Registered nurse

Overview
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 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 licensed practical or vocational nurse (LPN/LVN).

The scope of practice for a registered nurse is wider than for a 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 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.

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.

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

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.