Nursing

Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life.

Nurses may be differentiated from other health care providers by their approach to patient care, training, and scope of practice. Nurses practice in a wide diversity of practice areas with a different scope of practice and level of prescriber authority in each. Many nurses provide care within the ordering scope of physicians, and this traditional role has come to shape the historic public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.

Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient's family and other team members, that focuses on treating illness to improve quality of life. In the U.S. (and increasingly the United Kingdom), advanced practice nurses, such as clinical nurse specialists and nurse practitioners, diagnose health problems and prescribe medications and other therapies, depending on individual state regulations. Nurses may help coordinate the patient care performed by other members of a health care team such as therapists, medical practitioners and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.

The American Nurses Association (ANA) states nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.[1]
History Main articles: history of nursing and Timeline of nursing history
Traditional Before the foundation of modern nursing, nuns and the military often provided nursing-like services.[2] The Christian churches have been long term patrons of nursing and influential in the development of the ethos of modern nursing. Elsewhere, other nursing traditions developed, such as in Islam.

From its earliest days, and following the edicts of Jesus, Christianity had encouraged its devotees to tend the sick. Priests were often also physicians. According to the historian Geoffrey Blainey, while pagan religions seldom offered help to the infirm, the early Christians were willing to nurse the sick and take food to them - notably during the small pox epidemic of AD 165-180 and the measles outbreak of around AD 250 and that "In nursing the sick and dying, regardless of religion, the Christians won friends and sympathisers".[3] Christian emphasis on practical charity gave rise to the development of systematic nursing and hospitals after the end of the persecution of the early church.[4] Ancient church leaders like St. Benedict of Nursia (480) emphasised medicine as an aid to the provision of hospitality.[5] Ancient Catholic orders like the Dominicans and Carmelites have long lived in religious communities that work for the care of the sick.[6] The religious and military roots of modern nursing remain in evidence today in many countries, for example in the United Kingdom, senior female nurses are known as sisters. Nurses execute the orders of M.D.s, PAs, and NPs in addition to being responsible for their own practice.

The first nurse was Phoebe, mentioned in Romans 16:1. During the early years of the Christian Church, St. Paul sent a deaconess Phoebe to Rome as the first visiting nurse. She took care of both women and men.[7]

According to Geoffrey Blainey, during the Middle Ages, the Catholic Church in Europe provided many of the services of a welfare state: "It conducted hospitals for the old and orphanages for the young; hospices for the sick of all ages; places for the lepers; and hostels or inns where pilgrims could buy a cheap bed and meal". It supplied food to the population during famine and distributed food to the poor. This welfare system the church funded through collecting taxes on a large scale and possessing large farmlands and estates.[8] Monasteries of this era were diligent in the study of medicine, as were convents.

The Eastern Orthodox Church had established many hospitals in the Mid East, but following the rise of Islam from the 7th century, Arabic medicine developed in this region, where a number of important advances were made and an Islamic tradition of nursing begun. Arab ideas were later influential in Europe. The famous Knights Hospitaller arose as a group of individuals associated with an Amalfitan hospital in Jerusalem, which was built to provide care for poor, sick or injured Christian pilgrims to the Holy Land. Following the capture of the city by Crusaders, the order became a military as well as infirmarian order.[9]

A number of saints and orders like the Franciscans are recalled for tending the sick during the devastating bubonic plagues, but these events exposed the near impotence of the Medieval medicine to explain disease and prompted critical examination.[10]

During the Reformation of the 16th century, Protestant reformers shut down the monasteries and convents, allowing a few to continue in operation hundred municipal hospices. Those nuns who had been serving as nurses were given pensions or told to get married and stay home.[11] Nursing care went to the inexperienced as traditional caretakers, rooted in the Roman Catholic Church, were removed from their positions. These caretakers were scorned as the "consorts of prostitutes and drunks," since many of the hospitalized ill were indigent. The nursing profession suffered a major setback for approximately 200 years, only to be rescued by individuals, not organizations, in the nineteenth century.[12] In Catholic nations and religiously tolerant areas however, the role of the nursing sister continued uninterrupted.

19th century 
Florence Nightingale was influential figure in the development of modern nursing. No uniform had been created when Florence Nightingale was employed during the Crimean War. Both nursing role and education were first defined by Florence Nightingale.
Saint Marianne Cope was among many Catholic nuns to influence the development of modern hospitals and nursing.The Crimean War was a significant development in nursing history when English nurse Florence Nightingale laid the foundations of professional nursing. Her short books Notes on Nursing became popular.

Other important nurses in the development of the profession include: Dame Agnes Hunt from Shropshire, was the first "orthopaedic' nurse and was pivotal in the emergence of the orthopaedic hospital called 'The Robert Jones & Agnes Hunt Hospital'in Oswestry, Shropshire.

Mary Seacole, who also worked as a nurse in the Crimea
Agnes Elizabeth Jones and Linda Richards, who established quality nursing schools in the USA and Japan; Linda Richards was officially America's first professionally trained nurse, graduating in 1873 from the New England Hospital for Women and Children in Boston
Clarissa Harlowe "Clara" Barton, a pioneer American teacher, patent clerk, nurse, and humanitarian, and the founder of the American Red Cross.
Saint Marianne Cope, a Sister of St Francis who opened and operated some of the first general hospitals in the United States, instituting cleanliness standards which influenced the development of America's modern hospital system.[13]
New Zealand was the first country to regulate nurses nationally, with adoption of the Nurses Registration Act on 12 September 1901.

Nurses have experienced difficulty with the hierarchy in medicine that has resulted in an impression that nurses' primary purpose is to follow the direction of physicians.[14] This tendency is certainly not observed in Nightingale's Notes on Nursing, where the physicians are mentioned relatively infrequently, and often in critical tones—particularly relating to bedside manner.[15]

In the early 1900s, the autonomous, nursing-controlled, Nightingale era schools came to an end – schools became controlled by hospitals, and formal "book learning" was discouraged. Hospitals and physicians saw women in nursing as a source of free or inexpensive labor. Exploitation was not uncommon by nurse’s employers, physicians and educational providers. Nursing practice was controlled by medicine.[16]

The modern era has seen the development of nursing degrees and nursing has numerous journals to broaden the knowledge base of the profession. Nurses are often in key management roles within health services and hold research posts at universities.

Church sponsored hospitals See also: deaconess and Catholic Church and health care
 
"After the Battle of Gravelotte. The French Sisters of Mercy of St. Borromeo arriving on the battle field to succor the wounded." Unsigned lithograph, 1870 or 1871.Catholic women's religious institutes continued to spread their ministry in nursing, with orders like the Little Sisters of the Poor (aged care), Sisters of Mercy, Sisters of St. Mary, St. Francis Health Services, Inc. and Sisters of Charity developing large international hospital and hospice networks that helped shape the hospital and nursing systems of the modern world.

The Protestant churches reentered the health field, especially by setting up orders of women, called deaconesses who dedicated themselves to nursing services.

The modern deaconess movement began in Germany in 1836 when Theodor Fliedner and his wife opened the first deaconess motherhouse in Kaiserswerth on the Rhine. It became a model and within a half century were over 5,000 deaconesses in Europe. The Church of England named its first deaconess in 1862. The North London Deaconess Institution trained deaconesses for other dioceses and some served overseas.[17]

William Passavant in 1849 brought the first four deaconesses to Pittsburgh, in the United States, after visiting Kaiserswerth. They worked at the Pittsburgh Infirmary (now Passavant Hospital).[18]

The American Methodists – the largest Protestant denomination—engaged in large scale missionary activity in Asia and elsewhere in the world, making medical services a priority as early as the 1850s. Methodists in America took note, and began opening their own charitable institutions such as orphanages and old people's homes after 1860. In the 1880s, Methodists began opening hospitals in the United States, which served people of all religious backgrounds beliefs. By 1895 13 hospitals were in operation in major cities. well [19]

Lutherans in the U.S. in 1884 brought seven sisters from Germany to run the German hospital in Philadelphia. By 1963 the Lutheran Church in America had centers for deaconess work in Philadelphia, Baltimore, and Omaha.[20]

Military 
A Red Cross recruiting poster for nurses from World War I.
Nursing sisters at a Canadian military hospital in France voting in the Canadian federal election, 1917.With British public opinion shocked by Nightingale's revelations about the poor care of soldiers in the Crimean War, activists pushed for reform. In 1860 Queen Victoria ordered a hospital to be built to train Army nurses and surgeons, the Royal Victoria Hospital. The hospital opened in 1863 in Netley and admitted and cared for military patients. Beginning in 1866, nurses were formally appointed to Military General Hospitals. The Army Nursing Service (ANS) oversaw the work of the nurses starting in 1881. These military nurses were sent overseas beginning with the First Boer War (often called Zulu War) from 1879 to 1881.[21] They were also dispatched to serve during the Egyptian Campaign in 1882 and the Sudan War of 1883 to 1884. During the Sudan War members of the Army Nursing Service nursed in hospital ships on the Nile as well as the Citadel in Cairo. Almost 2000 nurses served during the second Boer War, the Anglo-Boer War of 1899 to 1902, alongside nurses who were part of the colonial armies of Australia, Canada and New Zealand. They served in tented field hospitals. 23 Army Nursing sisters from Britain lost their lives from disease outbreaks.[22]

Schools The Nightingale model of professional education spread widely in Europe and North America after 1870. Even so, as late as the 1870s, "women working in North American urban hospitals typically were untrained, working class, and accorded lowly status by both the medical profession they supported and society at large". Nursing had the same status in Great Britain and continental Europe before World War I.[23]

Hospital nursing schools in the United States and Canada took the lead in applying Nightingale's model to their training programmers:

standards of classroom and on-the-job training had risen sharply in the 1880s and 1890s, and along with them the expectation of decorous and professional conduct[23]

World War I Britain By the beginning of World War I, military nursing still had only a small role for women in Britain; 10,500 nurses enrolled in Queen Alexandra's Imperial Military Nursing Service (QAIMNS) and the Princess Mary's Royal Air Force Nursing Service. These services dated to 1902 and 1918, and enjoyed royal sponsorship. There also were Voluntary Aid Detachment (VAD) nurses who had been enrolled by the Red Cross.[24] The ranks that were created for the new nursing services were Matron-in-Chief, Principal Matron, Sister and Staff Nurses. Women joined steadily throughout the War. At the end of 1914, there were 2,223 regular and reserve members of the QAIMNS and when the war ended there were 10,404 trained nurses in the QAIMNS.[22]

 
Sister Grace Wilson of the 3rd Australian General Hospital on Lemnos. She sailed from Sydney, New South Wales on board RMS Mooltan on 15 May 1915.[25]Australian nurses served in the war as part of the Australian General Hospital. Australia established two hospitals at Lemnos and Heliopolis Islands to support the Dardanelles campaign at Gallipoli. During the course of the war, Australian nurses were granted their own administration rather than working under medical officers. Their work routinely included administering ether during haemostatic surgery and managing and training male medical assistants (orderlies).[26]

World War II 
Australia World War II posterIn early 1942, sixty-five front line nurses from the General Hospital Division in Singapore were ordered back home aboard two ships. The Japanese sank one ship; the 21 surviving nurses swam ashore but the Japanese captured and shot them at the Banka Island massacre. Sister Vivian Bullwinkel was the only survivor. She became Australia's premier nursing war hero.

United States  This section requires expansion. (September 2012)

As Campbell (1984) shows, the nursing profession was transformed by World War Two. Army and Navy nursing was highly attractive and a larger proportion of nurses volunteered for service higher than any other occupation in American society.[27][28]

The public image of the nurses was highly favorable during the war, as the simplified by such Hollywood films as "Cry 'Havoc'" which made the selfless nurses heroes under enemy fire. Some nurses were captured by the Japanese,[29] but in practice they were kept out of harm's way, with the great majority stationed on the home front. However, 77 were stationed in the jungles of the Pacific, where their uniform consisted of "khaki slacks, mud, shirts, mud, field shoes, mud, and fatigues."[30][31] The medical services were large operations, with over 600,000 men and women, ten enlisted men for every nurse. The nurses were all women and all officers. WACs (enlisted women) were used as hospital orderlies. Nearly all the doctors were men, with women doctors allowed only to examine the WAC.[32]

President Franklin D. Roosevelt hailed the service of nurses in the war effort in his final "Fireside Chat" of January 6, 1945, and urged an induction act to raise the number of nurses in the war service by Congress.[33]

Britain During World War II, nurses belonged to Queen Alexandra's Imperial Military Nursing Service (QAIMNS), as they had during World War I, and as they remain today. (Nurses belonging to the QAIMNS are informally called "QA"s.) Members of the Army Nursing Service served in every overseas British military campaign during World War II, as well as at military hospitals in Britain. At the beginning of World War II, nurses held officer status with equivalent rank, but were not commissioned officers. In 1941, emergency commissions and a rank structure were created, conforming with the structure used in the rest of the British Army. Nurses were given rank badges and were now able to be promoted to ranks from Lieutenant through to Brigadier.[34] Nurses were exposed to all dangers during the War, and some were captured and became prisoners of war.

Germany Germany had a very large and well organized nursing service, with three main organizations, one for Catholics, one for Protestants, and the DRK (Red Cross). In 1934 the Nazis set up their own nursing unit, the Brown Nurses, absorbing one of the smaller groups, bringing it up to 40,000 members. It set up kindergartens, hoping to seize control of the minds of the younger Germans, in competition with the other nursing organizations. Civilian psychiatric nurses who were Nazi party members participated in the killings of invalids, although the process was shrouded in euphemisms and denials.[35]

Military nursing was primarily handled by the DRK, which came under partial Nazi control. Front line medical services were provided by male medics and doctors. Red Cross nurses served widely within the military medical services, staffing the hospitals that perforce were close to the front lines and at risk of bombing attacks. Two dozen were awarded the highly prestigious Iron Cross for heroism under fire. They are among the 470,000 German women who served with the military.[36]

Definition Although nursing practice varies both through its various specialties and countries, these nursing organizations offer the following definitions:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

— International Council of Nurses[37]
The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.

—Royal College of Nursing UK[38]
Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.

—American Nurses Association[39]
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

—Virginia Avenel Henderson[40]
As a profession The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.

The aim of the nursing community worldwide is for its professionals to ensure quality care for all, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education.[37] There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide; all involve extensive study of nursing theory and practice as well as training in clinical skills.

Nurses care for individuals of all ages and cultural backgrounds who are healthy and ill in a holistic manner based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology in caring for those individuals.

To work in the nursing profession, all nurses hold one or more credentials depending on their scope of practice and education. A Licensed practical nurse (LPN) (also referred to as a Licensed vocational nurse, Registered practical nurse, Enrolled nurse, and State enrolled nurse) works independently or with a Registered nurse (RN). The most significant differentiation between an LPN and RN is found in the requirements for entry to practice, which determines entitlement for their scope of practice. For example, Canada requires a bachelors degree for the RN and a two-year diploma for the LPN. A Registered nurse (RN) provides scientific, psychological, and technological knowledge in the care of patients and families in many health care settings. Registered nurses may earn additional credentials or degrees.

In the USA, multiple educational paths will qualify a candidate to sit for the licensure examination as a registered nurse. The Associate Degree in Nursing (ADN) is awarded to the nurse who has completed a two-year undergraduate academic degree awarded by community colleges, junior colleges, technical colleges, and bachelor's degree-granting colleges and universities upon completion of a course of study usually lasting two years. The Bachelor of Science in Nursing (BSN) is awarded to the nurse who has earned an American four-year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school. After completing either the LPN or either RN education programs in the USA, graduates are eligible to sit for the a licensing examination to become a nurse, the passing of which is required for the nursing license.

RNs may also pursue different roles as advanced practice registered nurses.

Nurses may follow their personal and professional interests by working with any group of people, in any setting, at any time. Some nurses follow the traditional role of working in a hospital setting.

Around the world, nurses have been traditionally female. Despite equal opportunity legislation, nursing has continued to be a female-dominated profession.[41] For instance, the male-to-female ratio of nurses is approximately 1:19 in Canada and America.[42][43] This ratio is represented around the world. Notable exceptions include Francophone Africa, which includes the countries of Benin, Burkina Faso, Cameroon, Chad, Congo, Côte d'Ivoire, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses.[44] In Europe, in countries such as Spain, Portugal, Czechoslovakia, and Italy, over 20% of nurses are male.[44]

Theory and process Main articles: Nursing theory and Nursing process
Nursing practice is the actual provision of nursing care. In providing care, nurses implement the nursing care plan using the nursing process. This is based around a specific nursing theory which is selected based on the care setting and population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research.

In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate the outcomes of the care provided. Like other disciplines, the profession has developed different theories derived from sometimes diverse philosophical beliefs and paradigms or worldviews to help nurses direct their activities to accomplish specific goals.

Practice settings Nurses practice in a wide range of settings, from hospitals to visiting people in their homes and caring for them in schools to research in pharmaceutical companies. Nurses work in occupational health settings[45] (also called industrial health settings), free-standing clinics and physician offices, nurse-led clinics, long-term care facilities and camps. They also work on cruise ships and in military service. Nurses act as advisers and consultants to the health care and insurance industries. Many nurses also work in the health advocacy and patient advocacy fields at companies such as Health Advocate, Inc. helping in a variety of clinical and administrative issues.[46] Some are attorneys and others work with attorneys as legal nurse consultants, reviewing patient records to assure that adequate care was provided and testifying in court. Nurses can work on a temporary basis, which involves doing shifts without a contract in a variety of settings, sometimes known as per diem nursing, agency nursing or travel nursing. Nurses work as researchers in laboratories, universities, and research institutions. Nurses have also been delving into the world of informatics, acting as consultants to the creation of computerized charting programs and other software.

Work environment Internationally, there is a serious shortage of nurses.[47] One reason for this shortage is due to the work environment in which nurses practice. In a recent review of the empirical human factors and ergonomic literature specific to nursing performance, nurses were found to work in generally poor environmental conditions. De Lucia, Otto, & Palmier (2009)[48] concluded, "the profession of nursing as a whole is overloaded because there is a nursing shortage. Individual nurses are overloaded. They are overloaded by the number of patients they oversee. They are overloaded by the number of tasks they perform. They work under cognitive overload, engaging in multitasking and encountering frequent interruptions. They work under perceptual overload due to medical devices that do not meet perceptual requirements (Morrow et al., 2005), insufficient lighting, illegible handwriting, and poor labeling designs. They work under physical overload due to long work hours and patient handling demands which leads to a high incidence of MSDs. In short, the nursing work system often exceeds the limits and capabilities of human performance. HF/E research should be conducted to determine how these overloads can be reduced and how the limits and capabilities of performance can be accommodated. Ironically, the literature shows that there are studies to determine whether nurses can effectively perform tasks ordinarily performed by physicians. Results indicate that nurses can perform such tasks effectively. Nevertheless, already overloaded nurses should not be given more tasks to perform. When reducing the overload, it should be kept in mind that under loads also can be detrimental to performance (Mack worth, 1948). Both overloads and under loads are important to consider for improving performance."[48] Some countries and states have passed legislation regarding acceptable nurse-to-patient ratios.

The fast-paced and unpredictable nature of health care place nurses at risk for injuries and illnesses. In the United States, the Occupational Health Safety Network (OHSN) is a secure electronic surveillance system developed by the National Institute for Occupational Safety and Health (NIOSH) to address health and safety risks among health care personnel, including nurses. OHSN modules currently focus on three high risk and preventable events that can lead to injuries or musculoskeletal disorders among healthcare personnel: musculoskeletal injuries from patient handling activities; slips, trips, and falls; and workplace violence. Hospitals and other healthcare facilities can upload the occupational injury data they already collect to the secure database for analysis and benchmarking with other de-identified facilities. NIOSH works with OHSN participants in identifying and implementing timely and targeted interventions. OHSN enrollment is open to all healthcare facilities.

Worldwide Australia Catholic religious institutes were influential in the development of Australian nursing, founding many of Australia's hospitals - the Irish Sisters of Charity were first to arrive in 1838 and established St Vincent's Hospital, Sydney in 1857 as a free hospital for the poor. They and other orders like the Sisters of Mercy, and in aged care the Sisters of the Little Company of Mary and Little Sisters of the Poor founded hospitals, hospices, research institutes and aged care facilities around Australia.[49][50]

A census in the 1800s found several hundred nurses working in Western Australia during the colonial period of history, this included Aboriginal female servants who cared for the infirm.[51]

The state nursing licensing bodies amalgamated in Australia in 2011 to become a federal body AHPRA (Australian Health Practitioner Registration Authority). Several divisions of nursing license is available and recognized around the country.

Enrolled Nurses may initiate some oral medication orders with a specific competency now included in national curricula but variable in application by agency.
Registered nurses hold a university degree,
Nursing Practitioners have started emerging from postgraduate programs and work in private practise.
Midwives have recently been given access to public liability insurance which enables them to work in private practise at free standing birth centres or as homebirth midwives[52]
Mental Health nurses must complete further training as Advanced Mental Health Practitioners in order to administer client referrals under the mental health act.
Australia enjoys the luxury of a national curriculum for vocational nurses, trained at TAFE colleges or private RTO. Both Enrolled and Registered Nurses are identified by the department of immigration as an occupational area of need, although registered nurses are always in shorter supply, and this increases in proportion with specialisation.

In 1986 there were a number of rolling industrial actions around the country, culminating when five thousand Victorian nurses went on strike for eighteen days. The hospitals were able to function by hiring casual staff from each other's striking members, but the increased cost forced a decision in the nurses' favour [53]

European Union In the European Union, the profession of nurse is regulated. A profession is said to be regulated when access and exercise is subject to the possession of a specific professional qualification. The regulated professions database contains a list of regulated professions for nurse[54] in the EU member states, EEA countries and Switzerland. This list is covered by the Directive 2005/36/EC .

United Kingdom Main article: Nursing in the United Kingdom
To practice lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "Registered Nurse" can only be granted to those holding such registration. This protected title is laid down in the Nurses, Midwives and Health Visitors Act, 1997.[55]

First-level nurses First-level nurses make up the bulk of the registered nurses in the UK. They were previously known by titles such as RGN (registered general nurse), RSCN (registered sick children's nurse), RMN (registered mental nurse) and RNMS (registered nurse (for the) mentally subnormal). The titles used now are similar, including RNA (registered nurse adult), RNC (registered nurse child), RNMH (registered nurse mental health) and RNLD (registered nurse learning disabilities).

Main article: State Enrolled Nurse
Second-level nurse training is no longer provided, however they are still legally able to practice in the United Kingdom as a registered nurse. Many have now either retired or undertaken conversion courses to become first-level nurses. They are entitled to refer to themselves as registered nurses as their registration is on the Nursing & Midwifery Council register of nurses, although most refer to themselves as ENs or SENs.

There is also scope for advanced practice:

Nurse practitioners – Most of these nurses obtain a minimum of a Masters degree, and a desired post grad certificate. They often perform roles similar to those of physicians and physician assistants. They can prescribe medications as independent or supplementary prescribers, although are still legally regulated, unlike physician's assistants. Most NP's have referral and admission rights to hospital specialties. They commonly work in primary care (e.g. GP surgeries), A&E departments, or pediatrics although they are increasingly being seen in other areas of practice. In the UK, the title "nurse practitioner" is legally protected.
Specialist community public health nurses – traditionally district nurses and health visitors, this group of research and publication activities.
Lecturer-practitioners (also called practice education facilitators) – these nurses work both in the NHS, and in universities. They typically work for 2–3 days per week in each setting. In university, they train pre-registration student nurses (see below), and often teach on specialist courses for post-registration nurses
Lecturers – these nurses are not employed by the NHS. Instead they work full-time in universities, both teaching and performing research.
Managers Many nurses who have worked in clinical settings for a long time choose to leave clinical nursing and join the ranks of the NHS management. This used to be seen as a natural career progression for those who had reached ward management positions, however with the advent of specialist nursing roles (see above), this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organizations, some even as board members. Others choose to stay a little closer to their clinical roots by becoming clinical nurse managers or modern matrons.

Nurse education Pre-registration In order to become a registered nurse, and work as such in the NHS, one must complete a program recognized by the Nursing and Midwifery Council. Currently, this involves completing a degree or diploma, available from a range of universities offering these courses, in the chosen branch specialty (see below), leading to both an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university (i.e. through lectures, essays and examinations) and in practice (i.e. supervised patient care within a hospital or community setting).

These courses are three (occasionally four) years' long. The first year is known as the common foundation program (CFP), and teaches the basic knowledge and skills required of all nurses. The remainder of the program consists of training specific to the student's chosen branch of nursing. These are:

Adult nursing.
Child nursing.
Mental health nursing.
Learning disabilities nursing.
As of 2013, the Nursing and Midwifery Council will require all new nurses qualifying in England to hold a degree qualification.[56]

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. There are shortened (18 month) programmes to allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Shortened courses lasting 2 years also exist for graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation program.[57]

Student nurses currently receive a bursary from the government to support them during their nurse training. Diploma students in England receive a non-means-tested bursary of around £6000 per year (with additional allowances for mature students or those with dependent children), whereas degree students have their bursary means tested (and so often receive less). Degree students are, however, eligible for a proportion of the government's student loan, unlike diploma students. In Scotland, however, all student nurses regardless of which course they are undertaking, receive the same bursary in line with the English diploma amount. In Wales only the Degree level course is offered and all nursing students therefore receive a non-means-tested bursary.

Before Project 2000, nurse education was the responsibility of hospitals and was not based in universities; hence many nurses who qualified prior to these reforms do not hold an academic award.

Post-registration After the point of initial registration, there is an expectation that all qualified nurses will continue to update their skills and knowledge. The Nursing and Midwifery Council insists on a minimum of 35 hours of education every three years, as part of its post registration education and practice (PREP) requirements.[58]

There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venepuncture, intravenous drug therapy and male catheterization are the most common, although there are many others (such as advanced life support) which some nurses will undertake.

Many nurses who qualified with a diploma choose to upgrade their qualification to a degree by studying part-time. Many nurses prefer this option to gaining a degree initially, as there is often an opportunity to study in a specialist field as a part of this upgrading. Financially, in England, it is also much more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary.[59]

In order to become specialist nurses (such as nurse consultants, nurse practitioners etc.) or nurse educators, some nurses undertake further training above bachelors degree level. Masters degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and in order to become such they must undertake specialist training (often in the form of a top up degree (see above) or post graduate diploma).

All newly qualifying district nurses and Health Visitors are trained to prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these (and other) nurses will also undertake training in independent and supplementary prescribing, which allows them (as of 1 May 2006) to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.[60]

Canada Main article: Nursing in Canada
History Canadian nursing dates all the way back to 1639 in Quebec with the Augustine nuns.[61] These nuns were trying to open up a mission that cared for the spiritual and physical needs of patients. The establishment of this mission created the first nursing apprenticeship training in North America.[61] In the nineteenth century there were some Catholic orders of nursing that were trying to spread their message across Canada. Most nurses were female and only had an occasional consultation with a physician. Towards the end of the nineteenth century hospital care and medical services had been improved and expanded. Much of this was due to Nightingale's influence. In 1874 the first formal nursing training program was started at the General and Marine Hospital in St. Catharines in Ontario.[61]

Education All Canadian nurses and prospective nurses are heavily encouraged by the Canadian Nurses Association to continue their education to receive a baccalaureate degree. They believe that this is the best degree to work towards because it results in better patient outcomes. In addition to helping patients, nurses that have a baccalaureate degree will be less likely to make small errors because they have a higher level of education. A baccalaureate degree also gives a nurse a more critical opinion which gives he or she more of an edge in the field. This ultimately saves the hospital money because they deal with less problematic incidents. All Canadian provinces except for the Yukon and Quebec require that all nurses must have a baccalaureate degree.[61] The basic length of time that it takes to obtain a baccalaureate degree is four years. However, Canada does have a condensed program that is two years long.[61]

Nursing specialty certification is available in nineteen practice areas. According to the Canadian Nurses Association some of those specialties are cardiovascular nursing, community health nursing, critical care nursing, emergency nursing, gerontology nursing, medical-surgical nursing, neuroscience nursing, oncology nursing, orthopedic nursing, psychiatric/mental health nursing, and rehabilitation nursing.[61] Each specialty requires its own test and competencies. Many tests are offered online through the Canadian Nurses Association.

Public opinion Canadian nurses hold a lot of responsibility in the medical field and are considered vital. According to the Canadian Nurses Association, "They expect RNs to develop and implement multi-faceted plans for managing chronic disease, treating complex health conditions and assisting them in the transition from the hospital to the community. Canadians also look to RNs for health education and for strategies to improve their health. RNs assess the appropriateness of new research and technology for patients and adjust care plans accordingly".

Japan Main article: Nursing in Japan
History Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance.[61] From there the Registered Nurse Ordinance came into play in 1915. This established a legal substantiation to registered nurses all over Japan. A new law geared towards nurses was created during World War II. This law was titled the Public Health Nurse, Midwife and Nurse Law and it was established in 1948.[61] It established educational requirements, standards and licensure. There has been a continued effort to improve nursing in Japan. In 1992 the Nursing Human Resource Law was passed.[61] This law created the development of new university programs for nurses. Those programs were designed to raise the education level of the nurses so that they could be better suited for taking care of the public.

Types of nurses Japan only recognizes four types of nursing and they are Public Health Nursing, Midwifery, Registered Nursing and Assistant Nursing.

Public health This type of nursing is designed to help the public and is also driven by the public's needs. The goals of public health nurses are to monitor the spread of disease, keep vigilant watch for environmental hazards, educate the community on how to care for and treat themselves, and train for community disasters.

Midwifery Nurses that are involved with midwifery are independent of any organization. A midwife takes care of a pregnant woman during labour and postpartum. They assist with things like breastfeeding and caring for the child.

Assistant Individuals who are assistant nurses follow orders from a registered nurse. They report back to the licensed nurse about a patient's condition. the Assistant nurses are always supervised by a licensed registered nurse.

Education In 1952 Japan established the first nursing university in the country.[61] An Associate Degree was the only level of certification for years. Soon people began to want nursing degrees at a higher level of education. Soon the Bachelors Degree in Nursing (BSN) was established. Currently Japan offers doctorate level degrees of nursing in a good number of its universities.

There are three ways that an individual could become a registered nurse in Japan. After obtaining a high school degree the person could go to a nursing university for four years and earn a Bachelor degree, go to a junior nursing college for three years or go to a nursing school for three years.[61] Regardless of where the individual attends school they must take the national exam. Those who attended a nursing university have a bit of an advantage over those who went to a nursing school. They can take the national exam to be a registered nurse, public health nurse or midwife. In the cases of become a midwife or a public health nurse, the student must take a one year course in their desired field after attending a nursing university and passing the national exam to become a registered nurse. The nursing universities are the best route for someone who wants to become a nurse in Japan.[61] They offer a wider range of general education classes and they also allow for a more rigid teaching style of nursing. These nursing universities train their students to be able to make critical and educated decisions when they are out in the field. Physicians are the ones who are teaching the potential nurses because there are not enough available nurses to teach students. This increases the dominance that physicians have over nurses.

Students that attend a nursing college or just a nursing school receive the same degree that one would who graduated from a nursing university, but they do not have the same educational background. The classes offered at nursing colleges and nursing schools are focused on more practical aspects of nursing. These institutions do not offer many general education classes, so students who attend these schools will solely be focusing on their nursing educations while they are in school. Students who attend a nursing college or school do have the opportunity to become a midwife or a public health nurse. They have to go through a training institute for their desired field after graduating from the nursing school or college.[61] Japanese nurses never have to renew their licenses. Once they have passed their exam, they have their license for life.[61]

Today Like the United States, Japan is in need of more nurses. The driving force behind this need this is the fact that country is aging and needs more medical care for its people. The country needs a rapid increase of nurses however things do not seem to be turning around. Some of the reasons that there is a shortage are poor working conditions, an increase in the number of hospital beds, the low social status of nurses, and the cultural idea that married women quit their jobs for family responsibilities.[61] On average, Japanese nurses will make around 280,000 yen a month, which is one of the higher paying jobs. however, physicians make twice the amount that nurses do in a year.[61] Similar to other cultures, the Japanese people view nurses as subservient to physicians. They are considered lesser and oftentimes negative connotations are associated with nurses. According to the American Nurses Association article on Japan, "nursing work has been described using negative terminology such as "hard, dirty, dangerous, low salary, few holidays, minimal chance of marriage and family, and poor image".

Some nurses in Japan are trying to be advocates. They are promoting better nursing education as well as promoting the care of the elderly. There are some organizations that unite Japanese nurses like the Japanese Nursing Association (JNA). The JNA is not to be confused with a union, it is simply a professional organization for the nurses. Members of the JNA lobby politicians and produces publications about nursing. According to the American Nurses Association's article on Japan the JNA, "works toward the improvement in nursing practice through many activities including the development of a policy research group to influence policy development, a code of ethics for nurses, and standards of nursing practice". The JNA also provides certification for specialists in mental health, oncology and community health.[61] JNA is the not the only nursing organization in Japan. There are other subgroups that are typically categorized by the nurses' specialty, like emergency nursing or disaster nursing. One of the older unions that relates to nursing is the Japanese Federation of Medical Workers Union which was created in 1957.[61] It is a union that includes physicians as well as nurses. This organization was involved with the Nursing Human Resource Law.[61]

United States Main article: Nursing in the United States
The scope of practice of registered nurses is the extent to and limits of which an RN may practice. In the United States, these limits are determined by a set of laws known as the Nurse Practice Act of the state or territory in which an RN is licensed. Each state has its own laws, rules, and regulations governing nursing care. Usually the making of such rules and regulations is delegated to a state board of nursing, which performs day-to-day administration of these rules, qualifies candidates for censurer, licenses nurses and nursing assistants, and makes decisions on nursing issues. It should be noted that in some states the terms "nurse" or "nursing" may only be used in conjunction with the practice of a Registered Nurse (RN) or licensed practical or vocational nurse (LPN/LVN).

The scope of practice for a registered nurse is wider than for an LPN/LVN because of the level and content of education as well as what the Nurse Practice Act says about the respective roles of each.

In the hospital setting, registered nurses are often assigned a role in which they delegate tasks to LPNs and unlicensed assistive personnel.

RNs are not limited to employment as bedside nurses. Registered nurses are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, among others. Some registered nurses are independent consultants who work for themselves, while others work for large manufacturers or chemical companies. Research Nurses conduct or assist in the conduct of research or evaluation (outcome and process) in many areas such as biology, psychology, human development, and health care systems. The average salary for a staff RN in the United States in 2007 was over $60,000.

Educational and licensure requirements Diploma in Nursing Main article: Diploma in Nursing
The oldest method of nursing education is the hospital-based diploma program, which lasts approximately three years. Students take between 30 and 60 credit hours in anatomy, physiology, microbiology, nutrition, chemistry, and other subjects at a college or university, then move on to intensive nursing classes. Until 1996, most RNs in the US were initially educated in nursing by diploma programs.[62] According to the Health Services Resources Administration's 2000 Survey of Nurses only six percent of nurses who graduated from nursing programs in the United States received their education at a Diploma School of Nursing.[63]

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

Bachelor of Science in Nursing Main article: Bachelor of Science in Nursing
The third method is to obtain a Bachelor of Science in Nursing (BSN), a four-year degree that also prepares nurses for graduate-level education. For the first two years in a BSN program, students usually obtain general education requirements and spend the remaining time in nursing courses. The Bachelor of Science in Nursing degrees have many courses which stretches out the degree-acquiring process to over 4 years. Advocates for the ADN and diploma programs state that such programs have an on the job training approach to educating students, while the BSN is an academic degree that emphasizes research and nursing theory. Some states require a specific amount of clinical experience that is the same for both BSN and ADN students. A BSN degree qualifies its holder for administrative, research, consulting and teaching positions that would not usually be available to those with an ADN, but is not necessary for most patient care functions, although some hospitals are beginning to give preference in hiring to BSN prepared nurses as a rule. Nursing schools may be accredited by either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE).

Graduate nursing opportunities Further information: Master of Science in Nursing
Further information: Doctor of Nursing Practice
Advanced education in nursing is done at the master's and doctoral levels. It prepares the graduate for specialization as an advanced practice registered nurse (APRN) or for advanced roles in leadership, management, or education. Areas of advanced nursing practice include that of a nurse practitioner (NP), a certified nurse midwife (CNM), a certified registered nurse anesthetist (CRNA), or a clinical nurse specialist (CNS). Nurse practitioners work assessing, diagnosing and treating patients in fields as diverse as family practice, women's health care, emergency nursing, acute/critical care, psychiatry, geriatrics, or pediatrics, while a CNS usually works for a facility to improve patient care, do research, or as a staff educator. The clinical nurse leader (CNL) is an advanced generalist who focuses on the improvement of quality and safety outcomes for patients or patient populations from an administrative and staff management focus. Doctoral programs in nursing prepare the student for work in nursing education, health care administration, clinical research, or advanced clinical practice. Most programs confer the PhD in nursing and Doctor of Nursing Practice (DNP).

Licensure examination Completion of any one of these three educational routes allows a graduate nurse to take the NCLEX-RN, the test for licensure as a registered nurse, and is accepted by every state as an adequate indicator of minimum competency for a new graduate. However, controversy exists over the appropriate entry-level preparation of RNs. Some professional organizations believe the BSN should be the sole method of RN preparation and ADN graduates should be licensed as "technical nurses" to work under the supervision of BSN graduates. Others feel the on-the-job experiences of diploma and ADN graduates makes up for any deficiency in theoretical preparation. Regardless of this debate, it is highly unlikely that the BSN will become the standard for initial preparation any time soon, because of the nursing shortage, hospital lobbyist, and the lack of faculty to teach BSN students.

Earnings Median annual wages of registered nurses were $62,450 in May 2008. The middle 50 percent earned between $51,640 and $76,570. The lowest 10 percent earned less than $43,410, and the highest 10 percent earned more than $92,240. Median annual wages in the industries employing the largest numbers of registered nurses in May 2008 were:

Employment services $68,160; General medical and surgical hospitals $63,880; Offices of physicians $59,210; Home health care services $58,740; Nursing care facilities $57,060.

Many employers offer flexible work schedules, child care, educational benefits, and bonuses. About 21 percent of registered nurses are union members or covered by union contract.[64]

Top 10 Highest Paying Nursing Specialties

1.Certified Registered Nurse Anesthetist – $135,000
2.Nurse Researcher – $95,000
3.Psychiatric Nurse Practitioner – $95,000
4.Certified Nurse Midwife – $84,000
5.Pediatric Endocrinology Nurse – $81,000
6.Orthopedic Nurse – $81,000
7.Nurse Practitioner – $78,000
8.Clinical Nurse Specialist – $76,000
9.Gerontological Nurse Practitioner – $75,000
10.Neonatal Nurse – $74,000[65]
Shortage in the United States Main article: Nursing shortage
RNs are the largest group of health care workers in the United States, with about 2.7 million employed in 2011.[66] It has been reported[by whom?] that the number of new graduates and foreign-trained nurses is insufficient to meet the demand for registered nurses; this is often referred to as the nursing shortage and is expected[by whom?] to increase for the foreseeable future. There are data to support the idea that the nursing shortage is a voluntary shortage.[citation needed] In other words, nurses are leaving nursing of their own volition. In 2006 it was estimated that approximately 1.8 million nurses chose not to work as a nurse. The Bureau of Labor Statistics reported that 296,900 healthcare jobs were created in 2011. RN’s make up the majority of the healthcare work force, therefore these positions will be filled primarily by nurses. The BLS also states that by 2020, there will be 1.2 million nursing job openings due to an increase in the workforce, and replacements. (Rosseter, 2012).

Causes  This article may contain unsourced predictions, speculative material or accounts of events that might not occur. Please help improve it by removing unsourced speculative content. (July 2012)

A national survey prepared by the Federation of Nurses and Health Professionals in 2001 found that one in five nurses plans to leave the profession within five years because of unsatisfactory working conditions, including low pay, severe under staffing, high stress, physical demands, mandatory overtime, and irregular hours. The shortage will also be exacerbated by the increasing numbers of baby-boomer aged nurses who are expected to retire, creating more open positions than there are graduates of nursing programs. The faster than average job growth in this field is also a result of improving medical technology that will allow for treatments of many more diseases and health conditions. Nurses will be strong in demand to work with the rapidly growing population of senior citizens in the United States. Approximately 29.8 percent of all nursing jobs are found in hospitals.[66] However, because of administrative cost cutting, increased nurse's workload, and rapid growth of outpatient services, hospital nursing jobs will experience slower than average growth. Employment in home care and nursing homes is expected[by whom?] to grow rapidly. Though more people are living well into their 80s and 90s, many need the kind of long-term care available at a nursing home. Also, because of financial reasons, patients are being released from hospitals sooner and admitted into nursing homes. Many nursing homes have facilities and staff capable of caring for long-term rehabilitation patients, as well as those afflicted with Alzheimer's. Many nurses will also be needed to help staff the growing number of out-patient facilities, such as HMOs, group medical practices, and ambulatory surgery centers. Nursing specialties will be in great demand. There are, in addition, many part-time employment possibilities.[67]

Aggravating the already disparate ratio of qualified nurses to needed nurses is the ever shrinking qualified nursing faculty pool. Levsey, Campbell, and Green voiced their concern about the shortage of nurses, citing Fang, Wilsey-Wisniewski, & Bednash, 2006 who state that over 40,000 qualified nursing applicants were turned away in the 2005-2006 academic year from baccalaureate nursing programs due to a lack of masters and doctoral qualified faculty, and that this number was increased over 9,000 from 32,000 qualified but rejected students from just two years earlier. Several strategies have been offered to mitigate this shortage including; Federal and private support for experienced nurses to enhance their education, incorporating more hybrid/blended nursing courses, and using simulation in lieu of clinical (hospital) training experiences.[68][69]

Continuing education With health care knowledge growing steadily, nurses can stay ahead of the curve through continuing education. Continuing education classes and programs enable nurses to provide the best possible care to patients, advance nursing careers, and keep up with Board of Nursing requirements. The American Nurses Association and the American Nursing Credentialing Center are devoted to ensuring nurses have access to quality continuing education offerings. Continuing education classes are calibrated to provide enhanced learning for all levels of nurses. Many States also regulate Continuing Nursing Education. Nursing licensing boards requiring Continuing Nursing Education (CNE) as a condition for licensure, either initial or renewal, accept courses provided by organizations that are accredited by other state licensing boards, by the American Nursing Credentialing Center (ANCC), or by organizations that have been designated as an approver of continuing nursing education by ANCC. There are some exceptions to this rule including the state of California, Florida and Kentucky. National Healthcare Institute[70] has created a list to assist nurses in determining their CNE credit hours requirements. While this list is not all inclusive, it offers details on how to contact nursing licensing boards directly.[71][72]

Board certification Main article: Nursing credentials and certifications
Professional nursing organizations, through their certification boards, have voluntary certification exams to demonstrate clinical competency in their particular specialty. Completion of the prerequisite work experience allows an RN to register for an examination, and passage gives an RN permission to use a professional designation after their name. For example, passage of the American Association of Critical-care Nurses specialty exam allows a nurse to use the initials 'CCRN' after his or her name. Other organizations and societies have similar procedures.

The American Nurses Credentialing Center, the credentialing arm of the American Nurses Association, is the largest nursing credentialing organization and administers more than 30 specialty examinations.[73]

Specialties Main article: List of nursing specialties
Nursing is the most diverse of all healthcare professions. Nurses practice in a wide range of settings but generally nursing is divided depending on the needs of the person being nursed.

The major populations are:

communities/public
family/individual across the lifespan
adult-gerontology
pediatrics
neonatal
women’s health/gender-related
psych/mental health
There are also specialist areas such as cardiac nursing, orthopedic nursing, palliative care, perioperative nursing, obstetrical nursing, oncology nursing, nursing informatics, telenursing.