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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 conjunction with other health care professionals. Registered nurses work as patient advocates for the care and recovery of the sick and maintenance of their health. In their work as advocates for the patient, RNs use the nursing process to assess, plan, implement, and evaluate nursing care of the sick and injured. RN's have a significantly expanded scope of practice, education and clinical training compared to that of licensed practical nurses.

Nurses scope of practice is determined by each state's Nurse Practice Act. It oulines what is legal practice for registered nurses and what tasks they may or may not perform. Nurse Practice Acts also dictate the scope of practice for nurse practitioners (NPs). An example is prescriptive authority for NPs. In some states, NPs can practice completely autonomously and prescribe any category of medications. In other states, NPs cannot prescribe controlled substances and may only practice with the collaboration of a physician.

[edit] United Kingdom

Main article: Nursing in the United Kingdom

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.^[1]

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) , RNLD (registered nurse learning disabilities)

[edit] Second level nurses

For more inforation, see state enrolled nurse.

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.

[edit] 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 obtain advanced practice training. They often perform roles similar to those of Physicians and Physician Assistants, but they are not qualified to write orders or prescribe most medications. 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.

[edit] Managers

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

[edit] Nurse education

[edit] Pre-registration

In order to become a registered nurse, and work as such in the NHS, one must complete a program 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 program (CFP), and teaches the basic knowledge and skills required of all nurses. The remainder of the program 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 program.^[2]

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.

[edit] 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.^{[citation needed]}

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.^{[citation needed]}

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 1 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.^{[citation needed]}

[edit] United States

The scope of practice of registered nurses is the extent to and limits of which an RN may 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 such rules and regulations is delegated to a state board of nursing, which performs 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(RN)or licensed practical or vocational nurse (LPN/LVN).

The scope of practice for a registered nurse is wider than for an LPN/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 role to delegate tasks performed by LPNs and unlicensed assistive personnel such as nursing assistants.

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, 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. The average salary for a staff RN in the United States in 2007 was over $60,000.

[edit] Educational and licensure requirements

[edit] Diploma in Nursing

The oldest method of nursing education is the hospital-based 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.^[3]

[edit] Associate Degree in Nursing

The most common education for initial nursing education is a two-year Associate Degree in Nursing (Associate of Applied Science in Nursing, Associate of Science in Nursing, Associate Degree in Nursing), a two-year college degree referred to as an ADN. Some four-year colleges and universities also offer the ADN. Associate degree nursing programs have many prerequisite and co-requisite courses which ultimately stretch out the degree-acquiring process to about 3 years or greater.

[edit] 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 and 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. However, most states require a specific amount of clinical experience that is the same for both BSN and ADN students. Nursing schools may or may not be accredited by either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE).

[edit] 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 an adequate indicator of minimum competency for a new graduate. 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.

[edit] Graduate nursing opportunities

Advanced education in nursing is done at the master's and doctoral levels. A Master of Science in Nursing or a Master of Nursing takes from one to three years of additional full-time study beyond the program of initial licensure. It prepares the graduate for specialization as an advanced practice nurse (APRN). Areas of advanced nursing practice include that of a nurse practitioner (NP), a certified nurse midwife (CNM), a clinical nurse leader (CNL), a certified registered nurse anesthetist (CRNA), or a clinical nurse specialist (CNS). Nurse practitioners work assessing, diagnosing and treating patients in fields as diverse as family practice, women's health care, emergency nursing, acute/critical care, psychiatry, geriatrics, or pediatrics, while a CNS usually works for a facility to improve patient care, do research, or as a staff educator. The CNL is an advanced generalist who focuses on the improvement of quality and safety outcomes for patients or patient populations from an administrative and staff management focus. 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 and Doctor of Nursing Practice (DNP), but some confer the Doctor of Nursing Science (DNS or DNSc), 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.

[edit] 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.^[4]

[edit] The nursing shortage in the United States

Main article: Nursing Shortage

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 demand for registered nurses; this is often referred to as the nursing shortage and is expected to increase for the foreseeable future. There is data to support the idea that the nursing shortage is a voluntary shortage. In other words, nurses are leaving nursing of their own volition. In 2004 it was estimated that approximately 1.8 million nurses chose not to work as a nurse.

[edit] 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 is no faculty to teach them.^[5] 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.^{[citation needed]} The primary reason given for leaving the profession is poor working conditions (e.g. long and irregular hours and an absence of sufficient numbers of health care providers, such as aides).

Other factors such as role-limited autonomy and physical labor demanded of clinical positions are also seen as deterrents to those considering becoming a Registered Nurse. As well, many systems and practices in nursing are heavily oriented toward the social and gender patterns and practices of women, which can hinder consideration of nursing as a profession by men.

[edit] 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 people and groups to address this problem. The AACN has also published a fact sheet containing current statistics related to the shortage (found here [1]).

[edit] See also

[edit] References

^ United Kingdom Government Nurses, Midwives and Health Visitors Act, 1997. London: HMSO, 1997.
^ Nursing and Midwifery Council Pre-registration training. London: NMC, 2003.
^ American Nurses Association. "Nursing Facts: Today's Registered Nurse - Numbers and Demographics" Washington, D.C., American Nurses Association, 2006.
^ American Nurses Credentialing Center. "ANCC Certification" Washington, D.C., American Nurses Association, 2006.
^ Anderson, Carole A. "The Nurse Ph.D.: A Vital Profession Needs Leaders" Thomson-Peterson's,2006.

[edit] External links

[ACT-0] United Kingdom Government Nurses, Midwives and Health Visitors Act, 1997. London: HMSO, 1997.

[NMC-1] Nursing and Midwifery Council Pre-registration training. London: NMC, 2003.

[ANA-2] American Nurses Association. "Nursing Facts: Today's Registered Nurse - Numbers and Demographics" Washington, D.C., American Nurses Association, 2006.

[ANCC-3] American Nurses Credentialing Center. "ANCC Certification" Washington, D.C., American Nurses Association, 2006.

[Anderson-4] Anderson, Carole A. "The Nurse Ph.D.: A Vital Profession Needs Leaders" Thomson-Peterson's,2006.

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