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A registered nurse ("RN"), is a health care professional responsible for
implementing the practice of nursing through the use of the nursing process (in
concert with other health care professionals). Registered nurses work as patient
advocates for the care and recovery of the sick and maintenance of the healthy.
In their work as advocates for the patient, RNs ensure that the patient receives
appropriate and professional care. RNs use the nursing process to assess, plan,
implement, and evaluate nursing care of the sick and injured.
Scope of practice
The scope of practice of registered nurses is the extent to which an RN can
practice and the limits of that practice. In the United States, these limits are
determined by a set of laws known as the Nurse Practice Act of the state or
territory in which an RN is licensed. Each state has its own laws, rules, and
regulations governing nursing care. Usually the making of the rules and lakddsgf
regulations is delegated to a state board of nursing, which performs the
day-to-day administration of these rules, qualifies candidates for licensure,
licenses nurses and nursing assistants, and makes decisions on nursing issues.
It should be noted that in some states the terms "nurse" or "nursing" may only
be used in conjunction with the practice of a Registered Nurse or LPN/LVN.
The scope of practice for a registered nurse is wider than for a licensed
practical or vocational nurse (LPN or LVN) because of the level and content of
education as well as what the Nurse Practice Act says about the respective roles
of each.
In the hospital setting, registered nurses are often assigned a supervisory role
to oversee tasks performed by LPNs and unlicensed assistive personnel such as
nursing assistants. However, the RN remains responsible for the safety and care
of the patient.
RNs are not limited to employment as bedside nurses. Registered nurses are
employed by physicians, attorneys, insurance companies, private industry, school
districts, ambulatory surgery centers and fire departments, among others. Some
registered nurses are independent consultants who work for themselves, while
others work for large manufacturers or chemical companies. Research Nurses
conduct or assist in the conduct of research or evaluation (outcome and process)
in many areas such as biology, psychology, human development, and health care
systems.
Educational and licensure requirements
Two-year college degree
In the United States, there are three routes to initial licensure as a
registered nurse. The shortest path (and the most widely utilized) is a two-year
Associate of Science in Nursing, a two-year college degree referred to as an ADN;
this is the most common initial preparation for licensure in the U.S. Often in
competitive metropolitan areas within the US, two-year programs can require
several prerequisite courses which ultimately stretch out the degree acquiring
process to about 3 or sometimes even 4 years.
Hospital diploma program
Another method is to attend a diploma program, which lasts approximately three
years. Students take between 30 and 60 credit hours in anatomy, physiology,
microbiology, nutrition, chemistry, and other subjects at a college or
university, then move on to intensive nursing classes. Until 1996, most RNs in
the US were initially educated in nursing by diploma programs.
The Bachelor of Science in Nursing
The third method is to obtain a Bachelor of Science in Nursing, a four-year
degree that also prepares nurses for graduate-level education. For the first two
years in a BSN program, students usually obtain general education requirements
in the same manner as ADN and diploma graduates, they spend the remaining time
in nursing courses. Advocates for the ADN and diploma programs state that such
programs have a more "hands-on" approach to educating students, while the BSN is
an academic degree that emphasizes research and nursing theory. Nursing schools
must be accredited by either the National League for Nursing Accrediting
Commission(NLNAC) or the Commission on Collegiate Nursing Education (CCNE).
Licensure examination
Completion of any one of these three educational routes allows a graduate nurse
to take the NCLEX-RN, the test for licensure as a registered nurse, and is
accepted by every state as adequate preparation so long as the graduate attended
an NLNAC-accredited school. However, controversy exists over the appropriate
entry-level preparation of RNs. Some professional organizations believe the BSN
should be the sole method of RN preparation and ADN graduates should be licensed
as "technical nurses" to work under the supervision of BSN graduates. Others
feel the hands-on skill of diploma and ADN graduates makes up for any deficiency
in theoretical preparation. Regardless of this debate, it is highly unlikely
that the BSN will become the standard for initial preparation any time soon,
because of the nursing shortage and the lack of faculty to teach BSN students.
Graduate nursing opportunities
Advanced education in nursing is done at the masters and doctoral levels. A
Master of Science in Nursing or a Master of Nursing takes about three years of
full-time study to complete and prepares the graduate for specialization as a
nurse practitioner, a clinical nurse leader (CNL), a certified registered nurse
anesthetist (CRNA), or a clinical nurse specialist (CNS). Nurse practitioners
work in fields as diverse as midwifery, family practice, psychiatry, gerentology,
or pediatrics, while a CNS usually works for a facility to improve patient care,
do research, or as a staff educator. Doctoral programs in nursing prepare the
student for work in nursing education, health care administration, clinical
research, or advanced clinical practice. Most programs confer the Ph.D in
nursing, but some confer the Doctor of Nursing Science (DNS or DNSc), Doctor of
Nursing Practice (DNP), Doctor of Science in Nursing (DSN), or the Doctor of
Education (Ed. D.). Doctoral programs take from three to five years of full-time
study to complete. ok
Nursing board certification
Professional nursing organizations, through their certification boards, have
voluntary certification exams to demonstrate clinical competency in their
particular specialty. Completion of the prerequisite work experience allows an
RN to register for an examination, and passage gives an RN permission to use a
professional designation after their name. For example, passage of the American
Association of Critical-care Nurses specialty exam allows a nurse to use the
initials 'CCRN' after his or her name. Other organizations and societies have
similar procedures.
The American Nurses Credentialing Center, the credentialing arm of the American
Nurses Association, is the largest nursing credentialing organization and
administers more than 30 specialty examinations.
The nursing shortage in the United States
RNs are the largest group of health care workers in the United States, numbering
over 2.6 million. It has been reported that the number of new graduates and
foreign-trained nurses is insufficient to meet the market-place demand for
registered nurses; this is often referred to as the nursing shortage and is
expected to increase for the foreseeable future.
Causes of the nursing shortage in the United States
Among the many cited causes for the nursing shortage is the lack of qualified
doctoral or master degree prepared faculty for college RN programs. Students
cannot be admitted to school if there are no faculty to teach them. Furthermore,
there is evidence that faculty positions for RN programs do not command
equivalent salaries to those of their peers in other fields.
Another factor affecting the nursing shortage is that after education,
Registered Nurses typically do not remain long in the profession, especially
those working in more traditional hospital health care roles. The two primary
reasons given for leaving the profession are poor working conditions (e.g. long
and irregular hours and an absence of sufficient numbers of health care
providers, such as aides); and salaries which are not commensurate with the
responsibilities of the profession.
Hospital corporations and other health care organizations actively recruit
Registered Nurses from other countries. These recruits are routinely and quickly
granted a "V" visa for professional work in the United States. This practice has
accelerated in the last 10 years, and there are mounting concerns that this
solution is not in the best interest of patients or nursing professionals. The
primary concerns are:
(1) the level of professional training and preparation in some countries have
been reported to be inadequate;
(2) this practice may be interfering with changes which would otherwise occur to
keep Registered Nurses in the work force, that is, improvements in working
conditions and more appropriate salaries; and
(3) cultural and language proficiency has been reported to be lacking for some
immigrant nurses, and immigrant nurses do not always share the same goals
related to nursing interventions and/or outcomes.
Solutions to the nursing shortage
The American Association of Colleges of Nursing (AACN) is concerned about the
labor shortage in the field of nursing and has been working to enact
legislation, identify strategies, and form cooperative efforts with all
interested persons and groups to address this problem. The AACN has also
published a fact sheet containing current statistics related to the shortage
(found here ).
United Kingdom
See Nursing in the United Kingdom for more information.
To practice lawfully as a registered nurse in the United Kingdom, the
practitioner must hold a current and valid registration with the Nursing and
Midwifery Council. The title "registered nurse" can only be granted to those
holding such registration, this protected title is laid down in the Nurses,
Midwives and Health Visitors Act, 1997.
First level nurses
First level nurses make up the bulk of the registered nurses in the UK. They
were previously known by titles such as RGN (registered general nurse), RSCN
(registered sick children's nurse), RMN (registered mental nurse) and SRN (state
registered nurse) etc.
The majority of first level nurses are employed as staff nurses with the
minority in management and specialised roles.
Second level nurses
See state enrolled nurse for more information.
Second level nurse training is no longer provided, however they are still
legally able to practice in the United Kingdom as a nurse. Many have now either
retired or undertaken conversion courses to become first level nurses.
Specialist nurses
The NHS employs a huge variety of specialist nurses. These nurses have many
years of experience in their field, in addition to extra education and training
(see below).
They split into several major groups:
Nurse practitioners - these nurses carry out care at an advanced practice level.
They often perform roles similar to those of doctors. They commonly work in
primary care (e.g. GP surgeries) or A&E departments, although they are
increasingly being seen in other areas of practice.
Specialist community public health nurses - traditionally district nurses and
health visitors, this group of practitioners now includes many school nurses and
occupational health nurses.
Clinical nurse specialists - nurses undertaking these roles commonly provide
clinical leadership and education for the staff nurses working in their
department, and may also have special skills or knowledge which ward nurses can
draw upon.
Nurse consultants - these nurses are similar in many ways to the clinical nurse
specialist, but at a higher level. These practitioners are responsible for
clinical education and training of those in their department, and many also have
active research and publication activities.
Lecturer-practitioners - these nurses work both in the NHS, and in universities.
They typically work for 2-3 days per week in each setting. In university, they
train pre-registration student nurses (see below), and often teach on specialist
courses for post-registration nurses (e.g. a Lecturer-practitioner in critical
care may teach on a Masters degree in critical care nursing).
Lecturers - these nurses are not employed by the NHS. Instead they work full
time in universities, both teaching and performing research.
Managers
There are many nurses who have worked in clinical settings for a long time
choose to leave clinical nursing and join the ranks of the NHS management. This
used to be seen as a natural career progression for those who had reached ward
management positions, however with the advent of specialist nursing roles (see
above), this has become a less attractive option.
Nonetheless, many nurses fill positions in the senior management structure of
NHS organisations, some even as board members. Others choose to stay a little
closer to their clinical roots by becoming clinical nurse managers or modern
matrons
Nurse education
Pre-registration
In order to become a registered nurse, and work as such in the NHS, one must
complete a programme recognised by the Nursing and Midwifery Council. Currently,
this involves completing a degree or diploma, available from a range of
universities offering these courses, in the chosen branch speciality (see
below), leading to both an academic award and professional registration as a 1st
level registered nurse. Such a course is a 50/50 split of learning in university
(i.e. through lectures, essays and examinations) and in practice (i.e.
supervised patient care within a hospital or community setting).
These courses are three (occasionally four) years' long. The first year is known
as the common foundation programme (CFP), and teaches the basic knowledge and
skills required of all nurses. The remainder of the programme consists of
training specific to the student's chosen branch of nursing. These are:
Adult nursing.
Child nursing.
Mental health nursing.
Learning disabilities nursing.
Midwifery training is similar in length and structure, but is sufficiently
different that it is not considered a branch of nursing. There are shortened (18
month) programmes to allow nurses already qualified in the adult branch to hold
dual registration as a nurse and a midwife. Shortened courses lasting 2 years
also exist for graduates of other disciplines to train as nurses. This is
achieved by more intense study and a shortening of the common foundation
programme.
Student nurses currently receive a bursary from the government to support them
during their nurse training. Diploma students in England receive a
non-means-tested bursary of around ￡6000 per year (with additional allowances
for mature students or those with dependent children), whereas degree students
have their bursary means tested (and so often receive less). Degree students
are, however, eligible for a proportion of the government's student loan, unlike
diploma students. In Scotland, however, all student nurses regardless of which
course they are undertaking, receive the same bursary in line with the English
diploma amount. In Wales only the Degree level course is offered and all nursing
students therefore receive a non-means-tested bursary.
Before Project 2000, nurse education was the responsibility of hospitals and was
not based in universities; hence many nurses who qualified prior to these
reforms do not hold an academic award.
Post-registration
After the point of initial registration, there is an expectation that all
qualified nurses will continue to update their skills and knowledge. The Nursing
and Midwifery Council insists on a minimum of 35 hours of education every three
years, as part of its post registration education and practice (PREP)
requirements.
There are also opportunities for many nurses to gain additional clinical skills
after qualification. Cannulation, venepuncture, intravenous drug therapy and
male catheterisation are the most common, although there are many others (such
as advanced life support) which some nurses will undertake.
Many nurses who qualified with a diploma choose to upgrade their qualification
to a degree by studying part time. Many nurses prefer this option to gaining a
degree initially, as there is often an opportunity to study in a specialist
field as a part of this upgrading. Financially, in England, it is also much more
lucrative, as diploma students get the full bursary during their initial
training, and employers often pay for the degree course as well as the nurse's
salary.
In order to become specialist nurses (such as nurse consultants, nurse
practitioners etc.) or nurse educators, some nurses undertake further training
above bachelors degree level. Masters degrees exist in various healthcare
related topics, and some nurses choose to study for PhDs or other higher
academic awards. District nurses and health visitors are also considered
specialist nurses, and in order to become such they must undertake specialist
training (often in the form of a top up degree (see above) or post graduate
diploma).
All newly qualifying district nurses and health visitors are trained to
prescribe from the Nurse Prescribers' Formulary, a list of medications and
dressings typically useful to those carrying out these roles. Many of these (and
other) nurses will also undertake training in independent and supplementary
prescribing, which allows them (as of May 1st 2006) to prescribe almost any drug
in the British National Formulary. This has been the cause of a great deal of
debate in both medical and nursing circles.
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