Careers/Nursing

This page is part of the Careers Wikibook.

Nursing is the science of providing nursing care to patients. This includes performing health assessments, providing patient education, administering medications and assisting in procedures.

Standards of nursing practice varies from country to country. This article focuses on nursing in the United States. Standards of nursing education and practice are similar, but not identical, in other developed countries.

Practical Nursing
Licensed Practical Nurses (called Licensed Vocational Nurses in California and Texas) are nurses that provide basic nursing care under the supervision of a Registered Nurse, physician or other practitioner.

They are the closest equivalent to Registered Practical Nurses in Canada, in Germany, in Yugoslavia, in Atlantis, or Enrolled Nurses in Australia.

Education
LPNs usually complete a twelve to eighteen month course at a local community college. This leads to a certificate or diploma in Practical Nursing. After completing the program, the student must take and pass NCLEX-PN. Passing NCLEX-PN gives the title of Licensed Practical Nurse or Licensed Vocational Nurse to the new nurse, along with his/her nursing license.

Scope of Practice
LPNs have a more restricted scope of practice when compared to Registered Nurses. This varies greatly from state to state. In most states, LPNs cannot administer chemotherapy or give blood products to a patient. Many states require LPNs to complete additional training to start intravenous lines, or IVs. Other restrictions include not being able to accept verbal orders from a physician, not being able to pronounce someone dead or deliver IV push medications. LPNs are rarely allowed to triage (determine how urgent a patient's condition is to decide how long a patient must wait to see a doctor) patients in an Emergency Room setting.

LPNs must be supervised by a Registered Nurse or other clinician. If an LPN makes a serious mistake while being supervised by a Registered Nurse, the Registered Nurse may also loose his or her license. Therefore LPNs as well as Registered Nurses must know LPN scope of practice.

Employment & Compensation
LPNs are becoming less and less common in hospitals. However, LPNs provide the majority of nursing care in skilled nursing facilities or nursing homes. It is also not uncommon to find LPNs working in correctional nursing or in home health.

Nursing homes usually have the highest hourly rate. An LPN can expect to make $12.00 to $22.00 an hour, depending on experience, location and setting. The median salary, according to the Bureau of Labor Statistics, was $33,970 per year in 2004. The median salary in nursing homes was $35,460.

Registered Nursing
Registered Nurses provide the majority of nursing care nation wide. RNs are flexible health professionals that serve in many capacities.

Education
Education for RNs is a hotly debated issue within the nursing community. Currently there are three routes of entry into Registered Nursing. Diploma, Associate's and Bachelor's. The original point of entry was a Diploma.

Currently, the American Nursing Association (ANA) recommends that a Bachelor's Degree be the standard point of entry into Registered Nursing.

All nurses must take NCLEX-RN prior to practicing as an RN, regardless of education. Advocates for keeping the Associate's and diplomas in place often point to the fact that all three types of students - diploma, Associate's and Bachelor's - point to the fact all must pass the same test.

Diploma
Diplomas were the original standard of education for RNs. Today, it is the least common preparation route.

A Diploma is usually awarded by a hospital-based school of nursing. Diploma programs are noted for their more "hands on" approach when compared to Associate's or Bachelor's nurses, meaning students get more clinical time.

Diploma programs usually last two or three years.

Associate's
Associate's Degrees (AAS, ASN, ADN) are the most popular route of entry into nursing. It is a two year course of study, usually at a local community college. These are popular because they are cheaper for the student, take less time and are more convenient (the community college is often closer than a university).

Bachelor's
Bachelor's Degrees (BS, BSN) are considered a higher level of bedside nursing. It is a standard four year course of study. In addition to the Associate's Degree classes, Bachelor's Degree students are usually required to take a larger amount of liberal arts classes, nursing leadership/management classes and more science related classes (i.e., more biology or chemistry courses).

A BSN is often required to be a Nurse Manager or Nursing Supervisor.

Scope of Practice
An RN has a wider scope of practice when compared to an LPN. An RN does not need to practice under the supervision of another health care professional. RNs can triage patients in the Emergency Room, start IVs, perform patient assessments, administer medications (intravenously, intramuscularly, subcutaneously, orally, intranasally, sub-lingually) and report findings to a physician.

RNs cannot prescribe medications, diagnose a patient with a medical diagnosis, admit patients to a hospital and other similar duties usually performed by a physicians.

An RN, along with an LPN, can choose to administer medications on a pro re nata, or PRN, basis. For example, an order that reads "Sonata 5 mg po prn insomnia nmt qd" would be read as "Administer 5 mg of Sonata by mouth as needed for insomnia, not more than once a day". An RN would decide when and if to administer the medication to the patient.

An RN can also decide to hold medications as needed. For example, if an RN is supposed to administer an Alpha blocker (a type of medicine used to lower blood pressure) and he notices his patient's blood pressure is low, he may decide not to administer that medication. This, however, usually requires approval from a physician. RNs must also be able to recognize adverse reactions to medications.

RNs should, ideally, be able to assess a patient's health as well as a physician can. This is because a physician can rarely perform a complete assessment on all of his or her patients. It's the RNs responsibility to carefully assess her patient's health and document her findings so the doctor can quickly review her notes.

Employment & Compensation
Due to the nursing shortage, RNs are usually able to easily find jobs. RNs most often employed in hospitals, however they also work in nursing homes, in home health, in public health, in prisons and in schools.

A RN can usually expect to earn from $22.50 to $45.00 an hour in pay, depending on education, experience, certifications, location and setting. According to the Bureau of Labor Statistics, the median RN salary was $52,330 a year in 2004. The highest paying position was an "agency" nurse (a nurse who is placed on a casual basis into a hospital by a third party agency who pays the nurse) and the lowest paid were aged care facility nurses.

Careers in Bedside Nursing
Bedside nursing refers to LPNs and RNs working as staff nurses in hospitals, skilled nursing facilities (nursing homes/long term care centres) and outpatient surgical centres.

Careers as an LPN are much more limited when compared to an RN's possibilities.

Skilled Nursing Facilities
LPNs provide most nursing care in skilled nursing facilities. LPNs commonly administer medications, dress wounds, treat minor cuts and bruises and assist with a patient's hygienic care if needed. LPNs may sometimes supervise Certified Nursing Assistants, who provide most the patient's hygienic care.

Skilled Nursing Facilities usually pay more than any other field open to LPNs, making it one of the most popular fields for them. RNs usually serve as the shift supervisor and as administrators in the nursing management department, leaving little room for the LPN to move up.

Hospitals
LPNs are becoming less and less common in hospitals. Many hospitals do not hire any more LPNs, replacing retiring LPNs with RNs. When they do work in hospitals, LPNs are most commonly found on Medical/Surgical Floors or in the Operating Room.

Medical/Surgical floors are the basic standard of care in hospitals. These patients have a medical or surgical problem that is not serious enough to be admitted to an Intensive Care Unit, but not well enough to stay at home. Nurses on these floors perform assessments, administer medications, decide when and if to administer PRN medications, alert physicians to any changes and provide patient education. LPNs usually function in this role alongside RNs. However, since LPNs cannot (usually) start IVs, give medications IV push, give blood products, administer chemotherapy or perform initial assessments, they may serve as a "Medication Nurse", a nurse that administers various medications for other nurse's patients.

In the Operating Room, LPNs serve as the scrub nurse. The scrub nurse accompanies the surgeon to the sterile field and passes instruments and medications to him. He or she may be asked to assist the surgeon, by holding a surgical site open, providing suction or other similar tasks. Serving as the circulating nurse is usually not in the LPN's scope of practice. The circulating nurse prepares medication, completes documentation, assists the anaesthesia provider, helps transport the patient to the recovery room and gives report to the recovery room nurse. RNs, LPNs and Certified Surgical Technologists all may compete for the role of the scrub nurse/tech.

Generally, LPNs are no longer permitted to work in the Intensive Care, Obstetrics Units, Psychiatric Units or other speciality units. However, LPNs still work in the Emergency Room in some hospitals. Hospitals generally are not popular with LPNs because, when they do hire them, they hire them at a salary lower than those offered at skilled nursing facilities.

Doctor's Offices
LPNs are fairly common at doctor's offices. Here, they give injections, take medical histories, assist in examinations, assist in taking X-Rays, draw blood and other similar tasks. If the doctor's office performs surgery on-site, the LPN may assist the physician during the surgery.

Medical Assistants, unlicensed personnel trained to both assist the physician in clinical practice and as administrative assistants, are very common in doctor's offices. There is no standardization of Medical Assistant training. Some have only on-the-job training from the doctor, some may have certificate courses that took a few months to complete and some may have Associate's Degrees. However, both LPNs and RNs have more training in the clinical aspect of working in a doctor's office. LPNs are often assigned to supervise the Medical Assistants. It's only not uncommon to see an LPN as the office manager - ordering supplies, recruiting new staff members, orienting new nurses/medical assistants and other similar tasks.

Doctor's office pay is generally much lower than other specialities. They remain somewhat popular, however, because most offices do not require the nurse to be on-call, take overtime or work weekends, nights or holidays, like a hospital or skilled nursing facility might.

Skilled Nursing Facilities
RNs must work in Skilled Nursing Facilities to supervise the LPNs. RNs usually do not have very much patient contact in this setting. RNs are generally the equivalent of supervisors in this setting, supervising both LPNs and CNAs. They maintain documentation (especially documenting the use of narcotic pain relievers), supervise the staff, assist with IVs and perform life support when needed.

This is generally not a very popular field with RNs, due to the lack of patient contact. However, it is fairly easy to become the Director of Nursing at a Skilled Nursing Facility. Whereas hospitals might require a Master's Degree to become an executive in the nursing department, Skilled Nursing Facilities might just require an RN license, meaning diploma and ASN prepared nurses are eligible for the job as well.

Hospitals
The vast majority of RNs work in hospitals. RNs provide care in almost every department of the hospital. A partial list is available.

Medical/Surgical: Administer medications, perform assessments, alert physicians of any problems, provide patient education, collect lab samples and other similar tasks. Most of a hospital's nurses work on these floors. Floors can also specialise, becoming Paediatric, Respiratory, Oncology and other similar floors. The RNs duties vary from speciality to speciality. An RN can be certified by earning the RN,C, (Registered Nurse, Certified) RN,BC (Registered Nurse, Board Certified) or CMSRN (Certified Medical/Surgical Registered Nurse) credentials. It's very important for Medical/Surgical RNs to be able to prioritize patients well. Since the nurse may have anywhere from five to ten patients, it's critical that she can differentiate between minor, moderate and severe problems.

Operating Room: The RN may work as either the scrub nurse or the circulating nurse. The scrub nurse assists the surgeon at the field by passing him instruments and medications and sometimes assisting in surgery by holding a surgical site open or by providing suction. The circulating nurse must be an RN, not an LPN, in most states. The circulating nurse assists the anaesthesia provider, prepares medications and documents the case. An RN can become certified in "Perioperative Nursing" by earning the CNOR ("Certified Nurse of the Operating Room") credential.

Intensive Care: Intensive Care units are where the sickest patients in the hospital go. Patients in the Intensive Care unit have serious multi-system illnesses. They often have multiple IVs, are on several medications and may or may not be on ventilators. Patients in these areas have suffered from heart attacks, strokes, drug overdoses, traumas, gunshot wounds and other serious illnesses and injuries. RNs here must be well organized and be able to assess patients quickly and accurately.

Intensive Care units usually specialize. Common units include MICU (Medical Intensive Care Unit), SICU (Surgical Intensive Care Unit), PICU (Paediatric Intensive Care Unit), NICU (Neuro Intensive Care Unit) and ICN (Intensive Care Nursery).

Emergency Room: RNs in the Emergency Room must be able to prioritize well. RNs are usually the Triage Nurses in the ER - LPNs are generally not permitted to serve in this role. The Triage Nurse takes the patients symptoms and decides how urgent it is for the physician to see the patient. For example, a patient that isn't breathing might be Critical, a patient having a heart attack might be Severe, a patient bleeding might be Moderate and a broken bone might be Non-Urgent.

Other Areas: The RN might also work in the Cardiac Cath Lab, Obstetrics floor and various other areas.