Nursing is a profession within the healthcare 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.
Prior to the foundation of modern nursing, nuns and the military often provided nursing-like services.[1]
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 other health care professionals in addition to being responsible for their own practice.
The Crimean War was a significant development in nursing history, when English nurse Florence Nightingale, laid the foundations of professional nursing with the principles summarised in the book Notes on Nursing.
Other important nurses in the development of the profession include: 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, and Linda Richards who was officially America's first professionally trained nurse, graduating in 1873 from the New England Hospital for Women and Children in Boston.
New Zealand was the first country to regulate nurses nationally, with adoption of the Nurses Registration Act on the 12 September 1901. It was here in New Zealand that Ellen Dougherty became the first registered nurse. North Carolina was the first state in the United States to pass a nursing license law in 1903.[2] In the 1990s nurses became able to prescribe medications, order diagnostic and pathology tests and refer patients to other health professionals as needed. Reference Potter & Perrys (2009)
Nurses in the United States Army actually started during the Revolutionary War when a general suggested to George Washington that the he needed female nurses "to attend the sick and obey the matron's orders. In July 1775, a plan was submitted to the Second Continental Congress that provided one nurse for every ten patients and provided that a matron be allotted to every hundred sick or wounded".
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.[3] 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.[4]
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.[5]
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.
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.
Before the late 19th century, and into the early 20th century, women doing nursing work were generally members of religious orders or were effectively domestic servants, with the same lowly social status, caring for the sick either in private homes or at charity hospitals serving the poor. Florence Nightingale's efforts to improve nursing standards in the mid-nineteenth century increased interest in occupational improvements that would benefit patients, with particular importance given to military settings. In 1860, Florence Nightingale's work resulted in Queen Victoria's order for 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.[6] 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.[7]
Sporadic progress was made on several continents, where medical pioneers established formal nursing schools. But even 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.[8]
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[8]
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.[9] 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.[7]
When Canadian nurses volunteered to serve during World War I, they were made commissioned officers by the Royal Canadian Army before being sent overseas,[10] a move that would grant them some authority in the ranks, so that enlisted patients and orderlies would have to comply with their direction. Canada was the first country in the world to grant women this privilege. At the beginning of the War, nurses were not dispatched to the casualty clearing stations near the front lines, where they would be exposed to shell fire. They were initially assigned to hospitals a safe distance away from the front lines. As the war continued, however, nurses were assigned to casualty clearing stations. They were exposed to shelling, and caring for soldiers with "shell shock" and casualties suffering the effects of new weapons such as poisonous gas, as Katherine Wilson-Sammie recollects in Lights Out! A Canadian Nursing Sister’s Tale.[11] World War I was also the first war in which a clearly-marked hospital ship evacuating the wounded was targeted and sunk by an enemy submarine or torpedo boat, an act that had previously been considered unthinkable, but which happened repeatedly (see List of hospital ships sunk in World War I). Nurses were among the casualties.
Canadian women volunteering to serve overseas as nurses overwhelmed the army with applications.[8] A total of 3,141 Canadian "nursing sisters" served in the Canadian Army Medical Corps and 2,504 of those served overseas in England, France and the Eastern Mediterranean at Gallipoli, Alexandria and Salonika. By the end of the First World War, 46 Canadian Nursing Sisters had died[10] In addition to these nurses serving overseas with the military, others volunteered and paid their own way over with organizations such as the Canadian Red Cross, the Victorian Order of Nurses, and St. John Ambulance. The sacrifices made by these nurses during the War in fact gave a boost to the women's suffrage movement in many of the countries that fought in the war. The Canadian Army nursing sisters were among the first women in the world to win the right to vote in a federal election; the Military Voters Act of 1917 extended the vote to women in the service such as Nursing Sisters.
As Campbell (1984) shows, the nursing profession was transformed by World War Two. The profession contained a basic tension between the tender loving care provided sick people, on the one hand, and the well-trained efficient specialists on the other was a historic tension in the nursing profession that was partially resolved by the war. The military wanted well-trained efficient specialists. All the services used enlisted men to handle the routine care of sick patients are wounded patients, and use their nurses as officers who were trained specialists. In military units, male doctors supervised female nurses, and both were officers, while the women in practice supervised large numbers of enlisted men. Although enlisted medic could become an officer, it was not easy, and none could become a nurse. Indeed there were no male nurses in the American military until years later. Army and Navy nursing was highly attractive and a larger proportion of nurses volunteered for service higher than any other occupation in American society. The nation responded by a dramatic increase in the numbers and functions of nurses, and a moderate modest increase in their pay scales, with the expansion powered by the training of 200,000 nurses aides by the Red Cross, and the creation of a temporary new government agency, the Cadet Nurse Corps, which enrolled 170,000 young women in speeded up training programs in the nation's 1200 nursing schools. About 5% five percent of the Cadet nurses, and Army nurses were black, but the Navy refused to accept black nurses until it was forced to admit a handful by the White House near the end of the war. The black Army nurses were used in all-black units, handle and to handle medical services for prisoners of war.[12][13]
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,[14] 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."[15][16] The 20,000 nurses in Europe were safely behind the lines. They had two missions one provide technical nursing services to military hospitals and second to train and the male Army medics and male pharmacy mates in the Navy. These men handled front line nursing care, and also staffed home front hospitals, where the nurses directly supervised them. The medical services were large operations, with over 600,000 soldiers, and ten enlisted men for every nurse. Nearly all the doctors were men, with women doctors allowed only to examine the WAC. Forward medical units, were emergency surgery was undertaken, was done without the benefit of nurses. Well behind the battlefield, the nurses worked in evacuation hospitals, primarily in the role of supervising the medics and the Navy’s pharmacy mates. The closer to the front, the more flexible and autonomous was the nurse’s’ role. The women wanted to be much closer to the front, but they had too weak a voice to counter the Pentagon’s highly protective attitude.[17]
Down to 1942, the American Red Cross controlled access to the military. The Red Cross was controlled by civilian men, professional experts and social work and fundraising. The new leaders emerging from the war had learned command skills, maneuvering in complex bureaucracies, the taste of equal pay an officer status, and autonomy within military medical system. New technical skills validated their demands for an autonomy as they learned and employed in crisis situations the latest trauma and medical techniques and technologies. The military nurses returned home as the nation’s experts in blood transfusion and the application of new drugs like penicillin. When the nurses returned home they used the previously powerless American Nurses Association to take control of the nursing profession.[17]
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.[18] Nurses were exposed to all dangers during the War, and some were captured and became prisoners of war.
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.[19]
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.[20]
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.
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.
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.
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.
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.[21] There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide, but all involve extensive study of nursing theory and practice, and 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.
In order 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. 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 in Canada an RN requires a bachelors degree and a LPN requires a 2 year diploma. 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 also earn additional credentials or degrees. In the USA, in addition to the LPN, Registered nurses can earn 2 different degrees that qualify a nurse for the title RN. The title RN ADN is awarded to the nurse who has completed a 2 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 title RN 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.
RN's 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.[25] For instance, in Canada and America the male-to-female ratio of nurses is approximately 1:19.[26][27] This ratio is represented around the world. Notable exceptions include: Francophone Africa, which includes the countries of Benin, Burkina Faso, Cameroon, Chad, Congo, Ivory Coast, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses.[28] In Europe, in countries such as Spain, Portugal, Czechoslovakia, and Italy, over 20% of nurses are male.[28] 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 [25]
"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 [26]
"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[27]
"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[28]
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.
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[29] (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.[30] 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.
Internationally, there is a serious shortage of nurses.[31] 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)[32] 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."[32] Each county/ state in which a nurse is licensed has laws concerning how many patients one nurse can tend to(depending on the acuity of the patients needs).
Throughout the world nurses are known to be caring individuals that people look for as someone to advocate for the sick and provide empathy towards the needy.
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.[33]
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), RMHN (registered nurse (for the) mentally handicapped).
The titles used now are similar and with slight differences i.e. RNA (registered nurse adult), RNC (registered nurse child), RNMH (registered nurse mental health), RNLD (registered nurse learning disabilities).
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.
They split into several major groups:
- Nurse practitioners – These nurses obtain a minimum of a Bachelor's degree, and a desired masters or post grad. 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.
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.
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.[34]
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.[35]
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.
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.[36]
There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venepuncture, intravenous drug therapy and male cauterization 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.[37]
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.[38]
Canadian nursing dates all the way back to 1639 in Quebec with the Augustine nuns.[39] 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.[39] 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 Florence Nightingale who was training women in English Canada. In 1874 the first formal nursing training program was started at the General and Marine Hospital in St. Catharines in Ontario.[39] Many programs popped up in hospitals across Canada after this one was established. Graduates and teachers from these programs began to fight for licensing legislation, nursing journals, university training for nurses, and for professional organizations for nurses.
The first instance of Canadian nurses and the military was in 1885 with the Northwest Rebellion. Some nurses came out to aid the wounded. In 1901 Canadian nurses were officially part of the Royal Canadian Army Medical Corps.[39] Georgina Fane Pope and Margaret Clothilde Macdonald were the first nurses officially recognized as military nurses.[39] Nursing continued to expand and develop. In the early twentieth century more nursing programs were developed for public health nursing and disease prevention. More changes occurred after World War II. The health care system expanded and medicare was introduced. Currently there are 260,000 nurses in Canada but they face the same difficulties as most countries. Nurses are becoming more scarce and the population is aging which requires more nursing care.
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.[39] 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.[39]
There are nineteen specialties that a nurse could choose from if he or she wanted to narrow down his or her field. 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.[39] Each specialty requires its own test and competencies. Many tests are offered online through the Canadian Nurses Association.
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". It is rather uncommon to see nurses with this much independence. In most countries nurses appear to be considered lesser than a physician like in the United States or Japan.
Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance.[39] 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.[39] 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.[39] 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.
Japan only recognizes four types of nursing and they are Public Health Nursing, Midwifery, Registered Nursing and Assistant Nursing.
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.
Nurses that are involved with midwifery are independent of any organization. A midwife takes care of a pregnant woman during labor and postpartum. They assist with things like breastfeeding and caring for the child.
Individuals who are assistant nurses follow orders from a registered nurse. They report back to the licensed nurse about a patient's condition. Assistant nurses are always supervised by a licensed registered nurse.
In 1952 Japan established the first nursing university in the country.[39] 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.[39] 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.[39] 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.[39] Japanese nurses never have to renew their licenses. Once they have passed their exam, they have their license for life.[39]
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.[39] On average, Japanese nurses will make around 280,000 yen a year, which is one of the higher paying jobs. however, physicians make twice the amount that nurses do in a year.[39] 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.[39] 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.[39] It is a union that includes physicians as well as nurses. This organization was involved with the Nursing Human Resource Law.[39]
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 licensure, licenses nurses and nursing assistants, and makes decisions on nursing issues. It should be noted that in some states the terms "nurse" or "nursing" may only be used in conjunction with the practice of a Registered Nurse (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.
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.[40] 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.[41]
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.
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 a on the job training approach to educating students, while the BSN is an academic degree that emphasizes research and nursing theory. However the BSN graduate has both more classroom and clinical hours of study in nursing than the ADN graduate. The BSN graduate is professionally degreed; and as such is called a professional nurse. However, some states require a specific amount of clinical experience that is the same for both BSN and ADN students. Nursing schools may or may not be accredited by either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE).
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).
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.
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.[42]
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[43]
RNs are the largest group of health care workers in the United States, numbering over 2.6 million. It has been reported that the number of new graduates and foreign-trained nurses is insufficient to meet the demand for registered nurses; this is often referred to as the nursing shortage and is expected to increase for the foreseeable future. There are data to support the idea that the nursing shortage is a voluntary shortage. 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.
There has been a serious shortage of nurses for many years. 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 60 percent of all nursing jobs are found in hospitals. 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 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.[44]
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.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 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.[45][46]
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.[47]
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, and oncology nursing.
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Czech nursing students 2006.
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American nurses who were rescued from Santo Tomas in 1945.
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A British nurses uniform from 1900.
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American nurses from 1898.
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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, following her experience caring for the wounded in the Crimean War.
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Drawing of Jamaican nurse Mary Seacole who operated boarding houses for the sick during the Crimean War.
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A student nurse in the United States (1942).
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Nurse cares for a premature baby in Toronto, Ontario (1955).
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- ^ Florence Nightingale (1820–1910)
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Performance in Nursing". Reviews of Human Factors and Ergonomics 5: 1–40.
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