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This post is part four in an eight part continuing education series on Surviving Nursing. 

Part one. 

Part two.

Part three.

THE NURSING EXODUS HAS A LOT OF PEOPLE TALKING ABOUT MONEY

By this point it’s a well-known problem. In the US and globally, healthcare systems are facing a nursing exodus. Prompted by a complicated series of historical and social trends, and accelerated by the pandemic, in recent years nurses have been leaving an already short-staffed profession faster than they’re being replaced. There’s already a critical worldwide nursing shortage. In the US, studies are forecasting this will continue to get worse across the next decade. 

In this context, the topic of money comes up in interesting and complicated ways. 

For nurses themselves, money has become an emotional and moral issue as much as a practical one. Even if we’re working harder than we can sustain, most of us work for organizations that make a lot of money. During the pandemic, and now due to the ongoing staffing crisis, we’re acutely aware that our job requires us to regularly put our physical health, mental wellbeing, and even life at risk. It keeps the question at the front of our minds, why shouldn’t we get a cut of the profits from this? Why should we have to exhaust ourselves at work, then go home and worry about money? Why shouldn’t we be able to afford to live in the expensive cities where our employers are located? You hear the term “comparable worth” - isn’t the value of what we bring to our employers (and society) higher than the administrators at our hospitals whose average salaries more than double ours? (I’m not talking about CEOs here - I’m talking about average administrator income.)

NURSING PAY AND ADMINISTRATOR PAY

For organizational leadership, the issues around money in the modern healthcare environment are different.

I have a friend who works in HR doing financial compensation data analysis. She knows a lot about how big organizations dole out their money through pay and bonuses. 

We were discussing pay inequity in large organizations– specifically why money gathers at the tops of organizations and is unequally distributed. One of the things she told me is that if an organization is making money, leaders can easily justify higher executive pay and bonuses because it can take many months, or even years to replace these folks at the top. But people in the frontlines–those who are actually doing the work–are replaceable within 2-3 months. 

To be clear, my friend and I weren’t talking about health care. Her job is in tech. But the same line of thinking exists inside the healthcare industry. 

But that’s cold.

And it stung. 

But here’s what’s more important. For a second I internalized the feeling that administrators actually were more valuable to organizations than nurses. 

I checked myself. We need to be careful of what stories are allowed to be told, especially at the tops of organizations. 

When leadership crafts a story that over-inflates the value of administrators and undervalues those who do the work inside organizations (and by proxy the patients who they are meant to serve), it leads to obscene outcomes. This sort of reasoning, for example, explains why leaders at the American Hospital Association felt justified asking Congress to investigate high travel nurse pay during the pandemic, ignoring administrator costs. 

It’s also why hospital administrator pay has ballooned while nurses and their unions fight for measly salary increases that barely keep up with inflation. For example, the CEO of Hospital Corporation of America made over thirty million dollars in 2020. The average nurse salary is between 50-$100,000 dollars depending on where you are in the country. An advanced practice nurse’s salary might be double that max. 

By dollars alone, this would indicate that healthcare systems feel like a CEO’s value is at least 300 times more than a nurse. Imagine what your job would be like if there were 300 more nurses working at your hospital. Is that the kind of value that a CEO brings to the table?

If this isn’t a lesson in power, I don’t know what is.

An executive team of leaders convinces the people who control the purse strings that they are irreplaceable. The organization then feels justified funneling disproportionate amounts of money to the top.

In her excellent book Taking Care, Sarah DiGregorio said, “Unlike the correlation between nurse staffing and patient outcomes, researchers have found NO correlation between hospital CEO pay and hospital mortality, readmission rates, or value to the community.” 

I think as nurses we can smell what’s rotten here. We know it’s unethical and flat out wrong. 

Let’s not forget that this is patients' money, which is meant to be paying for their care delivery. 

When top-paid leaders collect millions of dollars in bonuses, what is actually happening is that organizations are stealing money from their patients. (They’re also robbing the nurses and staff who are doing the work by intentionally short staffing them, creating burnout environments, and setting up the conditions that exacerbated the nursing exodus in the first place.) 

When it comes to pay, nurses need to recognize that we are among the most irreplaceable, invaluable parts of the health care system. We cannot be swapped out and we need to be ready to spot these types of arguments and counter them. 

(By the way, the book Bullshit Jobs talks about how nursing will never be a bullshit job because nurses are out here doing the work. Read it. If you have any doubt about the importance of what you do as a nurse, it will reassure you.)

FOR NURSES, MONEY IS ABOUT FAIR COMPENSATION

For nurses, salary is most obviously about the question of fair compensation for what we’re asked to endure and the essential service we provide. 

As Sarah DiGregorio says, “You can treat me poorly or pay me poorly, but not both.”

Employers also talk a lot about nursing pay these days. Maybe I’m being cynical, but my impression is that employers care much less about the moral and emotional concerns around fair compensation. I don’t think they’re intentionally trying to make our lives worse, but I also don’t think they typically care much about the things that we do. The main issues for administrators are how to best run their business, and what pay equation will net the most profits. It’s generally agreed that turnover is expensive, and is therefore bad for business, so the nursing exodus is creating headaches for them. However, these are fundamentally numbers issues, not moral ones. 

The questions you'll find in business discussions about nursing pay are things like: How much do we decide to budget for nursing salaries vs. other expenses? How likely are nurses to quit if we don’t increase that budget? How much money will it cost us if they do quit vs. if they stick around? How much will negative PR cost us if nurses strike vs. if we keep strong-arming them? How much does burnout cost us vs. safe staffing? These are the sorts of financial questions that come up in business contexts. 

(Side note–you don’t usually hear people saying the gross parts out loud, but every once in a while you will get a whiff in business articles of the sentiment that, “Well, maybe it makes financial sense to just keep letting them burn out.” If you’re a nurse, elements of articles like this will send you into a rage spiral.)

This difference in values and priorities is one of the reasons that pay is such a contentious and important issue for nurses. It's important for nurses to understand why businesses behave the way that they do. It's also important for us to stick to our convictions about what is right when it comes to nursing pay when businesses inevitably behave in ways that are not in our best interests or the best interests of patients. 

HARD TRUTH: INCREASED WAGES WON’T FIX THE NURSING EXODUS

These sorts of discussions are mainly focused on wages. How much should nurses & APRNs get paid to come to work? 

For nurses, and for businesses, wages are an important discussion. Globally and historically, nursing has been underpaid compared to other similar professions. Also, increased pay is correlated with improved retention, at least in the short term. Improved retention is good for businesses. There’s a solid argument to be made that higher nursing pay leads to more people entering the field, and more nurses hesitant to leave it.  Generally speaking, by increasing nursing wages in the midst of all of this mess, everyone wins. 

But wages aren’t the whole discussion when it comes to money and the nursing exodus.

In the midst of all of the discussion around wages, there’s a stubborn problem you find when you look at the data. In short, nursing burnout rates are not significantly impacted by increased wages.  

Overall, increased wages are correlated with decreased overall life stress. Also, at least in the short term, increasing wages improves nurses’ sense of job satisfaction and decreases their desire to leave their job. 

However, many of the key factors that ultimately drive nurses out of the field don’t change with wage increases: toxic work environments, unsafe staffing ratios, and low levels of control over important decisions in the workplace. 

It makes sense. It’s not our paycheck that burns us out. It’s the work itself. Even if they’re paying us more to be thrown to the wolves, we’re still being thrown to the wolves.

The factors that drive the nursing exodus are complicated, so all of us - nurses and healthcare leadership - have a complicated problem to solve across the next few decades. Wage increases are part of that solution, but only one part. Factors like improving our work environment, improving staffing ratios, improving interactions between nurses, doctors, and administration, and giving nurses more input into crucial decisions in the workplace are just as important–if not more so.

THE FINANCIAL PROBLEM NO ONE IS TALKING ABOUT: HOW DO WE USE OUR MONEY TO SURVIVE THE NURSING EXODUS?

The hard news for those of us in the field is that the problems driving the nursing exodus are not likely to be solved in our lifetime – or at least in the time that we’ll be in the field. They’re likely to get worse during the next decade.

That raises a different question for nurses about money, which is entirely absent from most of these types of discussions. That is, 

How do we manage our money in a way that will allow us to survive in the midst of a nursing exodus?

The problem nurses face is that our situation is very hard. A huge number of us are leaving, and won’t make it to retirement in this profession. These things are difficult to measure accurately, but multiple reports say that nurses burn out at a rate higher than any other profession. Even if our wages increase, we won’t see the benefits because we can’t emotionally and physically handle it any more.

In all likelihood, if you’re a nurse, you will be impacted by this. You may burn out as well. You may not last long enough in the field to reach traditional retirement age. You may not last the next five years if you have to keep working full time in these conditions. 

Our financial reality is that regardless of wage increases, we may not earn at our current level throughout our lives because we may not be able to handle working the hours or jobs that we do now.

So, our dilemma - alongside the wage question - is how do we prepare for this reality financially?

It’s a significant stressor for many nurses I speak with directly, but I have never heard this topic discussed in HR or benefit or even union conversations about money. 

But it is what we will talk about in the next post!

HIGHLIGHT: A NURSE ENTREPRENEUR LEVELING THE PLAYING FIELD ON PAY TRANSPARENCY

In a competitive job market, nurses need more pay transparency, and we deserve to be able to find the top paying jobs that will let us stretch our salaries the furthest. 

When I asked Veronica Cooper, founder of Stellar Nurse, about this, here’s what she said. 

“StellarNurse was important for me to create because me and my fellow travel nurses were all struggling with the same issues. We didn't have enough pay transparency and we didn't have objective market overviews so that we could land the highest paying jobs and feel confident that we're getting the best deal.

I started travel nursing in 2016 and I quickly realized that we nurses were on the short end of a power imbalance in this job market. Our nursing skills are in critical need and our inboxes are full of travel nursing job offers, yet our employers have more access to job market information than we do. Even to see full job details on open offers, we have to give up all of our contact info only to be spammed into eternity with low paying jobs that aren't even worth a click.

The travel nursing job market releases 15,000 new jobs every day and there's a large variability in pay across specialties and locations that change and update week to week. How can we nurses feel confident that we're getting paid our value if we don't understand a nurse's worth in this job market?

This knowledge gap results in mistrust and resentment between our employers and us travel nurses. My travel nursing friends and I trade tips to avoid getting lowballed and we help look over each other's contracts so we don't get stuck in a bad deal. I started tracking pay packages on a spreadsheet years ago so that I wouldn't get taken advantage of either. We're always on high alert when we're discussing jobs with these agencies to avoid getting scammed.

But if we make pay more transparent, and if we share knowledge, then that makes everyone feel valued, and it gives everyone the same access to information and opportunities.

On StellarNurse, nurses can find all the highest paying travel nursing jobs in one search. And we have clear job market overviews to make spotting the best deals easy. This is information that has not been available to us nurses until now. Nurses can view pay trends going back all the way to July 2019, which is pre COVID, to see how our pay has changed through the years.

StellarNurse helps redistribute power back to the nurse by providing pay transparency and clear market data. This knowledge helps us understand our worth, a nurse's worth, in this job economy. StellarNurse also allows nurses to message hiring agencies anonymously to make sure the best deals are legitimate before giving up your contact info.

I built StellarNurse to help us nurses make informed career decisions, stretch our salaries, and negotiate our pay from a place of confidence and knowledge.”

I write about some of the things you need to know on this blog, but it’s not just what you know when it comes to finances, it’s what you do. Helping you change your financial behavior and therefore change your life isn’t something I can accomplish just on a blog, but it is what my program, Ultimate Nurse Investing, does for nurses. If you want to get started down that path, click here.

STUDIES AND ARTICLES CITED IN THIS POST

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Bae, Sung-Heui. “Noneconomic and economic impacts of nurse turnover in hospitals: A systematic review.” International Nursing Review vol. 69,3 (2022): 392-404. doi:10.1111/inr.12769

Bahlman-van Ooijen, W., Malfait, S., Huisman-de Waal, G., & Hafsteinsdóttir, T. B. (2023). “Nurses' motivations to leave the nursing profession: A qualitative meta-aggregation.” Journal of Advanced Nursing, 79, 4455–4471. https://doi.org/10.1111/jan.15696

Bimpong, Kweku Andrew Ampadu et al. “Relationship between labour force satisfaction, wages and retention within the UK National Health Service: a systematic review of the literature.” BMJ Open vol. 10,7 e034919. 21 Jul. 2020, doi:10.1136/bmjopen-2019-034919

Bland-Jones, C., Gates, M. “The Costs and Benefits of Nurse Turnover: A Business Case for Nurse Retention,” The Online Journal of Issues in Nursing, Vol 12, No. 3, September 2007. DOI: 10.3912/OJIN.Vol12No03Man04. https://doi.org/10.3912/OJIN.Vol12No03Man04

The Gender Pay Gap in the Health and Care Sector: A Global Analysis in the Time of COVID-19. Geneva: World Health Organization and the International Labour Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.

Eastabrook, D. (2023) “Report forecasts mass exodus by registered nurses by 2027,” McKnights Home Care. Available at: https://www.mcknightshomecare.com/report-forecasts-mass-exodus-by-registered-nurses-by-2027/ (Accessed: 14 March 2024).

Kaur, A. (2023) “10 degrees that lead to the worst burnout from work,” Study International. Available at: https://studyinternational.com/news/burnout-from-work/ (Accessed: 14 March 2024).

Lovell, V. (2006) “Solving the nursing shortage through higher wages.” Institute for Women’s Policy Research. Washington, D.C.: Institute for Women’s Policy Research.

McHugh, Matthew D, and Chenjuan Ma. “Wage, work environment, and staffing: effects on nurse outcomes.” Policy, Politics & Nursing Practice, Vol. 15,3-4 (2014): 72-80. doi:10.1177/1527154414546868

Nursing Shortage or Exodus?. AJN, American Journal of Nursing 122(3):p 12-13, March 2022. | DOI: 10.1097/01.NAJ.0000822928.16774.9a 

Snee, H., & Goswami, H. (2021). “Who Cares? Social Mobility and the ‘Class Ceiling’ in Nursing.” Sociological Research Online, 26(3), 562-580. https://doi.org/10.1177/1360780420971657

Tymkiw, C. (2022) Comparable worth: Meaning, equal pay, what’s next, Investopedia. Available at: https://www.investopedia.com/what-is-comparable-worth-5115639 (Accessed: 14 March 2024).

Whitmore Schanzenbach, D. et al. (2023) “Money Lightens the Load,” The Hamilton Project. Available at: https://www.hamiltonproject.org/publication/paper/money-lightens-the-load/ (Accessed: 14 March 2024).