Nursing is the nation's largest health care profession with more than 3.1 million registered nurses practicing nationwide. Despite its large size, many more nurses are needed into the foreseeable future to meet the growing demand for nursing care. As you plan or consider a career as a registered nurse, you should know these facts:
The U.S. Bureau of Labor Statistics projects that employment for registered nurses will grow faster than most other occupations through 2018.
Nursing students comprise more than half of all health professions students.
Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation's long-term care.
Most health care services involve some form of care by nurses. Although 62.2 percent of all employed RNs work in hospitals, many are employed in a wide range of other settings, including private practices, public health agencies, primary care clinics, home health care, outpatient surgicenters, health maintenance organizations, nursing school-operated nursing centers, insurance and managed care companies, nursing homes, schools, mental health agencies, hospices, the military, and industry. Other nurses work in careers as college and university educators preparing future nurses or as scientists developing advances in many areas of health care and health promotion.
Though often working collaboratively, nurses do not simply "assist" physicians and other health care providers. Instead, they practice independently within their own defined scope of practice. Nursing roles range from direct patient care to case management, establishing nursing practice standards, developing quality assurance procedures, and directing complex nursing care systems.
With more than four times as many RNs in the United States as physicians, nursing delivers an extended array of health care services, including primary and preventive care by advanced, independent nurse practitioners in such clinical areas as pediatrics, family health, women's health, and gerontological care. Nursing's scope also includes care by clinical nurse specialists, certified nurse-midwives and nurse anesthetists, as well as care in cardiac, oncology, neonatal, neurological, and obstetric/gynecological nursing and other advanced clinical specialties.
The primary pathway to professional nursing, as compared to technical-level practice, is the four-year Bachelor of Science degree in nursing (BSN). Registered nurses are prepared either through a four-year baccalaureate program; a three-year associate degree in nursing program; or a three-year hospital diploma program. Graduates of all three programs take the same state licensing exam, the NCLEX-RN. (The number of diploma programs has declined steadily -- to less than 10 percent of all basic RN education programs -- as nursing education has shifted from hospital-operated instruction into the college and university system.)
The Need For The Baccalaureate Nurse
The Bachelor of Science degree in nursing is the critical first step for a career in professional nursing. The American Association of Colleges of Nursing (AACN), American Organization of Nurse Executives (AONE), American Nurses Association (ANA) and other leading nursing organizations recognize the BSN degree as the minimum educational requirement for professional nursing practice. While graduates can begin practice as an RN with an associate degree or hospital diploma, the BSN degree is essential for nurses seeking to move up the career ladder and provide a higher level of quality care.
The BSN nurse is prepared for a broader role. The BSN nurse is the only basic nursing graduate preferred to practice in all health care settings -- critical care, ambulatory care, public health, and mental health -- and thus has the greatest employment flexibility of any entry-level RN. The BSN curriculum includes a broad spectrum of scientific, critical-thinking, humanistic, communication, and leadership skills, including specific courses on community health nursing not typically included in diploma or associate-degree tracks. These abilities are essential for today's professional nurse who must be a skilled provider, designer, manager, and coordinator of care. Nurses must make quick, sometimes life-and-death decisions; understand a patient's treatment, symptoms, and danger signs; supervise other nursing personnel; coordinate care with other health providers; master advanced technology; guide patients through the maze of health resources in a community; and teach patients how to comply with treatment and adopt a healthy lifestyle.
In particular, a report by the National Advisory Council on Nurse Education and Practice, an advisory panel to the federal Division of Nursing, noted that baccalaureate nursing programs are far more likely than other entry-level tracks to provide students with on-site clinical training in non-institutional settings outside the hospital. As a result, the BSN graduate is well-prepared for practice in such sites as home health agencies, outpatient centers, and neighborhood clinics where opportunities are fast expanding as hospitals focus more on acute care and health services move beyond the hospital to more primary and preventive care throughout the community.
The BSN nurse is preferred. More nurse executives are indicating their desire for the majority of their hospital staff nurses to be prepared at the baccalaureate level to meet the more complex demands of today's patient care. In fact, the words "BSN preferred" are appearing more frequently in classified ads for registered nurses nationwide.
Aware of the expanding opportunities, RNs are seeking the BSN degree in increasing numbers. In 1980, almost 55 percent of registered nurses held a hospital diploma as their highest educational credential, 22 percent held the bachelor's degree, and 18 percent an associate degree, according to figures from the federal Division of Nursing. By 2008, a diploma was the highest educational credential for only 13.9 percent of RNs, while the number with bachelor's degrees had climbed to 36.8 percent, with 36.1 percent holding an associate degree. In addition, 13.2 percent of the current nursing workforce hold master's or doctoral degrees. According to a report released by the Health Resources and Services Administration in July 2002, associate degree in nursing graduates are declining at a somewhat faster rate than baccalaureate graduates, with the net result that baccalaureate graduates now comprise an increasingly greater share of total graduates. These numbers indicate the high premium that nurses place on advanced education in today's growing market, and the demand by employers for RNs who are baccalaureate-prepared.
The Changing Job Market: Some Needed Perspective
Federal figures project that if current trends continue, the shortage of RNs will continue to grow throughout the next 20 years. By 2020, more than 800,000 RN positions are expected to go unfilled nationwide, according to the National Center for Workforce Analysis, an agency of the U.S. Department of Health and Human Services. But already, in an expanding number of markets, hospitals and other employers are struggling to meet the rising demand for RN care and have stepped up recruitment.
Today's intensified hiring of RNs is being spurred by: the mounting health care needs of increasing numbers of elderly;
As nursing and health care delivery expand, opportunities abound outside the hospital.
- a growing population of hospitalized patients who are older, more acutely ill, and in need of more skilled RNs per patient;
- the rapid expansion of front-line primary care to many sites throughout the community;
- technological advances requiring more highly skilled nursing care; and
- an aging RN workforce. The average age of working RNs in 2008 was 47.0 up from 40 in 1980.
Between 1996-2008, the number of registered nurses in community health settings, including home health care rose to 14.2 percent. An estimated 10.5 percent of RNs were practicing in outpatient settings in 2008, including health maintenance organizations and physician- and nurse-based practices, and 5.3 percent of RNs work in long-term care facilities.
The average annual earnings of registered nurses employed in nursing was $60,970 in 2007, according to the Federal Bureau of Labor Statistics.
Clinical Nurses Specialists, Nurse Practitioners, and other nurses prepared in graduate degree programs command much higher salaries.
With patient care growing more complex, ensuring a sufficient RN workforce isn't merely a matter of how many nurses are needed, but rather an issue of preparing an adequate number of nurses with the right educational mix to meet health care demands.
The National Advisory Council on Nurse Education and Practice has urged that at least two-thirds of the basic nurse workforce hold baccalaureate or higher degrees in nursing by 2010. Currently, only 50.0 percent do.
Moreover, a 1995 report by the Pew Health Professions Commission called for a more concentrated production of nurses from bachelor's- and graduate-degree programs. Today's rising need for registered nurses does not appear to be a repeat of the widespread nursing shortage of a decade ago, when employers hired qualified entry-level RNs virtually regardless of their nursing degree preparation.
Rather, today's demand is different because:
- Employers are seeking nurses prepared at the bachelor's and graduate-degree levels who can deliver the higher complexity of care required across a variety of acute-care, primary-care, and community health settings, and to provide other needed services such as case management, health promotion, and disease prevention.
- Demand is particularly acute for nurses in key specialties, such as critical care; neonatal nursing; emergency, operating room, and labor and delivery units; and for advanced practice RNs such as nurse practitioners and clinical nurse specialists.
- Though hiring of RNs is accelerating in more cities, today's demand varies region by region, market by market, contrary to the pervasive nationwide shortfall of RNs in the late 1980s.
BSN and BS/BA in Nursing Degree Titles
Depending on the nursing school you attend, graduates of the baccalaureate program may receive a BSN (Bachelor of Science in Nursing), BS in Nursing, or BA in Nursing degree. Please note that there is no substantive difference in the degrees offered, and graduates of both programs are expected to possess the competencies outlined in AACN's Essentials document. The degree title used is purely an institutional decision and does not connote differences between BSN and BS programs in nursing. This same rationale is true for the Master of Science in Nursing (MSN) and the MS in Nursing degrees.
Flexibility is the key. All projections forecast accelerating demand for nursing care and for nurses with expanded education and skills. Still, the accelerating demand for RNs varies by region and market. As a result, flexibility will be key both for entering and moving within the profession. Some graduates may need to pursue employment in different parts of their home states, in another state, or even in another region where hiring in certain clinical settings or specialties may be more plentiful.
Advanced Practice Nursing: Extending Primary Care's Reach
The health system's increasing demand for front-line primary care, and the accelerating drive toward managed care, prevention, and cost-efficiency, are driving the nation's need for nurse practitioners, clinical nurse specialists, certified nurse-midwives, and other RNs with advanced practice skills.
Prepared typically in graduate programs, advanced practice nurses (APNs) include the following four categories of clinicians:
Mounting studies show that the quality of APN care is equal to, and at times better than, comparable services by physicians, and often at lower cost.
- Nurse Practitioners (NPs) conduct physical exams; diagnose and treat common acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic problems; order and interpret X-rays and other lab tests; and counsel patients on adopting healthy lifestyles and health care options as a part of their clinical roles. In addition to practicing in clinics and hospitals in metropolitan areas, the nation's estimated 158,348 nurse practitioners also deliver care in rural sites, inner cities, and other locations not adequately served by physicians, as well as to other populations, such as children in schools and the elderly. Many NPs work in pediatrics, family health, women's health, and other specialties, and some have private practices. Nurse practitioners can prescribe medications in all states, while 23 states have given NPs authority to practice independently without physician collaboration or supervision.
- Clinical Nurse Specialists (CNSs) provide care in a range of specialty areas, such as cardiac, oncology, neonatal, and obstetric/gynecological nursing, as well as pediatrics, neurological nursing, and psychiatric/mental health. Working in hospitals and other clinical sites, CNSs provide acute care and mental health services, develop quality assurance procedures, and serve as educators and consultants. An estimated 59,242 clinical nurse specialists are currently in practice.
- Certified Nurse-Midwives (CNMs) provide prenatal and gynecological care to normal healthy women; deliver babies in hospitals, private homes, and birthing centers; and continue with follow-up postpartum care. In 2002, CNM deliveries accounted for 8.1 percent of all births in the U.S., up from 6.5 percent in 1996, according to the National Center for Health Statistics. There are approximately 18,492 CNMs nationwide.
- Certified Registered Nurse Anesthetists (CRNAs) administer more than 65 percent of all anesthetics given to patients each year, and are the sole anesthesia providers in approximately two-thirds of all rural hospitals in the U.S., according to the American Association of Nurse Anesthetists (AANA). Of the 24 million anesthetics given annually, about 20 percent are administered by CRNAs practicing independently and 80 percent by CRNAs in collaboration with physician anesthesiologists, says AANA. Working in the oldest of the advanced nursing specialties, CRNAs administer anesthesia for all types of surgery in settings ranging from operating rooms and dental offices to outpatient surgical centers. There are more than 34,821 CRNAs in practice nationwide.
Even after acknowledging flaws in some of the studies it reviewed in 1986, the congressional Office of Technology Assessment (OTA) concluded that nurse practitioners can deliver as much as 80 percent of the health services, and up to 90 percent of the pediatric care, provided by primary care physicians, at equal or better quality and at less cost. In the 12 studies reviewed, OTA found that the quality of care by nurse practitioners -- including communication with patients, preventive actions, and reductions in the number of patient symptoms -- was higher than comparable care by physicians.
At the University of Rochester, researchers reported that intensive-care babies cared for by neonatal nurse practitioners averaged 2.4 fewer hospital days and more than $3,400 less in charges than those cared for by medical residents, despite the fact that the NPs' infants were younger and had significantly lower birthweight. Unlike residents, nurse practitioners don't rotate, are "more consistent caregivers" who can follow infants through their entire stay, and need to rely less on support services to stay apprised of a patient's progress, the authors suggest in the 1994 study.