2017’s Best & Worst States for Nurses

May 3, 2017  |  John S Kiernan, Senior Writer & Editor

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.

Best States for Nurses

1. Wisconsin
2. New Mexico
3. Iowa
4. Texas
5. Colorado
6. North Dakota
7. Delaware
8. Utah
9. Arizona
10. Washington
11. Minnesota
12. Idaho
13. Oregon
14. Maine
15. Virginia
16. New Hampshire
17. Illinois
18. Nebraska
19. Rhode Island
20. South Carolina
21. Connecticut
22. Missouri
23. Montana
24. Michigan
25. Kentucky
26. Wyoming
27. Vermont
28. Tennessee
29. Maryland
30. North Carolina
31. South Dakota
32. Florida
33. Kansas
34. Arkansas
35. Indiana
36. Oklahoma
37. California
38. West Virginia
39. Pennsylvania
40. Mississippi
41. Massachusetts
42. Nevada
43. Georgia
44. Ohio
45. New Jersey
46. Alaska
47. Alabama
48. Louisiana
49. New York
50. Hawaii
51. District of Columbia

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?

Allison P. Squires

Associate Professor, Rory Meyers College of Nursing and Research Assistant Professor, School of Medicine, New York University

What are the biggest issues facing nurses today? 

The biggest issues depend on the role of the nurse. For staff nurses on the frontline of patient care delivery (e.g., hospitals, primary care clinics, home care), getting the right balance of nurses to deliver care is an ongoing challenge. Electronic health records (EHRs) have also complicated our work. EHRs are rarely designed by nurses nor do their architects seek input from frontline nurses often enough when under development. So, many nurses are spending lots of overtime or unpaid time after work trying to meet all the documentation requirements. This takes them away from the patients. With the patient experience now more important than ever, time away from patients to document detracts from their experiences. There’s a balance to be had there through better usability studies of EHRs that involve frontline nurses and not just risk managers. 

Nurses are also having more data placed in front of them every day. Good hospitals, for example, are letting staff know things like fall rates, patient satisfaction, etc. This can be helpful for addressing care issues, but it can also be used punitively against nurses by management who may not understand how to appropriately interpret changes in data that are normal. To illustrate, say the rate of falls that happens on a unit increases by 5% in one month. What usually happens is management freaks out and addresses the problem in various ways. The thing is, a 5% increase could be within the range of normal fluctuations of fall rates on the unit. Techniques like statistical process control can help managers and administrators determine when a fluctuation is normal, and when it needs to be a concern. That way, data is used proactively to address real problems while continuous quality improvement helps ensure there aren’t too many fluctuations happening outside the norm. 

Home care nurses are facing increased demand for services through the whole country. Since the Affordable Care Act encourages patients to receive more care in the home, home care is a major growth industry in health care but since it pays slightly less than hospitals and usually requires 2 years of patient care experience, it is harder to recruit nurses for those roles. 

For nurse practitioners, their main challenge is gaining full scope of practice rights in all 50 states. Currently, there are restrictions on nurse practitioner practice in every U.S. state, which means they cannot all practice the same way in every state. With the shortage in primary care, Nurse Practitioners are poised to fill in the gaps in the field since NP programs graduate up to 10 times as many primary care providers in a year compared to medical schools. 

Other roles in nursing all have their specific issues too. There is always a need for competent managers and those managers need to be able to hire qualified RNs to meet their needs. There is a shortage of faculty nationally, so we need more doctorally prepared individuals who can fill faculty roles so we can produce the number of nurses we will need to replace retiring baby boomers. 

Finally, a common issue facing all nurses is language barriers between themselves and their patients. In just about every part of the country, language diversity is increasing as immigrants and refugees make new communities. Many places have little experience caring for individuals with a language barrier so the supply of medical interpreters and bilingual healthcare providers is not keeping pace with demand. New regulations in the Affordable Care Act also forbid discrimination based on language or country of origin and place new requirements on health care facilities to make every effort to bridge the communication gap. So, every day nurses have to care for patients with language barriers and there isn’t always the resources and experience to do that well. 

What is the long term outlook for the field of nursing? 

The long-term outlook for nursing is excellent! The Department of Health and Human Services forecasts a shortage of nurses in 16 states, mostly in the Midwest and South. Nursing in the U.S. also has so many career options that when people join the profession now, they are sometimes overwhelmed by their choices. 

What tips do you have for recent nursing school grads looking for a place to live and work? 

Move away from where you went to school since you’re more likely to get a job in your first choice area. Some markets in the U.S. are oversaturated with nurses willing to work there. These include NYC, Boston, Philadelphia, San Francisco, and Seattle. It’s hard to get a job in those cities right out of school unless you know someone or are willing to work in a non-academic medical center. 

The other piece of advice I like to give is to use a cost of living calculator or pay check equivalent calculator. In New York City, our graduates get really excited about $85K starting salaries as a new graduate. They don’t realize that between their student loans and rent costs, more than 50% of their paycheck will be eating up by those two costs -- to live in a studio apartment. Most new graduates don’t know they can start at a lower salary in another city, like Atlanta, and get paid $70K but live close to work and have a nice, spacious one bedroom apartment. 

It’s also important that new grads avoid a long commute (more than 30 minutes). A number of recent studies have showed that 12-hour shifts are bad for the health of nurses and can adversely affect patient outcomes. The reason is because a 12 hour shift turns into a 16 hour + day. Between the commute, time spent after the shift ends documenting in the EHR, and then commuting home --sometimes by an hour or more -- the day gets long. A nurse that has to return the next day may have slept 6h or less, which research shows is not optimum for function for most people. Minimizing commute time is really critical. 

Finally, I recommend that new graduates trust their instincts about how they felt about an interview. If something in their gut is telling them it’s not the right place or right fit for them, go with that. Better to have the right fit and be happy. 

What can local governments and health systems do to attract and retain high quality nurses? 

For organizations, retention is all about the same things the basic management literature has identified for any business. Treat people with respect. Support them when there is a crisis. Develop a non-punitive environment so people can make a “great catch” instead of being punished for mistakes that may be the result of system issues. Give people an opportunity to stay positively engaged in their work and advance in their careers. Get rid of toxic people, no matter how many years they have worked there. Their experience is not worth high turnover rates because they are miserable individuals to work with for most people. 

Governments can best help by creating ways to keep student loan costs down. Nurses with high student loan debt often want to take the highest paying position, which disadvantages certain markets. Through sustaining or even increasing nursing student funding, student debt decreases and doesn’t become a recruitment barrier. 

Has the Affordable Care Act (ACA) been a net positive or net negative for the work life of nurses? 

Total net positive. Patients are less likely to be uninsured so there is less concern about them not being able to get the care they need. That means, for example, if they get hospitalized they aren’t as sick. Plus, fewer uninsured patients means hospitals can actually afford to hire the staff they need to care for patients and ensure good patient satisfaction. 

Are unions beneficial to nurses? 

This is a complicated answer, which is sometimes. When unions are run by nursing organizations, I’d say they’re better for nurses overall because the people running them understand their needs better. Other unions are more of a mixed bag. Non-nursing unions rarely have nurses, or women for that matter, in leadership roles and I think that disadvantages nurses overall. Keep in mind, of course, that if a hospital or other location has a union, it is because at some point there was bad management that forced nurses to organize for better working conditions so they could better care for patients.

Elaine L. Smith: Acting Dean in the College of Nursing and Public Health at Adelphi University

Carole R. Myers; Associate Professor in the College of Nursing at University of Tennessee and Secretary/Treasurer of the Tennessee Action Coalition

Allison P. Squires: Associate Professor, Rory Meyers College of Nursing and Research Assistant Professor, School of Medicine, New York University

Elaine L. Smith

What are the biggest issues facing nurses today? 

There are several issues that affect nurses today. First, is the major shift occurring from in-patient care to ambulatory/home care. The changing nature of where care is being provided requires nurses to acquire new skill sets that take into account out of hospital care environments. Assisting patients and families as they traverse levels of care is a priority for nurses -- new roles have been emerging that support this process -- such as patient navigators or care coordinators. The continuing technology explosion requires nurses to become familiar with an ever-growing number of applications and tools. Tele-health and remote monitoring are becoming more prevalent and nurses need the knowledge and skill to interface with these and other technological advances. 

Certainly, the anticipated wave of nursing retirements is a major concern. Labor statistics point to a growing shortage of nurses -- both to replace vacated positions and to fill newly created roles. An area of emphasis for nurses is the concept of health literacy -- being able to assist patients and families in understanding their care, treatment and self-maintenance skills. As the patient populations become increasingly more diverse, nurses will need deeper understanding of the ways to support the health and wellness of many different populations. Also, the growing prevalence of mental illness and associated issues will place a focus on providing both primary care and behavioral health care in tandem. Nurses will need a broader understanding of the spectrum of mental illness. 

From a policy perspective, registered nurses and advanced practice nurses are often restricted in their ability to function at the full scope of their education due to regulatory restrictions. There is a current shortage of nursing faculty that is getting deeper -- who will be there to prepare our next generation of professionals? 

What is the long term outlook for the field of nursing? 

The long-term outlook for the field of nursing is very bright. The employment market is strong with demand for nurses outpacing the supply. In particular, the areas of ambulatory care, home care and perioperative nursing will be in demand. Hospitals will be looking for more specialized critical care and Emergency department nurses. Nursing roles in interventional areas are likely to grow as well. Nursing faculty and nursing researchers prepared at the doctoral level will be in great demand. Strong growth for Nurse Practitioners and other advanced practice nurses is projected -- the Nurse Practitioner role was rated the #2 job by U.S. News and World report. 

What tips do you have for recent nursing school grads looking for a place to live and work? 

I think new graduates should think about a few things: What area of nursing appeals to me right now? Where do I see myself in 2-3 years? Will graduate study be in my future? Answers to these questions and others can guide a new nurse into the right job. New graduates may not always get their dream position right away -- that is OK. Every position offers an opportunity to learn and grow. When looking at a position it is important to think about what resources are available to support a new graduate entering practice -- is there a robust orientation program and preceptors willing to assist? What growth opportunities exist within the organization -- committee work, shared governance models, promotion potential, and continuing education availability? 

Magnet designation indicates that there is a strong nursing service dedicated to excellence -- these organizations are often great places for nurses to work. Nursing allows for great career and geographic mobility -- with an abundance of jobs anticipated in the coming years across all areas of the country, nurses can have their pick of assignment and location. To fulfill their career goals, additional continuing education or academic degrees may be needed. 

What can local governments and health systems do to attract and retain high quality nurses?

Many organizations are committed to healthy work environments that promote a focus on employee health and wellness. This often includes a value system promoting a positive work/life balance. Magnet designated healthcare facilities and systems have demonstrated a track record of exemplary patient care outcomes and infrastructures that support nursing empowerment. Using the Magnet guidelines as a framework, more facilities could achieve positive workplace changes that support nursing practice. 

Nurses are empowered through organizational structures that promote their involvement in practice decision making, peer review, research and inter-professional collaboration. Nursing requires a commitment to lifelong learning, organizations that provide tuition support for degree completions or new degrees promote a positive culture. Highly educated nurses improve patient care outcomes. Local and state government scholarships, low interest loans and loan forgiveness programs can make a difference in the academic progression of nurses. More nurses prepared at the masters and doctoral levels are needed to fill clinical, education and research positions.

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

• Monthly Average Starting Salary for Nurses: Full Weight (~6.67 Points)
• Note: This metric was adjusted for the cost of living.
• Average Annual Salary for Nurses: Double Weight (~13.35 Points)
• Note: This metric was adjusted for the cost of living.
• Health-Care Facilities per Capita: Full Weight (~6.67 Points)
• Share of Population Living in a Primary-Care HPSA: Full Weight (~6.67 Points)
• Note: “HPSAs,” as defined by the Health Resources & Services Administration, “are designations that indicate health care provider shortages in: Primary care; Dental health; or Mental Health” and “may be geographic-, population-, or facility-based.”
• Projected Share of Elderly Population in 2030: Full Weight (~6.67 Points)
• Note: “Elderly population” includes adults aged 65 and older.
• Educational Opportunities Based on Quality of Nursing Schools: Half Weight (~3.33 Points)
• Share of Licensed Nursing Professionals Not Working in Nursing Field: Full Weight (~6.67 Points)
• Nursing-Job Openings per Capita: Full Weight (~6.67 Points)
• Nurses per 1,000 Residents: Full Weight (~6.67 Points)
• Projected Competition in 2024: Full Weight (~6.67 Points)
• Note: “Competition” refers to the number of nurses per 1,000 residents.

Work Environment – Total Points: 30

• Mandatory Overtime Restrictions: Full Weight (~4.29 Points)
• Ratio of Nurses to Hospital Beds: Full Weight (~4.29 Points)
• Presence of Nursing Licensure Compact Law: Full Weight (~4.29 Points)
• Note: This metric considers the presence or absence of a Nursing Licensure Compact law in the state. The compact allows nurses to practice in their home state and other participating states.
• Share of Best Nursing Homes: Full Weight (~4.29 Points)
• Note: This metric is based on U.S. News & World Report’s Best Nursing Homes rating.
• Quality of Public Hospital System: Full Weight (~4.29 Points)
• Note: This metric is based on data from the Centers for Medicare & Medicaid Services.
• Friendliness Toward Working Moms: Full Weight (~4.29 Points)
• Note: This metric is based on WalletHub’s Best & Worst States for Working Moms ranking. In 2011, there were 3.5 million employed nurses in the U.S., and about 3.2 million were female.
• Average Number of Work Hours: Half Weight (~2.14 Points)
• Average Commute Time: Half Weight (~2.14 Points)

Sources: Data used to create this ranking were collected from the U.S. Census Bureau, Bureau of Labor Statistics, Council for Community and Economic Research, HRSA Data Warehouse, Center on Education and the Workforce, Indeed.com, National Council of State Boards of Nursing, Centers for Medicare & Medicaid Services, U.S. News & World Report, Projections Central - State Occupational Projections, American Nurses Association and WalletHub research.

Editorial Disclaimer: Editorial content is not provided or commissioned by financial institutions. Opinions expressed here are the author’s alone and have not been approved or otherwise endorsed by any financial institution, including those that are WalletHub advertising partners. Our content is intended for informational purposes only.