Nursing
by Dr. Gary Farr on 19 April 2002

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Nursing

Nature of the Work

Registered nurses (R.N.s) work to promote health, prevent disease, and help patients cope with illness. They are advocates and health educators for patients, families, and communities. When providing direct patient care, they observe, assess, and record symptoms, reactions, and progress; assist physicians during treatments and examinations; administer medications; and assist in convalescence and rehabilitation. R.N.s also develop and manage nursing care plans; instruct patients and their families in proper care; and help individuals and groups take steps to improve or maintain their health. While State laws govern the tasks R.N.s may perform, it is usually the work setting, which determines their day-to-day job duties.

Hospital nurses form the largest group of nurses. Most are staff nurses, who provide bedside nursing care and carry out medical regimens. They may also supervise licensed practical nurses and aides. Hospital nurses usually are assigned to one area such as surgery, maternity, pediatrics, emergency room, intensive care, or treatment of cancer patients. Some may rotate among departments.

Office nurses care for outpatients in physicians’ offices, clinics, surgicenters, and emergency medical centers. They prepare patients for and assist with examinations, administer injections and medications, dress wounds and incisions, assist with minor surgery, and maintain records. Some also perform routine laboratory and office work.

Nursing home nurses manage nursing care for residents with conditions ranging from a fracture to Alzheimer’s disease. Although they usually spend most of their time on administrative and supervisory tasks, R.N.s also assess residents’ medical condition, develop treatment plans, supervise licensed practical nurses and nursing aides, and perform difficult procedures such as starting intravenous fluids. They also work in specialty-care departments, such as long-term rehabilitation units for strokes and head-injuries.

Home health nurses provide periodic services, prescribed by a physician, to patients at home. After assessing patients’ home environments, they care for and instruct patients and their families. Home health nurses care for a broad range of patients, such as those recovering from illnesses and accidents, cancer, and child birth. They must be able to work independently and may supervise home health aides.

Public health nurses work in government and private agencies and clinics, schools, retirement communities and other community settings. They focus on populations, working with individuals, groups, and families to improve the overall health of communities. They also work as partners with communities to plan and implement programs. Public health nurses instruct individuals, families, and other groups in health education, disease prevention, nutrition, and child care. They arrange for immunizations, blood pressure testing, and other health screening. These nurses also work with community leaders, teachers, parents, and physicians in community health education.

Occupational health or industrial nurses provide nursing care at worksites to employees, customers, and others with minor injuries and illnesses. They provide emergency care, prepare accident reports, and arrange for further care if necessary. They also offer health counseling, assist with health examinations and inoculations, and assess work environments to identify potential health or safety problems.

Head nurses or nurse supervisors direct nursing activities. They plan work schedules and assign duties to nurses and aides, provide or arrange for training, and visit patients to observe nurses and to insure that care is proper. They may also insure records are maintained and equipment and supplies are ordered.

At the advanced level, nurse practitioners provide basic primary health care. They diagnose and treat common acute illnesses and injuries. Nurse practitioners can prescribe medications in all States and the District of Columbia. Other advanced practice nurses include clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives. Advanced practice nurses have met higher educational and clinical practice requirements beyond the basic nursing education and licensing required of all R.N.s.

Working Conditions

Most nurses work in well-lighted, comfortable health care facilities. Home health and public health nurses travel to patients’ homes and to schools, community centers, and other sites. Nurses may spend considerable time walking and standing. They need emotional stability to cope with human suffering, emergencies, and other stresses. Because patients in hospitals and nursing homes require 24-hour care, nurses in these institutions may work nights, weekends, and holidays. They may also be on-call; available to work on short notice. Office, occupational health, and public health nurses are more likely to work regular business hours. Almost 1 in 10 R.N.s held more than one job in 1998.

Nursing has its hazards, especially in hospitals, nursing homes, and clinics where nurses may care for individuals with infectious diseases such as hepatitis. Nurses must observe rigid guidelines to guard against these and other dangers such as radiation, chemicals used for sterilization of instruments, and anesthetics. In addition, they are vulnerable to back injury when moving patients, shocks from electrical equipment, and hazards posed by compressed gases.

Employment

As the largest health care occupation, registered nurses held about 2.1 million jobs in 1998. About 3 out of 5 jobs were in hospitals, in inpatient and outpatient departments. Others were mostly in offices and clinics of physicians and other health practitioners, home health care agencies, nursing homes, temporary help agencies, schools, and government agencies. The remainder worked in residential care facilities, social service agencies, religious organizations, research facilities, management and public relations firms, insurance agencies, and private households. About 1 out of 4 R.N.s worked part time.

Training, Other Qualifications, and Advancement

In all States, students must graduate from a nursing program and pass a national licensing examination to obtain a nursing license. Nurses may be licensed in more than one State, either by examination or endorsement of a license issued by another State. Licenses must be periodically renewed. Some States require continuing education for licensure renewal.

In 1998, there were over 2,200 entry level R.N. programs. There are three major educational paths to nursing: Associate degree in nursing (A.D.N.), bachelor of science degree in nursing (B.S.N.), and diploma. A.D.N. programs, offered by community and junior colleges, take about 2 years. About half of all R.N. programs in 1998 were at the A.D.N. level. B.S.N. programs, offered by colleges and universities, take 4 or 5 years. About one-fourth of all programs in 1998 offered degrees at the bachelor’s level. Diploma programs, given in hospitals, last 2 to 3 years. Only a small number of programs, about 4 percent, offer diploma level degrees. Generally, licensed graduates of any of the three program types qualify for entry level positions as staff nurses.

There have been attempts to raise the educational requirements for an R.N. license to a bachelor’s degree and, possibly, create new job titles. These changes, should they occur, will probably be made State by State, through legislation or regulation. Changes in licensure requirements would not affect currently licensed R.N.s, who would be "grandfathered" in, no matter what their educational preparation. However, individuals considering nursing should carefully weigh the pros and cons of enrolling in a B.S.N. program, since their advancement opportunities are broader. In fact, many career paths are open only to nurses with bachelor’s or advanced degrees. A bachelor’s degree is usually necessary for administrative positions and is a prerequisite for admission to graduate nursing programs in research, consulting, teaching, or a clinical specialization.

Many A.D.N. and diploma-trained nurses enter bachelor’s programs to prepare for a broader scope of nursing practice. They can often find a hospital position and then take advantage of tuition reimbursement programs to work toward a B.S.N.

Nursing education includes classroom instruction and supervised clinical experience in hospitals and other health facilities. Students take courses in anatomy, physiology, microbiology, chemistry, nutrition, psychology and other behavioral sciences, and nursing. Coursework also includes liberal arts classes.

Supervised clinical experience is provided in hospital departments such as pediatrics, psychiatry, maternity, and surgery. A growing number of programs include clinical experience in nursing homes, public health departments, home health agencies, and ambulatory clinics.

Nurses should be caring and sympathetic. They must be able to accept responsibility, direct or supervise others, follow orders precisely, and determine when consultation is required.

Experience and good performance can lead to promotion to more responsible positions. Nurses can advance, in management, to assistant head nurse or head nurse. From there, they can advance to assistant director, director, and vice president. Increasingly, management level nursing positions require a graduate degree in nursing or health services administration. They also require leadership, negotiation skills, and good judgment. Graduate programs preparing executive level nurses usually last 1 to 2 years.

Within patient care, nurses can advance to clinical nurse specialist, nurse practitioner, certified nurse-midwife, or certified registered nurse anesthetist. These positions require 1 or 2 years of graduate education, leading in most instances to a master’s degree, or to a certificate.

Some nurses move into the business side of health care. Their nursing expertise and experience on a health care team equip them to manage ambulatory, acute, home health, and chronic care services. Some are employed by health care corporations in health planning and development, marketing, and quality assurance. Other nurses work as college and university faculty or do research.

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