? Study the job market and the economic stability of the area where you may want to live and work. With that said, some of us have a higher calling – and head right off to those high risk areas where we see the greatest human suffering. I do think that you should chase your dreams while young – because age and complacency and comfort can become a tar pit from which you may not escape later. We need more PhD nurses who can drive the science agenda – so continue the education and do it now, before you get too comfortable. What can local governments and health systems do to attract and retain high quality nurses? Honor their work, harmonize with the robust scientific evidence showing the value of APRNs who are practicing within their educational and licensing capacity, and work on uniformity in state regulations for nursing practice across the entire US. What is the impact of the Affordable Care Act (ACA) on nurses? The ACA really encourages team-based care and has increased the availability of funding for primary health care workers, many whom have been nurses. This has meant additional funding (albeit insufficient) for nursing workforce development programs, geriatric education programs, the enhancement of community health centers, and many other systems to support the care that is so desperately needed in our communities. As noted earlier, the lack of a strong primary care system in the US is already problematic, and the increase in chronic disease, obesity, age, combined with a decrease in the family unit as a system of care is pointing to the need for urgent action. I think that the ACA is a wake-up call that is beginning to put some funding where it needs to be. With that said, it is not perfect – but I believe a basic human right is access to affordable care. Christopher Friese Assistant Professor in the School of Nursing at University of Michigan What are the biggest issues facing nurses today? Nursing in 2016 faces two critical challenges: an aging workforce and a less healthy patient population. The aging nurse workforce threatens our ability to deliver care to our patients. Long hours and stressful work lead nurses to leave the workforce and many are not replaced. Last year, US nursing schools reported over 1,300 vacant faculty positions, which resulted in denying 70,000 qualified applicants for admission. This potential gap in the supply of nurses comes at a time of an aging population with complex health needs. Patients need nurses to manage the complex care of people with multiple chronic conditions. Research studies have shown we need well-prepared nurses throughout our healthcare system to care for these vulnerable patients. What is the long term outlook for the field of nursing? Now is a great time to consider nursing, as job demand is high and there are great opportunities to specialize. The US Department of Labor ranked nurse practitioners (NPs) as the seventh fastest-growing occupation for 2014-2024. Nurse practitioners complete a graduate degree and provide primary or specialty care. In many states, nurse practitioners can practice independently without direct physician supervision. National and state policy efforts have focused on expanding access to these practitioners across 50 states. Between 2014-2024, the Department of Labor estimates over 400,000 new jobs for registered nurses, the second highest occupation. Nurse practitioners and registered nurses are often well-paid and have good benefits. What tips do you have for recent nursing school grads looking for a place to live and work? We know from research studies that the first job for nurses can be stressful. I recommend new graduates seek out hospitals and health systems that have achieved Magnet Recognition. Magnet-recognized facilities have focused their organization on supporting professional nursing practice. My research has shown they also have better patient outcomes. Many of these programs have intensive training (residency) programs to support newly-graduated nurses and reduce burnout from a potentially stressful job. Nurse practitioner graduates can review the map of states with the most favorable policies toward advanced practice nursing. NPs in states with "full practice authority" can practice independently without supervision and are often in higher demand from employers. I also encourage new nurses to join their appropriate specialty organization so they can stay up to date on the latest research in their clinical area. Networking is important to a fruitful career. What can local governments and health systems do to attract and retain high quality nurses? If we want better healthcare for the population, we need to invest in policy solutions and environments to support nursing. Despite a 2010 landmark report by the National Academy of Medicine, far too many states have laws that restrict NPs from delivering care that patients need. We have made progress, but many states continue to restrict NPs from caring for patients independently. Hospitals and health systems are under tremendous financial pressure. Administrators cut nursing positions or reduce the resources for patient care. This may help the short-term bottom line, but it leads to a vicious cycle of low morale, stress, and nurse resignations due to insufficient staffing. The challenge for hospitals and health systems is to improve efficiency without cutting critical personnel or services. We have learned that cutting nursing leads to care that is often more expensive and results in poorer care for patients. What is the impact of the Affordable Care Act (ACA) on nurses? There are many positive impacts of the ACA on nursing that the public may not have noticed. Nursing student loan availability has increased, as has funding for nurse-managed primary care clinics. Reimbursement boosts for primary care have also benefited NPs and other advanced practice nurses, like certified nurse midwives. There have also been promising trial projects to improve nurse practitioner training programs that were funded through the ACA. Perhaps the largest impact of the ACA is the millions of previously uninsured persons who now have access to care. We are seeing increased volume in primary care and emergency department settings as these patients enter the formal health care system. Are unions beneficial to nurses? There are pros and cons to unions for nurses. Unions have helped project the concerns of nurses over unsafe staffing levels and working conditions. Unions also provide nurses with clear expectations for salary, benefits, and grievance management. On the other side, nurses have reported conflicted feelings when labor negotiations fall flat. The threat of a strike can be very disruptive to health systems and patients. Fortunately, strikes do not happen often. Our research has shown repeatedly that open communication between management and front-line clinicians is the key to better, safer care. No matter where nurses choose to work or whether they choose to be in a union, this is a key question to ask their manager: "How involved are nurses in the decision-making on this unit?" Bobbie Berkowitz Dean, Columbia University School of Nursing and Senior Vice President, Columbia University Medical Center What are the biggest issues facing nurses today? One of the most critical challenges we face is a result of the variation in scope of practice regulations across the US. Depending on where a nurse practices, their ability to practice to the level at which they were educated is predicated on the regulations within that state. This limits their ability to provide the full range of care they are skilled to perform. We see this most often with advanced practice registered nurses (APRNs) (nurse practitioners, certified nurse anesthetists, certified nurse midwives, and clinical nurse specialists) but it can also apply to registered nurses. Policy on scope of practice for registered and advanced practice nurses needs a national perspective so that nurses can move across states knowing that they are able to practice to their full scope. A second challenge is the growing complexity of healthcare environments. As a result, there is increased demand for nurses to be both clinically and technically skilled, particularly when it comes to care of the critically ill. The complex health environments however, reach far beyond the technical innovations. For example, nurses must be adept at implementing culturally competent and evidence based interventions for patients. As we understand more about disease processes, nurses are primarily responsible for the patient’s engagement and activation of their own health that will lead to enhanced outcomes. And finally, we need to invest in science. Nurse scientists are instrumental in developing the knowledge base for a wide range of interventions applied across populations and within communities. These include management of symptoms for an array of diagnoses and care strategies such as palliative care, behavioral health, chronic disease, injuries, infectious disease, and more. Nurse scientists are forging pathways in precision medicine, data science that informs population health, policy solutions, and the technology to measure and report on patient outcomes. We must continue to groom scientists who advance knowledge, advocate for research funding, and pave the way for future nurse scientists; who in turn ultimately define how, where and for whom we practice. What is the long term outlook for the field of nursing? The outlook is strong. We are the future of primary care; care that integrates teams of providers focused on keeping populations healthy and partnering with patients to manage and control their illness, whether episodic or chronic. These are the professional registered nurses and advanced practice nurses of the future who will influence the design and implementation of best practices in primary care. Future health systems will turn to nurse leaders for the intelligence on quality and patient outcomes and the knowledge to design care environments where performance is consistently focused on evidence-based patient outcomes. The nurse leader of the future will have a combination of skills based in nursing science, clinical practice, systems, technology, environments, health economics, health policy, legal/ethics, equity, justice, communities, and a keen sense of the human experience. What tips do you have for recent nursing school grads looking for a place to live and work? A new professional registered nurse who wants to practice within a health care system should think seriously about finding a position with a hospital that has or is in the process of seeking the Magnet designation. The Magnet Recognition Program® was developed by the American Nurses Credentialing Center to recognize health systems that have a demonstrated commitment to quality patient care, nursing excellence, and innovation in professional nursing practice. As such, these health care environments are among the best in the world for evidence based practice, clinical quality, and patient safety and satisfaction. In addition, because independent practice can be challenging to the novice APRN with its many system requirements (finance, billing practices, quality measures/improvement, patient flow and productivity), I recommend that newly minted APRNs find a practice with a strong mentoring program and the commitment for a post-graduate residency period that is focused on integrating the new APRN into the practice, understanding the patient population, building skills and structured learning opportunities. I also recommend that the APRN seek a position that utilizes registered nurses as care partners with nurse practitioners. Patric Schine Assistant Professor in the Marybelle and S. Paul Musco School of Nursing and Health Professions, and Interim Director of the Post Master's Doctor of Nursing Practice Program at Brandman University What are the biggest issues facing nurses today? At this point in time, the market is saturated with good, qualified nurses. The demand will definitely rise in the future but right now, some nurses are having a difficult time finding a job… especially new grads. This, in turn, can lead to lower paying jobs in a setting that the nurse is not particularly fond of. What is the long term outlook for the field of nursing? The long term outlook for the field of nursing is amazing. Nurses have gained significant grounds in their profession over the past few decades. By continually basing their practices in evidence based health care, they have become ‘realized’ as a profession to be dealt with on par with that of physicians. Nurse educators and researchers continue to add to the body of evidence on which the foundations of nursing practice rely. Also, the innovative role of Advanced Practice Nursing has exploded over the past 10 years, especially with the adoption of the Doctor of Nursing Practice degree and course of study. As frequently reported in the news and other media outlets, Nurse Practitioners are poised to become the staple of Primary Care within the near future. What tips do you have for recent nursing school grads looking for a place to live and work? It’s all about getting your foot in the door. When nursing students (at any level) are in their clinicals, they should be networking and promoting themselves. Employers love to see that enthusiasm. Also, as far as finding a place to live, nurses might consider traveling nursing assignments. These assignments are generally short term, but offer some exotic locations with good pay. What can local governments and health systems do to attract and retain high quality nurses? Nurses must be paid well by their employers and given the opportunity to advance in their careers with full support. Nurses are often generous, kind and respectful individuals and employers should treat them with the same respect they deserve. Governments must also be educated on the roles of nurses and must have the foresight to understand the advances that the nursing profession is making and create laws and regulations accordingly. What is the impact of the Affordable Care Act (ACA) on nurses? With more people having access to health care, the demand for services has certainly increased. More people are getting procedures done and covered by their insurances… procedures that they haven’t had access to for many years. This has increased the overall need for skilled nursing in the acute care setting. Are unions beneficial to nurses? Historically, nursing unions have been quite effective in representing and protecting the rights of nurses. As a result, nurses who are part of a union generally have great benefits that include health insurance, paid time off, and the offering of a significant retirement plan. You will often hear of the ‘nursing strikes’ in the news, but these strikes are necessary for those nurses within a union in order to provide adequate, market-level pay and benefits. These are benefits that nurses without a union will often find themselves without, and generally non-union nurses will have a lack of acceptable representation. Norma A. Metheny Dorothy A Votsmier Endowed Chair in Nursing, and Associate Dean of Research at Saint Louis University What tips do you have for recent nursing school grads looking for a place to live and work? I encourage my students to look for hospitals with the best residency programs to help them transition from an academic setting to the ‘real-life’ role of a nurse. Schools of nursing often compete for practice sites for students – as a result, educational experiences in practice settings may be limited. This means students need time to practice under the guidance of experienced nurses after graduation to hone their nursing skills. When students are not tied to a specific geographic area, I encourage them to seek out a university-affiliated hospital (preferably one with Magnet status). These are the settings where practice is best and new graduates can continue to learn and become better nurses. What can local governments and health systems do to attract and retain high quality nurses? The typical answer is ‘greater pay’ – however, I think it goes beyond salary. We need to get away from the mentality that ‘a nurse is a nurse is a nurse’ and begin recognizing the need to reward dedicated nurses with advanced knowledge and skills. Too many nurses are leaving practice for more rewarding careers and it is damaging our profession. What is the impact of the Affordable Care Act (ACA) on nurses? In my view, the ACA has opened doors for nurse practitioners to grow in numbers and independent practice. And, in general, there are more job opportunities for nurses in clinics and community health centers because the ACA encourages outpatient care whenever feasible. Are unions beneficial to nurses? I understand the frustration that bedside nurses feel when they are not allowed sufficient time and resources to provide safe care to their patients. However, I feel that unions demean the nursing profession. In my view, nurses should organize more around their state and national professional organizations to put pressure on hospital administrators to provide better working environments. Leslie Neal-Boylan Professor and Dean of the College of Nursing at University of Wisconsin-Oshkosh What are the biggest issues facing nurses today? According to the 2016 Institute of Medicine report assessing progress on the IOM report “The future of nursing,” the biggest issues confronting nursing today are: Barriers to practice and care: We need to continue to work with other professional groups, communities and policy makers to remove remaining restrictions on nursing scope of practice. Registered Nurses get paid differently based on location and many work very long hours. Advanced Practice Registered Nurses (APRNS) (Nurse Practitioners, Certified Nurse Midwives, Certified Nurse Anesthetists, and Clinical Nurse Specialists) continue to have scope of practice restrictions in some states. For example, a Nurse Practitioner may require physician supervision in one state and be able to practice independently in another state. It is also vitally important that the public be able to differentiate a registered nurse from others who are not professional nurses. There is a lot of research to show that RNs improve patient outcomes. However, the public still frequently mistakes others for the professional nurse. Achievement of higher levels of education: Since 1965, the nursing profession has had a goal of the Bachelors of Science degree in Nursing (BSN) as the degree required for entry into practice as a registered nurse. However, we have been unsuccessful in reaching this goal largely due to financial constraints on students and hospitals. Many rural areas do not have access to baccalaureate degree granting institutions and that is an additional barrier. We now have a goal of 80% of RNs with a BSN by 2020. Our universities work closely with community colleges to articulate associate degree prepared nurses into BSN programs. We also have developed bridge programs to help transition Licensed Practical Nurses into BSN programs. Promoting diversity: Workforce assessments reveal that minorities and people from diverse backgrounds are underrepresented in nursing. Schools of nursing are working hard to recruit and retain students and faculty from diverse backgrounds. Collaborating and leading in care delivery and redesign: The nursing profession is striving to achieve recognition for nurses as leaders in healthcare and in the boardroom. In addition to increased interprofessional collaboration within healthcare environments, we need to collaborate more with business and policy leaders. We have added curricula on leadership, business, finance, entrepreneurship, and organizational behavior to better prepare nurses for these roles. Workforce data infrastructure: The profession needs to collect more and detailed workforce data and combine our efforts to make these data useful as we plan for the future. What is the long term outlook for the field of nursing? The long term outlook for nursing is generally very good. At some point or another, everyone needs or will need a nurse. However, our nurse educators are aging. It takes a long time to achieve a doctorate and traditionally, nurses have been in clinical practice for several years before returning to school for the doctoral degree and to teach. We have started to encourage nurses to obtain graduate degrees earlier in their careers and to consider teaching. Even so, many nursing programs are suffering from reduced budgets and limited resources. If we do not have the faculty or infrastructure to be able to educate future nurses, the quality of healthcare will suffer significantly in the future. We also need grants to help us recruit people from diverse backgrounds and help support them and all of our students and nurses to be successful. What tips do you have for recent nursing school grads looking for a place to live and work? There are nursing jobs available for new graduates. However, the school from which one graduates plays a role in how and when a new graduate will be hired. NCLEX (nursing board exam) pass rates are a significant indicator of the quality of the nursing program. Board certification pass rates are an important indicator for graduate certificate programs such as the Nurse Practitioner. Nursing programs develop their reputation among employers based on the quality of the students they admit and retain and on their NCLEX and certification scores. So my first tip is to attend a good program with NCLEX and certification scores above 90%. My second tip is to apply to employers who have good relationships with your school of nursing and who know the quality of the program from which you graduated. My third tip is to explore settings other than the hospital for your first job. There are so many things to do in nursing. The majority of patients we care for are in the community. You can get excellent nursing experience working in community non-hospital settings. Hospitals often want nurses with experience and this is a great way to get that. What can local governments and health systems do to attract and retain high quality nurses? Local governments can advocate for higher salaries for Registered Nurses, APRNs and nurse educators. They can support increased funding to programs that train BSN prepared Registered Nurses and APRNs. They can speak out against budget reductions for these programs. In addition, they can advocate for funding to the arts and sciences within colleges and universities. Nursing education requires a strong foundation of the liberal arts, such as history, literature, sociology, and the arts. If funding is restricted to the arts and humanities, then nursing programs can lose that foundation and their accreditation. They should support the elimination of barriers to practice such as supervisory and collaborative practice agreements required in some states for APRNs to practice. Health systems can commit to only hiring BSN prepared nurses and to paying a higher salary to BSN prepared Registered Nurses than to those who are less educated. They should build solid orientation and nurse residency programs that help prevent new nurse burnout and significantly increase new nurse retention. They should have a no tolerance policy for workplace violence and microaggression. They should ensure adequate staffing so nurses are not overworked to the point of wanting to quit the facility and leave the profession. Interprofessional teams that work well together should be developed and encouraged. What is the impact of the Affordable Care Act (ACA) on nurses? Nurses are, first and foremost, patient advocates and are often the first people with whom patients have contact when entering the health care system. Consequently, nurses have had the role of explaining and interpreting the ACA to patients and families. While it has been a much needed advance to provide insurance to the previously uninsured, there are many people who are insured under the ACA who still have hefty copays and deductibles. This has resulted in different patient populations for our community clinics who treat the poor and underserved. Now, our free and sliding scale community clinics are partnering with health systems to say “You perform the initial workup to determine the patient has diabetes [for instance] and we will give them all of the education they need to learn how to live with diabetes.“ The health systems still only have 15 minutes to assess and treat the patient but our clinics can see the patient for free and help them understand and manage their disease. Unfortunately, not every community has one of these clinics so it is still hard for many patients to access high quality care. Cynthia Anderson Assistant Professor in the School of Nursing, and Coordinator of the CNS Program at California Baptist University What are the biggest issues facing nurses today? An increasing time crunch (do more in less time). The expectation by hospital administrations is that the addition of technology improves not only safety but efficiency and therefore requires less nursing time. This is not the case. If you look at the medication pass process alone, scanning of each medication and patient wrist bands, retrieving medications from the med room, providing patient teaching on the indications and side effects of each medication, it has taken the process from approximately 15 minutes per patient to upwards of 45 minutes per patient. For a Telemetry nurse, this means 45 minutes times 4 patients or 3 hours for initial medication passes during a 12 hour shift. This is only part of the day that includes: preparing patients for procedures, answering phone calls from family, physician, laboratory, pharmacy; completing computerized charting on each patient, ensuring hygiene and nutrition for each patient and any additional medication pass. And this is not an exhaustive list… Administrators need to improve the work environment substantially or continue to see high levels of turnover among new nurses (some estimates are as high as 70%). We have an aging population. The need for skilled, competent nurses has never been greater. What is the long term outlook for the field of nursing? Excellent. The push to advance entry level education to the Bachelor degree level and the addition of the doctorate level for advanced practice is expected to bring improved recognition and negotiating power for the practice of nursing within healthcare institutions. What tips do you have for recent nursing school grads looking for a place to live and work? I would encourage pursuing employment in facilities with the Magnet designation. These facilities have demonstrated a proven investment in creating a healthy work environment and in advancing nursing. What can local governments and health systems do to attract and retain high quality nurses? Ensure that nurses are represented on committees at all levels of government in issues regarding the provision of healthcare. What is the impact of the Affordable Care Act (ACA) on nurses? The ACA has had a huge impact on the use and need for advanced practice nurses, particularly nurse practitioners. Access to healthcare is greater but the numbers of available providers is well below that need. Are unions beneficial to nurses? I think unions have provided a much needed voice for nurses who have traditionally not been able to put forward a unified front regarding the improvement of the work environment. Mary Elizabeth Mancini Senior Associate Dean for Education Innovation in the College of Nursing and Health Innovation at The University of Texas at Arlington What are the biggest issues facing nurses today? The focus on enhancing the educational level of nurses in this country – Recognizing its impact on patient safety and enhancing patient outcomes, the Institute of Medicine in its report on the Future of Nursing made recommendations focused on increasing the percentage of nurses holding a Baccalaureate degree or higher from ~ 40% in 2010 to 80% by 2020. To meet this ambitious goal it is required that individual nurses make a commitment to advance their education. This requires that they have access to affordable and high quality nursing programs designed to meet the needs of practicing nurses. Stress of working in the healthcare field – Regardless of specialty or location, nurses are facing significant stress related to caring for high-acuity patients and the increasing demands of a rapidly changing healthcare field. Ensuring that our nurses have the support they need and the personal resiliency to deal with the high stress environment is critical to maximizing the health of individuals and communities. What is the long term outlook for the field of nursing? Excellent – nurses are increasingly in demand for positions in the healthcare field. The U.S. Bureau of Labor Statistics projects that more than 430,000 additional registered nurse positions will be created in the decade 2014-2024. The Texas Center for Nursing Workforce Studies estimates that demand for registered nurses in the Lone Star state will rise by 86 percent by 2020. What tips do you have for recent nursing school grads looking for a place to live and work? There are many opportunities for new graduate nurses – whether they are new to the profession or having just completed an advanced degree. If there are not positions available locally or in the specific specialty that one prefers, new graduates should be willing to look at alternative locations – such as those outside a metro area or alternative care settings such as long-term care – where positions are available. What can local governments and health systems do to attract and retain high quality nurses? Achieving and maintaining an adequate supply of appropriately qualified nurses to meet the needs of a region or the nation requires action from local/state/federal governments. Specifically, it requires support for student financial aid and competitive salaries for nursing faculty. Right now, nursing schools across the country have a hard time attracting qualified faculty because most nurses with master’s or doctoral degrees can get better paying jobs in healthcare systems or in the corporate world. What is the impact of the Affordable Care Act (ACA) on nurses? The ACA has increased the need for more nurses with advanced practice degrees to meet the primary care needs of newly insured populations. In many rural areas, there is a growing demand for nurse practitioners because they are licensed to do many of the things primary care physicians can do. In these communities, there is often a shortage of primary care doctors. Also, the role of nurses is becoming more critical as our healthcare system, spurred in part by the ACA, places more of an emphasis on prevention. Christina Melvin Clinical Associate Professor of Nursing at University of Vermont, College of Nursing and Health Sciences What are the biggest issues facing nurses today? Increasing shortage of nurses - I don’t have the exact stats but I believe there are more RNs older than the age of 50 rather than under the age of 30. Increasing shortage of nursing faculty - this is an emerging issue. Finally, the changing demographics - by 2030, 20% of the population will be age 65 and older. I think that if we want to attract nurses and keep them, our wages need to increase. Few people understand the magnitude of our responsibility. What is the long term outlook for the field of nursing? I think the future of nursing is just great. Around the country, applications to schools of nursing have risen dramatically, often outnumbering the available capacity. What tips do you have for recent nursing school grads looking for a place to live and work? Look wide and keep your chin up. It often takes a few months to secure a job. Be persistent! What can local governments and health systems do to attract and retain high quality nurses? Nursing traineeships to help offset the loans for student nurses. Loan Forgiveness Models whereby if a new graduate works for a few years in one place, his/her loan will be reduced by a certain amount. Are unions beneficial to nurses? Absolutely. Historically, nurses have been taken advantage of. The very characteristics that draw us to nursing also put us at risk for being taken advantage of, i.e., caring, compassion, desire to help others, etc. Erin Poe Ferranti Research Assistant Professor in the Nell Hodgson Woodruff School of Nursing at Emory University What are the biggest issues facing nurses today? Some major issues facing nurses are the aging and retirement of our profession and a shortage of doctorally prepared faculty in our schools of nursing. As a profession, we are still also challenged by multiple routes of education preparation at the RN level – we have long needed to standardize the baccalaureate degree as the entry into practice. What is the long term outlook for the field of nursing? I believe the demand for high quality nursing leaders at all levels (BSN, MSN/NP and doctorally prepared) will continue to grow. With the implementation of the ACA and a greater focus on public health, primary care and care management, there is also a shift in the settings where nurses will be employed – moving to more outpatient and community-based settings. What tips do you have for recent nursing school grads looking for a place to live and work? My tips are to find a setting that is going to be a good match with your interests, and that especially will provide an adequate new graduate training or residency program. Another important component is to seek out settings that are highly collaborative across the interdisciplinary health care team and implement shared governance models in their organization. What can local governments and health systems do to attract and retain high quality nurses? Nurses are retained in settings where they are valued, participate equally within the interdisciplinary team of providers, and are able to practice at the full scope of their license and preparation. What is the impact of the Affordable Care Act (ACA) on nurses? The ACA is shifting care from acute care, hospital settings to outpatient, community settings. This is creating a greater demand for public health nurses who provide population-focused care, community-based nurses and nurses with skill in care management, case management, and home-based care. Are unions beneficial to nurses? I think it depends on the setting. I think what is most beneficial to nurses is to practice in settings with models of shared governance and strong interdisciplinary team collaboration.

Methodology

In order to determine the best and worst states for nurses, WalletHub’s analysts compared the 50 states and the District of Columbia across two key dimensions, namely “Opportunity & Competition” and “Work Environment.”

We evaluated those dimensions using 18 relevant metrics, which are listed below with their corresponding weights. Each metric was graded on a 100-point scale, with a score of 100 representing the most favorable conditions for nurses.

We then calculated the total score for each state and the District based on its weighted average across all metrics and used the resulting scores to construct our final ranking.

Opportunity & Competition – Total Points: 70 Work Environment – Total Points: 30

 

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