Per Diem Nursing in the Bay Area: Or How to Earn Over $100K as an RN.

Rob (not his real name) is a registered nurse with over 20 years of nursing experience, the majority of which has been gained in critical care areas.

For the past several years, Rob has been working in hospitals in the San Francisco Bay Area as a per diem nurse in critical care units (MSICU, CVICU, CCU, PACU, and ER). He has found this an extremely lucrative career path, and wants to share his tips with fellow nurses.

Q: Last year you earned approximately US$120,000. How did you do this?

A: I work as a per diem nurse in the San Francisco Bay Area, which is the highest paying region in the United States. This is possible for a few reasons:

• The nursing unions are very strong.

• About a year ago, the state regulated a mandatory nurse-to-patient ratio in all areas (prior to this, many individual hospitals had minimum nurse-to-patient ratios for certain units, such as ICU).

• Nurses' salaries are based on experience, not education.

As a per diem nurse, I am a hospital employee, and I can become an employee of several hospitals. I receive no benefits: no vacation, no sick leave, no assurance of work, and no healthcare insurance. If something happens to you, the government will take your house.

Per diem RN jobs are regulated by the unions and the pay rate is based on years of full-time service. At my experience level, I generally earn between $54/hour and $60/hour, depending on whether it is a union or non-union hospital. (The non-union hospitals pay more.)

The union regulations also require that after the first eight hours of work, the nurse must be paid time-and-a-half. Therefore, if I work a 12-hour shift at a hospital that pays $60 an hour, I earn $480 for the first eight hours and $90 for the last four hours, for a total of $840 for a 12-hour shift.

I work in all critical care areas, including the Recovery Room, so if I take call in the RR, I am paid 50% of the wage while I'm at home and available for a case, and if I'm called into work, I'm paid time-and-a-half of the rate. And because of union regulations, I have to be paid for a minimum of four hours of work, even if the case takes just one hour.

But you work very, very hard. There is so much pressure to work. I once worked 17 days straight. Last year, I made US$119,400 and worked about nine months.

Q: If there is so much pressure to work and the work is so hard, why do you work per diem?

A: I like learning and in per diem, I can work in a variety of services: critical care, recovery room, ER, CVICU. I try to keep current in all the skills. I like the flexibility. It has allowed me to return to school. I like floating around the hospital. And I have the freedom where to work, when to work, and how much to work. But it's very, very hard.

Q: Are there negative sides to working per diem in the San Francisco Bay Area?

A: As I said, you have no benefits. I pay my own healthcare insurance, which costs me $5,040 per year. You have to be very disciplined in how you manage your money.

There are also the issues of high tax rate and high cost of living, as well as the social problems (which mean that you work very, very hard).

Q: Do a lot of nurses work per diem?

A: On some units, especially critical care, 50% of nurses can be per diem. Single mothers will often take a part-time job which gives benefits, and in addition will work per diem for 12 hours per week or more. I know one nurse who wanted to buy a house and worked 12-hour shifts every day for six months straight.

Q: You keep talking about the work being very, very hard. Tell me more about this.

A: There is a mix of social problems – you see a lot of workplace violence, drug addictions, HIV, hepatitis. The patients are very acute. They are chronically ill then become acutely ill. There's terrific pressure to get people out of the ICU to a stepdown (when they are not ready, but other patients are waiting to come in). It's also a very litigious society. Nurses are under intense pressure and don't get a lot of respect from patients and family members.

The nurses as a group lobbied to get minimum staffing ratios. Nurses are on the frontlines when there are budget deficits and withholding of healthcare. You have to fight for your patients.

There are even more per diem nurses on medical/surgical units because the acuity is very high. It used to be eight patients to one RN, now it's six patients to one RN and no nursing aide.

"We get it from all sides: the doctors, administration, the patients, the families."

Per Diem Nursing in the Bay Area

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Joyce Goodwin

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