Answer the following questions. Supply APA CITATION (IN-TEXT AND REFERENCE). Each question needs to be answer in a minimum of two paragraph. Remember to use the rubric when developing your work. CHAPTERS 10,11,13
1.List one or two ways that novice thinkers and expert thinkers differ and give an example that illustrates each.
2. Do you think religion and/or spirituality are essential elements within the practice of nursing? Why or why not? Discuss aspects of spiritual nursing care that you have used, feel comfortable using, or do not feel comfortable using. What interventions primarily benefit the patient? What interventions benefit the nurse?
IMPORTANT NOTE: Use the book as a source.
Concepts & Challenges
Beth Perry Black, PhD, RN
Associate Professor, School of Nursing, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina
Table of Contents
1. Nursing in TodayÃ¢â‚¬â„¢s Evolving Health Care Environment
Nursing in the United States Today
Nursing Opportunities Requiring Advanced Degrees
Employment Outlook in Nursing
Concepts and Challenges
Ideas for Further Exploration
2. The History and Social Context of Nursing
Historical Context of Nursing
Social Context of Nursing
Concepts and Challenges
Ideas for Further Exploration
3. NursingÃ¢â‚¬â„¢s Pathway to Professionalism
Characteristics of a Profession
From Occupation to Profession
NursingÃ¢â‚¬â„¢s Pathway to Professionalism
Collegiality in Professional Nursing
Barriers to Professionalism in Nursing
Concepts and Challenges
Ideas for Further Exploration
4. Nursing Education in an Evolving Health Care Environment
Development of Nursing Education in the United States
Educational Paths to Become a Registered Nurse
RN-to-BSN, Accelerated BSN, Distance Learning: Alternate Paths in Nursing Education
Accreditation: Ensuring Quality Education
Taking the Next Steps: Advanced Degrees in Nursing
Becoming Certified: Validating Knowledge and Proficiency
Maintaining Expertise and Staying Current Through Continuing Education
Challenges: Faculty Shortages and Quality and Safety Education in TodayÃ¢â‚¬â„¢s Complex Health Care
Concepts and Challenges
Ideas for Further Exploration
5. Becoming a Professional Nurse: Defining Nursing and Socialization into
Defining Nursing: Harder than it Seems
Becoming a Nurse: Shaping Your Professional Identity
From Student to Nurse: Facilitating the Transition
Ã¢â‚¬Å“Just Going Through a StageÃ¢â‚¬Â: Models of Socialization
From Student to Employed Nurse: Socialization Specific to the Work Setting
Concepts and Challenges
Ideas for Further Exploration
6. Nursing as a Regulated Practice: Legal Issues
American Legal System
State Boards of Nursing, Nursing Practice Acts, and Licensure
Legal Risks in Professional Nursing Practice
Confidentiality: The Challenge to Protect Privacy
Evolving Legal Issues Affecting Nursing
Protecting Yourself from Legal Problems
Concepts and Challenges
Ideas for Further Exploration
7. Ethics: Basic Concepts for Professional Nursing Practice
Definitions of Basic Concepts in Ethics
Approaches to Moral Reasoning
Theories of Ethics
Six Ethical Principles Based on Human Dignity and Respect
Codes of Ethics for Nursing
Navigating the Gray Areas: Ethical Decision Making
Exploring Ethical Dilemmas in Nursing
Concepts and Challenges
Ideas for Further Exploration
8. Conceptual and Philosophical Foundations of Professional Nursing Practice
Understanding Systems: Connections and Interactions
Person: An Open System with Human Needs
Environment: The Suprasystem in which Persons Live
Health: A Continuum
Nursing: Forming the Meaningful Whole
Beliefs: Guiding Nursing Behaviors
Philosophies and their Relationship to Nursing Care
Developing A Personal Philosophy of Nursing
Concepts and Challenges
Ideas for Further Exploration
9. Nursing Theory: The Basis for Professional Nursing
Philosophies of Nursing
Conceptual Models of Nursing
Theories of Nursing: From Grand to Middle Range
Using Theory for Nursing Education, Practice, and Research
Concepts and Challenges
Ideas for Further Exploration
10. The Science of Nursing and Evidence-Based Practice
Science and the Scientific Method
Nursing Research: Improving Care of Patients
Evidence-Based Practice: Evidence, Expertise, Patient Preference
The Research Process
The Relationship of Research to Theory and Practice
Financial Support for Nursing Research
Advancing the Profession Through the Use of Research
Concepts and Challenges
Ideas for Further Exploration
11. Developing Nursing Judgment through Critical Thinking
Critical Thinking: Cultivating Intellectual Standards
Critical Thinking in Nursing
The Nursing Process: A Universal Intellectual Standard
Steps of the Nursing Process
The Dynamic Nature of the Nursing Process
Developing Clinical Judgment in Nursing
Concepts and Challenges
Ideas for Further Exploration
12. Communication and Collaboration in Professional Nursing
The Therapeutic Use of Self
The Development of Human Communication
Criteria for Successful Communication
Developing Effective Communication Skills
Effective Communication with Other Providers
Interprofessional Collaboration: Prescription for Improved Patient Outcomes
Concepts and Challenges
Ideas for Further Exploration
13. Nurses, Patients, and Families: Caring at the Intersection of Health, Illness,
Acute and Chronic Illness
Adjusting to Illness
The Impact of Illness on Patients and Families
The Impact of Caregiving on Nurses
Concepts and Challenges
Ideas for Further Exploration
14. Health Care in the United States
TodayÃ¢â‚¬â„¢s Health Care System
Financing Health Care
Health Care Reform and Universal Access
Concepts and Challenges
Ideas for Further Exploration
15. Political Activism in Nursing: Communities, Organizations, Government
Policy and Politics: Not Just in Washington, D.C
Professional Organizations: Strength in Numbers
Benefits of Joining a Professional Organization
Political Activism in Government
Nursing Needs Your Contribution
Concepts and Challenges
Ideas for Further Exploration
16. NursingÃ¢â‚¬â„¢s Challenge: To Continue to Evolve
The Challenge: Caring for Yourself
The Challenge: Caring for the Profession
The Challenge: Caring for the Environment
The Final Challenge: Unite and Act
Concepts and Challenges
Ideas for Further Exploration
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PROFESSIONAL NURSING: CONCEPTS & CHALLENGES, EIGHTH
EDITION ISBN: 978-0-323-43112-5
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This book and the individual contributions contained in it are protected under
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Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses. In order
to make safe and effective judgments using NANDA-I diagnoses it is essential
that nurses refer to the definitions and defining characteristics of the diagnoses
listed in this work.
Knowledge and best practice in this field are constantly changing. As new
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Practitioners and researchers must always rely on their own experience and
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Library of Congress Cataloging-in-Publication Data
Names: Black, Beth Perry, author.
Title: Professional nursing : concepts & challenges / Beth Perry Black.
Description: Eighth edition. | Maryland Heights, Missouri :
Elsevier/Saunders,  | Includes bibliographical references and index.
Identifiers: LCCN 2016001024 | ISBN 9780323431125 (pbk. : alk. paper)
Subjects: | MESH: Nursing | Vocational Guidance
Classification: LCC RT82 | NLM WY 16.1 | DDC 610.73068–dc23 LC record
available at http://lccn.loc.gov/2016001024
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Printed in China
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I dedicate this edition to the memory of my beloved husband, Tal, who lived his
life in grace, peace, and love.
Michele Bunning, RN, MSN, Associate Professor, Good Samaritan College
of Nursing and Health Science, Cincinnati, Ohio
Nancy Diede, EdD, MS, RN, PHCNS-BC, CNE, Department Head, Health
Sciences, Associate Professor, Rogers State University, Claremore, Oklahoma
Christine K. Finn, PhD, RN, FNP, MS, FNE, Associate Professor, Nursing
Department, Regis University, Denver, Colorado
Eileen M. Kaslatas, MSN, RN, CNE, Professor, Nursing Department,
Macomb Community College, Clinton Township, Michigan
Bobbi Shatto, PhD(c), RN, CNL, Assistant Professor, School of Nursing,
Saint Louis University, St. Louis, MO
Nursing is evolving, as is health care in the United States. With the debates and
discussions, lawsuits, and legislation that surround the Affordable Care Act,
health care has become a central feature of American political and social
discourse. With their increasing response to calls to advance their education
and their strong record of safety and quality care, nurses are positioned to take
a leadership role in the provision of health care in the United States.
To be effective leaders, nurses must master knowledge about health and
illness and human responses to each, think critically and creatively, participate
in robust interprofessional collaborations, be both caring and professional, and
grapple with ethical dilemmas that are complex and that challenge providers in
a time when health care resources are not unlimited. As leaders, nurses must
have an understanding of their history, because the past informs the present,
and have a vision for the future that builds on the lessons of today.
The eighth edition of Professional Nursing: Concepts & Challenges reflects my
commitment to present current and relevant information. Since the last edition,
the Affordable Care Act (ACA) has withstood repeated attempts in Congress to
repeal it. Importantly, the ACA has withstood two significant challenges
brought before the U.S. Supreme Court. The provisions of the ACA have been
implemented, and more Americans than ever have health insurance. The 2016
presidential election is 1 year away as this is being written, with one side
arguing for the repeal of the ACA, while one candidate on the other side is
arguing for a single-payer health care system. This early posturing almost
certainly foreshadows a continuing lively debate on critical questions of health
care in America.
In this edition, the order of the chapters has been changed considerably to
reflect a more cohesive view of nursing, its history, education, conceptual and
theoretical bases, and the place of nursing in the U.S. health care system.
Faculty are encouraged, however, to use the chapters in any order that reflects
their own pedagogical and theoretical approaches. This edition has additional
examples from nurses, especially textboxes featuring compelling stories from
nurses who have shaped their careers in creative, innovative ways. The effects
of the Internet and social media on nursing are addressed extensively with
regard to their legal and ethical implications and their role in professional
socialization and communication. There are fewer figures and statistics than in
previous editions because students respond more favorably to narratives and
examples. With the easy and free availability of health-related statistics from
.gov websites, I decided that todayÃ¢â‚¬â„¢s students would benefit more from
narrative and less from pages of statistics. I have rarely met a nurse engaged in
practice who didnÃ¢â‚¬â„¢t start a story with, Ã¢â‚¬Å“I had a patient once whoÃ¢â‚¬Â¦Ã¢â‚¬Â These
narratives teach us about what is important in nursing.
Throughout the book, I have been very careful to be inclusive, to avoid
heteronormative and ethnocentric language, to use examples that avoid
stereotypes of all types, and to include photographs that capture the wonderful
diversity of American nursing.
A note about references: older references refer to classic papers or texts. There
are a few references that donÃ¢â‚¬â„¢t reach the level of Ã¢â‚¬Å“classicÃ¢â‚¬Â texts, but the author
turned a phrase in a clever or elegant way that needed to be cited. No manner
of updated paper could replace these interesting comments or points of view.
Research and clinical works are relevant and contemporary.
As with the last three editions, the eighth edition is written at a level
appropriate for use in early courses in baccalaureate curricula, in RN-to-BSN
and RN-to-MSN courses, and as a resource for practicing nurses and graduate
students. An increasing number of students in nursing programs are seeking
second undergraduate degrees, such as midlife adults seeking a career change
and others who bring considerable experience to the learning situation.
Accordingly, every effort has been made to present material that is
comprehensive enough to challenge users at all levels without overwhelming
beginning students. The text has been written to be engaging and interesting,
and care has been taken to minimize jargon that is so prevalent in health care. A
comprehensive glossary is provided to assist in developing and refining a
professional vocabulary. As in previous editions, key terms are highlighted in
the text itself. All terms in color print are in the Glossary. The Glossary also
contains basic terms that are not necessarily used in the text but may be
unfamiliar to students new to nursing.
Some features from previous editions have gotten significant Ã¢â‚¬Å“makeovers.Ã¢â‚¬Â
Some self-assessment exercises were retained, but the language was updated.
Several chapters contain Challenge boxes that typically, but not always, are
related to an issue of culture. Some older textboxes from previous editions have
been eliminated to make room for fresher content. To be consistent with the
focus of the bookÃ¢â‚¬â€concepts and challengesÃ¢â‚¬â€I have changed the former Ã¢â‚¬Å“Key
PointsÃ¢â‚¬Â content to address major concepts from each chapter with a
corresponding challenge for the student or for nursing as a profession. I have
included Ã¢â‚¬Å“Ideas for Further ExplorationÃ¢â‚¬Â to replace Ã¢â‚¬Å“Critical Thinking
QuestionsÃ¢â‚¬Â with the hope that these ideas will generate a spark of curiosity in
students as they consider some of the challenging aspects of the profession.
I sincerely hope that the eighth edition continues to reach the high standards
set forth by Kay Chitty, who edited the first four editions of this book. I hope
that students and faculty will find this edition readable, informative, and
thought provoking. More than anything, I hope that Professional Nursing:
Concepts & Challenges, Eighth Edition, will in some way contribute to the
continuing evolution of the profession of nursing.
Beth Perry Black
With each new edition of Professional Nursing: Concepts & Challenges, I find
myself increasingly in awe of the intelligence, creativity, humility, and work
ethic of the nurses who continue to inspire me.
I am so grateful to the many people whose support and assistance have made
this book possible, each in different ways:
Ã¢â‚¬Â¢ To the faculty who used earlier editions and shared their helpful suggestions
to make this book better.
Ã¢â‚¬Â¢ To students who sent e-mails, expressing their gratitude for an interesting
and readable textbook while offering ideas for improvement.
Ã¢â‚¬Â¢ To the many nurses who were generous in sharing their experiences when I
asked for an example or a story. Nurses narrate their work like no others.
Ã¢â‚¬Â¢ To my colleagues in the School of Nursing at the University of North Carolina
at Chapel Hill, and to our extraordinary nursing students and alumni who
make us proud.
Ã¢â‚¬Â¢ To Trish Wright and Rana Limbo, my Ã¢â‚¬Å“grief buddies,Ã¢â‚¬Â who are also my dear
friends and writing companions.
Ã¢â‚¬Â¢ To my friend Paula Anderson, who assisted me in the preparation of this text
and whose warm, generous spirit infuses everything she does with light.
Ã¢â‚¬Â¢ To my dear friends Jen and Rick Palmer, whose loving support has been and
continues to be a lifeline.
Ã¢â‚¬Â¢ To my incredibly smart, funny, and supportive daughters, Amanda Black and
Kylie Johnson, and to their respective partners, Hudson Santos, Jr., and Pierce
Johnson, who serve to both buoy and anchor them. Thanks, schweeties!
I am deeply indebted to each of you.
Nursing in TodayÃ¢â‚¬â„¢s Evolving Health
After studying this chapter, students will be able to:
Ã¢â‚¬Â¢ Describe the demographic profile of registered nurses today.
Ã¢â‚¬Â¢ Recognize the wide range of settings and roles in which todayÃ¢â‚¬â„¢s registered
Ã¢â‚¬Â¢ Identify evolving practice opportunities for nurses.
Ã¢â‚¬Â¢ Consider nursing roles in various practice settings.
Ã¢â‚¬Â¢ Explain the roles and education of advanced practice nurses.
To enhance your understanding of this chapter, try the Student Exercises on
the Evolve site at http://evolve.elsevier.com/Black/professional.
Chapter opening photo used with permission from iStockphoto.
Nurses comprise the largest segment of the health care workforce in the United
States and have increasing opportunities to practice in an enormous variety of
settings. The profession of nursing is more than ever requiring the education of
well-trained, flexible, and knowledgeable nurses who can practice in todayÃ¢â‚¬â„¢s
evolving health care environment. Recent legislation, demands of patients as
consumers of health care, and the need to control costs while optimizing
outcomes have had a great influence on the way that health care is delivered in
the United States. Nursing is evolving to meet these demands.
One of the most notable influences on todayÃ¢â‚¬â„¢s health care environment is the
Affordable Care Act (ACA), passed in 2010 by the 111th Congress. The ACA is
actually two lawsÃ¢â‚¬â€the Patient Protection and Affordable Care Act (PL 111-148)
and the Health Care and Education Affordability Reconciliation Act (PL 111152). Signed into law by President Barack Obama, this combination of laws is
sometimes referred to as simply Ã¢â‚¬Å“health care reformÃ¢â‚¬Â by the public. These laws
provide for incremental but progressive change to the way that Americans
access and pay for their health care. In an important report of the opportunities
this legislation affords nurses, the Committee on the Robert Wood Johnson
Foundation Initiative on the Future of Nursing at the Institute of Medicine
noted that Ã¢â‚¬Å“nurses have a considerable opportunity to act as full partners with
other health professionals and to lead in the improvement and redesign of the
health care system and its practice environmentÃ¢â‚¬Â (Institute of Medicine, 2010,
pp. 1Ã¢â‚¬â€œ2). This important initiative continues to have a profound influence on the
evolution of nursing and nursing education since its publication.
Welcome to nursing. You are entering this great profession at an exciting time
in our history. Writing about Ã¢â‚¬Å“nursing todayÃ¢â‚¬Â poses a challenge, because what
is current today may have already changed by the time you are reading this.
What does not change, however, is the commitment of nurses to what
Rosenberg (1995) referred to as Ã¢â‚¬Å“the care of strangersÃ¢â‚¬ÂÃ¢â‚¬â€professional caring,
learned through focused education and deliberate socialization (Storr, 2010). In
other words, you will be taught to think like a nurse and to do well those things
that nurses do. You will become a nurse.
In this chapter, you will learn some basic information about todayÃ¢â‚¬â„¢s nursing
workforce: who nurses are, the settings where they practice, and the patients for
whom they are providing care. You will also be introduced to some nurses who
have had intriguing experiences and opportunities that you may not know are
even possible. One of the best features of nursing is the flexible set of skills that
you will develop and, therefore, the wide variety of experiences that await you
as your begin your career as a professional registered nurse (RN).
Nursing in the United States Today
High-quality, culturally competent nursing care depends on a culturally diverse
nursing workforce (American Association of Colleges of Nursing [AACN],
2014a). The need to enhance diversity in nursing through the recruitment of
underrepresented groups into the profession is a priority (AACN, 2014b).
Understanding the composition of the nursing workforce is necessary to
identify underrepresented groups and to recognize workforce trends such as
age of nurses in practice and percentage of licensed nurses holding jobs in
The U.S. Department of Health and Human Services responded to this need
by conducting a comprehensive survey of the nursing workforce every 4 years,
beginning in 1977. Known as the National Sample Survey of Registered Nurses
(NSSRN), this effort gave policy makers, educators, and other nurse leaders
data about the workforce, allowing them to make informed decisions about
allocation of resources, development of programs, and recruitment of nurses.
The final NSSRN was conducted in 2008 and results were published in 2010.
The federal government has since discontinued this very useful survey. The
final version of the 2008 federal nursing workforce survey The Registered Nurse
Population: Findings from the 2008 National Sample Survey of Registered Nurses
(U.S. Department of Health and Human Services, 2010) is available as a .pdf file
in a direct link:
In response to the discontinuation of the NSSRN and the ongoing need to
understand the nursing workforce, in 2013 the National Council of State Boards
of Nursing (NCSBN) and the Forum of State Nursing Workforce Centers
(FSNWC) combined efforts to conduct a comprehensive national survey of RNs
(Budden, Zhong, Moulton, et al., 2013). In this chapter, data from the 2013
NCSBN and FSNWC survey are presented in conjunction with other sources of
workforce data, including the 2008 NSSRN data, to provide you with a
thumbnail sketch of nursing, specifically focusing on the number of nurses in
the workforce, as well as their gender, age, race, ethnicity, and educational
Nurses in the Workforce
Registered nurses (RNs) are the largest group of health care providers in the
United States, and in the 2000s grew by 24.1% (Health Resources and Services
Administration, 2013). More than 4 million individuals held licenses as RNs in
2013 (Budden et al., 2013). That same year, approximately 2.8 million nurses
were currently working (Health Resources and Services Administration, 2013).
In the 2008 NSSRN data, 90% of nurses younger than 50 years old were
employed in nursing either full or part time and fewer than half of the nurses
older than 65 were working in nursing. A significant percentage of nurses held
two nursing positions. Among those working full time in nursing, 12% had a
second nursing position; 14% of those working part time in nursing held a
second nursing position (U.S. Department of Health and Human Services,
Nursing remains a profession dominated by women; however, the percentage
of men in nursing increased by 50% between 2000 and 2008 (U.S. Department of
Health and Human Services, 2010). Overall, 7% of nurses are men. Among
NCSBN/FSNWC survey respondents licensed before 2000, 5% were men. Of
those licensed between 2010 and 2013, 11% were men (Budden et al., 2013).
In 2014, men comprised 11.7% of students in entry-level bachelor of science in
nursing (BSN) programs (AACN, 2015a). Male and female RNs were equally
likely to have a bachelorÃ¢â‚¬â„¢s or higher degree in nursing or nursing-related fields
(49.9% and 50.3%, respectively). Men, however, were more likely than women
to have a bachelorÃ¢â‚¬â„¢s or higher degree in nursing and any nonnursing field (62%
vs. 55%). A higher percentage of the men work in hospitals (76% vs. 62%). At
41%, men are overrepresented in the advanced practice role of certified
registered nurse anesthetists. Among all other job titles held by men, staff nurse
and administration have proportional representation, with about 7% of these
positions held by men. Nurse practitioners and Ã¢â‚¬Å“otherÃ¢â‚¬Â positions (e.g.,
consultant, clinical nurse leader, informatics, researcher) are slightly less
proportional, with 6% of these positions held by men. Interestingly, men hold
only about 3.8% of faculty positions.
The future of any profession depends on the infusion of youth, and the steady
increase in the age of the nursing workforce has been a concern. In the past
decade, however, the rate of aging of nurses in the workforce has slowed (U.S.
Department of Health and Human Services, 2010). This is a result of the
increased number of working RNs who are under age 30, which offsets the
increasing number of nurses age 60 or older who continue to work. The rise in
the number of nurses under age 30 is attributed to the increased number of
graduates from BSN programs, who tend to be younger than graduates from
other types of nursing programs. Since 2005, the average age of graduates from
all nursing programs has been 31 years old. BSN graduates, at an average age of
28 years old, are 5 years younger than graduates of associate-degree and
diploma (hospital-based) programs, who are on average 33 years old.
The median age is that point at which half of the nurses are older and half are
younger, and it provides a more useful metric of the workforce than does
calculating a mean age. Since 1988, when the median age was 38, the median
age of nurses rose by 2 years between each survey, so that by 2004, the median
age was 46, a worrisome figure in that it means the nursing workforce was
continuing to age. The increasing number of nurses age 60 and older who are
still in the workforce is possibly a result of the recent economic downturn in
which unemployment rates were high. Older nurses are more likely to remain
in the workforce because the nursing field is reasonably protected from the
layoffs and downsizing experienced in other professions.
This stabilization of the aging pattern seen in the final NSSRN survey is an
optimistic sign that nursing is seen as an option for younger people entering the
workforce, and that nursing will not face a shortage as older nurses age out of
the workforce in a few years. However, with about one third of the current
nursing workforce older than age 50 (Health Resources and Services
Administration, 2013), the profession of nursing must continue to recruit and
educate younger nurses to prevent a nursing shortage as older nurses move
Race and Ethnicity
Racial and ethnic minorities make up 37% of the population of the United States
today but only 19% of the RN population, an underrepresentation by about 50%
in 2013 (Budden et al., 2013). This is similar to the findings in 2008 in the
NSSRN (Figure 1-1). Although troublesome, the number is an improvement
from 2004, when only 12.2% of RNs had racial/ethnic minority backgrounds.
Detailed data from the NSSRN show that the largest disparity between the U.S.
general population and the RN population is seen with Hispanics/Latinos of
any race. Although this group forms about 15.4% of the U.S. population, they
make up only 3.6% of RNs. Black/African American, non-Hispanics also have a
significant disparity; now constituting 12.2% of the U.S. population, this group
makes up just 5.4% of RNs. The only group that exceeds its representational
percentage in the general population is the Asian or Native Hawaiian/Pacific
Islander, non-Hispanic group. Composing 4.5% of the general population, this
group makes up 5.8% of the RN population, possibly because a substantial
number of RNs practicing in the United States received their nursing education
in India or the Philippines, thus contributing to their overrepresentation (U.S.
Department of Health and Human Services, 2010).
FIG 1-1 RN and the U.S. populations by race/ethnicity, 2008. The proportion
of nurses who are White, non-Hispanic is greater than their proportion in the
U.S. population. (Data from U.S. Department of Health and Human Services, Health Resources
and Services Administration: The Registered Nurse Population: Findings from the 2008 National Sample
Survey of Registered Nurses, Washington, DC, 2010, U.S. Government Printing Office, p. 7-7.)
Despite efforts to recruit and retain racial/ethnic minority women and men in
the nursing profession, nursing still has a long way to go before the
racial/ethnic composition of the profession more accurately reflects that of the
United States as a whole. This situation is improving, however. In a recent
report on enrollment and graduation in bachelorÃ¢â‚¬â„¢s and graduate programs in
nursing, the American Association of Colleges of Nursing (AACN, 2015a)
showed that 30.1% of nursing students in entry-level BSN programs were from
The basic education to become a nurse is referred to as the entry level into
practice. Successful completion of your basic education, however, does not
qualify you to become a nurse. Once you have graduated from a school of
nursing approved by your state, you are qualified to take the National Council
Licensure Examination for Registered Nurses, known as the NCLEX-RNÃ‚Â®.
Successfully passing the NCLEX-RNÃ‚Â® then qualifies you to be licensed as an
Nursing has three mechanisms by which you can get basic nursing education
to qualify to take the NCLEXÃ‚Â®: (1) 4-year education at a college or university
conferring a bachelor of science in nursing (BSN) degree; (2) 2-year education at
a community college or technical school conferring an associate degree in
nursing (ADN); and (3) a diploma in nursing, awarded after the successful
completion of a hospital-based program that typically takes 3 years to complete,
including prerequisite courses that may be taken at another school.
According to the Robert Wood Johnson Foundation (RWJF), the number of
diploma programs has steadily declined, educating only 4% of all new RNs in
2013 (RWJF, 2013) as nursing education has shifted to colleges and universities
(AACN, 2011). The majority of nurses (53%) in the United States get their initial
nursing education in ADN programs (RWJF, 2013); in the NCSBN/FSNWC
(2013) survey, 39% of the 41,823 respondents reported having an ADN as their
first degree or credential, and 36% reported having a BSN as their first degree
Many ADN-prepared RNs eventually return to school to complete a BSN
degree. Between 2004 and 2012, the number of RNs enrolled in BSN programs
almost tripled, from 35,000 to slightly fewer than 105,000 (RWJF, 2013).
Currently, approximately 55% of RNs have BSN or higher degrees (Health
Resources and Services Administration, 2013). Many colleges and universities
offer BSN programs, often online, to accommodate RNs in practice who want to
work toward a BSN degree as a supplement to their basic nursing education at
the ADN or diploma level. Nursing education is discussed in greater detail in
Globalization and the international migration of nurses has resulted in an
increase of internationally educated nurses practicing in the United States, up
from 3.7% in 2004 to 5.6% in 2008 (Thekdi, Wilson, and Xu, 2011). The
recruitment of foreign-educated nurses to the United States has been a strategy
to expand the nursing workforce in response to the recent nursing shortage.
This strategy, however, has been criticized because recruitment of these nurses
to the United States may result in shortages in their own countries. Foreigneducated nurses face challenges as they join the workforce in the United States,
including speaking English as a second language and problems with their peers
who may not perceive them as knowledgeable (Thekdi et al., 2011). Deep
cultural differences may further separate the foreign-educated nurses from their
American peers. Thekdi and colleagues (2011) noted that foreign-educated
nurses might have very different views of gender, authority, power, and age
that affect their communication styles. Furthermore, absolute respect for experts
and teachers is common among foreign-educated nurses, creating a permanent
barrier between nurse-managers and foreign-educated nurses.
Sigma Theta Tau International (STTI) has published a position paper on
international nurse migration. Although this paper was published in 2005, it
reflects STTIÃ¢â‚¬â„¢s current, ongoing position regarding international nurse
migration (STTI, 2005). STTI recognizes the autonomy of nurses in making
decisions for themselves about where to live and work, noting that Ã¢â‚¬Å“push/pullÃ¢â‚¬Â
factors shape nurse migration. Push factors include poor compensation and
working conditions, political instability, and lack of opportunities for career
development that drive (push) a nurse to seek employment in another country.
Factors that pull nurses to emigrate include opportunities for a better quality of
life, personal safety, and professional incentives such as increased pay, better
working conditions, and career development. STTI calls for further exploration
of the issue with a focus on identifying Ã¢â‚¬Å“solutions that do not promote one
nationÃ¢â‚¬â„¢s health at the expense of anotherÃ¢â‚¬Â (p. 2). Furthermore, STTI endorsed
the International Council of Nurses position in calling for a regulated
recruitment process based on ethical principles that deter exploitation of
foreign-educated nurses and reinforce sound employment policies (p. 4).
Practice Settings for Professional Nurses
As members of the largest health care profession in the United States, nurses
practice in a wide variety of settings. The most common setting is the hospital,
and many new nurses seek employment there to strengthen their clinical and
assessment skills. Nurses practice in clinics, community-based facilities, medical
offices, skilled nursing facilities, and other long-term settings. Nurses also
provide care in places where people spend much of their time: homes, schools,
and workplaces. In communities, nurses can be found in the military,
community and senior centers, childrenÃ¢â‚¬â„¢s camps, homeless shelters, and,
recently, in retail clinics found in some pharmacies. Nurses also provide
palliative care (i.e., symptom management to improve quality of life) and endof-life care, typically in the homes of terminally ill patients or in inpatient
hospice homes or facilities. Increasingly, nurses with advanced degrees,
training, and certification are working in their own private practices or in
partnership with physicians or other providers. This expansion of practice
holds promise for nurses to widen their roles in health care, especially as the
American health care system continues to evolve.
Hospitals remained the primary work site for RNs, with 63.2% of nurses
employed by hospitals in either inpatient or outpatient settings, an increase of
25% in the past decade (Health Resources and Services Administration, 2013).
Most of these nurses (39.6%) work in inpatient units in community hospitals,
whereas others work in specialty hospitals, long-term hospitals, and psychiatric
units. The federal government employs nurses, generally in the U.S.
Department of Veterans Affairs (VA) hospitals, where 1.1% of RNs work.
Ambulatory care settings, such as nurse-based practices, physician-based
practices, and free-standing emergency and surgical centers, accounted for
10.5%, the second largest segment of the nurse workforce. Public and
community health accounted for 7.8% of employed nurses, and an additional
6.4% worked in home health. Nursing homes or extended care facilities
employed 5.3% of nurses in the workforce. The remainder of employed RNs
worked in settings such as schools of nursing; nursing associations; local, state,
or federal governmental agencies; state boards of nursing; or insurance
companies (U.S. Department of Health and Human Services, 2010, pp. 3Ã¢â‚¬â€œ9).
Not all nurses provide direct patient care as their primary role. A small but
important group of nurses spend the majority of their time conducting research,
teaching undergraduate and graduate students in the classroom and in clinical
settings, managing companies as chief executives, and consulting with health
care organizations. Nurses who have advanced levels of education, such as
masterÃ¢â‚¬â„¢s and doctoral degrees, are prepared to become researchers, educators,
and administrators. Nurses can practice as advanced practice nurses (APNs),
including a variety of types of nurse practitioners (NPs), clinical nurse
specialists (CNSs), certified nurse-midwives (CNMs), and certified registered
nurse anesthetists (CRNAs). These advanced practice roles are described later
in this chapter.
Nurses have much to consider in deciding where to practice. Some settings
will not be immediately open to new nurses because they require additional
educational preparation or work experience. Importantly, nurses entering the
workforce need to consider their special talents, likes, and dislikesÃ¢â‚¬â€neither the
nurse nor patients benefit when a nurse is working with a population for which
he or she has little affinity. A nurse who enjoys working with children may not
feel at ease in caring for elderly patients; on the other hand, a nurse who loves
children may find that caring for sick children is emotionally stressful. A nurse
with excellent communication skills may find that a postanesthesia care unit
(PACU) does not allow the formation of professional relationships with patients
that this nurse might enjoy in a psychiatric setting. Nursing school offers the
chance to experience a wide variety of settings with diverse patient
populations. At the end of your studies, you may be surprised at the skills you
have developed and by which populations appeal to you (Figure 1-2).
Health care reform and the push to transform the health care system are
moving nurses into new territory. Numerous new opportunities and roles are
being developed that use nursesÃ¢â‚¬â„¢ skills in innovative and exciting ways. In the
following section, you will be introduced to a range of settings in which nurses
practice. These areas are only a sampling of the growing variety of
opportunities available to nurses entering practice today.
Nursing in Hospitals
Nursing care originated and was practiced informally in home and community
settings and moved into hospitals only within the past 150 years. Hospitals vary
widely in size and services. Certain hospitals are referred to as medical centers
and offer comprehensive specialty services, such as cancer centers, maternalfetal medicine services, and heart centers. Medical centers are usually
associated with university medical schools and have a complex array of
providers. Medical centers can have 1000 or more beds and have a huge nursing
workforce. Medical centers are often designated as Ã¢â‚¬Å“Level 1 Trauma CentersÃ¢â‚¬Â
because they offer highly specialized surgical and supportive care for the most
severely injured patients. The patients at community-based hospitals usually
are less severely ill than those needing comprehensive care or trauma care at a
medical center. However, if a patient becomes highly unstable or if the patientÃ¢â‚¬â„¢s
condition warrants, he or she can be transported to a larger hospital or a
medical center. Nurses play an important role in identifying very sick patients,
helping stabilize them, and preparing them for transport.
In general, nurses in hospitals care for patients who have medical or surgical
conditions (e.g., those with cancer or diabetes, those in need of postoperative
care), children and their families on pediatric units, women and their newborns,
and patients who have had severe trauma or burns. Specialty areas are referred
to as Ã¢â‚¬Å“units,Ã¢â‚¬Â such as operating suites or emergency departments, intensive care
units (e.g., cardiac, neurology, medical), and step-down or progressive care
units, among others. In addition to providing direct patient care, nurses are
educators, managers, and administrators who teach or supervise others and
establish the direction of nursing on a hospital-wide basis.
FIG 1-2 Although most nurses work in hospitals, nurses in home health
settings often enjoy long-term relationships with their patients. (Photo used with
permission from iStockphoto.)
Various generalist and specialist certification opportunities are appropriate
for hospital-based nurses, including medical-surgical nursing, pediatric
nursing, pain management nursing, informatics nursing, genetics nursingÃ¢â‚¬â€œ
advanced, psychiatricÃ¢â‚¬â€œmental health nursing, nursing executive, nursing
executiveÃ¢â‚¬â€œadvanced, hemostasis nursing, and cardiovascular nursing, among
others. No other health care facility offers such variety of opportunities for
practice as do hospitals.
The educational credentials required of RNs practicing in hospitals can range
from associate degrees and diplomas to doctoral degrees. In general, entry-level
positions require only RN licensure. Many hospitals require nurses to hold
bachelorÃ¢â‚¬â„¢s degrees to advance on the clinical ladder or to assume management
positions. A clinical ladder is a multiple-step program that begins with entrylevel staff nurse positions. As nurses gain experience, participate in continuing
education (CE), demonstrate clinical competence, pursue formal education, and
become certified, they become eligible to move up the clinical ladder. There is
no single model for clinical advancement for nurses across hospitals and other
health care agencies. When exploring work settings, nurses as prospective
employees should ask about the clinical ladder and opportunities for career
Most new nurses choose to work in hospitals as staff nurses initially to gain
experience in organizing and delivering care to multiple patients. For many,
staff nursing is extremely gratifying and they continue in this role for their
entire careers. Others pursue additional education, sometimes provided by the
hospital, to work in specialty units such as neonatal intensive care or cardiac
care. Although specialty units often require clinical experience and additional
training, some hospitals allow new graduates to work in these units.
Some nurses find that management is their strength. Nurse managers are in
charge of all activities on their units, including patient care, continuous quality
improvement (CQI), personnel hiring and evaluation, and resource
management, including the unit budget. Being a nurse manager in a hospital
today requires business acumen and knowledge of business and financial
principles to be most effective in this role. Nurse managers typically assume 24hour accountability for the units they manage, and are often required to have
earned a masterÃ¢â‚¬â„¢s degree.
Most nurses in hospitals provide direct patient care, sometimes referred to as
bedside care. In the past, it was necessary for nurses to assume administrative
or management roles to be promoted or receive salary increases. Such positions
removed them from bedside care. Today, in hospitals with clinical ladder
programs, nurses no longer must make that choice; clinical ladder programs
allow nurses to progress professionally while staying in direct patient care
At the top of most clinical ladders are clinical nurse specialists (CNS), who
are advanced practice nurses with masterÃ¢â‚¬â„¢s, post-masterÃ¢â‚¬â„¢s, or doctoral degrees
in specialized areas of nursing, such as oncology (cancer) or diabetes care. The
CNS role varies but generally includes responsibility for serving as a clinical
mentor and role model for other nurses, as well as setting standards for nursing
care on one or more particular units. The oncology clinical specialist, for
example, works with the nurses on the oncology unit to help them stay
informed regarding the latest research and skills useful in the care of patients
with cancer. The clinical specialist is a resource person for the unit and may
provide direct care to patients or families with particularly difficult or complex
problems, establish nursing protocols, and ensure that nursing practice on the
unit is evidence based. Evidence-based practice (EBP) refers to nursing care
that is based on the best available research evidence, clinical expertise, and
patient preference. More details about EBP are found in Chapter 10.
Salaries and responsibilities increase at the upper levels of the clinical ladder.
The clinical ladder concept benefits nurses by allowing them to advance while
still working directly with patients. Hospitals also benefit by retaining
experienced clinical nurses in direct patient care, thus improving the quality of
nursing care throughout the hospital. Research has demonstrated that patient
outcomes are more positive for patients cared for by RNs with a bachelorÃ¢â‚¬â„¢s or
higher degree. Linda Aiken, PhD, RN, FAAN, is a leader in nursing who has
conducted important research documenting the positive impact of adequate RN
staffing on patient outcomes. More than a decade ago, Aiken, Clarke, Cheung,
and colleagues (2003) published a groundbreaking study in which they found
that patients on surgical units with more BSN-prepared nurses had fewer
complications than patients on units with fewer BSN nurses. Aiken has
published widely on nurse staffing and safety since publishing this landmark
study. In 2010 Aiken, Sloane, Cimiotti, and colleagues reported on a comparison
of nurse and patient outcomes among hospitals in California, which has statemandated nurse-to-patient ratios, and in Pennsylvania and New Jersey, neither
of which has state-mandated nurse-to-patient ratios. Furthermore, concern
about patient quality and safety is an international issue. In 2012 Aiken,
Sermeus, Van den Heede, and colleagues led a very large team in examining
nurse and patient satisfaction, hospital environments, quality of care, and
patient safety across 12 European countries and the United States. See the
Evidence-Based Practice Box 1-1 for a description of these studies.
EVIDENCE-BASED PRACTICE BOX 1-1 The Evidence:
B e t t e r P r o f e s s i o n a l N u r s e S t a f f i n g I m p r o ve s Q u a l i t y
a n d S a f e t y o f Pa t i e n t C a r e
Linda Aiken, PhD, RN, FAAN, Professor of Nursing and Professor of
Sociology at the University of Pennsylvania School of Nursing, is the director
of the Center for Health Outcomes and Policy Research. She is an authority
on causes, consequences, and solutions for nursing shortages both in the
United States and worldwide. Dr. Aiken has published extensively. She and
her colleagues (2003) noted growing evidence suggesting Ã¢â‚¬Å“that nurse staffing
affects the quality of care in hospitals, but little is known about whether the
educational composition of registered nurses (RNs) in hospitals is related to
patient outcomes.Ã¢â‚¬Â They wondered whether the proportion of a hospitalÃ¢â‚¬â„¢s
staff of bachelorÃ¢â‚¬â„¢s or higher degreeÃ¢â‚¬â€œprepared RNs contributed to improved
patient outcomes. To answer this question, they undertook a large analysis of
outcome data for 232,342 general, orthopedic, and vascular surgery patients
discharged from 168 Pennsylvania hospitals over a 19-month period. They
used statistical methods to control for risk factors such as age, gender,
emergency or routine surgeries, type of surgery, preexisting conditions,
surgeon qualifications, size of hospital, and other factors. Their findings were
To our knowledge, this study provides the first empirical evidence that
hospitalsÃ¢â‚¬â„¢ employment of nurses with BSN and higher degrees is
associated with improved patient outcomes. Our findings indicate that
surgical patients cared for in hospitals in which higher proportions of
direct-care RNs held bachelorÃ¢â‚¬â„¢s degrees experienced a substantial
survival advantage over those treated in hospitals in which fewer staff
nurses had BSN or higher degrees. Similarly, surgical patients
experiencing serious complications during hospitalization were
significantly more likely to survive in hospitals with a higher proportion
of nurses with baccalaureate education (p. 1621).
Noting that fewer than half of all hospital staff nurses nationally are
prepared at the bachelorÃ¢â‚¬â„¢s or higher level, and citing a shortage of nurses as a
complicating factor, this group of researchers recommended Ã¢â‚¬Å“placing greater
emphasis in national nurse workforce planning on policies to alter the
educational composition of the future nurse workforce toward a greater
proportion with bachelorÃ¢â‚¬â„¢s or higher education as well as ensuring the
adequacy of the overall supplyÃ¢â‚¬Â (p. 1623). They concluded that improved
public financing of nursing education and increased employersÃ¢â‚¬â„¢ efforts to
recruit and retain highly prepared bedside nurses could lead to substantial
improvements in quality of care.
More recently, California became the first state to enforce state-mandated
minimum nurse-to-patient ratios. Much commentary about the pros and
cons of these types of mandates has been generated. To determine whether
nurse and patient outcomes were different in California than in two states
without mandated staffing, Aiken and colleagues analyzed survey data from
22,336 hospital staff nurses in California, Pennsylvania, and New Jersey, as
well as state hospital discharge databases. From this highly complex analysis
they determined the following:
When we use the predicted probabilities of dying from our adjusted
models to estimate how many fewer deaths would have occurred in New
Jersey and Pennsylvania hospitals if the average patient-to-nurse ratios
in those hospitals had been equivalent to the average ratio across the
California hospitals, we get 13.9% (222/1598) fewer surgical deaths in
New Jersey and 10.6% (264/2479) fewer surgical deaths in Pennsylvania
In addition, the nurses in California experienced lower levels of burnout (a
condition associated with intense and prolonged stress in work settings) and
were less likely to report being dissatisfied with their jobs. These important
findings can inform ongoing debates in other states regarding nurse-patient
ratio legislation or mandatory reporting of nurse staffing. Aiken and
colleagues (2010) concluded, Ã¢â‚¬Å“Improved nurse staffing, however it is
achieved, is associated with better outcomes for nurses and patientsÃ¢â‚¬Â (p.
Quality and safety of patient care is an international concern. In 2012
Aiken and a team of researchers from the United States and Europe
published findings from a very large, cross-sectional study of 488 general
acute care hospitals in 12 European countries and 617 similar hospitals in the
United States. Despite deficits in the quality of care present in all countries,
Aiken and colleagues found that hospitals providing good work
environments and better staffing by professional nurses were found to have
nurses and patients who were more satisfied with care. Furthermore, their
findings suggested that good work environments and better professional
nurse staffing resulted in improving quality and safety of care. The
implication of these findings is that improvement of hospital work
environments could be an affordable strategy to improve both patient
outcomes and retention of professional nurses who provide high-quality
Aiken LH, Clarke SP, Cheung RB, Sloane D, Silber JH: Educational levels of
hospital nurses and surgical patient mortality, JAMA 290(12):1617Ã¢â‚¬â€œ1623,
Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, Seago JA, et al.:
Implications of the California nurse staffing mandate for other states, Health
Serv Res 45(4):904Ã¢â‚¬â€œ921, 2010.
Aiken LH, Sermeus W, Van den Heede K, Kutney-Lee A, et al.: Patient safety,
satisfaction, and quality of hospital care: Cross sectional survey of nurses
and patients in 12 countries in Europe and the United States, BMJ 344:1717,
Rigid work scheduling was one of the greatest drawbacks to hospital nursing
in the past. These schedules usually included evenings, nights, weekends, and
holidays. Although hospital units must be staffed around the clock, flexible
staffing is more common now, a process by which nurses on a particular unit
negotiate with one another and establish their own schedules to meet personal
and family responsibilities while ensuring that appropriate staffing for highquality patient care is provided. Staffing needs may be predictable, such as in
the emergency department or surgical units when times of high use can be
anticipated. Accordingly, some units may decrease staffing over holidays
because numbers of admissions are known to be low during certain days of the
year when elective procedures are not routinely scheduled.
Each hospital nursing role has its own unique characteristics. In the following
profile, an RN discusses his role as a nurse in a neonatal intensive care unit
Many people are surprised when I tell them that I work in a NICU. They donÃ¢â‚¬â„¢t
seem to expect that a man might enjoy working with the tiniest patients in the
hospital. But I appreciate the technical challenges of providing care for an infant
born very prematurely or that has a serious birth defect. The biggest challenge for
me though is working with a full-term baby that had some kind of unexpected
trauma at birth. These babies can be very, very sick and their parents need a lot of
support and information. I take care of my little patients the same way I would
want someone to take care of my own child. I can only imagine how terrifying it is
for the parents for their baby to be so sick. I know that some of the procedures that I
have to do are painful, so I make sure that I talk to a baby while I am doing a
procedure and try to provide comfort the best I can. Sometimes, when it is possible,
IÃ¢â‚¬â„¢ll wrap a baby in a blanket and rock him or her for a while when things are quiet
in the unit. The only thing better than that is the day when the parents take the
When the Ã¢â‚¬Å“fitÃ¢â‚¬Â between nurses and their role requirements is good, being a
nurse is particularly gratifying, as an oncology nurse demonstrates in
discussing her role:
Being an oncology nurse and working with people with illnesses that may shorten
their lives brings you close to patients and their families. The family room for our
patients and their families is much like someoneÃ¢â‚¬â„¢s home. Families bring in food and
have dinner with their loved one right here. Working with terminally ill patients is
a tall order. I look for ways to help families determine what they hope for as their
loved one nears the end of life. It varies. Sometimes they hope for a peaceful death,
or hope to make amends with an estranged family member or friend or hope to go to
a favorite place one more time. The diagnosis of cancer is traumatic, and patients
may struggle to cope, especially if their cancer is very advanced or untreatable. I
love getting to know my patients and their families and feel that I can be helpful to
them as they face death, sometimes by simply being with them. They cry, I cryÃ¢â‚¬â€it
is part of my nursing, and I would have it no other way.
These are only two of the many possible roles nurses in hospital settings may
choose. Although brief, these descriptions convey the flavor of the
responsibility, complexity, and fulfillment to be found in hospital-based
nursing (Figure 1-3).
Nursing in Communities
Lillian Wald (1867Ã¢â‚¬â€œ1940) is credited with initiating community health nursing
when she established the Henry Street Settlement in New York City in 1895.
Community health nursing today is a broad field, encompassing areas formerly
known as public health nursing. Community health nurses work in ambulatory
clinics, health departments, hospices, homes, and a variety of other communitybased settings.
Community health nurses may work for either the government or private
agencies. Those working for public health departments provide care in clinics,
schools, retirement communities, and other community settings. They focus on
improving the overall health of communities by planning and implementing
health programs, as well as delivering care for individuals with chronic health
problems. Community health nurses provide educational programs in health
maintenance, disease prevention, nutrition, and child care, among others. They
conduct immunization clinics and health screenings and work with teachers,
parents, physicians, and community leaders toward a healthier community.
FIG 1-3 Hospital staff nurses work closely with the families of patients, as well
as with the patients themselves. (Photo used with permission from Photos.com.)
Many health departments also have a home health component. Since 1980
there has been a tremendous increase in the number of public and private
agencies providing home health services, a form of community health nursing.
In fact, home health care is a growing segment of the health care industry.
Many home health nurses predict that most health care services in the future
will be provided in the home.
Home health care is a natural fit for nursing. Home health nurses across the
United States provide quality care in the most cost-effective and, for patients,
most comfortable setting possible. Patients cared for at home tend to have
significant health challenges, in part because of early hospital discharges in
efforts to control costs. As a result, technological devices such as ventilators and
intravenous pumps, and significant interventions such as administration of
chemotherapy and total parenteral nutrition, are routinely encountered in home
health care. Wound care is another domain of home health nursing. Wounds
can be extensive, but home health nurses are able to assess the patientÃ¢â‚¬â„¢s home
environment for factors that help or hinder healing.
Home health nurses must possess up-to-date nursing knowledge and be
secure in their own nursing skills because they do not have the expertise of
more experienced nurses quickly available, as they would have in a hospital
setting. Strong assessment and communication skills are essential in home
health nursing. Home health nurses must make independent judgments and be
able to recognize patientsÃ¢â‚¬â„¢ and familiesÃ¢â‚¬â„¢ teaching needs. Home health nurses
must also know their limits and seek help when the patientÃ¢â‚¬â„¢s needs are beyond
the scope of their abilities. An RN working in home health care relates her
I have always found home care to be very rewarding. I got to know patients in a
way I never could have if I had continued to work in a hospital. One of my favorite
success stories involved a man with a long history of osteomyelitisÃ¢â‚¬â€an infection in
the boneÃ¢â‚¬â€as a result of a car wreck 18 years before. He had a new central line and
was going to get 6 months of intravenous antibiotics. If this treatment didnÃ¢â‚¬â„¢t work,
he was facing an above-the-knee amputation. I taught his wife how to assess the
dressing and site, how to change the dressing, and how to infuse the antibiotics
twice a day. At my once-a-week visits to draw blood, I counseled the patient about
losing weight and quitting smoking because these measures would help in his
healing. He lost 80 pounds, quit smoking completely, and at the end of 6 months he
had no signs of infection. He described himself as Ã¢â‚¬Å“a new man.Ã¢â‚¬Â I was so happy for
him and his wife. Holistic nursing care in his own home made a huge difference for
the rest of his life.
Some nurses are certified as community health or home health nurses by the
American Nurses Credentialing Center (ANCC). The examinations for these
two specialties have been retired, but nurses certified before this can have their
credentials renewed. The ANCC does have an examination for certification as a
public health nurseÃ¢â‚¬â€œadvanced. The demand for nurses to work in a variety of
community settings is expected to continue to increase as care moves from
hospitals to homes and other community sites.
Nursing in Medical Offices
Nurses who are employed in medical office settings work in tandem with
physicians, NPs, and their patients. Office-based nursing activities include
performing health assessments, reviewing medications, drawing blood, giving
immunizations, administering medications, and providing health teaching.
Nurses in office settings also act as liaisons between patients and physicians or
NPs. They expand on and clarify recommendations for patients, as well as
provide emotional support to anxious patients. They may visit hospitalized
patients, and some assist in surgery. Often, RNs in office practices supervise
other care providers, such as licensed practical/vocational nurses, nurse aides,
and, depending on the size of the practice, other employees of the practice such
as assistants who schedule patient appointments and manage patient records.
An RN who works for a group of three nephrologists describes a typical day:
I first make rounds independently on patients in the dialysis center, making sure
that they are tolerating the dialysis procedure and answering questions regarding
their treatments and diets. I then make rounds with one of the physicians in the
hospital as he visits patients and orders new treatments. The afternoon is spent in
the office assessing patients as they come for their physicianÃ¢â‚¬â„¢s visit. I might draw
blood for a diagnostic test on one patient and do patient teaching regarding diet
with another. No two days are alike, and that is what I love about this position. I
have a sense of independence but still have daily patient contact.
RNs considering employment in office settings need good communication
skills because many of their responsibilities involve communicating with
patients, families, employers, pharmacists, and hospital admissions offices.
Nurses should be careful to ask prospective employers the specifics of the
position because nursing roles in office practices can range from routine tasks to
challenging responsibilities requiring expertise in a particular practice setting,
such as that described by the nurse in the nephrology office. Educational
requirements, hours of work, and specific responsibilities vary, depending on
the preferences of the employer. Some nurses find that a predictable daily
schedule with weekends and holidays off to be an advantage in working in an
office practice. An important advantage of employment in an office setting is
that over time, nurses get to know their patients well, including several
members of a family, depending on the type of practice.
Nursing in the Workplace
Many companies today employ occupational and environmental health nurses
to provide basic health care services, health education, screenings, and
emergency treatment to employees in the workplace. Corporate executives have
long known that good employee health reduces absenteeism, insurance costs,
and worker errors, thereby improving company profitability. Occupational
health nurses (OHNs) represent an important investment by companies in the
health and safety of their employees. They are often asked to serve as
consultants on health matters within the company. OHNs may participate in
health-related decisions, such as policies affecting health insurance benefits,
family leaves, and acquisition and placement of automatic external
defibrillators. Depending on the size of the company, the OHN may be the only
health professional employed in a company and therefore may have a good
deal of autonomy.
Being licensed is generally the minimum requirement for nurses in
occupational health roles. The American Association of Occupational Health
Nurses (AAOHN) recommends that OHNs have a bachelorÃ¢â‚¬â„¢s degree. OHNs
must possess knowledge and skills that enable them to perform routine
physical assessments (e.g., vision and hearing screenings) for all employees.
Good interpersonal skills to provide counseling and referrals for lifestyle
problems, such as stress or substance abuse, are a bonus for these nurses. At a
minimum, they must know first aid and basic life support. If employed in a
heavy industrial setting where the risk of burns or trauma is present, OHNs
must have special training to manage those types of medical emergencies.
OHNs also have responsibilities for identifying health risks in the entire work
environment. They must be able to assess the environment for potential safety
hazards and work with management to eliminate or reduce them. They need indepth knowledge of governmental regulations, such as those of the
Occupational Safety and Health Administration (OSHA), and must ensure that
the company is in compliance. They may instruct new workers in the effective
use of protective devices such as safety glasses and noise-canceling earphones.
OHNs also understand workersÃ¢â‚¬â„¢ compensation regulations and coordinate the
care of injured workers with the facilities and providers who provide care for
an employee with a work-related injury. Some injuries may be life threatening;
others may be chronic but clearly related to work, such as musculoskeletal
injuries from repetitive motion or poorly designed workspaces.
Nurses in occupational settings have to be confident in their nursing skills, be
effective communicators with both employees and managers, be able to
motivate employees to adopt healthier habits, and be able to function
independently in providing care. The AAOHN is the professional organization
for OHNs. The AAOHN provides conferences, webcasts, a newsletter, a journal,
and other resources to help OHNs stay up to date (website: www.aaohn.org).
Certification for OHNs is available through the American Board for
Occupational Health Nurses (ABOHN).
Nursing in the Armed Services
Nurses practice in both peacetime and wartime settings in the armed services.
Nurses serving in the military (Ã¢â‚¬Å“military nursesÃ¢â‚¬Â) may serve on active duty or
in military reserve units, which means that they will be called to duty in the
case of an emergency. They serve as staff nurses and supervisors in all major
medical specialties. Both general and advanced practice opportunities are
available in military nursing, and the settings in which these nurses practice use
Military nurses often find themselves with broader responsibilities and scope
of practice than do civilian nurses because of the demands of nursing in the
field, on aircraft, or onboard ship. Previous critical care, surgery, or trauma care
experience is very desirable but not required. Military nurses are required to
have a BSN degree for active duty. They enter active duty as officers and must
be between the ages of 21 and 46Ã‚Â½ years when they begin active duty.
Professional Profile Box 1-1 is a profile of the work of LTJG Joseph Biddix, BSN,
RN, a nurse in the Navy stationed on a hospital ship.
PROFESSIONAL PROFILE BOX 1-1 Military Nurse
L.T.J.G. Joseph Biddix, NC, USN
USN Naval Medical Center Portsmouth, Va
My nursing path was untraditional. I graduated from college in 2005 with an
Arts degree in Media Studies and Production and immediately began an
internship with the entertainment industry in Los Angeles. I eventually
worked for a top talent management firm, yet after 4 successful years in the
business, something was missing. I kept asking myself, Ã¢â‚¬Å“Why doesnÃ¢â‚¬â„¢t this
feel more rewarding?Ã¢â‚¬Â
I began exploring other options in search of professional gratification and
the idea of military service kept popping into my head. I questioned what
the military would do with a film major whose only job experience was
working in Hollywood. While deciding options, a close friend told me that
he was planning to return to school for a second-degree nursing program. It
didnÃ¢â‚¬â„¢t sound like a bad idea and this would be a perfect career for the
military. My internal wheels were spinning, so I called my Mom for advice
about what I should do, as she was a nurse of 30 years. She said, Ã¢â‚¬Å“IÃ¢â‚¬â„¢ve always
thought you would make an excellent nurse, but I never wanted to push it. I
figured I would let you find your path on your own.Ã¢â‚¬Â
That was all the encouragement I needed. Once accepted into a nursing
program, I contacted the local Navy recruiter. Following a rigorous
application process, I was accepted into a program to become a Nurse Corps
Officer and on graduation, I was commissioned as an ensign in the United
Nearly 3 years later, I have found military nursing to be a phenomenal
experience. I have the opportunity to provide nursing care to active duty and
retired service members and their families. Additionally, it is my
responsibility to train our hospital corpsmen who regularly care for our
forward deployed Sailors and Marines. These young men and women carry
a heavy responsibility to provide first responder care to our warfighters. As a
Navy nurse, I have a direct role in mentoring them. There is no greater
reward than training newly enlisted corpsmen and seeing their faces light up
when they Ã¢â‚¬Å“get it.Ã¢â‚¬Â Whether weÃ¢â‚¬â„¢re discussing the physiology of hypertension
or how to treat for shock following a blast injury, you know when the light
bulb turns on and your Sailor has added another layer to his or her
Currently, I am deployed aboard the USNS Comfort (T-AH 20) hospital
ship for 6 months in support of Continuing Promise 2015. This mission
allows me to provide humanitarian assistance alongside partner nation and
civilian experts to patients in 11 countries in Central and South America and
the Caribbean. As a Navy nurse, I have spent 10 days in Belize providing
nursing care and education to patients and helped provide nursing
assistance to our Seabees construction crew while painting buildings in
Panama. In between providing care to thousands of patients in other nations,
I am a postoperative nurse on a hospital ship. This all is a world away from
my old life in Hollywood, but I wouldnÃ¢â‚¬â„¢t trade anything for this time at sea
with my fellow Navy nurses and corpsmen and helping those in need.
Note: The views expressed in this article are those of the author and do not
necessarily reflect the official policy or position of the Department of the
Navy, the Department of Defense, or the United States government.
(Courtesy LTJG Joseph Biddix)
A major benefit of military nursing is the opportunity for advanced
education. Military nurses are encouraged to seek advanced degrees, and
support is provided during schooling. The U.S. Department of Defense pays for
tuition, books, moving expenses, and even salary for nurses obtaining advanced
degrees. This allows the student to focus on his or her studies. Nurses with
advanced degrees are eligible for promotion in rank at an accelerated pace.
Travel and change are integral to military nursing, so these nurses must be
flexible. Military nurses in the reserves must be committed to readiness; they
must be ready to go at a momentÃ¢â‚¬â„¢s notice. All military nurses may be called on
for active wartime duty anywhere in the world.
In 2011, Lieutenant General Patricia Horoho was nominated and confirmed to
become the Army Surgeon General, the first nurse and the first woman to serve
in this capacity. Horoho had previously commanded the Walter Reed Health
Care System and was serving in the Pentagon on September 11, 2001, where she
cared for the wounded after terrorists crashed a plane into the building. Lt.
Gen. Horoho is an experienced clinical trauma nurse (National Journal, 2011).
Nursing in Schools
School nursing is an interesting, specialized practice of professional nursing.
The National Association of School Nurses (NASN) (2015) defines their work:
Ã¢â‚¬Å“School nursing is a specialized practice of professional nursing that advances
the well-being, academic success, life-long achievement, and health of
To that end, school nurses facilitate positive student responses to normal
development; promote health and safety, including a healthy environment;
intervene with actual and potential health problems; provide case management
services; and actively collaborate with others to build student and family
capacity for adaptation, self-management, self-advocacy, and learning.
School nurses are in short supply. Very few states achieve the federally
recommended ratio of 1:750 (a recommended minimum number of 1 school
nurse for every 750 students). Reported ratios vary from a low ratio of 305
students per RN in Vermont to a high ratio of 4952 students per RN in Utah
(Trossman, 2007). This poses a serious problem for children with disabilities, for
those with chronic illnesses that need occasional management at school, and for
children who become ill or injured at school. With higher than recommended
ratios of students per RN, it is difficult to imagine how children in these states
can be deriving substantial health benefits from the school nurse program.
FIG 1-4 School nurses manage a variety of studentsÃ¢â‚¬â„¢ health problems, from
playground injuries to chronic illnesses such as asthma and diabetes. (Photo used
with permission from iStockphoto.)
School nursing has the potential to be a significant source of communitiesÃ¢â‚¬â„¢
health care. In medically underserved areas and with the number of uninsured
families increasing, the role of school nurse is sometimes expanded to include
members of the schoolchildÃ¢â‚¬â„¢s immediate family. This requires many more
school nursesÃ¢â‚¬â€requiring willingness of state and local school boards to hire
them. Without adequate qualified staffing, the nationÃ¢â‚¬â„¢s children cannot receive
the full benefits of school nurse programs.
Most school systems require nurses to have a minimum of a bachelorÃ¢â‚¬â„¢s
degree in nursing, whereas some school districts have higher educational
requirements. Prior experience working with children is also usually required.
School health has become a specialty in its own right, and in states where school
health is a priority, graduate programs in school health nursing have been
established. The National Board for Certification of School Nurses (NBCSN) is
the official certifying body for school nurses.
School nurses need a working knowledge of human growth and
development to detect developmental problems early and refer children to
appropriate therapists. Counseling skills are important because many children
turn to the school nurse as counselor. School nurses keep records of childrenÃ¢â‚¬â„¢s
required immunizations and are responsible for ensuring that immunizations
are current. When an outbreak of a childhood communicable illness occurs,
school nurses educate parents, teachers, and students about treatment and
prevention of transmission. For children with special needs, school nurses must
work closely with families, teachers, and the studentsÃ¢â‚¬â„¢ primary providers to
care for these children while at schoolÃ¢â‚¬â€and these needs can be significant.
Management of the health of children with diabetes and serious allergies is
important in the daily life of school nurses.
School nurses work closely with teachers to incorporate health concepts into
the curriculum. They endorse the teaching of basic health practices, such as
handwashing and caring for teeth. School nurses encourage the inclusion of
age-appropriate nutritional information in school curricula and healthful foods
in cafeteria and vending machine choices. They conduct vision and hearing
screenings and make referrals to physicians or other health care providers when
routine screenings identify problems outside the nursesÃ¢â‚¬â„¢ scopes of practice.
School nurses must be prepared to handle both routine illnesses of children
and adolescents and emergencies. One of their major concerns is safety.
Accidents are the leading cause of death in children of all ages, yet accidents are
preventable. Prevention includes both protection from obvious hazards and
education of teachers, parents, and students about how to avoid accidents.
School nurses work with teachers, school bus drivers, cafeteria workers, and
other school employees to provide the safest possible environment. When
accidents occur, first aid for minor injuries and emergency care for more severe
ones are additional skills school nurses use (Figure 1-4). Detection of evidence
of child neglect and abuse is a sensitive but essential aspect of school nursing.
School violence or bullying can also result in injury, absenteeism, and anxiety.
In the wake of school violence involving guns and the possibility of
experiencing a natural disaster, the NASN has made disaster preparedness a
The mission of NASN is Ã¢â‚¬Å“advancing school nurse practice to keep students
healthy, safe, and ready to learnÃ¢â‚¬Â (www.nasn.org). This underscores their
commitment to both the health and education of schoolchildren across the
United States. The NASN 2013Ã¢â‚¬â€œ2014 annual report noted that sensitivity to the
cultural needs of students is important in assisting with a childÃ¢â‚¬â„¢s health and to
that end created a section on their website focusing on cultural competence. An
important recent initiative by the NASN has been to address the epidemic of
childhood obesity, creating a continuing education program for school nurses
to provide them with resources and skills to address the problems and
challenges of overweight and obese children (NASN Annual Report, 2014).
Nursing in Palliative Care and End-of-Life Settings
Hospice and palliative care nursing is a rapidly developing nursing specialty
dedicated to improving the quality of life of seriously ill and dying patients and
their families. The World Health Organization (WHO) defines palliative care as
Ã¢â‚¬Å“an approach that improves the quality of life of patients and their families
facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and
impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritualÃ¢â‚¬Â (WHO, 2015). Hospice care is Ã¢â‚¬Å“the model for
quality, compassionate care for people facing a life-limiting illness or injuryÃ¢â‚¬Â
and involves an interdisciplinary approach to symptom management, including
pain management and emotional and spiritual support shaped to the specific
needs of the patient and family as the patient approaches the end of his or her
life (National Hospice and Palliative Care Organization, 2015).
In the past decade, schools of nursing and other nursing organizations have
increased attention to this important realm of care. According to the American
Nurses Association (ANA) document Hospice and Palliative Care Nursing: Scope
and Standards of Practice, Ã¢â‚¬Å“Hospice and palliative care nursing reflects a holistic
philosophy of care implemented across the life span and across diverse health
settings. The goal of hospice and palliative nursing is to promote and improve
the patientÃ¢â‚¬â„¢s quality of life through the relief of suffering along the course of the
illness, through the death of the patient, and into the bereavement period of the
familyÃ¢â‚¬Â (ANA, 2007, p. 1). Three major concepts are foundational to end-of-life
1. Persons are living until the moment of death.
2. Coordinated care should be offered by a variety of professionals, with
attention to the physical, psychological, social, and spiritual needs of patients
and their families.
3. Care should be sensitive to patient/family diversity (or cultural beliefs)
In 1986, the Hospice and Palliative Nurses Association (HPNA) was
established and is now the largest and oldest professional nursing organization
dedicated to the practice of hospice and palliative care. HPNA has a journal,
JHPNÃ¢â‚¬â€Journal of Hospice and Palliative Nursing, a peer-reviewed publication that
promotes excellence in end-of-life care that as of 2015 is published 6 times each
year. HPNAÃ¢â‚¬â„¢s website is www.hpna.org. In addition to HPNA, two other
organizations are central to supporting this domain of nursing: the Hospice and
Palliative Nurses Foundation (HPNF) and the Hospice and Palliative
Credentialing Center (HPCC). In 2014 these three organizations adopted shared
mission and vision statements, in addition to pillars of excellence held in
common. The shared mission is Ã¢â‚¬Å“advancing expert care in serious illnessÃ¢â‚¬Â and
the shared vision is Ã¢â‚¬Å“transforming the care and culture of serious illness.Ã¢â‚¬Â The
pillars on which these organizations base their work are education, competence,
advocacy, leadership, and research (HPNA, 2015).
Because nursing curricula traditionally have not included extensive content
to prepare nurses to deal effectively with dying patients and their families, the
AACN developed a document titled Peaceful Death: Recommended Competencies
and Curricular Guidelines for End-of-Life Nursing Care. This document identifies
the competencies needed by bachelorÃ¢â‚¬â„¢s-degree nurses for palliative/hospice care
and outlines where these competencies can fit into nursing curricula. You can
review this document online at www.aacn.nche.edu/elnec/peaceful-death.
In 2000, End-of-Life Nursing Education Consortium (ELNEC) was funded by
the Robert Wood Johnson Foundation, and has since received additional
funding by a variety of organizations. The foundation for the ELNEC project
reflects the core areas identified by the AACN in the Peaceful Death document.
As of 2015, more than 19,500 nurses and other providers have received ELNEC
education in Ã¢â‚¬Å“train the trainerÃ¢â‚¬Â symposia. These new ELNEC trainers then
returned to their communities and institutions and have educated almost
600,000 other nurses and providers in end-of-life care. Currently there are six
available curricula: core, pediatric palliative care, critical care, geriatric, advance
practice registered nurse, and international (AACN, 2015b).
Hospice and palliative care nurses work in a variety of settings, including
inpatient palliative/hospice units, free-standing residential hospices,
community-based or home hospice programs, ambulatory palliative care
programs, teams of consultants in palliative care, and skilled nursing facilities.
Both generalist and advanced practice nurses work in palliative care.
Nursing from a Distance: Telehealth
Telehealth is the delivery of health care services and related health care
activities through telecommunication technologies. Telehealth nursing (also
known as telenursing or nursing telepractice) is not a separate nursing specialty,
because few nurses use telehealth systems exclusively in their practices. Rather,
it is most often found as a part of other nursing roles. Current technology
includes bedside computers, interactive audio and video linkages,
teleconferencing, real-time transmission of patientsÃ¢â‚¬â„¢ diagnostic and clinical
data, and more. The fastest growing applications of these technologies are
telephone triage, remote monitoring, and home care. Patient data that can be
monitored remotely include physiologic data (e.g., blood pressure, blood
glucose, oxygen levels) (American Telemedicine Association, 2015a). The use of
telehealth devices expands access to health care for underserved populations
and individuals in both urban and rural areas. Telehealth can also reduce the
sense of professional isolation experienced by those who work in such areas
and may assist in attracting and retaining health care professionals in remote
Technologies available for telehealth nurses include remote access to
laboratory reports and digitalized imaging; counseling patients on medications,
diet, activity, or other therapy on mobile phones or by voice-over-Internet
protocol services (e.g., Skype); or participating in interactive video sessions,
such as an interdisciplinary team consultation about a complex patient issue.
Although the fundamentals of basic nursing practice do not change because of
the nurseÃ¢â‚¬â„¢s use of telehealth technologies, their use may require adaptation or
modification of usual procedures. In addition, telehealth nurses must develop
competence in the use of each new type of telehealth technology, which
Numerous legal and regulatory issues surround nursing care delivered
through telehealth technologies; however, in 2015, eight telehealth-related bills
were introduced in the U.S. Congress. One of these (H.R. 2516) would allow
health professionals working for the U.S. Department of Veterans Affairs to
treat veterans nationwide under one state license (American Telemedicine
Association, 2015b). Care of patients across state lines may require licensing in
the state not only where the nurse is employed but also where the patients
reside. You can learn more about telehealth, an area of growing interest in
nursing and other health professions, as well as some controversy, from the
Association of Telehealth Service Providers (www.atsp.org), from the American
Telemedicine Association (www.americantelemed.org), and from the American
Academy of Ambulatory Care Nursing (www.aaacn.org).
Nursing in a Faith Community
Interest in spirituality and its relation to wellness and healing in recent years
prompted the development of a practice area known as faith community
nursing. This area of nursing, also known as parish nursing, is a Ã¢â‚¬Å“practice
specialty that focuses on the intentional care of the spirit, promotion of an
integrative model of health, and prevention and minimization of illness within
the context of a faith communityÃ¢â‚¬Â (ANA, 2012a, 2012b). Faith community
nursing takes a holistic approach to healing that involves partnerships among
congregations, their pastoral staffs, and health care providers. Since its
development in the Chicago area in the 1980s by a hospital chaplain, Dr.
Granger E. Westberg, faith community nursing has spread rapidly and now
includes more than 10,000 nurses in paid and volunteer positions across the
The spiritual dimension is central to faith community nursing practice. The
nurseÃ¢â‚¬â„¢s own spiritual journey is an essential aspect of this nursing role. Faith
community nursing is based on the belief that spiritual health is central to wellbeing and influences a personÃ¢â‚¬â„¢s entire being.
Faith community nurses serve as members of the ministry staff or clergy of a
church or other faith community. They practice independently within the legal
scope of the individual stateÃ¢â‚¬â„¢s nurse practice act. Faith community nurses work
as health educators and counselors, advocates for health services, referral
agents, and coordinators of volunteer health ministers. Faith community nurses
often sponsor health screenings and support groups while integrating the
concepts of health and spirituality.
Managing Information in Nursing: Informatics
Nursing informatics (NI) is a rapidly evolving specialty area defined by the
Nursing Informatics Nursing Group as Ã¢â‚¬Å“the science and practice [integrating]
nursing, its information and knowledge, with management of information and
communication technologies to promote the health of people, families, and
communities worldwideÃ¢â‚¬Â (American Medical Informatics Association, 2015).
Informatics nurses (also known as nurse informaticians) were well positioned to
assist in the implementation of the 2009 American Recovery and Reinvestment
Act and the Health Information Technology Act. This legislation contained
federal incentives for the adoption of electronic health records (EHRs) with
criteria known as meaningful use. To qualify for Centers for Medicare and
Medicaid Services (CMS) incentive payments, health care organizations had to
select, implement, enhance, and/or measure the impact of EHRs on patient care.
Meaningful use (MU) of health care information technologies refers to a threestage approach to adoption of the use of technologies. Stage 1 MU refers to
basic EHR use, data sharing, and protection of patient privacy, with the goal to
complete this stage between 2011 and 2012. Stage 2 MU in 2014 refers to use of
EHR to advance clinical processes; stage 3 MU in 2016 refers to the goal of
improved population health through the use of data to improve health care
delivery and outcomes (HealthIT.gov, 2015).
Because they are nurses themselves, nurse informaticians are best able to
understand the needs of nurses who use the systems and can customize or
design them with the needs, skills, and time constraints of those nurses in mind.
In contrast to computer science systems analysts, nurse informaticians must
clearly understand the information they handle and how other nurses will use
it. In a 2011 survey of 660 nurse informaticians, over half identified systems
implementation and systems development as their top two job responsibilities.
Implementation refers to activities required to prepare, train, and support users
of an EHR system. Development refers to the customizing or updating of EHR
systems purchased from a vendor, or developing or updating a system
designed for oneÃ¢â‚¬â„¢s specific health care agency. The third most common role
responsibility involved quality initiatives, such as evaluating a system, solving
problems, and improving patient safety (Murphy, 2011). As health care
organizations continue to adopt and implement EHRs, nurse informaticians
will be in increasing demand.
At a minimum, nurses specializing in informatics should have a BSN and
additional knowledge and experience in the field of informatics. An increasing
number of nurse informaticians have advanced degrees, including doctorates.
Certification as an informatics nurse is available through the ANCC. The
American Medical Informatics Association (AMIA; www.amia.org) and the
Health Information and Management Systems Society (HIMSS;
www.himss.org) sponsor the Alliance for Nursing Informatics (ANI), whose
mission is to Ã¢â‚¬Å“advance nursing informatics practice, education, policy and
research through a unified voice of nursing informatics organizationsÃ¢â‚¬Â (ANI,
2015). The ANI website is www.allianceni.org.
Thede (2012) published an interesting retrospective on NI, describing the
developments that she has seen in this field over the past 30 years, reporting
that basic computer skills, informatics knowledge, and information literacy are
three Ã¢â‚¬Å“threadsÃ¢â‚¬Â of importance to nursing. She noted that one of the failures of
Ã¢â‚¬Å“early dreamersÃ¢â‚¬Â in informatics was not considering the cultural changes that
would be required to move into a multidisciplinary perspective regarding the
use of information in health care settings, including Ã¢â‚¬Å“abandonment of the paper
chart mentality.Ã¢â‚¬Â With the incentives from CMS driving the widespread
adoption of EHR, nurse informaticians will be instrumental in moving the
development of these technologies into clinical usefulness with the goal of
improving the populationÃ¢â‚¬â„¢s health.
Nurses in Business: Entrepreneurs
Some nurses are highly creative and are challenged by the risks of starting a
new enterprise. Such nurses may make good nurse entrepreneurs.
Similar to an entrepreneur in any field, a nurse entrepreneur identifies a
need and creates a service to meet the identified need. Nurse entrepreneurs
enjoy the autonomy derived from owning and operating their own healthrelated businesses. Groups of nurses, some of whom are faculty members in
schools of nursing, have opened nurse-managed centers to provide direct care
to clients. Nurse entrepreneurs are self-employed as consultants to hospitals,
nursing homes, and schools of nursing. Others have started nurse-based
practices and carry their own caseloads of patients with physical or emotional
needs. They are sometimes involved in presenting educational workshops and
seminars. Some nurses establish their own apparel businesses, manufacturing
clothing for premature babies or for persons with physical challenges. Others
own and operate their own health equipment companies, health insurance
agencies, and home health agencies. Still others invent products, such as
stethoscope covers that can be changed between patients to prevent the spread
of infection. Here are a few comments from one such entrepreneur, the chief
executive officer of a privately owned home health agency:
I enjoy working for myself. I know that my success or failure in my business is up
to me. Having your own home health agency is a lot of work. You have to be very
organized, manage other people effectively, and have excellent communication
skills. You cannot be afraid to say no to the people. There is nothing better than the
feeling I get when a family calls to say our nurses have made a difference in their
loved oneÃ¢â‚¬â„¢s life, but I also have to take the calls of complaint about my agency.
Those are tough.
Increasingly, nurses are entering the business of health care, finding
increasing opportunities to create their own companies. One such company
offers nursing care for mothers, babies, and children. This companyÃ¢â‚¬â„¢s emphasis
is the care of women whose pregnancies may be complicated by diabetes,
hypertension, or multiple births. The RN who founded this company described
the services offered by her company:
Our main specialty is managing high-risk pregnancies and high-risk newborns.
Home care for these individuals is a boon not only to the patients themselves, but
also to hospitals, insurance companies, and doctors. With the trend toward shorter
hospital stays, risks are minimized if skilled maternity nurses are on hand to
provide patients with specialty care in their homes.
As with almost any endeavor, disadvantages come with owning a business,
such as the risk of losing your financial investment if the business is
unsuccessful. Fluctuations in income are common, especially in the early
months, and regular paychecks may be somewhat rare, at least in the
beginning. A certain amount of pressure is created because of the total
responsibility for meeting deadlines and paying bills, salaries, and taxes, but
there is great opportunity as well.
In addition to financial incentives, there are also intangible rewards in
entrepreneurship. For some people, the autonomy and freedom to control their
own practice are more than enough to compensate for the increased pressure
and initial uncertainty.
With rapid changes occurring daily in the health care system, new and
exciting possibilities abound. Alert nurses who possess creativity, initiative, and
business savvy have tremendous opportunities as entrepreneurs. The website
www.nursingentrepreneurs.com provides a long list of categories of businesses
operated by nurse entrepreneurs, the variety of which is extensive (e.g., movie
set nurses, holistic life change strategists, medical bill auditing, nurse poet,
nursing business start-up coaching). In Professional Profile Box 1-2, you can
read a description of the career of Kay Wagoner, PhD, RN, whose career in
nursing gave her expertise in cardiovascular nursing; using her knowledge
from nursing, she founded her own drug development company.
PROFESSIONAL PROFILE BOX 1-2 Nurse Entrepreneur
Kay Wagoner, PhD, RN (Cardiovascular Nurse Specialist)
It is my belief that everyone should go to nursing school, because it prepares
one for diverse professional opportunities and life in general. My life has
taken several tumbles and turns, careening forward, backward, up, and
down. At each point along the way, there were reasons to be forever grateful
to nursing. Nursing taught me to look in more detail at incongruences, to
seek the essence of each dilemma, while keeping a holistic perspective. I
have been a consistent collector of data, be it from direct patient experience,
from educational endeavors, or from scientific experimentation. Although
the data always molded my thinking, final decisions were based on a desire
to do something that made a difference in health and health care.
I cherished my time in intensive care nursing, one of my first careers,
because it was there that I began to appreciate the need to better understand
organ systems and cellular interactions in order to intervene with the
critically ill on a moment-to-moment basis. My desire to learn more about
how one responds to a variety of health challenges and life crises propelled
me to advance my nursing education at the masterÃ¢â‚¬â„¢s level.
With my newly minted masterÃ¢â‚¬â„¢s degree and a specialty in cardiovascular
nursing, I was challenged to teach undergraduate nursing students that
which I strove hardest to understand: how organ systems and the cells that
comprised them functioned and malfunctioned. While learning through
teaching, my nursing practice shifted to cardiovascular disease prevention
and rehabilitation. I founded my first company, which provided a new
treatment paradigm for individuals attempting to stave off or repair from
cardiovascular disease. This combination of teaching and practice provided
great growth opportunities for me, including the confidence to delve deeper
into the science of health and disease.
I went back to the classroom and completed doctoral and postdoctoral
studies in physiology and pharmacology. I gained a more complete
understanding of how cells, organ systems, and the human body works and
fails. I also came to realize that many of the available treatments were too
little too late, and many of the available medications woefully inadequate in
terms of efficacy and safety.
Thus for the next 20 years, I explored the discovery and development of
new treatments and medications by founding the science-based drug
discovery company Icagen, Inc., which was sold to Pfizer, Inc., in 2011. As
the CEO and President of Icagen, I used my nursing background to provide
focus on truly unmet medical needs such as new treatments for sickle cell
disease, arrhythmias, epilepsy, and pain. We sought to make data-driven
decisions by asking and answering the question, Ã¢â‚¬Å“What are the most
efficacious and safe mechanisms to target for new treatments to improve
Today I am working with nurse educators and entrepreneurs and can be
frequently heard asking, Ã¢â‚¬Å“How can we innovate to make a difference?Ã¢â‚¬Â Our
great nursing profession can lead us down many different career paths, some
clearly more direct than mine. Along the way we can let nursing help drive
evidence-based decision making to make a positive difference in health and
Courtesy Kay Wagoner.
Nursing Opportunities Requiring Advanced
Many RNs choose to pursue careers that require a masterÃ¢â‚¬â„¢s degree, doctoral
degree, or specialized education in a specific area. These roles include clinical
nurse leaders, nurse managers, nurse executives in hospital settings, nurse
educators (whether in clinical or academic settings), nurse anesthetists, nurs…
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