Career Marginality


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Career Marginality Characteristics and employment situation of registered nurses who work in long-term care facilities and hospitals
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viii, 171 leaves : ill. ; 28 cm.
Schultz, Ronald C
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Subjects / Keywords:
Nurses -- United States   ( lcsh )
Geriatric nursing -- United States   ( lcsh )
Nursing homes -- United States   ( lcsh )
Long-term care of the sick -- United States   ( lcsh )
Medical care -- United States   ( lcsh )
Sociology thesis Ph.D
Dissertations, Academic -- Sociology -- UF
bibliography   ( marcgt )
non-fiction   ( marcgt )


Thesis (Ph. D.)--University of Florida, 1989.
Includes bibliographical references (leaves 155-170)
Statement of Responsibility:
by Ronald C. Schultz.
General Note:
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University of Florida
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oclc - 22249695
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Appreciation is owed to Dr. Michael Radelet,

supervisory committee chair, and to committee members Dr.

Gordon Streib, Dr. Lee Crandall, Dr. John Henretta, Dr. Gary

Lee, and Dr. Melody Marshall. Also to be acknowledged is

Dr. Felix Berardo, Department of Sociology Chair, who kindly

substituted for Dr. Crandall at the oral examination of the

dissertation. Gratitude is expressed to Mrs. Nadine Gillis

for preparing the manuscript in the final editorial form

acceptable to the University of Florida Graduate School.

Thanks go to family members, who provided a personal

computer so that the dissertation could be more easily

composed. Lastly, a special acknowledgement goes to my

wife, Linda, for patience and assistance during the course

of this dissertation.



ACKNOWLEDGEMENTS...................................... ii

LIST OF TABLES........................................ v

ABSTRACT................................................. vii


1 INTRODUCTION....................................... 1

Problem.............................................. 1
Scope and Purpose of the Study..................... 8

2 REVIEW OF THE LITERATURE............................ 12

The Professional Registered Nurse................... 12
Social Structural Factors Related to Health Care
for Elderly People: The Long-Term Care Facility
Versus the Hospital.............................. 15
Social Psychological Factors Related to Health Care
for Elderly People.............................. 29
Individual Characteristics Related to Nursing Care
for Elderly People.............................. 37

3 CONCEPTUAL FRAMEWORK............................... 44

4 METHODS............................................ 58

Data............................................... 58
Sample Characteristics............................. 59
Variables.......................................... 61
Prediction Equations and Hypotheses................ 69
Statistical Analysis............................... 75

5 RESULTS................................ ............ 87

Demographic Characteristics of RNs................. 88
Employment Characteristics of RNs.................. 89
Logistic Analysis.................................. 95


6 SUMMARY AND DISCUSSION............................ 128

Implications of Logistic Regression Findings........ 130
General Observations.............................. 133
Limitations of the Study and Possibilities for
Further Research................................ 144

APPENDIX................................................ 150

REFERENCES.......................................... 155

BIOGRAPHICAL SKETCH................................... 171


Table Page

1 Registered Nurses by Work Setting and Age.......... 80

2 Registered Nurses by Work Setting and Highest
Education Level................................. 80

3 Registered Nurses by Work Setting and Current
Enrollment in an Academic Degree Program........ 81

4 Registered Nurses by Work Setting and Participation
in Continuing Education........................ 81

5 Registered Nurses by Work Setting and Employed
in 1979........................................ 82

6 Registered Nurses by Work Setting and Employment
Status ................... ..... .... ........... 82

7 Registered Nurses by Work Setting and Percent of
Time Employed in Nursing Since Graduation from
Basic Nursing Education Program................. 83

8 Registered Nurses by Work Setting and Marital
Status......................................... 83

9 Registered Nurses by Work Setting and Children
Living at Home.................................. 84

10 Registered Nurses by Work Setting and Job
Location Change. ................................ 84

11 Registered Nurses by Work Setting and Career
Line............................................ 85

12 Employed and Unemployed Registered Nurses.......... 85

13 Registered Nurses 1980 by Field of
Employment...................................... 87

14 Demographic Characteristics of Registered Nurses
by Work Setting.............................. 90

15 Employment Characteristics of Registered Nurses
by Work Setting................................. 91
16 Type of Position by Education: Hospital
Registered Nurses............................... 93

17 Type of Position by Education: Long-Term Care
Facility Registered Nurses...................... 94

18 Independent Variable Statistics for Long-Term Care
Setting Main Effects Logistic Regression
Model.......................................... 97

19 Independent Variable Statistics for Long-Term Care
Setting Interaction Logistic Regression
Model........................................... 98

20 Logistic Transformation Values for Long-Term Care
Setting Interaction Multiple Regression Model... 101

21 Career Line by Education........................... 110

22 Independent Variable Statistics for Nonmarginal
Career Line Main Effects Logistic Regression
Model........................................... 112

23 Independent Variable Statistics for Nonmarginal
Career Line Interaction Logistic Regression
Model ................................ ........ 113

24 Logistic Transformation Values for Nonmarginal
Career Line Interaction Multiple Regression
Model........................................... 114

25 Independent Variable Statistics for Unemployment
Main Effects Logistic Regression Model........... 117

26 Independent Variable Statistics for Unemployment
Interaction Logistic Regression Model........... 118

27 Logistic Transformation Values for Unemployment
Interaction Multiple Regression Model............ 120

28 Job Location Change by Employment Setting........... 122

29 Independent Variable Statistics for Job Change
Interaction Logistic Regression Model .......... 124

30 Independent Variable Statistics for Job Change
Main Effects Logistic Regression Model.......... 124

31 Logistic Transformation Values for Job Change
Multiple Regression Model....................... 126


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



Ronald C. Schultz

December, 1989

Chairman: Michael L. Radelet, Ph.D.
Major Department: Sociology

Using secondary data analysis, this study compares

registered nurses (RNs) who work in long-term care

facilities with RNs who work in hospitals. Among health

care professionals, employment in long-term care facilities

tends not to be considered a high status position.

Additionally, factors such as greater career opportunity and

higher pay seem to place hospitals in a more favorable

position in recruiting qualified, career oriented RNs. This

situation creates a dilemma for long-term care facilities,

where there is a critical need for such nurses.

The central concept of the study is "career

marginality," which is defined as the occupational situation

of long-term care facility employment, as well as individual

demographic and employment characteristics of RNs which

might make them less qualified or desirable from the


perspective of employers, or less career oriented from a

personal standpoint. Using data from the 1980 National

Sample Survey of Registered Nurses II, multiple logistic

regression analysis was used to investigate career


It was hypothesized that RNs having the following

marginal characteristics were more likely to be employed in

long-term care facilities than in hospitals: (a) limited

formal education, (b) current nonpursuit of a higher

academic degree, (c) nonparticipation in continuing

education, (d) part-time employment, (e) limited percent of

time employed in nursing since graduation from basic nursing

education, (f) being in an older age category, and (g)

having the family responsibility of children at home.

Findings revealed that hospital employed RNs were less

likely to have these marginal characteristics than RNs

employed in long-term care facility RNs. It was also

hypothesized that a nonmarginal career orientation--

operationally defined as full-time employment, having been

employed in nursing 80% or more of the time since graduation

from basic nursing education, and participation in

continuing education--would be more likely to exist among

hospital employed RNs. Results indicated that this was the

case. The significance of the study findings is the

implications they might have for adequately providing an

acceptable standard of care for the rapidly growing number

of elderly people in long-term care facilities.




As a consequence of the aging of its population,

American society is currently experiencing a significant

demographic shift. Americans are living significantly

longer than in the past, and the elderly population is

growing at a more rapid rate than the remainder of the

population. At the beginning of this century, only one in

25 Americans was over age 65 (Schick, 1986). In 1984, one

in nine American citizens was at least age 65. By the year

2050, one in five Americans will fall into this age

category. In the last two decades, the 65 and older

population increased twice as fast as the under-65

population. Whereas in 1980 only 40% of elderly people were

over age 75, 50% are expected to be in the 75-plus age

category by the year 2000.

Life expectancy at birth in the United States has also

changed dramatically. In 1900, the average individual could

expect to live 47.3 years (Schick, 1986). By 1950, this

life expectancy figure had risen to 68.2 years. In 1983,

the average life expectancy at birth had increased to 71.0

years for men and 78.3 years for women. Of persons reaching



age 65 in 1987, men had an average life expectancy of 14.8

more years and women had an average life expectancy of 18.6

more years (American Association of Retired Persons &

Administration on Aging, 1988). These changes in life

expectancy help explain the upward movement of the median

age of the American population, which reached 31 years in

1984 and is expected to increase to 36 years by the year

2000 (Schick, 1986).

Particularly relevant with regard to the aging of the

population is the increase in the number of persons 85 years

of age and older; these individuals constitute the fastest-

growing subgroup of the older population. Between 1960 and

1980, this age group increased by 142% as compared to 26%

for the total population, and by the year 2000 the 85 and

older age group is projected to increase by 117% compared to

18% for the overall population (Rosenwaike, 1985). This

segment of the population is expected to triple its 1980

size by 2020, and by 2050 is expected to increase by seven

times its 1980 size (U.S. Senate Special Committee on Aging,


Life expectancy at age 85, which in 1980 was 5.08 years

for males and 6.32 years for females, increased 23.7%

between 1960 and 1980, and is projected to increase an

additional 43.8% by the year 2040 (Soldo & Manton, 1985a).

At age 85 the average years remaining is 5.3 for white males

and 6.7 for white females; for black men and women at this


age, the average years remaining is 6.7 for males and 7.8

for females (Zopf, 1986). Partly because of the increased

life expectancy of older people in the higher age

categories, between 1984 and 2050 the 85 years and over

population is expected to rise from approximately 1% to over

5% of the total population, and from 9% to 24% of the 65 and

older population (U.S. Senate Special Committee on Aging,


A major problem posed by the older age groups, and in

particular the 85-plus age group, is a very heightened

demand for institutional health care (Soldo & Manton,

1985b). Along with greater life expectancy come frequent

chronic health conditions with accompanying functional

limitations which put elderly persons at an increased risk

of both hospital and long-term care facility admittance. It

has been pointed out that the greater likelihood of physical

dependency is a distinguishing characteristic of the 85

years and older age group (Rosenwaike, 1985; Rosenwaike &

Logue, 1985), and studies which present reliable data

indicate a dramatic and significant increase in functional

limitation for persons 85 years and older as compared to

those 75 to 84 years or even 80 to 84 years (Cornoni-Huntley

et al., 1985).

In the elderly population, more than 70% of persons 85

years of age and older require some type of assistance with

one or more activities of daily living (Johnson & Hoover,


1982; Soldo & Longino, in press; Suzman & Riley, 1985). For

noninstitutionalized elderly people, 36% of those 85 years

and older have one or more limitations in their daily living

activities which require assistance (Longino & Soldo, 1987),

and these persons are three to five times as likely to need

personal care assistance than older individuals aged 65 to

74 (Manton & Soldo, 1985). It has been noted that, because

there is such a high correlation between advanced age and

increased functional disability, the demand for long-term

care in particular in the United States will continue to

increase (Barberis, 1981).

Institutionalization has increasingly become a recourse

in dealing with incapacitation and limited functional

capability among people in the older age groups. For

instance, one out of four persons over age 85 resides in a

nursing home (Kane & Kane, 1980; Longino, 1988; Rosenwaike,

1985). Moreover, the number of older persons in nursing

homes in general is expected to double in the next twenty

years (U.S. Department of Health and Human Services, cited

in Robinson, 1987). This trend necessitates an increase in

the number of health care providers required to meet the

growing need.

An examination of the health care needs of elderly

people, regardless of setting, reveals that most of the

professional care required is nursing care (Davis et al.,

1985). Consequently, as the aging population continues to


grow, it is apparent that the need for nurses will also

increase. Currently, there is a nationwide shortage of

nurses in both hospitals and long-term care facilities, and

the demand for registered nurses (RNs) continues to grow

(Associated Press, 1987; "Why Nurses Quit," 1988). While

much attention is being paid to the critical nursing

shortage in hospitals, the consequences in those settings

specifically geared to elderly persons are even greater

(Brower, 1988). Thus, an area for particular concern is the

supply of RNs for long-term care facilities, since the

presence of physicians is limited in this setting. State

and federal regulation requires only that physicians visit

nursing homes once every 30 days, and it has been reported

that the 17% of physicians who make nursing home visits

spend little time there (Aiken, 1982).

Martinson (1984) has emphasized that the disparity

between the need for and supply of nurses to care for older

persons is an issue that affects the quality of health care

available to elderly people. This care provider shortage is

unfortunate, since nurses represent a segment of the health

care profession which, given sufficient numbers, can provide

quality care for elderly persons at a reasonable cost (Davis

et al., 1985; Kaeser, 1981; Morishita & Hansen, 1986;

Wolanin, 1981).

Recently, there has also been a significant decrease in

applications to, enrollment in, and graduation from nursing


education programs (Johnson, 1980; Rosenfeld, 1987). Data

on 1986 fall admissions to nursing schools reveal an 8.8%

decrease from 1985 to about 83,000, which is the lowest fall

admission figure since 1970 (Rosenfeld, 1987). Moreover,

the number of nursing school graduates in 1986 was only

three-fourths of what it had been in 1983 ("Why Nurses

Quit," 1988). The U.S. Department of Health and Human

Services (1985) has projected a shortage of 600,000 nurses

prepared at the baccalaureate and higher levels by the year

2000. One reason for declining nursing school enrollment

appears to be that women, who traditionally have comprised

the bulk of the nursing work force, are gaining greater

access to other professions (Rosenfeld, 1987).

An additional factor affecting nursing care for older

people is that home health care and health maintenance

organizations have in recent years begun to attract many of

those persons who do become nurses (Coleman, 1987). Other

areas of nursing also compete for RNs. The dilemma

involving home health care is that although this care

approach has made it possible to delay

institutionalization as health problems occur in older

persons, the increasing number of nurses committed to home

health care means that fewer nurses are available for work

in long-term care facilities.

Currently, there are an estimated 21,000 vacant RN

positions in long-term car facilities (Pulley, 1988). It is


estimated that, by the year 2000, there may be an overall

shortage of from 500,000 to 600,000 RNs in budgeted nursing

positions nationwide (Fowler, 1989). However, because there

also presently are an estimated 117,000 RN vacancies in

hospitals (Pulley, 1988), the nurse recruiting competition

from hospitals implies that long-term care facilities may

face a difficult task in attempting to fill nursing

vacancies. In long-term care facilities the demand for

nursing personnel is such that this area of employment has

become the fastest growing of any within the health care

field (Abdellah, 1981).

The increasing age of long-term care facility

residents, whose average age is 83 years (Davis et al.,

1985), coupled with the polypathology of advanced age, is

requiring more highly skilled professional nursing care in

this health care setting. Along with this, the recently

implemented Medicare payment policy based on the

"Prospective Payment System" (Health Care Financing

Administration, 1989) has resulted in hospitals discharging

older patients sooner than in the past, and with lingering

health conditions requiring continued health care attention

(Donley & Flaherty, 1989; Hamilton & Wilson, 1989; Kayser-

Jones, 1989; Walsh & Wilhere, 1988). These persons

frequently are transferred to long-term care facilities, and

the implication of this is that the need to have skilled RNs


to manage the health problems of these elderly people

becomes of increased importance.

A crucial factor in long-term care is the quality of

care rendered. Since the physician is largely absent in

long-term care facilities, the level of care in this setting

is greatly dependent on the skills and knowledge of the

registered nurse. Increasingly, there is a critical need

for dedicated, well-educated RNs in long-term care

facilities. In this regard, one might question whether

committed, qualified RNs are being employed in long-term

care facilities or in other more competitive work settings

such as hospitals. With respect to recruitment, hospitals

may, in fact, have an edge in certain areas. For instance,

it has been pointed out that in the recruitment of younger,

better-educated RNs, the increasing salary lag puts long-

term care facilities at a disadvantage as hospitals increase

pay in the competitive struggle to employ nurses (Brower,


Scope and Purpose of the Study

The literature reveals that compared with younger

persons, elderly people are less favorably viewed by society

(Achenbaum, 1978; Bradt-Ryan, 1979; Cowgill, 1974; Tuckman &

Lorge, 1953). Similarly, within the health professions,

employment in long-term care facilities generally is not

considered to be a high status position (Davis et al., 1985;


Miller & Barry, 1979; Reif, 1982). Besides this attitudinal

influence, factors such as greater career opportunity and

higher pay seem to place the hospital in a favorable

position in terms of recruiting qualified, career-oriented

RNs for employment. If this is the case, the situation

creates a dilemma for long-term care facilities, where there

is a critical need for qualified, committed RNs.

Using data from the National Sample Survey of

Registered Nurses II (Moses & Spencer, 1980), this study

compares RNs who work in long-term care facilities (i.e.,

the work setting category designated as "nursing home or

extended care facility" on the research questionnaire) with

RNs who work in hospitals. Because more than 96% of the

residents in long-term care facilities are in nursing homes

(Zopf, 1986), for the purposes of this study the terms

"nursing home" and "long-term care facility" will

essentially be considered synonymous.

The central thesis of the study is that RNs who are

less qualified professionally in terms of educational

preparation, who are less career oriented from the

standpoint of limited participation or discontinuity in

their nursing employment (i.e., part-time employment and

limited percent of time employed in the nursing profession

since graduation from basic nursing), or who might have less

marketability or attractiveness to employers due to being in

an older age category, are more likely than other nurses to


be employed in long-term care facilities and less likely to

be employed in hospitals. In regard to these

characteristics, they are more "marginal" from a career

standpoint than RNs who work in hospitals. Combining with

individual demographic and employment characteristics of RNs

when considering occupational marginality, is the lower

status employment position within the health profession of

the long-term care facility itself. The concept of career

marginality and its empirical indicators, as related to the

present research, are more fully presented in the

"Conceptual Framework" chapter of this study.

Although the data for this study are from 1980, the

study has applicability in terms of investigating the

concept of career marginality in the health care profession,

specifically, among registered nurses who work in long-term

care facilities and hospitals. Also, since Section 951 of

PL 94-63 and Section 708 of PL 94-484 require reports to

Congress on a continuing basis on national data pertaining

to the supply, distribution, and characteristics of RNs

(Bentley et al., 1982), the present study can serve as a

comparative base for more recent data. For example, the

recent release of the National Sample Survey of Registered

Nurses 1988 (National Technical Information Service, 1989)

allows the comparison of data over an eight year span.

Finally, an advantage of this study is that it employs a

large sample within which RNs working in two different


settings, long-term care facilities and hospitals, are

compared. This approach differs from the frequent method of

studying nurses in a single setting, and it provides a

comparative frame of reference for evaluating the career

marginality of registered nurses when such marginality among

long-term care facilities RNs is of particular concern.


The Professional Registered Nurse

The present study is a study of registered nurses

(RNs), with special emphasis on RNs who work with the

elderly in long-term care facilities (i.e., "nursing homes"

and "extended care facilities"). Registered nurses are

professionally trained individuals who have the skill and

knowledge to supervise and administer patient care, and thus

are valuable as providers of care for aging persons, who

have unique and special health care needs. Educational

preparation for the RN profession can be obtained from one

of five types of programs (Martinson, 1984). These are (1)

diploma (traditionally a three-year program attached to a

hospital), (2) associate degree (a two-year program most

often found in junior or community colleges), (3)

baccalaureate degree (generally a four-year program

associated with a college or university), (4) master's

degree (a two-year program that requires a baccalaureate

degree in another field), and (5) ND degree for students who

have college degrees in other areas (usually a four-year

program), presently offered only at Case Western University.


Successful completion of any one of these programs

gives students the right to take state board examinations

which, if passed, confers the right to use the title,

"registered nurse."

Through the nursing process, which involves planning,

implementing, and evaluating patient care, direct care is

provided by RNs. Registered nurses work in a collaborative

and collegial association with other health professionals to

assess health care needs, and assume responsibility for

nursing care. During the course of their nursing practice,

RNs evaluate the effectiveness of actions pursued, identify

and undertake systematic investigations of clinical

problems, and conduct periodic reviews of their own and

their peers' delivery of professional health care (Nichols,

1982). The nursing profession has been moving steadily in

the direction of more academic preparation for its members.

Specialization has also evolved with the specialty

gerontological nursing of particular relevance when

considering the changing demographic structure of American


In recent decades, governmental policy has helped

establish long-term care institutionalization as a standard

course of action for dealing with the declining functional

capacity of aging individuals. Consequently, the nursing

home has emerged as a primary, medically oriented facility

serving the health care needs of older persons. For


example, whereas in 1939 there were approximately 1,200

nursing homes in the United States with a total of

approximately 25,000 beds, by 1972 there were 23,000 nursing

homes with over 900,000 beds (American Nurses' Association,

1982). Thereafter, nursing homes did not continue to

increase dramatically in number, but rather began to

increase in size. In 1985, for instance, there were

approximately 23,600 nursing homes nationwide serving 1.5

million residents (Ebersole, 1985).

The following sections of this chapter focus on three

different approaches to studying RNs in the context of their

employment in the two contrasting work settings, long-term

care facilities and hospitals. The first, the social

structural approach, deals with the various aspects of the

institutional employment setting. The second, the social

psychological approach, is centered around attitudes toward

working with elderly people. The third approach focuses on

individual demographic and employment characteristics of

RNs. Of central interest to the present study is the third

approach, but it is accompanied by the significance of the

social structural component, employment setting, as

manifested in a long-term care facility or hospital work



Social Structural Factors
Related to Health Care for Elderly People:
The Long-Term Care Facility Versus the Hospital

In dealing with social structural factors, the focus is

on large-scale social function and interaction patterns

(Johnson, 1981), which involve the two social institutions,

long-term care facilities and hospitals. The social

structural components of health care institutions include

factors associated with the defined occupational and social

roles of the people found there, as well as the

organizational characteristics of, and interaction patterns

within, the institutions. The social structural factors of

long-term care facilities and hospitals dealt with below are

(a) the organizational model, (b) salary, benefits, and

career opportunity for RNs, (c) the status of the employment

setting position, and (d) the patient population.

The Organizational Model

It has been noted that there are contrasting

organizational models for hospitals and long-term care

facilities (Rogers, 1989; Shore, 1977). These are the

medical model and the nursing care model. Whereas hospitals

are characterized by the medical model, long-term care

facilities are more appropriately characterized by the

nursing care model.

The medical model focuses on diagnosing and medically

treating illness or disease. Care is typically short-term


care given in the hospital or clinic setting to "patients"

with acute conditions. The care given is directed and/or

administered by physicians, who are very prominent and

authoritative figures in the hospital and clinic health care

settings. Because the medical orientation toward immediate

and threatening conditions frequently involves the use of

technological equipment (e.g., cardiac and neurological

monitors), as well as the ability to deal competently with

emergency situations, hospitals generally require a higher

level of nursing skills than do long-term care facilities.

The ultimate objective in the medical model is a cure for

the physician-diagnosed disease or illness. There is a

paradox here, because it is the advancement in medical

technology and treatment that has resulted in a burgeoning

of inevitable chronic impairments frequently requiring long-

term care facility institutionalization as people live


Whereas the hospital is the domain of the physician as

the central figure in the medical model, the long-term care

facility is the domain of the nurse. Care in long-term care

facilities, where the physician is largely absent, is

typically nursing care rather than medical treatment.

Haight has summed up the situation in this way: "Nursing

home care belongs to nurses. Nurses make the decisions,

provide the care, educate the caregivers, suggest changes,


act as role models, and influence the decisions of the

physician" (1989, p. 10).

The nursing care model is centered around the fact that

people in long-term care facilities can generally be

characterized as being "residents" for an extended period of

time, and do not have an immediate, acute health problem.

They are not patients to be quickly cured and discharged as

in a hospital, but rather persons for whom the long-term

care facility has essentially become their home, and who

thus need a more nonmedical, comprehensive approach to meet

their totality of needs during the course of their daily

living. Although long-term care does include essential

medical care, it nonetheless does not involve the same type

of medical model orientation as found in the hospital. The

long-term care facility, while not geared toward medical

care as its central activity, does have medical capability,

which essentially means having medical care available when

needed. Consequently, there remains a significant role for

medical care in long-term care facilities, even though the

medical model does not assume the dominant role in this


Essentially, long-term care is characterized by chronic

illness or impairment, be it physical, mental, or both, and

the professional care given is mostly nursing care. The

dilemma is that, whereas the hospital has been characterized

as the physician's domain, the long-term care facility

unfortunately has not attracted the professional registered

nurse in significant numbers. For example, in 1986

hospitals employed 96.0 RNs per 100 patients while long-term

care facilities employed only 5.7 RNs per 100 residents

(Donley & Flaherty, 1989). Possible reasons for this

situation may become more apparent in the following


Earnings. Benefits. and Career Opportunity

It has been pointed out that nurses who work in long-

term care facilities, as compared with nurses who work in

hospitals, receive lower salary, fewer benefits, and have

limited opportunity for career advancement (Davis et al.,

1985; Reif, 1982; Robb, 1979). A survey by Levine and Moses

(1982) revealed that nurse administrators in nursing homes

received an average salary 30% below the salary paid to

nurses employed in a comparable position in hospitals, and

that salaries of staff nurses in nursing homes averaged only

80% of that received by hospital nurses. Giordano and

Panfil (1987) have reported that RNs working in long-term

care facilities in Los Angeles County were paid $4,000 less

in annual salary than RNs working in hospitals, and also

received fewer fringe benefits. Other studies have shown

that an additional disincentive in long-term care facility

employment is the limited opportunity for staff development

and career advancement (Health Resources Administration,

1980; Kayser-Jones, 1981; Vladeck, 1980).


In a study which compared benefits received by nurses

working in different settings, it was found that only 9.2%

of nursing home nurses were paid for sick leave and

vacations; only 10.8% of these nurses had health or life

insurance paid for by their employers, and only 11% had

retirement programs (Health Resources Administration, 1980).

This contrasts with benefits received by hospital nurses,

virtually all of whom had paid holidays and vacations as

well as retirement and health insurance plans, and most of

whom received overtime and shift differential pay. Hospital

nurses, in fact, continue to receive better benefits than

general industry employees (Lappa, 1989).

Presently, hospitals nationwide are using pay and

benefits to recruit and retain registered nurses. In 1988,

for example, full-time hospital staff RNs averaged $12.18

per hour and part-time RNs averaged $12.20 per hour

(Powills, 1989). Data compiled by the American Nurses'

Association reported the largest real pay increase in

history for hospital employed RNs in 1988, with the average

starting salary increasing by 6.9% to $22,416 annually and

the average maximum salary increasing by 10.6% to 32,160

annually (Tolchin, 1989). A survey by the Commonwealth Fund

of 15,000 nurses and 400 hospitals in New York, Boston,

Pittsburgh, Chicago, Houston, and Los Angeles revealed that,

for hospital employed nurses, 1988 entry level salaries

ranged from $20,000 to $28,000 and nursing salaries peaked


between $30,000 and $40,000 (Associated Press, 1989). These

figures are consistent with those compiled by the American

Nurses' Association for 1988 (Tolchin, 1989). With regard

to benefits, along with medical insurance, continuing

education, and vacation time, hospitals offer pension plans

(86.3%), tax-sheltered annuities (81.9%), tuition

reimbursement (76.4%), and maternity leave (73%). Some

hospitals also provide child care (12.0%), housing (5.9%),

and adult dependent care (2.8%) (Powills, 1989).

The implication of hospitals' recruitment and retention

strategy is that long-term care facilities, which very often

are not able to compete financially with hospitals, are at a

disadvantage in recruiting well-educated, young, career

oriented RNs. This is a factor that might well have an

effect on the quality of care available for long-term care

facility residents.


Due to negative attitudes toward aging and elderly

people, employment in long-term care facilities generally is

not favorably viewed, and it has been pointed out that one

of the major problems associated with long-term care

facilities is social values regarding the older persons

(Miller & Barry, 1979). Robb has noted that "the elderly

are undervalued in numerous ways by most segments of

society" (1979, p. 50). It has also been suggested that

there is a lack of public policy defining what older persons


are worth in our society and, because of a prevailing

utilitarian orientation, there is a tendency to invest in

things with a productive future (Shore, 1977).

The low status of long-term care facility employment,

then, is partially linked to the fact that the residents

themselves are devalued and of low status. A characteristic

of long-term care facility residents is that their income is

generally below poverty level (Miller & Barry, 1979), which

socially is a low status characteristic. Moreover, whereas

most acute hospital care is financed by private insurance

(or by Medicare for Social Security recipients 65 and older

or disabled), the bulk of long-term care is financed through

Medicaid, which is essentially a means tested welfare

program based on need. Compared with private insurance and

Medicare, Medicaid is a low status financing program for low

status persons. However, many long-term care facility

residents financed by Medicaid originally entered under

Medicare and/or private insurance or private payment

coverage, but then had to switch to Medicaid financing when

other coverage ended and personal finances were depleted.

For persons applying for long-term care facility admission,

evidence suggests that discrimination against Medicaid

sponsored individuals exists (Beeby et al., 1987; Blake et

al., 1987).

It has been emphasized that one factor directly related

to the shortage of nurses and quality of care in long-term


care facilities is the low status and prestige associated

with the practice setting and positions (Davis et al., 1985;

Reif, 1982). Besides the influence of the status of long-

term care facility residents themselves, it has been noted

that nurses tend to value medical knowledge more highly than

nursing knowledge, and often attempt to emulate physicians

through the acquisition of medical or technical knowledge,

values, skills, and beliefs (Rogers, 1989). Medical

knowledge, as prevalent in the medical model hospital

setting, is afforded more value because it is seen as being

scientific and objective, whereas nursing knowledge

continues to be seen as unscientific, intuitive, and highly


The Elderly Patient Population

The general hospital is the primary source of health

care services for elderly people. Of the population 65

years and older, 20% use inpatient services at least once a

year (Davis et al., 1985). Most of the hospital admissions

for elderly people are for acute episodes of chronic

problems, and 60% of beds may be occupied by older persons

on any given day. Hospital stays typically are of short

duration; they average 5.6 days for persons under 65 years

of age and 8.8 days for people 65 years of age and older

(Dyer, 1989). Utilization of such services as emergency

room, radiology, pathology, and rehabilitation has risen

sharply in recent years (Davis et al., 1985).


Although only 5% of people 65 years and older reside in

long-term care facilities, about 20% who reach age 65 will

spend some time in such institutions, this usually being

during the last years of their lives (Davis et al., 1985).

Long-term care facility residents have much longer stays

than hospital patients. Residents typically fall into one

of the two categories of short-stay and long-stay. The

average length of stay for the shorter-term residents is 1.8

months and for the longer-term residents, 2.5 years (Davis,

et al., 1985).

In contrast to the hospital, the long-term care

facility is characterized by a much more homogeneous patient

population. The average age of this population is about 83

years, with over 60% of the residents being at least 80

years of age, and there is a preponderance of persons

severely and chronically impaired by multiple, advanced

physical diseases, behavioral pathology, or a combination of

the two (Davis et al., 1985; Miller & Barry, 1979; Zopf,

1986). In the home wives very often serve as caregivers for

ailing spouses (Dimond, 1989), but since wives generally

outlive husbands, they are typically left alone to face

their own eventual decline, unless a child is available and

willing to care for them. Consequently, in long-term care

facilities about three-fourths of the residents are women.

Mental impairment is one factor which may make working

with elderly people in long-term care facilities difficult,


and staff who work with mentally impaired residents have

reported high levels of stress (Chartock, 1987). One-half

to three-quarters of long-term care facility residents have

some type of cognitive disorder which affects their thinking

and/or behavior (Doty, 1987; Hing, 1987; LaPorte, 1982;

Rovner & Rabins, 1985; Sacharow, 1987; Schick, 1986). Some

degree of cognitive impairment has also been reported in

anywhere from 24% to 80% of hospitalized elderly persons

(Cavanaugh, 1983; Foreman, 1989; Gillick et al., 1982;

Lipowski, 1983; Williams et al., 1985). However, if such

disorder presents itself as other than an acute episode, it

then typically becomes a primary reason for long-term care

facility placement (Levkoff et al., 1986; Zarit & Zarit,

1983). There has been a tendency for reaction toward mental

disorder to be negative (Scheff, 1966, 1974, 1975), and this

coupled with reaction to the severe and irreversible

physical deficits of aging may have a compounding effect on

long-term care facility employed nurses.

In addition to the communication difficulty posed by

mentally impaired long-term care facility residents,

behavioral problems such as noncompliance, verbal abuse and

vocal disturbance, agitation and aggression, wandering, and

self-injury may present difficulties for the nursing staff

(Burgio et al., 1988; Hoffman, 1987; Rader, 1987; Zimmer et

al., 1984).


Another type of problem with residents in long-term

care facilities is "excess disability," which exists when

functional incapacity is greater than that warranted by

actual impairment (Burgio et al., 1988). In long-term care

facilities, nursing care problems requiring psychiatric

consultation are frequent (Ferrario, 1987). The literature

suggests that mentally impaired residents of long-term care

facilities present unique problems that may result in low

morale, high stress, and burnout among nursing care

providers (Hoffman, 1987; Wilson & Patterson, 1987).

Heine (1986) has focused on the negative impact of the

nursing home environment in relation to "burnout" among

nursing home personnel. Heine's contention was that the

constant daily demands on nurses working in nursing homes

with confused, dependent, elderly residents often lead to

job stress and, ultimately, burnout. This situation, in

turn, negatively affects the nursing home organization and

the residents, thus lowering the quality of care rendered.

Heine, however, did not conduct a systematic, empirical

study to test her assumptions.

Along with physical appearance and state of dependency,

death potential of long-term care facility residents may

elicit a negative response from nurses (Robb, 1984). It has

been noted that working with aged or dying patients may

raise nurses' fears and anxiety about their own aging and

death, and serve as a reminder of the loss of family members

or friends (McConnell, 1981). Vickio and Cavanaugh (1985)

have reported that increasing levels of death anxiety among

nurses who work in long-term care facilities are associated

with more negative views of aging and older persons.

Given the negative factors associated with long-term

care facility employment, it is important that nursing

students, in their preparation for employment, be provided

with an unbiased and positive presentation of what working

with elderly people in long-term care facilities can be

like. If preconceived ideas can be altered through actual

clinical experience in an innovative manner, then perhaps

more students might choose long-term care facility

employment. This issue is more fully discussed below.

Clinical Experience in Nursing Education

It has been pointed out that clinical experience for

nursing students has been oriented largely toward preparing

nurses to work in hospitals (Reif, 1982). Although there

has recently been some movement toward clinical experience

in long term care facilities, clinical experience in

hospitals is still much more the rule.

Some concern exists that when nursing students are

exposed primarily to badly incapacitated older persons such

as those frequently found in nursing homes, negative

attitudes toward caring for aging individuals may be formed

or reinforced, and this might contribute to students

pursuing other specialties in preference to gerontological


nursing. Investigation of nursing home clinical experience

on attitudes of student nurses toward working with elderly

people has found the overall impact to be negative (Cook &

Pieper, 1985).

In order to provide a more favorable alternative to the

nursing home environment for nursing students many nursing

education programs incorporate experience in other settings

with older persons who are in fairly good health. The

reasoning here is that this type of clinical exposure to

elderly people might help foster more positive attitudes

toward aging individuals. Such success has been reported

using the experience with well elderly people strategy with

nursing students (Brock, 1977; Dunn & Abel, 1983; Spier &

Yurick, 1989).

Another successful approach to clinical experience in

long-term care facilities has been to place nursing students

under the supervision of registered nurses who are given

more control of the patient care situation. It was found

that increased job satisfaction and improved quality of care

result from giving nurses more autonomy, responsibility, and

authority (Patterson, 1987). Moreover, student nurses given

clinical experience under supervision of such nurses react

favorably to the situation, and come to see the long-term

care facility setting as an opportunity for autonomous,

challenging, and satisfying practice. This enthusiasm is in


contrast to previous reactions of students, who tended to

view long-term care as an inappropriate clinical setting.

By being allowed to function in the full scope of their

role, RNs can be a powerful resource in the nursing home

setting. Administrators can benefit from relying more on

the professional abilities of RNs, while at the same time

being cautious not to overwork nurses and consequently

contribute to job stress and dissatisfaction. Similarly,

it was found that RNs feel more accountable for their

patients' care when they are given more responsibility in

planning, implementing, and evaluating the care of

specifically assigned patients in long-term care (Jones,


In response to the realization that professional

nursing practice is not well established in the nursing home

industry, there is currently a trend in nursing education

toward utilizing the nursing home as a positive clinical

experience for students. It is hoped that this will foster

greater interest in working in such a setting in individuals

who become RNs. Gass and Tarr have maintained that this

approach can be successful if nursing home clinical

experience is "guided by a philosophy which emphasizes

independence, choice, and flexibility" (1986, p. 27), and

if students are allowed a greater role in structuring their

learning experience and in developing objectives based on

their specific interests and learning needs. Burke and


Donley (1987) have also stressed the value of utilizing the

nursing home to educate health professionals in the field of

gerontology and to develop a model of gerontological

nursing. Burke and Donley reported on a project centered

around the "teaching nursing home," where academic nursing

principles were applied to test models of advanced nursing


Social structural aspects of working with elderly

people have been discussed. In the sections which follow,

social psychological and individual factors are discussed in

relation to nurses' employment experience with older

persons. These are factors that may play an important role

in determining the supply of registered nurses available to

provide quality care for America's elderly population.

Social Psychological Factors Related
to Health Care for Elderly People

Attitudes toward Elderly People in the Health Care

It has been argued that the attitudes of health care

professionals affect the quality of geriatric care (Keith,

1977), and there have been suggestions that medical care of

older people in the United States has been characterized by

negativism, defeatism, and antipathy (Futrell & Jones, 1977;

Gruber, 1977). Similarly, it has been pointed out that

health care professionals may or may not be providing

services to elderly patients as a matter of choice and may,

in fact, have negative and stereotypic attitudes regarding

the geriatric population (Kosberg, 1983). Even where

attitudes tend to be favorable, health care professionals

may, given a choice, still not be willing to work with older

persons (Lutsky, 1980).

Upon examining 12 empirical studies, Palmore (1977)

found that most health professionals expressed negative

stereotypes about elderly people, and preferred to work with

younger adults or children. Few medical students and

practitioners specialized or were interested in geriatrics.

The studies Palmore examined concluded that many negative

attitudes derive from the lack of factual information about

elderly persons and lack of contexts in which stereotypic

attitudes can be examined and altered. It has been pointed

out that failure to have a realistic understanding of older

people can have a negative effect on the quality of both the

medical treatment rendered and the client-health care

professional relationship (Kart, 1981).

Studies from the time of Palmore's analysis have

similarly indicated limited interest in gerontological

practice among various health profession students and

practitioners, as well as a lack of knowledge of and false

ideas held about elderly people (Belgrave et al., 1982;

Geiger, 1978; Michielutte & Diseker, 1984-85). These

studies involved physician assistant students and medical

students, as well as practicing physician assistants, family


practice physicians, family practice residents, and


Kosberg (1983) has suggested that in addition to

improvement in general societal attitudes toward elderly

people, three specific approaches might be used to help

promote positive attitudes among health care professionals.

These are (1) formal education, (2) continuing education

programs, and (3) staff assessment to identify individuals

with positive attitudes.

Nurses' Attitudes toward Elderly People

Benson (1982) has emphasized that one issue of

paramount importance is the fostering of positive attitudes

among nurses in view of a pervasive "ageism" (Butler, 1975)

in American society. Benson, in reviewing the nursing

literature of the last two decades, found a growing

awareness of this issue among nursing educators and

practitioners, as well as an increasing commitment to the

improvement of health care for older Americans. Much

research, however, has implied that societal attitudes may

be hindering this health care goal. For example, it has

been noted that many nurses and nursing students tend to

believe negative stereotypes and lack factual information

about elderly people (Campbell, 1971; Coe, 1967; Green,

1981; Hart et al., 1976; Palmore, 1977; Williams, 1982;

Williams et al., 1986), and several studies have reported

that baccalaureate nursing students are not interested in


gerontological nursing as an area of specialization,

preferring other areas of nursing specialization instead

(Buschmann et al., 1981; DeLora & Moses, 1969; Gunter, 1971;

Jaeger & Simmons, 1970; Kayser & Minnigerode, 1975; Knowles

& Sarver, 1985; Shimamoto & Rose, 1987; Williams et al.,

1986). Thirty-eight empirical studies of stereotyping by

nurses and nursing students were critically examined by

Ganong et al. (1987), and it was concluded that evidence

does exist that students and nurses stereotype persons based

on age.

A number of the more recent studies have contradicted

the negative findings of earlier studies (Chandler et al.,

1986; Downe-Wamboldt & Melanson, 1985; Olsen, 1982; Robb,

1979; Snape, 1986; Taylor & Harned, 1978). This may point

to an increasing improvement in attitude toward elderly

people among nurses and other health care providers as noted

in the literature (Benson, 1982; Snape, 1986). A review of

the literature since 1970 suggests a correlation between

positive attitude formation among nursing students and

practicing nurses and an increase in the number of nurses

choosing to work with elderly people (Stanley & Burggraf,

1986). Coe (1967) found that attitudes of health

professionals toward aging and older persons are closely

bound to professional ideology, and Wilhite and Johnson

(1976) found a positive correlation between faculty and

student attitudes, suggesting that role modeling may be a


significant factor. Moreover, Futrell and Jones (1977) have

emphasized that lack of role models hinders the recruitment

of qualified personnel for the specialized field of

geriatrics. Goodwin and Trocchio (1987) have stressed that

nurses can help promote positive attitudes and behavior by

displaying respect for older persons and acting as role

models. If nursing educators, administrators, and

practitioners can instill gerontological ideals in nursing

students and also serve as role models, positive attitudes

toward aging and elderly people may continue to increase.

Influencing Attitudes through Educational Programs

Many educational programs for health personnel who care

for aging people are directed toward increasing the

knowledge base of health care workers and implementing more

positive attitudes toward elderly persons. These programs

assume that more knowledge and positive attitudes regarding

older individuals increase both the quantity and quality of

care for elderly people.

After conducting a multidisciplinary gerontological

training program for health care providers, Nodhturft et al.

(1986) concluded that although many health professionals

hold negative attitudes and stereotypic views of elderly

people, educational programs can improve knowledge about and

attitudes toward aging. Studies that focused specifically

on nursing students and nurses have similarly demonstrated

the positive effect of gerontologically oriented educational


programs (Green, 1981; Gunter, 1971; Heller & Walsh, 1976;

La Monica, 1979).

Although some inconsistencies exist, in general the

literature appears to indicate that gerontological/geriatric

educational programs influence persons' knowledge,

perceptions, and attitudes regarding aging and elderly

people. Most educational programs focusing on cognitive

aspects associated with understanding older persons appear

to have a positive effect on nursing students and nurses.

The implication of the influence of educational programs is

the effect they might ultimately have on nursing

specialization choice and working with elderly people.

Conclusions about Aging-Related Attitude Research

One primary area of question regarding aging-related

attitude research is the accuracy and effectiveness with

which assessment instruments measure true personal values

and beliefs. It has been noted that most aging-related

attitude research has utilized measures, such as self-

report questionnaires, which are susceptible to conscious

control of responses (Robb, 1979). Societal beliefs about

elderly people are becoming more positive, raising the

question of whether persons tested indicate actual beliefs

or those which they feel are socially desirable. For

example, neither the Tuckman-Lorge (1953) Attitude

Questionnaire nor Kogan's (1961) Attitudes toward Old People

Scale, two commonly used assessment instruments in aging-


related attitude research, incorporate controls for tendency

of persons tested to respond in what they perceive to be a

socially desirable manner or in terms of learned rather than

actual beliefs, and very few of the studies of nurses'

attitudes toward elderly people have reported using an

external criterion to assess social desirability set.

Moreover, the reliability and validity of aging-related

attitude assessment instruments often come into question.

For instance, the reliability of Kogan's scale was assessed

as being only moderate at the time of its development (.73

to .83 for the negative scale, and .66 to .77 for the

positive scale), and consequently very likely needs to be

reevaluated in the context of contemporary usage.

Another significant factor to be considered in attitude

research in general is the association between attitudes and

behavior. It has proven difficult to demonstrate direct,

consistent relationships between attitudes and behavior, and

such relationships often tend to be dependent on the methods

used to assess these associations. For example, Hatton

(1977) failed to find a statistically significant

relationship between registered nurses' attitudes toward

elderly people (measured by Kogan's Attitudes toward Old

People Scale) and quality of care (measured as performance

of nursing functions) provided.

The social value of establishing the existence of a

relationship between attitudes and behavior lies in the


ability to predict and ultimately influence behavior. With

regard to gerontological nursing, this would imply

translating positive attitudes toward elderly people into

quality nursing care as defined, for example, in Standards

and Scope of Gerontological Nursing Practice (American

Nurses' Association, 1987). However, it has been noted that

the influence of attitudes on the quality of care provided

by health professionals is not known (Robb, 1979). For

instance, Welsh (1973) did not find consistent correlations

between favorability of attitudes and ratings of counselors'

effectiveness with physically impaired clients. That is,

counselors with negative attitudes were nonetheless able to

provide effective service for these clients. The

implication of such a finding is that the learning of a

profession is essentially the learning of a standardized,

professionally defined social role (e.g., the role of

counselor, the role of physician, the role of nurse, etc.).

Consequently, adequate preparation as a health care

professional is assumed to ensure a separation of quality

health care delivery from attitude. If this situation

should indeed to be the case, with attitudes having little

or no impact on behavior, then researchers might better

spend less time studying attitudes and more time studying

behavioral aspects of health care delivery to the elderly



Individual Characteristics Related to
Health Care for Elderly People

The literature pertaining to attitudes toward aging has

indicated that elderly people, as compared to younger

people, are a less valued group. This circumstance,

combined with structural factors such as comparably lower

salary and fewer benefits, and less favorable work

conditions and environment, would logically seem to put

long-term care facilities in comparison to hospitals at a

disadvantage in RN recruitment. A good question to ask,

then, is who are the RNs that are being employed in long-

term care facilities? In this regard, the literature below

pertaining to individual characteristics of RNs who study

aging and/or work with elderly people is reviewed. It is

hoped that this review will provide a suitable reference

point for comparing the results of the present study.

Hospital Registered Nurses

In a large sample study of RN recruitment and

retention, specific sociometric, education, and practice

variables of hospital employed nurses were reported (Whaley

et al., 1989). The data for this study were drawn from the

1986 Biennial Survey of Illinois RNs, which was conducted

for the Illinois Department of Registration and Education by

the University of Illinois at Chicago. The data described

the characteristics of nurses renewing their Illinois RN

license. Characteristics were compiled for 12,234 RNs who

worked in suburban and urban hospitals in the Chicago

metropolitan area.

Among the sociodemographic variables in the Whaley et

al. study were sex, ethnic background, age, and marital

status. Of the 12,234 RNs, 97.75% were females and 2.25%

were males. The percentage who were of white, non-Hispanic

ethnic background was 88.86%; 11.47% were of other ethnic

background. With regard to age, 4.38% of the RNs were

younger than 25 years, 71.27% were in the 25-44 years age

range, 23.57% were in the 45-64 years age range, and .78%

were 65 years of age or older. As for marital status,

71.15% of the RNs were married, 11.62% were widowed,

divorced, or separated, and 17.23% were never married.

Education variables included level of basic nursing

education, degrees earned after completion of nursing

education, and current enrollment in a formal education

program leading to an academic degree. Regarding basic

nursing education, 45.03% of the nurses were prepared at the

diploma level, 28.37% at the associate degree level, 26.43%

at the baccalaureate degree level, and .17% at the master's

degree level. Almost 20% of the RNs earned academic degrees

after completion of their basic nursing programs, these

being primarily baccalaureate and master's degrees in

nursing. About 17% of the RNs were currently enrolled in a

formal education program leading to an academic degree.

With respect to the type of position held, 71.90% of

the RNs were employed in staff nursing positions. In the

position of charge nurse or team leader were 7.27% of the

RNs. A head nurse or assistant head nurse position was held

by 7.87% of the RNs. In a position of administrator or

assistant administrator were 6.19% of the RNs. Clinical

specialist or practitioner positions were held by 3.97% of

the RNs. Other positions were held by 2.80% of the RNs.

There are a couple of limitations to be noted with

regard to the Whaley et al. study of hospital nurses.

First, the geographic area where the hospitals were located

was restricted to the Chicago metropolitan area. Second,

all of the RNs in the study resided in suburban areas; the

study did not include RNs who lived in Chicago's urban


In a smaller and different study focusing on staff

retention in a university medical center hospital located in

a midwestern metropolitan area, some of the individual

demographic and employment characteristics of all 59 RNs

were recorded (Taunton et al., 1989). The average age of

the RNs was 29.81 (SD = 7.27). With regard to level of

education, 67% of the nurses held a baccalaureate degree or

higher. The average number of years in the nursing

profession was 6.86 (SD = 6.39). The average number of

years employed in the hospital was 4.70 (SD = 4.29), and the

average number of years in the current nursing position was


3.30 (SD = 4.23). The RNs in this study had a higher level

of education than the hospital employed RNs in the Whaley et

al. study, which may be due to the education characteristics

of nurses who work in a university-based medical setting.

Long-Term Care Facility Registered Nurses

Using preliminary data from the 1985 National Nursing

Home Survey (NNHS), Strahan (1988) reported on

characteristics of registered nurses in nursing homes. NNHS

is a nationwide (excluding Alaska and Hawaii) sample survey

of nursing and related care homes, their residents, and

staff conducted periodically by the National Center for

Health Statistics. The NNHS was conducted from August 1985

through January 1986.

The nurses reported on by Strahan were a stratified

random sample of 2,763 RNs. Nursing care has traditionally

been provided by females, and this is reflected in the ratio

of female to male RNs working in nursing homes in 1985; only

2% of the more than 103,000 RNs in nursing homes were males,

as compared to 98% females. Minority groups made up a much

smaller proportion of RNs working in nursing homes than

their representation in the overall population; about 90% of

the RNs in nursing homes were white, non-Hispanic nurses.

This rate was about the same as that in hospitals (Jones et

al., 1987), and studies indicate that although minority

individuals as a whole are more likely than white non-

Hispanic persons to serve the older age groups, this care is


generally in a setting other than a hospital or nursing home

(Feldbaum & Feldbaum, 1981; Smith, et al., 1982).

The median age of the RNs in 1985 National Nursing Home

Survey was 45. Of these nurses, 75% were under age 55.

More than two-thirds of the RNs working in nursing homes

were married. RNs who were divorced, separated, or never

married worked full-time more frequently than married or

widowed RNs. More than one-half of the RNs had no children

living at home; of the RNs who had children living at home,

most were of school age (5-17 years old). Most of the RNs

surveyed had a diploma level training in nursing, with 56%

of the RNs working in nursing homes having a 3-year diploma

program as the highest nursing-related education. An

associate degree was held by 22% of the nurses, and 18%

held a bachelor's degree. Less than 3% of the RNs held a

master's degree.

In summarizing the characteristics of RNs who worked in

nursing homes in 1985, the typical RN employed in a nursing

home in 1985 was female, married, white, older than the

average RN, and had been working in her profession for 10

years or more. Studies have indicated that nursing students

tend to associate negative stereotypes with caring for aged

persons and that older health care providers, regardless of

their profession, are more likely than their younger

colleagues to view elderly people favorably (Feldbaum &

Feldbaum, 1981; Smith et al., 1982).


In studying the association between individual

characteristics and registered nurses' employment in a

specifically designated gerontological care setting such as

a long-term care facility as opposed to a hospital, there is

the question of the exact role that individual factors play.

That is, do certain individual factors directly influence

the choice of working in long-term care facilities or is

this choice indirectly influenced through such social

psychological factors as attitudes? The literature

regarding nurses' attitudes toward aged individuals has been

reviewed and research findings have been shown to be

inconsistent and contradictory. The accuracy of attitude

assessment has been a concern and, moreover, a definite link

between attitudes and behavior has been difficult to


Although numerous studies in this specific area have

been conducted, the present study acknowledges the problems

associated with attitude research. Social structural

factors such as those discussed earlier--organizational

factors, pay and benefits, employment setting status, and

the characteristics of the patient population--present a

more concrete area of study, but this also is not an area

intensively pursued in this investigation, with the specific

exception of employment setting, long-term care facility

versus hospital.


A literature review of gerontological nursing covering

1979-1984 revealed a preponderance of studies of attitudes

among nurses and nursing students to the exclusion of other

topics (Burnside, 1985). A similar review covering 1984-

1988 showed a shift to mainly studies of physical problems

of elderly people (Haight, 1989). What is recognized in the

present investigation is the paucity of existing studies

dealing with individual demographic and employment

characteristics as they relate to RNs working in long-term

care facilities as opposed to hospitals. Specifically,

there is a lack of research employing a large,

representative sample in which nurses working with elderly

people in long-term facilities are compared with nurses

working in other settings, particularly hospitals. These

factors, along with theoretical relevance of the study and

its potential to be used as a comparative frame of reference

for the evaluation of more current data, constitute the

contribution of the present study to the existing



The concept of marginality was originally delineated by

Stonequist (1937) in his study of the process of

acculturation. Stonequist's approach to marginality focused

on the "marginal man" as a social product of acculturation,

such as inevitably results when people of different races

and different cultures--and consequently different social

statuses--come together to carry on a common life.

Stonequist maintained that persons who through migration,

education, marriage, or other influence leave one social

group or culture without making a satisfactory adjustment to

another, find themselves on the margin of each but a member

of neither. Thus, the marginal man as conceived in

Stonequist's study is the person tenuously poised between

two or more social worlds, where group membership is based

on social status and where exclusion removes the person from

a system of group relations.

Stonequist's study set the stage for marginality to be

more fully and widely explored, although essentially as a

social relationship phenomenon. Then, as conceptual

analysis and empirical work on the theme of marginality

expanded, further distinctions and nuances were added.


Consequently, it became apparent that differentiation should

be made between marginality as a social situation,

considered the result of historic and structural conditions,

and marginality at the individual or personality level,

which was considered to be a psychosocial and cultural

problem (Germani, 1980).

It was Germani's approach to marginality that

emphasized a wider application of the concept. The

importance of Germani's work was that it broadened the

concept of marginality so that it could be modeled as a

multidimensional phenomenon, not just strictly as a social

relationship phenomenon. That is, Germani stressed that

under the global term, "marginality," different types of

marginality could be distinguished. The plural dimensional

conception of marginality, accepted whenever different forms

of marginality (e.g., economic, political, cultural,

educational) are considered, recognizes different dimensions

of marginality, as well as different degrees within the same

dimension. This kind of approach makes it possible to make

more specific and selective applications of the concept of

marginality, including more succinct definitions and

explanatory factors.

Germani's general conception of marginality centers

around the exercise of roles in different institutions and

spheres of individual and collective life such that one

might think, for example, of roles in family life, in the

productive subsystem, or in the political subsystem. In

Germani's scheme, marginality is imputed through a

comparison between a de facto situation and a certain

model--the role set which the individual or group should

exercise according to expected or desired criteria. Thus,

one could discuss a marginality profile for individuals and

groups which would examine the specific configuration that

characterizes them in relation to the type and degree of

participation they exercise, and in comparison to the type

and degree that would correspond to them according to the

model assumed.

Germani cited degree and form of participation in the

productive or economic subsystem of society as one of the

main categories used in observing marginality. An element

essential to participation and marginality was identified as

being "personal conditions," which Germani defined as those

characteristics and capabilities that individuals ought to

have in order to effectively exercise their given roles.

"Objective resources" were also considered to be essential.

These would be all material and nonmaterial elements

necessary for participation to be effectively possible.

Another important factor in Germani's treatise on

marginality is the relationship between modernization and

marginality. Germani emphasized that marginality is one of

the perspectives from which modernization can be approached.

From Germani's point of reference, modernization involves


the social and human aspects of development, and the

problems generated as dilemmas of the contemporary world.

The fundamental fact which creates marginality and makes

problematic its perception, according to Germani, is the

asynchronous, or uneven nature of transition. From these

asynchronies arise coexisting institutions, values,

attitudes, patterns of behavior, structures, and groups or

social categories which may not be appropriate or efficient

for the times.

In modern society, psychosocial inadequacy may make

effective participation difficult or improbable. Germani

points out that psychosocial and individual factors cannot

be dismissed a priori when integrated into a broader scheme

of explanation which takes into consideration structural

factors (e.g., economic-social, cultural) to explain the

emergence and maintenance of situations of marginality.

The persistence of a group participating only partially in a

sector of society, perceived from the perspective of

efficiency, can be considered as a limitation and threat for

productive society to the extent that it impedes the

optimization of existing human resources, thereby reducing

its functionality. A modern society requires modern

attitudes along with an adequate education to meet the

demands of an increasingly complex technology.

It has been maintained that decline of the status of

elderly people accompanied modernization (Achenbaum, 1978;


Cowgill, 1974). If that is the case, this situation would

seem to place elderly people in a marginal category as

valued members of society. The carry-over is that because

of the devalued status of older people, particularly older

people in irreversible declining health, long-term care

facility employment can itself be considered a marginal

occupational position because of the low status associated

with it.

There are paradoxical aspects of modernization. On the

one hand, modernization led to the devaluation of elderly

people. At the same time, the higher standard of living and

advanced medical technology resulting from modernization has

led to a rapidly growing older population. The consequence

of this growth phenomenon, however, has been a corresponding

influx of elder people into long-term care facilities as

inevitable decline in health occurs, leaving the dilemma of

providing for them a level of efficient quality care.

Also relevant to the theory of marginality as it is

applied to this study is Mizruchi's (1983) approach to the

concept. Mizruchi was concerned with marginality in

relation to given organizations in society, and perceived

marginality as existing when persons are weakly tied to

important social structures such as the family or work

organizations, the latter of which is central to the study

at hand. More specifically, Mizruchi was interested in the

relationship between marginality and the short-term or long-



term imbalance between people and places, for example,

shortages of labor to fill vacant positions. Important to

Mizruchi were sociological questions pertaining to

discrepancies between the available work force and

structural opportunities, the societal dynamics which create

these discrepancies, and the way they impact on and are

responded to by diverse segments of society.

The present study recognizes the significance of

Mizruchi's analysis of marginality, and has as a major and

specific problem relevant in today's society--long-term

health care for institutionalized elderly people. In terms

of people-place imbalance, a rapidly increasing, homogeneous

resident population is filling long-term care facilities

and, although quality professional nursing care is badly

needed in the long-term care setting, there appears to be a

serious discrepancy between existing structural opportunity

and the recruitment of well-qualified RNs to work in long-

term care facilities. It is on this basis that it might

reasonably be hypothesized that whereas hospitals are more

likely to attract better-educated RN's who have a strong

career commitment, given the previously cited negative

factors associated with the long-term care setting, long-

term care facility RNs are more likely to be nurses who have

greater career marginality.

The theoretical approach to this study, then, focuses

on marginality in a structural sense that is analogous to


that of microeconomics rather than in a social relationship

sense. That is, certain individual RN characteristics can

be thought of as human capital economic demand

characteristics. A primary example is education.

Presently, a higher level of education and the skills that

accompany it are becoming more important for RNs in long-

term care facilities. This is because of the need to be

knowledgeable of the unique health needs of older people,

and also because of the recent implementation by Medicare of

the "Prospective Payment System," under which hospitals

receive fixed amounts based on the principal diagnosis for

each Medicare-covered hospital stay (Health Care Financing

Administration, 1989).

With regard to the Prospective Payment System, since

hospitals get a preset payment for a given condition no

matter what length of time a patient remains at the

hospital, the tendency has been to discharge patients more

quickly than in the past in order to minimize loss and

maximize profit (Donley & Flaherty, 1989; Hamilton & Wilson,

1989; Kayser-Jones, 1989; Walsh & Wilhere, 1988). When this

situation occurs when elderly people are involved, discharge

is frequently to a long-term care facility where skilled

care may likely be required because the health condition was

not completely dealt with at the hospital. A consequence of

this discharge orientation is that the intermediate care-

skilled care long-term care facility dichotomy that has

existed in the past has begun to shift in the direction of a

single skilled care facility identity.

Intermediate care has essentially involved a more

custodial type of care in which medically stabilized chronic

conditions are prevalent. Skilled care, however, must

accommodate acute care needs. Long-term care facilities

have seen an increase in the number of acute illness

patients who nurses' aides are not able to deal with as

would have been possible in the intermediate care situation

(Kayser-Jones, 1989). Also, the acute type of care requires

greater technology, along with personnel knowledgeable in

the use of such technology (Walsh & Wilhere, 1988).

Below, the level of education for RNs is discussed in

relation to the quality of labor, and hence care, offered in

long-term care facilities. From this discussion will emerge

the awareness that a low level of education results in one

facet, among others, of employment marginality for RNs.

It has been noted that an assumption prevails that

health care services can be provided to elderly persons

regardless of the knowledge held by service providers (Robb

& Malinzak, 1981). However, when speaking of long-term care

for aged people, knowledge appears to be an essential

factor. It has been emphasized that a strategic influence

over nurses' ability to provide quality care for older

persons is the knowledge base used to guide nursing practice

(Brower, 1988), and the expectation is that the level of


gerontological health care will improve as factual knowledge

in the care of elderly people increases (Nkongho, 1988).

Stanley and Burggraf have stated that "the importance of a

strong knowledge of the unique needs of the elderly as a

basis for providing quality care cannot be overstated"

(1986, p. 32).

In providing long-term nursing care for older people,

the knowledge level required of nurses has increased

considerably over the past few years (Robb & Malinzak,

1981). There is a specific behavioral and biological

knowledge about aging that serves as the basis for designing

and implementing the nursing process, and failure to have an

adequate and accurate understanding of the characteristics

of older persons can negatively affect their care (Gunter &

Estes, 1979; Kart, 1981). To cite an example of the unique

knowledge required for adequately caring for elderly

persons, when the nursing specialty, gerontological nursing,

is mentioned in newspaper articles, it is presented as being

a relatively high education specialty compared to other

nursing specialties (Kalisch & Kalisch, 1985). Only a very

small number of RNs who care for aged people, though, have

gone as far in their education as a gerontological nurse

specialty program, which makes the level of general nursing

education even more important, since more gerontological

content tends to be included in the higher levels of nursing

education. However, it has been noted that in long-term

care facilities the number of RNs with baccalaureate degrees

or higher is minuscule in comparison to the need (Nkongho,


In assessing the extent of gerontological nursing

knowledge among nursing personnel, it was found that as

educational preparation for nursing increased, so did,

generally, mean knowledge scores (Robb & Malinzak, 1981).

Reif (1982) has pointed out that more substantial

preparation in gerontology and long-term care is provided in

graduate level nursing programs. It has been noted that

graduates of master's degree programs in nursing are

prepared to function at a higher level of expertise

(Martinson, 1984). Williams et al. (1986) have reported

that nurses with master's degrees score higher on Palmore's

(1977) Facts on Aging Quiz than do baccalaureate nursing


Evidence suggests that the attitudes that health

professionals hold about older people influence the quality

of the service they render (Hatton, 1977; Wolk & Wolk,

1971). Campbell (1971) has noted that advanced levels of

education appear to be associated with decreased

stereotyping of aged persons, and Kosberg et al. (1972)

found that attitudes of professional staff members in a

nursing home were significantly related to the amount of

formal education. Similarly, Thorson et al. (1974) found,

that among students and practitioners in service to elderly


people, better-educated persons had significantly more

positive attitudes toward aged individuals.

Knowledge about aging and older persons seems to be a

crucial factor in delivering quality health care to older

people. It is therefore reasonable to take the position

that nurses with limited general and/or nursing education

are marginal from a job qualification standpoint. This is

because nurses with a lower level of education can be

considered less capable of providing a desired quality of

care for elderly persons. Although the recruitment and

retention of qualified nurses in long-term care is a

critical concern (Nagy et al., 1987), it has been found that

nurses with more formal education tend not to work with

older people (Meyer et al., 1980). Consequently, in this

respect career marginal nurses would be more likely to be

found working in long-term care settings.

Continuing education programs offer another way of

increasing the knowledge and skills of nurses. Nurses who

do not maintain or update their knowledge and skills may

well be considered marginal in terms of their job

qualifications and capabilities when compared with nurses

who take part in continuing education programs. The

importance of continuing education has grown in the last

half of the 20th century as a result of the rapid

development of medical information and technology. Nursing

information begins to become out of date after only about

two to two and one-half years (Williams, 1976). With

advances in scientific knowledge and increasing changes in

health care delivery, it has become essential that nurses

maintain a current knowledge and practice base (Kristjanson

& Scanlan, 1989).

Computer literacy has become more of a necessity for

nurses, and it has been continuing education rather than

standard educational programs that has played the major role

in providing nurses with computer usage skills (Reynolds &

Ferrell, 1989). Computers can increase the effective use of

nursing resources and improve the quality of patient care

(Packer, 1989).

An evaluation of education programs in long-term care

settings has shown that continuing education is an effective

means of influencing the knowledge and attitudes of nursing

personnel, and has recommended it as a first step toward

improving the quality of care of elderly long-term care

facility residents (Almquist et al., 1981). Haley (1988)

has emphasized that quality long-term care is dependent on

committed staff members whose education continues throughout

employment. In a study of the benefit of continuing

education on RNs working in hospitals, it was found that the

majority of these nurses perceived continuing education as

positively affecting their practice (Keltner, 1983).

Continuing education is particularly important for hospital


RNs, because of the higher level of skill required in acute

care as opposed to chronic care nursing.

Improved technology has also become a significant

factor in providing quality care for elderly people. As

medical technology continues to advance and the population

continues to age, nurses must increasingly be able to deal

with the special health problems of older persons, such as

cardiovascular and neurological conditions. This is

particularly important for acute care nurses such as

hospital RNs. Consequently, current nursing education must

necessarily incorporate the operation and reading of complex

equipment such as electronic monitors (Kirby, 1988).

Younger RNs and RNs continuing on to higher levels of

nursing education are the nurses most likely to have been

exposed to training in the use of advanced equipment.

The importance of level of education in providing

quality care for older persons has been discussed. Another

important function that level of education serves is the

ability to command interprofessional collaboration (Nkongho,

1988), which makes available a broader range of resources

and makes health care more efficient. With higher education

comes higher status, and it is this higher status that makes

it possible for RNs to obtain a greater degree of

interprofessional collaboration. This collaboration is

heightened by the fact that the presence of physicians is


not nearly as great in long-term care facilities as it is in


A lower level of knowledge or education is a major

factor that may contribute to job marginality in terms of

qualifications considered in the competition for higher pay,

benefits, and status for RNs which hospitals are able to

offer. Additional, and likely interacting, factors that may

contribute to employment or career marginality among RNs are

(a) employment continuity, (b) age, (c) marital status, (d)

children living at home, and (e) work setting. These

variables are more fully presented and discussed in Chapter

4, "Methods."


The study design is secondary data analysis of a

preexisting data set. To analyze the data, the inferential

statistical method of multiple logistic regression is



The data for this study are from the National Sample

Survey of Registered Nurses II (Moses & Spencer, 1980), and

are contained on National Technical Information Service

public use tape number PB82-253410. This survey was

conducted by the Research Triangle Institute of Research

Park, North Carolina for the purpose of assessing the number

and characteristics of the registered nurse population.

Such an assessment was considered to be essential to a

reliable evaluation of the nation's health resources and to

a determination of whether these resources are adequate

for meeting the health care needs of the nation. The survey

questionnaire is presented in the Appendix of this study.

In the fall of 1980 questionnaires were mailed to a

sample of 39,573 individuals having current licenses to

practice as registered nurses. The total number of

respondents was 30,642, yielding an effective response rate



of 80.0% after correction was made for the fact that 1,264

nurses held licenses from more than one state and therefore

were duplicated on the mailing list. Responses to the

survey were weighted so as to reflect the universe of

registered nurses. The estimated number of RNs within the

United States with licenses to practice in November, 1980

was 1,662,382. Of these, an estimated 1,272,851 RNs, or

76.6%, were actually employed in the field of nursing, with

the remaining nurses being either unemployed or employed in

a field other than nursing. The number of usable

questionnaires for which data were recorded was 30,535, or

79.7% of the nurses surveyed. In the present study, only

data for RNs working and/or living in the United States are

processed. The number of nurses in this category totals

30,375, which is 99.5% of the nurses who returned usable

questionnaires. The survey data include information on the

demographic characteristics of the registered nurse

population, their educational background, their type of

nursing employment and functions performed, their hours of

work and earnings, their activities if not employed in

nursing, and their geographic location.

Sample Characteristics

Data were obtained from 30,375 registered nurses who

were working and/or living in the U.S. in 1980. Of these

nurses, 23,563 (77.63%) were employed in nursing as of

November 15, 1980, with 67.86% being employed full-time and


32.14% part-time. The highest percentage (65.59%) of RNs

employed in nursing worked in hospitals. The next highest

percentage (8.07%) worked in long-term care facilities

("nursing homes" and "extended care facilities"). Other

work situations for the RN's in this sample included (a)

nursing education, (b) public/community health, (c) school

nurse, (d) occupational health, (e) physician's or dentist's

office, and (f) private duty. A staff or general duty

position was held by 69.19% of the nurses, whereas 19.32%

held an administrative, supervisory, or head nurse position.

Females comprised 97.26% of the sample, and the race

classification of 93.49% of the sample was white, not of

Hispanic origin. The median age of the sample was 38 years,

with 26.77% of the nurses being less than 30 years old,

55.26% being less than 40 years old, and 75.33% being less

than 50 years old. The percentage of nurses who were

married was 71.80%; 13.76% were divorced, widowed, or

separated and 14.44% were never married. The highest

education related to nursing for 72.22% of the nurses was

less than a baccalaureate degree. Of these nurses, 53.91%

had a diploma in nursing and 18.31% had an associate degree

in nursing. The percentage of nurses who had a

baccalaureate degree in nursing or other related field was

22.75%, while 5.03% had a master's degree or doctoral

degree. Of these, only 0.23% had a doctoral degree.



This study centers around differences in long-term care

facility employment as opposed to hospital employment both

in terms of employment characteristics of the two health

care settings themselves and of specific individual

demographic and employment characteristics of RNs who work

in these settings. The theme of marginality is central to

the study, and in this sense the marginal status of long-

term care facility employment is considered, along with

individual characteristics which would make an RN

occupationally marginal from an employer's point of view,

and RNs' employment characteristics which would make a nurse

marginal from a career orientation or commitment standpoint.

The variables in this study are related to the concept

of "career marginality." As a general concept in the study,

career marginality is composed of: (a) individual

demographic characteristics of RNs which would make a nurse

less job qualified (e.g., a limited level of education) from

an employer's standpoint when compared with more qualified

RNs, or less able to be fully career committed from a

personal standpoint (e.g., having family responsibility such

as children); (b) employment characteristics of RNs which

would be considered less than the ideal model or conception

of career participation (e.g., part-time employment; lack of

participation in continuing education programs); and (c) the

lower status and comparably less materially rewarding (i.e.,


pay and benefits) employment setting of the long-term care


The variables that follow are used to investigate some

of the various dimensions of career marginality. The

rationale behind their employment and the way in which the

variables are operationalized accompany each variable


Employment Setting

Employment setting, long-term care facility versus

hospital, is a variable of central interest in this study,

and consequently it is investigated both as a dependent

variable and as an independent variable predictor of degree

of career participation and also job change. Employment

setting is important in the sense that the long-term care

facility can be considered a somewhat marginal field of

employment within the health care profession, and thus may

have a greater likelihood of employing RNs who have career

marginality characteristics.

Career Line

The "career line" variable is a combination of three of

the variables presented below--full-time/part-time

employment, percent of time employed in nursing since

graduation from basic nursing education, and whether or not

the RN had participated in any type of continuing education

program during the past year. Creation of the career line


variable is meant to both provide the basis for a more

concrete definition and serve as a direct empirical

indicator of career orientation among RNs. By definition, a

nonmarginal career line would be full-time employment, a

relatively high percentage of time employed in nursing since

graduation from basic nursing education, and participation

in continuing education. The situation of not having these

three positive career line characteristics is defined as

having a marginal career line, or having "career


In the operationalization of the career line variable

only extreme cases (all coded positive or all coded negative

on the three variables comprising it) were selected. The

rationale for this particular mode of operationalization is

that it compares those RNs who are most different with

regard to career line and eliminates RNs in the "grey area"

in between. The alternative approach would have involved

comparing nurses coded positive on all three variables

comprising career line with nurses coded negative on at

least one of the variables.

Formal Education

Two variables of interest relate to formal education.

The first variable indicates the highest education related

to nursing that the RN has received. The supposition is

that, in today's job market, nurses who receive only a

diploma or associate degree as opposed to a baccalaureate


degree or higher may have less career commitment, or less

potential for career advancement, and may thus be marginal

in this respect. The second variable related to formal

education is whether or not the nurse is currently enrolled

in a formal education program leading to an academic degree.

Not currently being enrolled in a formal education program

leading to an academic degree would appear to indicate

career marginality for nurses with a lower level of

education. That is, RNs who do not extend their educational

attainment beyond a diploma in nursing or an associate

degree in nursing may be limited in their job performance

qualifications and job promotion potential.

Continuing Education

This variable indicates whether or not the nurse has

participated in any type of continuing education program

during the past year. Since a central purpose of continuing

education is to keep abreast of recent developments in a

given field, it is an important factor in maintaining

quality of care in the nursing profession (Day, 1989), and

not participating in continuing education might be

indicative of occupational marginality.

Continuing education will be used as an independent

variable in only one of this study's four multiple logistic

regression equations. Although the data for this study are

from 1980, research involving this variable and using more

current data should take into consideration the fact that 13


states now require continuing education for all registered

nurses (Newbern, 1989). Florida, for example, is one of the

states that sets trends for the rest of the country

(Naisbitt, 1982). Feeling that rapidly changing technology

results in complexity and transition within the health care

field which necessitates continuous updating of nursing

knowledge and skills, in 1986 the Florida Board of Nursing

adopted a continuing education requirement for RNs (Penny,

1989). In Indiana, mandatory continuing education for RNs

was implemented after a study (Puetz, 1983) concluded that

the least educated nurses were the least likely to attend

continuing education activities (Newbern, 1989).

Employment Continuity

Five employment continuity variables are used in this

study. The first indicates the percentage of time (measured

in years) that the RN has worked as a nurse since graduation

from basic nursing education. A limited percentage of time

employed would be a case of partial participation in the RN

work force and might be indicative of limited career

commitment. The second variable indicates whether or not

there has been a change in the location of the nurse's

employment within the past year. The literature implies a

high rate of turnover of personnel in long-term care

facilities, and job change in conjunction with working in

this particular employment setting might be construed as one

indicator of career marginality (Giordano & Panfil, 1987;


Kiyak & Kahana, 1987). However, although job location

change could possibly be an indicator of career

discontinuity, this is not necessarily so. For instance,

although job change might be indicative of an unstable or

unestablished career situation, at the same time it could be

a positive career move indicating promotion or improvement

in the career situation. Also, the change might be no worse

than a status quo transition, for example, when the

establishment at which the RN worked has relocated.

A third employment continuity variable is full-time

versus part-time employment. Part-time employment might be

considered an indicator of career marginality, since most

employment situations are oriented toward full-time

employment. Part-time employment, however, would not

necessarily be an indicator of less career commitment for

some nurses. For example, RNs currently pursuing an

academic degree full-time might be very career oriented, and

pursuing the degree might well be an indication of this.

Whether or not the RN was employed in nursing one year

prior to the time of the survey is a fourth employment

continuity variable. However this limited single point

check variable may not have as much relevance as, for

example, the longer time span variable of percentage of time

the RN has been employed in nursing since graduation from

basic nursing education. The fifth employment continuity

variable, being employed versus not employed, compares two


extremes, with particular interest in the characteristics of

nurses who have an RN license, but who are nonetheless



Older nurses, as opposed to younger nurses, are closer

to the end of their career and thus from an employment

standpoint might be considered marginal. For example, age

might be a factor in the situation where a nurse attempts to

resume working after raising a family, since there could be

employer preference for younger persons who are more likely

to have had exposure to new technology. Marginality for

older nurses might be of additional concern in the presence

of limited education or having returned to work for

financial reasons following widowhood, divorce, or

separation. In the latter case, returning to work out of

financial necessity might bring with it limited employment

commitment. Age, along with education, may be the two most

salient factors influencing employers' personnel decisions,

since these factors are so readily noticeable during the

employee application process.

Marital Status

Marital status by itself would not be assumed to be a

career marginality variable. However, it might be a

marginality indicator in the presence of children living at

home or among older nurses. For example, for older RNs who


are widowed, divorced, or separated, the absence of a

spouse's income may be an influential factor in returning to

or continuing to work, and in terms of job qualifications

these nurses might not be knowledgeable with regard to the

latest nursing technology and may be only diploma level

RNs. For younger single RNs with children living at home a

similar financial factor may exist, but these nurses may be

more up-to-date on new technology and may possess a higher

level of education.

A factor to consider in the marital status situations

noted is differences in motivation. The extrinsic

motivational factor of monetary reward may operate for many

older unmarried RNs and also for younger single RNs with

children. For other nurses the intrinsic motivational

factor of personal satisfaction in performing their

occupational roles may be of paramount importance.

Attempting to determine motivational reasons for nurses'

employment, however, is difficult, and one limitation of the

present study is the lack of such information in the data.

Children Living at Home

In terms of career marginality, this variable would

appear to assume particular relevance when linked with

marital status. Participation in the RN work force may be

interrupted or even ended for those women who have the

responsibility of raising children. Ending of an RN career

following the birth of children would be more expected for


married women, because spouses' income may be adequate to

maintain the household. Actually, ending an RN career

because of the responsibility of children is the ultimate

degree of career marginality, because it signifies total

lack of participation in the professional nurse role.

For single women not having the benefit of spouses'

income, a return to work following childbearing would be

more likely. Nurses who are single parents with children

living at home may be working largely because of financial

necessity, and the responsibility of children may interfere

with continuing education participation or pursuing a higher

academic degree. In this situation RNs would be marginal

from the career commitment or improvement standpoint.

Prediction Equations and Hypotheses

Prediction Equations

Utilizing various combinations of the variables

presented above, equations are analyzed in terms of their

function in predicting the probability or likelihood of the

opposing categories of the dependent variables. Since

sample regression equations will be used to estimate

population regression equations, the equations are

prediction equations in the sense that their independent

variables, or predictors, are used to generate predictions

about the dependent variables of interest. Statistical


findings for the equations are reported in the "Results"

chapter of this study.

The first prediction equation designates employment

setting as a dependent variable. Individual demographic

characteristics, in combination with employment

characteristics of RNs, are used as predictors of long-term

care facility employment. Demographic characteristics

include education, age, marital status, and children living

at home. Independent variables classified as employment

characteristics include full-time/part-time employment,

percent of time employed as a nurse since graduation from

basic nursing education, whether or not the RN was employed

in nursing the previous year, whether or not the RN

participated in any type of continuing education program

during the past year, and whether or not the RN was

currently enrolled in a formal education program leading to

an academic degree.

The second prediction equation has career line as the

dependent variable. In this equation, employment setting is

treated as an independent variable, along with education,

age, and children living at home. In the third prediction

equation being employed versus unemployed is the dependent

variable, and education, age, marital status, and children

living at home are the independent variables. The fourth

prediction equation employs as the dependent variable

whether or not the RN had experienced a job location change

within the past year. Employment setting, education, age,

and full-time/part-time employment are the independent


Figures 1-4 give a diagrammatic representation of the

four prediction equations used in this study.

Demographic Characteristics
of Registered Nurses

Marital Status
Children at Home

Employment-Related Characteristics
of Registered Nurses

Full-Time/Part Time
% Time Employed Since Basic Nursing
Employed/Unemployed Previous Year
Continuing Education Participation
Current Pursuit of Academic Degree


Figure 1.

Predictors of long-term care
hospital employment setting.

facility vs.

Employment Setting
Age > Career Line: Marginal
Education vs. Nonmarginal
Children at Home

Figure 2. Predictors of career line

Education > Employment Status: Employed
Marital Status vs. Unemployed
Children at Home

Figure 3. Predictors of employment status

> Job Change

Figure 4. Predictors of job change


Although in an effort to avoid unnecessary repetition

the research hypotheses presented below are stated in a

manner such that the dependent variables are grouped in

Employment Status
Full-Time/Part-Time Employment


single statements, the supposition is that each dependent

variable individually will be statistically significant in

influencing the independent variable. With regard to the

way in which the independent variables were dichotomized,

the rationale for variable categorization is presented in

the "Statistical Analysis" section of this chapter.

As for the demographic characteristic variables in the

first prediction equation, it is hypothesized that RNs who

have less than a baccalaureate degree level of education and

who are 45 years of age or older have a greater likelihood

of working in long-term care facilities than RNs who have a

baccalaureate degree or higher level of education and who

are younger than 45 years of age. Also, although marital

status is not hypothesized to have a main effect in

predicting long-term care facility employment, it is

hypothesized to interact with age and also with children

living at home. Here, it is hypothesized that single RNs 45

years of age or older, and single RNs who have children

living at home are more likely to be employed in long-term

care facilities than in hospitals.

With respect to the employment characteristic variables

in the first prediction equation, it is hypothesized that

RNs who are employed part-time, who have been employed in

nursing less than 80% of the time since graduation from

basic nursing education, who were not employed in nursing

the previous year, who did not participate in any type of


continuing education during the past year, and who are not

currently pursuing an academic degree, have a greater

likelihood of being employed in long-term care facilities

than in hospitals.

In terms of the second prediction equation, it is

hypothesized that RNs who are employed in hospitals, who

have higher than a diploma level of education, who are

younger than 45 years of age, and who have no children

living at home will have a greater likelihood of having a

nonmarginal career line than RNs who work in long-term care

facilities, who hold only a diploma in nursing, who are 45

years of age or older, and who have children living at home.

With regard to the third prediction equation it is

hypothesized than RNs who have less than a baccalaureate

degree level of education, who are 45 years of age or older,

who are married, and who have children living at home will

have a greater likelihood of not being employed than RNs who

have a baccalaureate degree or higher level of education,

who are younger than 45 years of age, who are not married,

and who do not have children living at home.

As for the fourth prediction equation it is

hypothesized that RNs who work in long-term facilities, who

have less than a baccalaureate degree level of education,

who are 45 years of age or older, and who are employed part-

time have a greater likelihood of having had a job location

change within the past year than RNs who work in hospitals,


who have a baccalaureate degree or higher level of

education, who are younger than 45 years of age, and who

work full-time.

Statistical Analysis

The data analysis approach employed in this study is

logistic regression analysis (Agresti & Finlay, 1986; Cleary

& Angel, 1984; Hanushek & Jackson, 1977). This approach was

selected because the dependent variables are dichotomous

categorical variables. Computer analysis of the data using

the Northeast Regional Data Center facilities at the

University of Florida employed the Statistical Analysis

System LOGIST procedure (Harrell, 1986), which fits a

logistic multiple regression model to a single binary (0, 1)

dependent variable. Except for the career line dependent

variable, the category of each dependent variable

conceptualized as marginal was coded "I," with the opposing

nonmarginal category being coded "O." For career line, the

reverse coding pattern was adopted. That is, in this

situation nonmarginal career line was coded "1" and marginal

career line was coded "O." In an effort to maximize

category frequencies the independent variables were also

dichotomized (although some--"yes" versus "no"--responses

were inherently dichotomous) and coded as "0" and "1."

Again, as in the case of the dependent variables, and again

with the exception of the career line equation, the

independent variable categories which represented marginal


characteristics were coded "1," and the nonmarginal

categories were coded "O."

The two categories of age were designated as those

nurses younger than age 45 and those 45 and older. This

point of division was selected because 45 years was the

median age of long-term care facility RNs. Priority was

given to long-term care facility RNs in dichotomizing

variable categories because these nurses comprised only 11%

of the study sample. Education was dichotomized between

less than a baccalaureate degree (diploma in nursing or

associate degree) and baccalaureate degree (in nursing or

other related field) or higher. This dichotomization was

chosen because the nursing literature has stressed the

importance of a baccalaureate degree or higher level of

education in exposing nurses to more gerontological content.

Whether or not the RN was currently enrolled in a formal

education program leading to an academic degree and whether

or not the nurse had participated in any type of continuing

education program during the past year simply involved a

"yes" or "no" response.

Whether or not the nurse was employed in nursing one

year ago also involved a "yes" or "no" response. Full-time

or part-time employment categorization was according to

whether or not the RN was scheduled to work for the normal

full work week throughout the normal work year as defined by

the employing institution. The variable, percentage of time

(based on years) that the RN has been employed as a nurse

since graduation from the basic nursing education program

was dichotomously divided between nurses who had worked 80%

of the time or more and nurses who had worked less than 80%

of the time, since 46% of long term care facility RNs had

been employed less than 80% of the time and 54% had been

employed 80% or more of the time.

The job location change within the past year variable

was inherently dichotomized in terms of being either a "yes"

or a "no" category, as was also the employment status

variable, currently employed or not currently employed. The

career line variable, being a combination of the three

variables full-time/part-time employment, percent of time

employed as a nurse since graduation from basic nursing

education, and participation in continuing education, was

dichotomized into nonmarginal and marginal career line

categories. That is, an RN with a nonmarginal career line

would be an individual who was employed full-time, had been

employed in nursing 80% or more of the time since graduation

from basic nursing education, and who had participated in

some type of continuing education program during the past

year. Constituting a marginal career line would be part-

time employment, having been employed less than 80% of the

time since graduation from basic nursing education, and not

having participated in continuing education during the past


The final two independent variables were marital status

and children living at home. The expectations for these two

variables involve the interaction of marital status and age,

and marital status and children living at home. The

dichotomization of age has already been explained. Marital

status was categorized according to whether the nurse was

married, or was widowed, divorced, separated, or never

married. The rationale for this particular marital status

dichotomization was to differentiate between nurses who

might benefit from the spouses' income and those who do not,

especially in the presence of the financial responsibility

of having children living at home. In adhering to the

chosen method of dichotomizing all variables, and taking

into consideration the somewhat confounding nature of the

original categorization of the children living at home

variable (see Table 14, p. 87), this variable was simply

dichotomized in terms of whether there were or were not

children living at home most of the time. The basic concern

with the children living at home variable was whether or not

there existed the financial and parenting responsibilities

entailed by having children at home.

Below are tables displaying the categorization

frequencies of the variables, in addition to employment

setting, used in this study. Since the comparative scheme

of the study revolves around long-term care facility

employment as opposed to hospital employment, the variables


are cross-tabulated with employment setting. The employed

versus the unemployed variable, however, is not cross-

tabulated with employment setting, because the unemployed

category of this variable has no corresponding work setting


The higher missing values for the two variables,

employed in 1979 and percent of time employed as a nurse

since graduation from basic nursing education, are due to

nurses who received their first RN license in 1980 and

nurses employed in nursing for less than one year not

being included as part of these variables. Similarly, since

by definition the career line variable involved

simultaneously falling into either all three marginal

categories, or all three nonmarginal categories, of the

three variables of which career line was comprised, many RNs

were deleted from the analysis of the career line equation.

For example, only RNs who were employed full-time, who had

worked 80% or more of the time as a nurse since graduation

from basic nursing education, and who had participated in

some type of continuing education program within the past

year were included in the nonmarginal career line category.

The chi-square statics accompanying Table 1 through Table 11

indicate statistical significance, with the exception of

Table 10, "Registered Nurses by Work Setting and Job

Location Change."

Table 1: Registered Nurses by Work Setting and Age

Work Setting Age Total

Row Percent
Under 45 Years 45 Years & Older

Hospital 11,828 3,267 15,095
78.36 21.64

Long-Term Care 909 941 1,850
Facility 49.14 50.86


chi-square = 753.91 (df = 1, p < .001)
frequency missing = 312

Table 2: Registered Nurses by Work Setting and Highest
Education Level

Work Setting Education Total

Row Percent
Less Than a Baccalaureate
Baccalaureate Degree or
Degree Higher

Hospital 11,165 4,129 15,294
73.00 27.00

Long-Term Care 1,636 243 1,879
Facility 87.07 12.93


chi-square = 174.44 (df = 1, p < .001)
frequency missing = 84

Table 3:

Registered Nurses by Work Setting and Current
Enrollment in an Academic Degree Program

Work Setting Current Enrollment in Academic Total
Degree Program

Row Percent
Yes No

Hospital 1,847 13,165 15,012
12.30 87.70

Long-Term Care 103 1,706 1,809
Facility 5.69 94.31


chi-square = 68.82 (df = 1, p < .001)
frequency missing = 436

Table 4: Registered Nurses by Work Setting and
Participation in Continuing Education

Work Setting Participation in Continuing Total

Row Percent
Yes No

Hospital 13,003 2,126 15,129
85.95 14.05

Long-Term Care 1,406 445 1,851
Facility 75.96 24.04


chi-square = 128.06 (df = 1, P < .001)
frequency missing = 277

Table 5: Registered Nurses by Work Setting and Whether or
Not Employed in 1979

Work Setting Employed in 1979 Total

Row Percent
Yes No

Hospital 13,486 754 14,240
94.71 5.29

Long-Term Care 1,679 171 1,850
Facility 90.76 9.24


chi-square = 47.11 (df = 1, p < .001)
frequency missing = 1,167

Table 6: Registered Nurses by Work Setting and Employment

Work Setting Employment Status Total

Row Percent
Full Time Part Time

Hospital 10,551 4,736 15,287
69.02 30.98

Long-Term Care 1,028 852 1,880
Facility 54.68 45.32


chi-square = 156.77 (df = 1, p < .001)
frequency missing = 90

Table 7:

Registered Nurses by Work Setting and Percent of
Time Employed in Nursing Since Graduation from
Basic Nursing Education Program

Work Setting Percent of Time Employed Total

Row Percent
Less Than 80% 80% or More

Hospital 2,470 11,131 13,601
18.16 81.84

Long-Term Care 790 941 1,731
Facility 45.64 54.36


chi-square = 692.53 (df = 1, 1 < .001)
frequency missing = 1,925

Table 8: Registered Nurses by Work Setting and Marital

Work Setting Marital Status Total

Row Percent
Widowed, Divorced
Separated, Never
Married Married

Hospital 10,124 5,133 15,257
66.36 33.64

Long-Term Care 1,369 505 1,874
Facility 73.05 26.95


chi-square = 33.89 (df = 1, R < .001)
frequency missing = 126

Table 9:

Registered Nurses by Work Setting and
Living at Home


Work Setting Children Living At Home Total

Row Percent
Yes No

Hospital 7,991 6,954 14,945
53.47 46.53

Long-Term Care 1,127 683 1,810
Facility 62.27 37.73


chi-square = 50.36 (df =1, B < .001)
frequency missing = 502

Table 10: Registered Nurses by Work Setting and Job
Location Change

Work Setting Job Location Change Total

Row Percent
Yes No

Hospital 1,433 12,043 13,476
10.63 89.37

Long-Term Care 181 1,498 1,614
Facility 10.78 89.22


chi-square = .034 (df = 1, p = .854)
frequency missing = 10


Table 11: Registered Nurses by Work Setting and Career Line

Work Setting Career Line Total

Row Percent
Nonmarginal Marginal

Hospital 7,032 247 7,279
96.61 3.39

Long-Term Care 492 126 618
Facility 79.61 20.39


chi-square = 365.60 (df = 1, R < .001)
frequency missing = 9,360

Table 12: Employed and Unemployed Registered Nurses

Row Percent

Employed 23,563

Unemployed 6,791

Total 30,354

frequency missing = 21


Logistic analysis is useful in fitting a logistic

regression model to a binary dependent variable. Whereas

general linear models rest on the assumptions concerning

linearity and the distribution of the error terms in the

model, logistic models are based on the assumption that the

underlying relationship can be represented by a logistic

function (Theil, 1970). Such a function is sigmoid or S-

shaped, lies between zero and one, and has its maximum slope

in the midrange of X, thus conforming to what might be

expected of a probability. For dichotomous dependent

variables, logistic regression analysis models the way in

which the proportion of responses in one of the categories

("1" response) is dependent on the values the independent

variables. If r = E(Y) denotes the proportion of "1"

responses in the population, then r also represents the

probability that a randomly selected individual falls into

the "1" response category, and this probability varies

according to the values of the independent variables. The

multiple logistic regression model has the form log [r/(1-

r)] = a + Z BX, where log [R/(1-i)] is the logistic

transformation or "logit." The logit is the log of the odds

of falling into one group as opposed to the other.


The nurses analyzed in this study included 15,367 RNs

who worked in hospitals and 1,890 RNs who worked in long

term care facilities. Of the combined group of hospital and

long-term care facility RNs, 89% worked in hospitals whereas

11% were employed in long-term care facilities. In the

various fields of employment, 66% of the RNs who were

employed in 1980 worked in hospitals, and eight percent

worked in long-term care facilities. Table 13 indicates the

distribution of RNs in different fields of employment in


Table 13: Registered Nurses 1980 by Field of Employment

Cumul. Cumul.
Field of Employment Frequency Percent Frequency Percent

Hospital............. 15,367 65.6 15,367 65.6
Long-Term Care Facil. 1,890 8.1 17,257 73.7
Nursing Education.... 928 4.0 18,185 77.6
Public/Commun. Health 1,611 6.9 19,796 84.5
School Nurse......... 772 3.3 20,568 87.8
Occupational Health.. 527 2.2 21,095 90.0
Physician's or
Dentist's Office... 1,426 6.1 22,521 96.1
Private Duty.......... 319 1.4 22,840 97.5
Other................ 588 2.5 23,428 100.0

Frequency missing = 135

Demographic Characteristics of RNs

Females comprised 96.37% and males 3.37% of the

hospital RNs, whereas of the long-term care facility RNs

98.40% were females and 1.60% were males. The mean age of

the hospital RNs was 35.53, compared to a mean age of 44.90

for long-term care facility RNs. Of the hospital RNs,

66.36% were married, 13.37% were widowed, divorced, or

separated, and 20.27% were never married. As for the long

term care facility RNs, 73.05% were married, 18.41% were

widowed, divorced or separated, and 8.54% were never

married. With regard to children living at home, 46.53% of

the hospital nurses had no children living at home as

opposed to 37.73% of the long-term care facility RNs having

no children living at home. Of the hospital RNs, 7.85% were

non-Caucasian, whereas 5.27% of the long-term care facility

RNS were non-Caucasian. As for education, 24.27% of the

hospital RNs, as opposed to 11.82% of the long-term care

facility RNs, had a baccalaureate degree in nursing or other

related field. The mean number of years since graduation

from basic nursing education was 12.10 for hospital RNs and

21.64 for long-term care facility RNs. The mean for the

survey question, "year in which nurse received highest

nursing-related degree," was 1968 for hospital RNs and 1959

for long-term care facility RNs. Of the hospital RNs,

12.30% were currently enrolled in a formal education program


leading to an academic degree; this contrasts with 5.69% of

the long-term care facility RNs.

Table 14 gives comparisons of the demographic

characteristics of hospital and long-term care facility RNs.

The chi-square statistics in the table indicate that for

each characteristics there is a significant difference

between long-term care facility RNs and hospital RNs.

Employment Characteristics of RNs

Table 15 contains comparisons of some of the employment

characteristics of hospital and long-term care facility RNs.

With regard to employment status, 69.02% of the hospital RNs

were employed full-time, whereas 54.68% of the long-term

care facility RNs were employed full-time. Of the hospital

nurses, 6.61% had less than one year experience as an RN, as

opposed to 2.29% of the long-term care facility RNs. The

mean number of years hospital nurses had worked for pay as

an RN since graduation from basic nursing education was

11.30; the mean number of years for long-term care facility

RNs was 15.84. The percentage of hospital nurses receiving

their first RN license in 1980 was 7.33%, whereas this

percentage for long-term care facility nurses was 2.06%.

Whereas 70.46% of the hospital RNs were employed in nursing

80% or more of the time since graduation from basic nursing

education, the percentage for long-term care facility RNs

was 43.91%. Of the hospital RNs, 4.91%, as opposed to 9.05%

Table 14: Demographic Characteristics of Registered Nurses
by Work Setting

Hospital Care Facility
RN Characteristic Number Percent Number Percent

Female................ 14,694
Male.................. 553
chi-square =

Race and Ethnicity
White, not Hispanic... 13,999
Black, Hispanic, other 1,193



(gf = 1, P

(dt = 1, P

Less than 25 years....
25-44 years...........
45-64 years............
65 years and older....


chi-square =

Marital Status
Married ............... 10,124
Widowed, divorced,
separated........... 2,040
Never married......... 3,093

Ages of Children at Home
No children at home...
All < 6 years old.....
All 6 years and older.
Some < 6 and some r 6

Highest Education
Diploma in nursing....
Associate degree......
Baccalaureate degree..
Master's degree.......

i-square =





= 162.63


5 48.68
0 24.32
1 24.27
3 2.70
5 0.03
re = 320.39

(df = 3,


(d- = 2,

(df = 3,

(df = 3,

p = .000)


p = .000)

S= .000)

P = .000)

= .000)

= .000)

Note: In Table 14 education chi-square was computed with
master's and doctorate categories combined due to low
doctorate frequencies.

Table 15: Employment Characteristics of Registered Nurses
by Work Setting

Hospital Care Facility
Characteristic Number Percent Number Percent

Type of Position
Staff or general duty.. 11,066
Head nurse or assistant 1,342
Supervisor.............. 934
Administrator or assist. 459
Other................... 1,541
chi-square =

Full/Part Time
Full-time.............. 10,551
Part-time............. 4,736
chi-square =

% Time Employed as
Nurse Since Graduation
Less than 80%.......... 3,304
80 or greater %....... 10,297
RN employed < 1 year.. 1,014
chi-square =

Year of 1st RN License
1977-1980 .............. 4,126
Prior to 1977 .......... 10,882
chi-square =





(df = 4,

(df = 1,

(df = 2,

(df = 1,

p = .000)

E = .000)

R = .000)

p = .000)

Years Employed as RN..

Annual Earnings.......

Full-time RNs..........

Part-time RNs..........




t = -19.42 (df = 15,806, p = .0001)

15,074 12,126
t = 18.31 (df = 16,489, R = .0001)

17,571 15,491
t = 13.07 (df = 11,236, p = .0001)

9,496 8,163
t = 6.34 (df = 5,251, e = .0001)



of the long-term care facility RNs, were not employed in

nursing a year prior to the time of the 1980 survey. With

regard to continuing education, 85.95% of the hospital RNs

and 75.96% of the long-term care facility RNs had

participated in some type of continuing education program

during the past year. Of the nurses who did not participate

in continuing education, 16.22% of the hospital RNs, as

opposed to 30.24% of the long-term care facility RNs, felt

that their job did not require continuing education.

With respect to type of employment position, 74.85% of

hospital RNs and 55.53% of long-term care facility RNs held

a staff or general duty position; 18.50% of hospital RNs and

40.47% long-term care facility RNs held a position as

administrator or assistant administrator, supervisor, or

head or assistant head nurse. The annual earnings from

current principal nursing position for RNs in the survey who

worked in hospitals was higher than the earnings received by

RNs who worked in long-term care facilities. For full-time

and part-time employment combined, the average annual

earnings for hospital RNs was $15,069, whereas for long-term

care facility RNs it was $12,107. Full-time hospital RNs

had an average annual income of $17,571 as opposed to

$15,491 for long-term care facility RNs. The average annual

earnings for part-time hospital RNs was $9,496, and for

part-time long-term care facility RNs it was $8,163.

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