REGISTERED NURSE (R.N.)
When providing direct patient care, registered nurses 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 nursing aides. Hospital nurses usually are assigned to one area such as surgery, maternity, pediatrics, emergency room, intensive care, or treatment of cancer patients, or may rotate among departments.
Office nurses assist physicians in private practice, clinics, surgicenters, emergency medical centers and health maintenance organizations (HMO's). 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.
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.
Nursing home nurses manage nursing care for residents with conditions ranging from a fracture to Alzheimer's disease. Although they generally 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.
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 ensure that records are maintained and that 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 most States. 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.
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. Office, occupational health and public health nurses are more likely to work regular business hours. Almost 1 in 10 RN's held more than one job in 1996.
Nursing has its hazards, especially in hospitals, nursing homes and clinics, where nurses may care for individuals with infectious diseases such as hepatitis and AIDS. 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 face back injury when moving patients, shocks from electrical equipment, and hazards posed by compressed gases.
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.
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 1996, there were over 1,500 entry level R.N. programs. There are three major educational paths to nursing: Associate degree (A.D.N.), diploma, and bachelor of science degree in nursing (B.S.N.). A.D.N. programs, offered by community and junior colleges, take about 2 years. About two-thirds of all R.N. graduates in 1995 were from A.D.N. programs. B.S.N. programs, offered by colleges and universities, take 4 or 5 years. Nearly one-third of all graduates in 1995 were from these programs. Diploma programs, given in hospitals, last 2 to 3 years. Only a small number of graduates come from these programs. 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, some career paths are open only to nurses with bachelor's or advanced degrees. A bachelor's degree is generally 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. in their spare time.
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.
ADVANCEMENT Experience and good performance can lead to promotion to more responsible positions. Nurses can advance to assistant head nurse or head nurse. From there, they can advance to assistant director, director and vice president of nursing. 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 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.
Median weekly earnings of full-time salaried registered nurses were $697 in 1996. The middle 50 percent earned between $571and $868. The lowest 10 percent earned less than $415; the top 10 percent, more than $1,039.
According to a Hay Group survey of HMO's, group practices, and hospital-based clinics, the median annual base salary of full-time nurse practitioners was $66,800 in May 1996. The middle 50 percent earned between $54,200 and $69,200. Nurse midwives earned about $70,100, and the middle 50 percent earned between $59,300 and $75,700. According to the Hay Group's survey of acute care hospitals, the median annual base salary of full-time nurse anesthetists was $82,000 in January 1997. The middle 50 percent earned between $74,700 and $90,300.
According to the Buck Survey conducted by the American Health Care Association, staff R.N.'s in chain nursing homes had median hourly earnings of $15.85 in 1996. The middle 50 percent earned between $14.03 and $17.73.
Many employers offer flexible work schedules, child care, educational benefits and bonuses.
As the largest health care occupation, registered nurses held about 1,971,000 jobs in 1996. About 2 out of 3 jobs were in hospitals, in both inpatient and outpatient departments. Others were in offices and clinics of physicians, home health care agencies, nursing homes, temporary help agencies, schools and government agencies. About 3 out of 10 R.N.'s worked part time.
Employment of registered nurses is expected to grow faster than the average for all occupations through the year 2006 and, because the occupation is large, many new jobs will result. As nursing school enrollments level off or decline, as they have on a cyclical basis in the past, the number of qualified applicants will fall, reducing reported competition for jobs. There will always be a need for traditional hospital nurses, but a large number of new nurses will be employed in home health, long-term and ambulatory care. Many job openings also will result from the need to replace experienced nurses who leave the occupation, especially as the average age of the registered nurse population continues to rise.
Employment in hospitals, the largest sector, is expected to grow more slowly than in other health-care sectors. While the intensity of nursing care is likely to increase, requiring more nurses per patient, the number of inpatients (those who remain overnight) is not likely to increase much. Also, patients are being released earlier and more procedures are being done on an outpatient basis, both in and outside hospitals. Most rapid growth is expected in hospitals' outpatient facilities, such as same-day surgery, rehabilitation and chemotherapy.
Employment in home health care is expected to grow the fastest. This is in response to a growing number of older persons with functional disabilities, consumer preference for care in the home, and technological advances which make it possible to bring increasingly complex treatments into the home. The type of care demanded will require nurses who are able to perform complex procedures.
Employment in nursing homes is expected to grow much faster than the national average due to increases in the number of people in their eighties and nineties, many of whom will require long-term care. In addition, the financial pressure on hospitals to release patients as soon as possible should produce more nursing home admissions. Growth in units to provide specialized long-term rehabilitation for stroke and head injury patients or to treat Alzheimer's victims will also increase employment.
An increasing proportion of sophisticated procedures, which once were performed only in hospitals, are being performed in physicians' offices and clinics, including HMO's, ambulatory surgicenters and emergency medical centers. Accordingly, employment is expected to grow faster than average in these places as health care in general expands.
In evolving integrated health care networks, nurses may rotate among employment settings. Since jobs in traditional hospital nursing positions are no longer the only option, R.N.'s will need to be flexible. Opportunities will be best for nurses with advanced education and training, such as nurse practitioners.