A career in nursing is a great decision for many people. Indeed, many nurses feel it is more of a calling than a career per se; they are driven to provide care to those who need it. Few other professions, if any, afford the opportunity to care for a multitude of other people to such an extent as nursing. And so the satisfaction derived from this career is an immense reward for the hard work and challenges nurses face both in pursuit of their career and each year that they serve in their chosen field. The world will always need great nurses.
As it is not the ideal path for everyone, you must carefully consider this career choice, reflecting on your own strengths and motivations as well as what you desire most in a workplace and schedule.
On this page:
- Is nursing for you?
- Unlicensed Assistive Personnel (UAP)
- Licensed Practical (or Vocational) Nurse - LPN
- Registered Nurse (RN)
- Master's Degree (MSN)
- References and Further Reading
Is Nursing for You?
Successful nursing team members must possess numerous skills and qualities, including:
- Attention to detail
- Multi-tasking skills
- Compassion and caring
- A strong ethical and moral code
- Respect for all people
- Superior communication skills
- The ability to work as a collaborative and cooperative member of the nursing care team
- Adherence to basic safety measures
- Good “hands on” skills
- Flexibility regarding work shifts
- Solid stress management
Healthcare facilities rely on nurses during all hours of the day and all days of the week, including holidays. The life of a nurse is different than that of a classic 9-5 worker; nurses must be flexible and willing to face the sometimes challenging hours of care. As with other prominent healthcare professions, duty sometimes calls the nurse away from important holidays and family gatherings.
Many healthcare facilities offer onsite daycare as a benefit for their staff, but in other environments childcare can become a challenge for nurses as well.
Prospective nurses must also consider the stressful nature of the job. Multiple demands and needs often occur simultaneously and without any warning. For example, the nursing team may have to reprioritize their work immediately when a client has a cardiac arrest or when a patient has fallen on the floor from the bed. Medical emergencies such as these often occur in the healthcare setting. Nurses possess superb stress management skills and the ability to react swiftly and correctly when facing challenging situations.
If you posses these skills and want to make a positive and meaningful difference in the lives of others, then the noble and highly rewarding profession of nursing may be the ideal career choice for you.
Entry into Nursing: Getting Your Foot in the Door
One of the great appeals of nursing is the sheer number of pathways available for entering the field – everything from entry-level positions up to master’s degree options. To choose the best path, you must carefully consider many factors, including:
- Duration of education and training
- Availability of the required degree path in your area
- Job outlook, salary and prospects for advancement after you gain the requisite education
For example, some unlicensed assistive personnel, like personal care aides, can be trained at no cost in a hospital or home care agency, making this career choice understandably very appealing for many people. Pursuing a bachelor’s degree in nursing, on the other hand, takes four or more years to complete and the costs of this college or university preparation are far greater than those that require less academic training in a university. The person holding the BSN, however, will enjoy a higher salary as well as more varied prospects for career advancement and specialty.
The Job Outlook For Nursing and Other Healthcare Careers
At the current time, the robust job outlook for nursing and other healthcare careers remains a compelling reason for pursuing a career as a nurse. According to the U.S. Bureau of Labor Statistics, members of the nursing care team in the near future are expected to be in greater demand than ever, with job growth expected to be between 19% and 31% during years 2012-2022 (depending on the specific nursing profession). This growth can be attributed to several factors including the aging population; rising healthcare costs; the pervasiveness of working single- and two-parent homes; and the retiring baby boomer generation.
- The Aging Population
Americans are living longer and longer for a number of reasons including advancements in medical care; earlier diagnosis and treatment; a greater national focus preventative care, and a decrease in the number of environmental risk factors like poor water quality, which had, in the past, placed people at risk for some diseases that shortened the life span.
The need for healthcare services incrementally increases as the population continues to age. Not only are there more people who require care, but the aging population also presents many chronic and acute disorders that require medical and nursing care. For example, elderly people more often than younger populations require care for chronic diseases and conditions like heart disease, diabetes, a lack of mobility and the inability to care for themselves. There are also more people in this age group who are at greater risk for acute disorders and diseases like pneumonia, cerebrovascular accidents (stroke), cancer, and fractured bones than those of younger ages. All of these factors increase the demand for healthcare workers.
- Rising Healthcare Costs
The costs of healthcare in our nation are a matter of great concern and political debate; our costs in the United States are the highest of all developed nations in the world. Along with changes of our reimbursement system from retrospective to prospective payment methods, these rising costs have forced healthcare agencies to find less expensive ways of providing patient care, without jeopardizing its quality and the safety of the consuming public.
One of the most successful solutions to rising healthcare costs was the emergence, and continued expansion, of nurse extender roles like those of the personal care aide, nursing assistant, and patient care technician, among others. These nurse extender roles, also referred to as unlicensed assistive personnel, cost less than all nursing staff and also enable many more people to enter the nursing and healthcare field than in the past.
Highly trained advanced practice nurses with master's degrees - like clinical nursing specialists and nurse practitioners, for instance - provide healthcare facilities with significant cost-saving capabilities as well, because they possess the ability to provide a degree of independent care rivaled only by doctors. In many communities, the NP for example can provide care that was once provided strictly by a primary care doctor.
Maintaining people in either the home, a long-term care facility, a rehabilitation setting or a subacute care setting is less expensive than acute hospital care. This too has led to the emergence and continued use of unlicensed assistive staff as well as nurses in these relatively new specialty areas.
- Working Families
The fact that many families have employment outside of the home has also increased the need for healthcare workers. In the distant past, many families enjoyed the luxury of stay-at-home mothers. This is no longer the case. Single parents and both parents have to seek and maintain employment outside of the home in order to sustain an adequate standard of living for their families.
This change has led to the need for healthcare workers to care for elderly parents because the adult children are no longer able to perform this role as the result of gainful employment outside of the home.
- The Baby Boomer Generation
Further compounding the need for healthcare workers is the fact that our country has just begun to feel the impact of escalating baby boomer retirements. The women of this generation had fewer career choices than those enjoyed by younger generations. Three of the most promising paths for them were nursing, teaching and secretarial positions. Now, these boomers will be retiring in great numbers, leaving vacancies in virtually all nursing roles and in all settings. These retirements increase demand, which is great news for those interested in the nursing profession. A growing need for nurses, and nursing staff, is anticipated to persist for many years.
Unlicensed Assistive Personnel (UAP) - Training & Responsibilities
During recent years unlicensed assistive personnel have increased dramatically. One of the primary reasons for this increase is the rising cost of healthcare and nursing care. In the far distant past, only registered nurses and licensed practical/vocational nurses (in addition to a few nursing assistants) provided nursing care in the hospital, nursing home and in the home environment. As healthcare costs began to spiral out of control, the numbers of these valued UAP team members dramatically increased and their roles, as well as titles, continue to evolve as a response to the changing healthcare needs of the public.
Some of the many titles of unlicensed assistive personnel include:
- Nursing assistant
- Care attendant
- Certified nursing assistant
- Patient care technician
- Personal care aide
- Restorative/rehabilitation aide
- Physical therapy aide
- Occupational health aide
- Psychiatric aide
- Home health aide
Although these titles and roles vary somewhat from state to state and among various healthcare settings, there are nevertheless many consistencies in terms of suitable duties and responsibilities. According to most state laws and typical healthcare setting’s policies and procedures, common responsibilities include:
- Patient assistance with daily activities like bathing, grooming, oral hygiene, dressing, eating, ambulation and elimination
- Monitoring vital signs including blood pressure, pulse, temperature, and respiratory rate
- Observation and reporting of the client’s physical and emotional, or psychological, condition
- Documentation of tasks done and observations made
- Exercises, like range of motion (ROM) exercises and muscle strengthening exercises
- Helping the person to walk or use their wheelchair or walker
- Helping the patient to transfer from the chair to the bed and from the bed to the chair
- The collection of nonsterile laboratory specimens
- Companionship to the patient
Home health aides and other UAPs in the home also perform these aspects of care:
- Housekeeping like laundry, bed making, and cleaning
- Meal and snack preparation
- Errands and shopping
Unlicensed assistive nursing team members can work in a variety of healthcare settings and with all age groups, from infancy to aged adults. For example, they can work in the hospital; a private home; a long-term nursing home; in an assisted living home; at a school; in a group home for children or adults; and in a rehabilitation or subacute care setting.
Generally speaking, UAPs do not assess clients, plan the care of clients, or evaluate the outcomes of client care. Although UAPs can contribute data and information like vital signs for use in assessment, planning and evaluation, it is only the registered nurse who is prepared to perform these aspects of care.
UAPs also do NOT perform any tasks that involve sterile technique and generally they do not administer medications, although a few states have limited mechanisms for the unlicensed assistive staff members to assist clients with their self-administration in the home, in an assisted living facility and in a long-term care nursing home. All unlicensed assistive staff work under the direct guidance and supervision of a nurse.
This role is very interesting and very satisfying as it enables the UAP to work with the rest of the nursing team. Some prefer to remain in this role for their entire nursing career, while others elect to continue their education to become a certified nursing assistant (CNA); a licensed practical or vocational nurse (LPN or LVN); or a registered nurse (RN). The choice can be yours!
Differences in Training and Certification Among Various UAPs
Education requirements for UAPs vary from career to career. According to the U.S. Bureau of Labor Statistics May 2012 Occupational Outlook Handbook, the psychiatric aide requires a high school diploma or equivalent. For many other UAP careers - such as home health aide, personal care aide/assistant, orderly and physical therapy aide - a high school diploma might not be officially required in all cases but most candidates possess one.
Meanwhile, occupational therapy aides need to acquire an associate's degree. And according to the BLS, nursing assistants must enter a state-approved training program. These programs can be found in high schools, vocational schools, healthcare facilities, nursing homes and community colleges.
There is quite a bit of confusion among members of the public relating to the differences between nursing assistants and certified nursing assistants (CNAs). Some states refer to a nursing assistant as a CNA, while others simply call them nursing assistants; the label varies from state to state, just as the approved programs vary from state to state. Both a 'nursing assistant' and a 'certified nursing assistant' perform the same roles.
According to the Omnibus Budget Reconciliation Act of 1987, all nursing assistants who work in nursing homes have to become certified, after a minimum of 75 hours of training, in order to work in a nursing home after October 1, 1990. In order to become certified, the nursing assistant must successfully passing a state-certified nursing assistant test. This test consists of two parts:
- A knowledge portion consisting of a multiple-choice examination.
- A clinical skills portion during which the candidate demonstrates the correct performance of nursing assistant skills like bathing, grooming and feeding.
The nursing assistant can be trained in a hospital, home care agency and in a vocational school, but the primary difference between a nursing assistant and a certified nursing assistant is that the nursing assistant may not have gone to a state-approved educational program or has not passed the state-certified nursing assistant examination.
It is important to check with your state about their specific requirements, if any, for nursing assistants, home health aides, personal care aides, patient care technicians, and restorative/rehabilitation aides. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) does mandate that all healthcare staff, including unlicensed assistive personnel, must be deemed competent before rendering any patient care. State laws outline exactly what registered nurses, licensed practical or vocational nurses, and unlicensed assistive personnel can and cannot do in their nurse practice acts. Anyone practicing outside of his or her respective scope of practice can be found guilty of practicing without a license.
The Salary and Job Outlook for Unlicensed Assistive Personnel
Certified Nursing Assistant, Orderly, Personal Care Aide and Similar Job Titles
According to the U.S. Bureau of Labor Statistics, the 2012 median annual salaries for these UAPs are as follows:
Additionally, the BLS May 2012 Occupational Outlook Handbook states that job outlook for these entry-level healthcare positions is strong. Job growth for nursing assistants and orderlies is expected to be about 21% during the decade of time between 2012 and 2022, while it's an even rosier growth forecast of 49% for personal care aides.
Home Health Aide
Like the positions discussed above, the job outlook and salary for the home health aide is quite strong. According to the BLS, it is expected that the need for home health aides will increase by about 48% during the years of 2012 and 2022, which is staggeringly high compared to the average job growth rate. The May 2012 median salary for a home health aide is about $20,820.
Physical Therapy Aide
According to the BLS, the national average annual salary for a physical therapy aide is about $23,880 and it is anticipated that the need for additional physical therapy aides will increase by about 40% between 2012 and 2022, which is very high.
Occupational Therapy Aide or Assistant
The average annual salary for an occupational therapy aide is about $27,430 and it is anticipated that the need for additional physical therapy aides will increase by about 33% between the years 2010 and 2020.
Good Reasons to Enter Nursing as an Unlicensed Assistive Staff Member
In addition to the attractive salary and excellent job outlook, some additional qualities that make this a compelling entry-level career choice are its relatively low cost, its short duration of training, and the fact that many healthcare facilities provide tuition assistance and other forms of motivation for current UAPs to advance in the nursing field while gaining invaluable on-the-job experience. For example, a hospital may provide a UAP with the tuition necessary to become a registered nurse or to attend a licensed practical (or vocational) nursing school.
Licensed Practical Nurse (LPN) - Programs & Licensing
These nurses are referred to as licensed practical nurses (LPNs) in all states except Texas and California where they are called licensed vocational nurses (LVNs). For the purpose of this discussion, the term licensed practical nurse will be used.
Licensed practical nurses emerged and evolved over the last century in terms of their level of education and their statutory requirements. Until 1938, when New York State mandated licensure, practical nurses did not even have to pass an examination or obtain state licensure. Now, as the U.S. Bureau of Labor Statistics points out, all LPNs must be licensed by the state after the candidate has successfully completed a state-approved course of study for practical nurses and has successfully passed the NCLEX-PN examination.
The curriculum for an LPN includes coursework in sciences, such as anatomy and physiology, and clinical nursing practice. Approximately two thirds of the curriculum is clinical practice in a nursing laboratory and/or healthcare setting (like a nursing home or hospital), while one third is classroom instruction.
Students may find state-approved LPN programs in a wide variety of settings, including the following:
- Community vocational or technical schools
- High schools in collaboration with technical schools
- Privately owned schools
- Community colleges
- Some universities
The duration of practical nursing training varies from one year of full-time study to two years of part-time study, depending on the school and its offerings. Part-time options provide valuable flexibility for those who are working full or part time while going to school. Some schools offer a practical nursing Associate in Applied Sciences degree (AAS), which typically requires 1-2 years to complete and includes credits in some liberal arts subjects in addition to all of the necessary applied sciences. Most schools offer a diploma track, however, which lasts closer to a year and adheres to a stricter science and nursing focus.
Students often debate the merits of these two academic paths; the goal of both tracks is preparation for passing the NCLEX-PN. AAS degrees will be costlier in terms of tuition. LPNs shouldn’t expect an increase in salary for holding the AAS as opposed to a diploma, and the license at the end of the path is the most important thing for landing a job. However, the broader skills and additional credits of an AAS may be worth the additional investment for those who know they will pursue a higher degree in the future.
Despite the varying duration of study, all states have legislative requirements for the approval of curriculum and the minimal number of training hours required before the candidate can graduate and take the NCLEX-PN examination.
Some licensed practical nursing courses grant college credit and others do not. For example, vocational and technical schools do not grant college credit for the LPN course, but colleges and universities may. Many community colleges have a career ladder curriculum that grants college credit for nursing courses that have been successfully completed. At the end of one year of study, with this type of curriculum, a student can take the NCLEX-PN examination, become a LPN and then leave the college program; other students can choose to remain for another year in order to graduate as registered nurses eligible to take the NCLEX-RN exam.
What Is the Difference Between a Licensed Practical Nurse (LPN) and a Registered Nurse (RN)?
All 50 states have separate scopes of practice and state practice acts for both licensed practical nurses and registered nurses. Although all of these licensed personnel are referred to as “nurses”, their scopes of practice differ and the LPN always works under the supervision of a registered nurse or other professional, like a medical doctor.
Unlike a registered nurse, LPNs are dependent practitioners who perform their role only under the direction and supervision of a professional. Registered nurses, on the other hand, are independent practitioners with a few dependent roles, such as following doctors’ medication orders. Additionally, LPNs are best suited for structured settings where they care for those with relatively simple and less complex nursing care needs, such as those with predictable chronic healthcare needs in a hospital or long-term care facility.
Licensed practical nurses can perform all the roles and tasks of unlicensed assistive personnel. They are legally able to perform most of the same nursing interventions and treatments that registered nurses render, except those prohibited in the state’s practice act, scope of practice and the policies and procedures of the employing healthcare facility.
Some specific roles and responsibilities of an LPN or LVN nurse include:
- Collecting and recording patient assessment data
- Monitoring and recording client’s vital signs, level of pain, and blood glucose levels
- Administering medications
- Sterile procedures such as sterile dressing changes, wound care, wound irrigations and inserting – as well as caring for – urinary catheters
- Collecting laboratory specimens, including sterile specimens
- Participating in patient care conferences and committees
- Documenting all care rendered and all nursing observations
Licensed practical nurses perform certain additional functions in some states after completing additional training and education. For example, some states legally permit LPNs to supervise, initiate and/or administer intravenous fluids and medications after some additional training. Other states prohibit it.
LPNs and LVNs work in a wide variety of healthcare settings and clinical areas, including hospitals, nursing homes, subacute care facilities, schools, doctors’ offices and in the patient’s home as a home care nurse.
Salary and Job Outlook for LPNs
The median annual wage for LPNs and LVNs on a national basis in May 2012 was about $41,540, according to the U.S. Bureau of Labor Statistics' Occupational Outlook Handbook. This annual salary differs slightly across the nation. For example, cities and areas with a high cost of living, like Los Angeles, typically pay the LVN slightly more than rural areas with lower costs of living.
The United States Bureau of Labor Statistics projects that our nation needs an approximately 25% increase in the number of LPNs and LVNs between 2012 and 2022. This makes a career as a licensed practical nurse far more attractive than other occupations and careers.
Entering Nursing as a Licensed Practical Nurse
Two major reasons to pursue entry into nursing as an LPN are the superior job outlook compared to other professions, and the entry-level salary, which is higher than that of UAPs and many other healthcare careers. But there are many other advantages to entering the nursing field as a licensed practical nurse.
The costs and duration of LPN training and education are less than those associated with college-level registered nursing courses and training. Many candidates complete their LPN training in just less than one year with full-time study.
Some colleges and universities provide additional flexibility through academic courses that students can take online, with or without personal contact with academic instructors, so that the LPN can “bridge” to registered nursing. For example, many brick and mortar colleges for registered nurse coursework permit currently licensed LPNs to “challenge” college level courses for credit by taking a standardized examination like a College Level Examination Program (CLEP). Courses may include English, psychology, the fundamentals of nursing and anatomy and physiology.
Registered Nurse (RN) - ADN, BSN, Licensing & Certification
There are three traditional ways that a person can become a registered nurse:
- Four-year bachelor's degree called the Bachelor of Science in Nursing (BSN)
- Two-year Associate Degree in Nursing (ADN)
- Diploma in Nursing
Recently, generic master’s and doctoral programs are offered for those who have bachelor’s or master’s degrees in a field other than nursing.
Diploma Schools of Nursing
As the oldest form of registered nursing education, diploma schools of nursing have been around for a long time, although the number of them has dwindled to only a few in recent times. Historically, in these hospital-based programs, nursing students lived in hospital dormitories while attending school. These students provided care to the hospital’s patients as a cheap source of labor while gaining valuable hands-on experience. Often, the quality of the nursing education was only secondary to the long work hours that the students performed as they cared for the patients. In the 1950s, most of these diploma schools of nursing merged with academic facilities in order to improve the quality and breadth of the education provided to the students. Today, the few remaining diploma schools are funded with endowments and other private funding.
The Associate Degree in Nursing (ADN)
The Associate Degree in Nursing has virtually wiped out the diploma schools of nursing. Shortly after World War II, public recognition of the need for improved nursing education, as well as a severe shortage of nurses, led to the development and expansion of ADN.
In 1951, Mildred Montag, a doctoral student at New York’s Columbia University, addressed these forces and published her dissertation entitled, “The Education of Nursing Technicians”. This work was the impetus for the rise of the two-year ADN offered at junior, or community, colleges.
At the current time, a two-year associate degree is a popular way to enter the nursing field as an RN. The curriculum for the associate degree student consists of many exciting subjects such as the following:
- Anatomy and physiology
- English and writing
- Four semesters of nursing coursework
The nursing coursework includes both classroom instruction and clinical experiences in hospitals, nursing homes and other settings.
Like the baccalaureate and diploma nurse, the associate degree nurse must successfully pass all required course work for graduation and then sit for, and successfully pass, the NCLEX-RN exam for licensure as an RN.
The Bachelor of Science in Nursing (BSN)
The third way of becoming a registered nurse is by attending a college or university for a bachelor’s degree in nursing (BSN). Unlike the ADN, which takes two years to accomplish, this degree requires four years, unless the student already holds a bachelor’s degree. These estimated durations are based on full-time study; many working adults who pursue a two- or four-year nursing degree in a college or university, however, spend more than those amounts of time in the program because they attend as a part time student.
Though the BSN program is four years in duration, students who already have a bachelor’s degree in an unrelated field of study may enroll in an accelerated BSN program, significantly reducing the duration of the program often to 1-2 years.
Similar to the ADN, the bachelor's degree consists of coursework in the sciences - like microbiology, anatomy, physiology, chemistry, psychology, anthropology and sociology - as well as liberal arts courses such as music, foreign language, art and English. The remainder of the courses are nursing classroom and nursing clinical experiences in hospitals, nursing homes, in the community and other healthcare settings like schools and prisons.
The BSN provides greater liberal arts exposure than the ADN, resulting in a broader education intended to foster interpersonal and leadership skills, which is why the BSN is often considered a requirement for nurses to assume roles of greater leadership and non-clinical responsibility.
Practical Differences Between the Diploma, Associate Degree and Baccalaureate Degree
This has been a source of confusion for healthcare consumers as well as within the healthcare community, where it’s also been heavily debated. Recent years have brought changes that will lend greater clarity and lead to increased differentiation.
For decades, the nursing community mulled the ideal roles and responsibilities of registered nurses based on their degree. The original intention was to call the ADN nurse a technical nurse, while a nurse holding the BSN would be called a professional nurse. It was also intended that each distinctive RN entry level would take a separate licensing examination and that each level would be utilized differently in practice. Although many in the profession have believed that each of these three levels should be utilized in practice differently - and that each of these three entry levels should take a different NCLEX exam - the debate continued for decades without any change. All three levels have taken the same NCLEX examination and all three often perform the same roles and functions during employment in a healthcare facility, though at times the BSN nurse has been paid slightly more than the ADN and the diploma nurses.
In recent years, however, prominent voices within the healthcare community mandated increasing distinction among registered nurses and also advocating for a dramatic increase in the proportion of RNs who hold bachelor's degrees or higher.
- The American Nurses Association in 2008 minted their “BSN in 10” resolution, which states that all RNs entering with an ADN should gain their BSN within a decade of earning their license.
- In 2010 came the “80/20” proposal by the Institute of Medicine, setting a new goal for the healthcare community: 80% of nurses ought to have a BSN by 2020. While many debate whether this is an overly ambitious goal or a realistic one, the trajectory is clear: more and more nurses will be entering the workforce with a BSN and/or advanced degrees.
- The American Association of Colleges of Nursing (AACN) has held the position that the BSN should be the minimum degree requirement for professional nurses.
This trajectory explains why the RN-to-BSN pathway has become an increasingly common pursuit within the nursing community.
There is general and growing consensus within the nursing community that RNs should be subjected to greater differentiation based upon acquired degree. Nurses with an ADN are technically prepared to serve roles in all aspects of acute care, including the ICU and emergency care units. And unlike the LPN, an ADN nurse may provide care to clients with unpredictable health problems and within unstructured care environments. Further differentiating themselves from LPNs, nurses with an associate degree may delegate, supervise and manage nursing care units.
A nurse with a BSN, on the other hand, is qualified to perform the same roles as the ADN nurse and, additionally, can provide long-term complex planning for clients who have multiple and complex health care needs. The RN with a bachelor’s degree can work in a community health setting, which is very different than home care. And very importantly, a BSN degree prepares nurses to assume expanded leadership roles like mid-level administration and chairing hospital committees. Employers increasingly seek out and reward nurses with these leadership skills that the BSN helps to strengthen.
Lastly, RNs with a bachelor’s degree may find that they are in a better position to specialize in a certain area of nursing – some certification processes require that nurses first attain a bachelor’s degree or higher.
Advantages of Certification as a Registered Nurse
Some nurses have jobs in which they do not work directly with patients, but they must still have an active registered nurse license. For example, they may work as nurse educators; healthcare consultants; nurse researchers; hospital administrators; nursing salespeople for pharmaceutical and medical supply companies; or as authors.
The duties and titles of RNs vary somewhat depending on their chosen specialty, the setting in which they work, and their specific role within that setting. Specialization allows nurses to focus their career on specific age groups, a specific disease or set of conditions, and specific healthcare settings. Here are just some of the many specialized roles that RNs play within healthcare:
- Case managers
- Dialysis nurses and other nephrology nurses
- Gerontology or pediatric nurses
- Intensive care nurses, such as the NICU nurse
- Emergency department nurses
- Perioperative nurses, such as the scrub nurse
- Psychiatric nurses
- Trauma nurses
- Travel nurses
- Forensic nurses
- Correctional facility nurses
- Office nurses
- Occupational health nurses
- School nurses
None of these titles legally mandate more than a current license to practice as a registered nurse. However, many employers certainly prefer certification in the specialty area, and in some cases employing healthcare facilities require certification. As the BLS points out, many nurses voluntarily elect to become certified for personal and professional reasons.
Certifications validate competency in a specialty area. This competency is more current and more advanced than the competency required for licensure, and relicensure, as a registered nurse. Certification validates that RNs have met the current knowledge requirements for a specialty area; that they have successfully passed a rigorous certification exam in the specialty area; and that they have maintained ongoing and continuous competency when they successfully renew this certification.
How Does a Nurse Become Certified?
Many different professional nursing organizations and associations offer specialty area certifications for nurses. The nurse’s chosen specialty will determine which certification board will administer the exam.
All of these nursing certifications share a set of requirements:
- A fee
- A current and unencumbered license to practice as a nurse
- Documented evidence of a certain number of hours of employment in the specialty
- Successful completion of a certification examination
However, there are some very important differences nurses must consider. For example, most certifications are open only to RNs, but some may also be achievable for LPNs. Additionally, some certifications may only be offered to RNs with a BSN or higher nursing degree; others offer certifications to all registered nurses, including diploma nurses and those who have earned an ADN. If you are interested in becoming certified in a specialty area, it is imperative that you check the eligibility requirements so you know what you need in order to become certified.
The American Nurses Association offers certifications through its American Nurses Credentialing Center (ANCC) for the following specialty areas, either alone or in collaboration with another professional nursing association or organization.
- CCRN – Acute/Critical Care Nursing (Adult, Neonatal Pediatric)
- CCRN-E – Tele-ICU Acute/Critical Care Nursing (Adult)
- PCCN – Progressive Care Nursing (Adult)
- CNML – Nurse Manager and Leader
- CMC – Cardiac Medicine (Adult)
- CSC – Cardiac Surgery (Adult)
These specialty certifications are offered, for a fee, strictly to registered nurses who pass the exam and have a valid and unencumbered nursing license as well as validated clinical hours in the specialty area. Once acquired, the certifications remain valid for a period of five years, after which time they can be renewed with documented evidence of continued clinical practice in the specialty area along with either documented continuing education course completion or the successful passing of the certification exam again.
The certifications for Adult Cardiac Medicine (CMC) and Adult Cardiac Surgery (CSC) are only offered to RNs who already have another certification such as a CCRN, or PCCN. The CMC and CSC certifications are added to these basic specialty certifications after accruing additional clinical hours and, of course, after passing the test.
The American Board for Occupational Health Nurses (ABOHN) is the only certifying body for occupational health nurses throughout our nation. This professional board grants certifications for the following:
- Certified Occupational Health Nurse (COHN), which is offered to all RNs
- Certified Occupational Health Nurse - Specialist (COHN-S), offered to nurses with a bachelor’s or higher degree
- Case Management (CM), offered to all RNs who have completed at least 10 contact hours of continuing education in the past 5 years
- Safety Management (SM), which is offered to COHN or COHN-S certified nurses who are currently employed in a position that includes at least 25% of the role in safety activities. These nurses must have accumulated at least 50 contact hours of safety continuing education and at least 1000 hours of safety experience in the prior five years.
The American Organization of Nurse Executives (AONE) grants a certification in Executive Nursing Practice (CENP) to the following candidates:
- Currently licensed registered nurses who have a master’s degree in nursing, or higher, in addition to at least two years of experience in an executive nursing role
- RNs with a bachelor of science in nursing (BSN) in addition to four years of experience in an executive nursing role.
Salary and Job Outlook for RNs
Nationwide, the median annual salary for a registered nurse as of May 2012 is $65,470, according to the U.S. Bureau of Labor Statistics. The average varies slightly by geographic area, based primarily on cost of living in the particular area. For example, RNs typically receive a higher salary in New York City than they do in upstate, rural New York State.
There may also be differences in salary among the diploma nurse, the ADN and the BSN in healthcare facilities. Increased salaries for different levels of entry education is completely discretionary, particularly where all RNs perform the same roles. The growing demand for nurses to pursue bachelor’s degrees or higher, however, probably makes salary differences more likely moving forward as roles become more distinguishable.
Similarly. there also may or may not be increased salary expectations for the registered nurse who works in specialty areas and/or becomes certified in a specialty. This, too, varies from employer to employer.
Like practically all professional fields, the nursing job sector is not impervious to recessions. This most recent recession hit the nursing community and unfortunately affected initial job availability for newly graduated nurses trying to enter the workforce. These young nurses who had been told for years about the “nursing shortage” suddenly found their job prospects in the short term to be less robust than anticipated, primarily because older nurses who would have retired realized they needed to work longer due to lost savings from the downturn.
Master's Degrees & Additional Certification
Master of Science in Nursing (MSN)
Master’s degrees in nursing are offered in colleges and universities and, as the U.S. Bureau of Labor Statistics points out, are a requirement for certain nursing professions such as those collectively referred to as advanced practice registered nurses. Full-time students can complete a Master of Science in Nursing (MSN) in a two-year period of time, but many master’s degree students attend part time because they are often employed as a full-time registered nurse while attending school.
Master’s degree paths are numerous and varied. They may be general or may focus on preparing students for an array of specialist roles, including:
- Nurse anesthetist
- Nursing administrator
- Nurse midwife
- Nurse educator or faculty member
- Clinical nurse specialist
- Nurse practitioner
Some master’s degree programs can be completed online, while others require attendance in a brick and mortar school. Students will find bridge programs designed for nurses beginning with a specific degree, such as an ADN for example. Other programs combine the pursuit of a BSN and an MSN, an appealing accelerated choice for students who know what nursing specialty they aim to pursue.
Advanced Practice Registered Nurses (APRNs)
Advanced practice registered nurses (also called "advanced practice nurses", or APNs) are nurses with a state-approved master’s degree in nursing, at minimum, who have successfully fulfilled the state’s requirements in terms of clinical hours and the completion of an advanced practice certification exam. Quite a few APRNs go further to pursue a DNP (Doctor of Nursing Practice) degree or Ph.D.
APRNs can work in specialty care areas, regular medical surgical areas, in perioperative care areas and in community healthcare settings, among many others. These nurses are regulated by the states’ boards of nursing and state legislation. Some offer primary care and can prescribe medications under certain circumstances. They can care for patients with a greater degree of autonomy than an RN could.
The American Nurses Credentialing Center certifies APRNs with:
- ACNPC-AG – Acute Care Nurse Practitioner (Adult-Gerontology)
- ACCNS – Clinical Nurse Specialist; Wellness through Acute Care (Adult-Gerontology, Pediatric & Neonatal)
- ACNPC – Adult Acute Care Nurse Practitioner (Adult)
- CCNS – Acute Care Clinical Care Nurse Specialist (Adult, Neonatal & Pediatric)
To attain these advanced practice certifications, candidates must meet the following requirements:
- Must pay a fee
- Must be an RN with a valid and unencumbered nursing license
- Must have validated clinical hours in the advanced practice area
- Must have a graduate degree in nursing which satisfies all of the ANCC-established criteria
- Must pass the ANCC certification examination.
There are four different types of APRNs: clinical nurse specialists, nurse practitioners, nurse midwives and nurse anesthetists.
- Clinical nurse specialists (CNSs) provide direct and indirect patient care in all settings and in all specialty areas, including the following:
- Critical care
- Adult care
- Infectious diseases
- Respiratory care
- Pediatric care
- Psychiatric mental health
Clinical nurse specialists perform a number of powerful roles including leadership, case management, provision of direct patient care, consulting, education, research, quality assurance and performance improvement. These APRNs usually operate under the supervision of another nurse like the Vice President for Nursing Services. They cannot provide patient care independently of a doctor, and they do not prescribe medication. However, studies show that their ability to assume greater responsibility for care - and administer it in a home care setting as well as in hospital - leads to more favorable patient outcomes and simultaneous savings for cash-strapped healthcare facilities.
Their role in healthcare continues to grow thanks to their proven abilites in case management, leadership and patient care.
- Nurse practitioners (NPs) tend to be more frequently utilized in community-based primary care settings than in hospitals and other healthcare settings. NPs provide direct patient care with autonomy that in many cases rivals primary care doctors:
- They perform complete physical assessments.
- They render some minor procedures and tests.
- They diagnose and treat diseases and conditions both acute and chronic in nature.
- They can, in most states, prescribe medications when they have gained these privileges according to the state laws which govern the practice of NPs.
NPs are often supervised by a licensed medical doctor, although some states allow this nurse to function independently without any supervision of a medical doctor.
- Nurse anesthetists are an extension of medical anesthesiologists and, as such, they work under the supervision of these medical doctors. Nurse anesthetists provide perioperative and pain assessments; they administer anesthesia prior to and during invasive procedures like surgery, invasive diagnostic tests and during childbirth. Certified nurse anesthetists (CRNAs) also serve a role in pain management that is similar to the role of an anesthesiologist.
- Nurse midwives (CNMs) are APRNs who perform gynecological and obstetrical care for female clients. They play an important role in physical assessment, prenatal care, family planning, assistance during labor and delivery, and neonatal care.
The Salary and Job Outlook for APRNs
According to the U.S. Bureau of Labor Statistics, salaries for APRNs as of May 2012 are as follows:
- Nurse practitioners - $89,960
- Nurse anesthetists - $148,160
- Certified nursing midwives - $89,600
Salary varies depending on area of subspecialty. For instance, the BLS states that APRNs who work in a hospital earn a median salary $101,990 a year, but those who work in family planning may earn slightly less, and those in obstetrics may earn slightly more. Expected salary also varies depending on the cost of living in particular geographic regions or urban environments.
Because of their qualifications, their preparedness to administer care with greater autonomy, and their ability to assume positions of leadership among nursing staffs, job outlook for APRNs appears very robust indeed. The Bureau of Labor Statistics cites that advanced practice nurses are expected to remain in great demand throughout our country, particularly in rural and inner-city communities that face a serious shortage of primary care doctors. Job growth is expected to be 31% for these APRNs from 2012 to 2022.
References & Further Reading
- Bureau of Labor Statistics May 2012 Occupational Outlook Handbook
- BLS - Psychiatric Aide
- BLS - Home Health Aide
- BLS - Personal Care Aide/Assistant
- BLS - Physical Therapy Aide
- BLS - OT Aide Education
- Bureau of Labor Statistics - Nursing Assistant
- Bureau of Labor Statistics - Licensed Practical and Licensed Vocational Nurses
- Bureau of Labor Statistics - Registered Nurses
- Bureau of Labor Statistics - Advanced Practice Registered Nurses
- AACN Nursing Certifications
- American Board for Occupational Health Nurses (ABOHN)
- Berman A, Snyder S, Kozier B, Erb G. Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice. 9th Edition, Jan. 2011
- Early History of Associate Degree Nursing - Nursing Education History
- Ellis, Janice Rider and Celia Love Hartley. Nursing In Today's World. 10th Edition, Sept. 2011.
- U.S. Department of Labor's Bureau of Labor Statistics
- Yoder-Wise, Patricia S. Leading and Managing in Nursing. 4th Edition, Oct. 2010
- Hughes RG, Editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 43 - Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality. Rockville, MD. http://www.ncbi.nlm.nih.gov/books/NBK2641/
- Mancino, Diane J., EdD, RN, CAE, FAAN. “Recalculating: The ‘Nursing Shortage’ Needs New Direction”. Dean’s Notes Vol 34, No. 3, Jan/Feb 2013. National Student Nurses’ Association, Inc.