Registered Nurses

Significant Points


  • Registered nurses constitute the largest health care occupation, with 2.6 million jobs.
  • About 60 percent of jobs are in hospitals.
  • The three typical educational paths to registered nursing are a bachelor's degree, an associate degree, and a diploma from an approved nursing program; advanced practice nurses—clinical nurse specialists, nurse anesthetists, nurse-midwives, and nurse practitioners—need a master’s degree.
  • Overall job opportunities are expected to be excellent, but may vary by employment and geographic setting; some employers report difficulty in attracting and retaining an adequate number of RNs.

Nature of the Work

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Registered nurses (RNs), regardless of specialty or work setting, treat patients, educate patients and the public about various medical conditions, and provide advice and emotional support to patients' family members. RNs record patients' medical histories and symptoms, help perform diagnostic tests and analyze results, operate medical machinery, administer treatment and medications, and help with patient follow-up and rehabilitation.

RNs teach patients and their families how to manage their illness or injury, explaining post-treatment home care needs; diet, nutrition, and exercise programs; and self-administration of medication and physical therapy. Some RNs work to promote general health by educating the public on warning signs and symptoms of disease. RNs also might run general health screening or immunization clinics, blood drives, and public seminars on various conditions.

When caring for patients, RNs establish a plan of care or contribute to an existing plan. Plans may include numerous activities, such as administering medication, including careful checking of dosages and avoiding interactions; starting, maintaining, and discontinuing intravenous (IV) lines for fluid, medication, blood, and blood products; administering therapies and treatments; observing the patient and recording those observations; and consulting with physicians and other health care clinicians. Some RNs provide direction to licensed practical nurses and nursing aids regarding patient care. RNs with advanced educational preparation and training may perform diagnostic and therapeutic procedures and may have prescriptive authority.

RNs can specialize in one or more areas of patient care. There generally are four ways to specialize. RNs can choose a particular work setting or type of treatment, such as perioperative nurses, who work in operating rooms and assist surgeons. RNs also may choose to specialize in specific health conditions, as do diabetes management nurses, who assist patients to manage diabetes. Other RNs specialize in working with one or more organs or body system types, such as dermatology nurses, who work with patients who have skin disorders. RNs also can choose to work with a well-defined population, such as geriatric nurses, who work with the elderly. Some RNs may combine specialties. For example, pediatric oncology nurses deal with children and adolescents who have cancer.

There are many options for RNs who specialize in a work setting or type of treatment. Ambulatory care nurses provide preventive care and treat patients with a variety of illnesses and injuries in physicians' offices or in clinics. Some ambulatory care nurses are involved in telehealth, providing care and advice through electronic communications media such as videoconferencing, the Internet, or by telephone. Critical care nurses provide care to patients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses often work in critical or intensive care hospital units. Emergency, or trauma, nurses work in hospital or stand-alone emergency departments, providing initial assessments and care for patients with life-threatening conditions. Some emergency nurses may become qualified to serve as transport nurses, who provide medical care to patients who are transported by helicopter or airplane to the nearest medical facility. Holistic nurses provide care such as acupuncture, massage and aroma therapy, and biofeedback, which are meant to treat patients' mental and spiritual health in addition to their physical health. Home health care nurses provide at-home nursing care for patients, often as follow-up care after discharge from a hospital or from a rehabilitation, long-term care, or skilled nursing facility. Hospice and palliative care nurses provide care, most often in home or hospice settings, focused on maintaining quality of life for terminally ill patients. Infusion nurses administer medications, fluids, and blood to patients through injections into patients' veins. Long- term care nurses provide health care services on a recurring basis to patients with chronic physical or mental disorders, often in long-term care or skilled nursing facilities. Medical-surgical nurses provide health promotion and basic medical care to patients with various medical and surgical diagnoses. Occupational health nurses seek to prevent job-related injuries and illnesses, provide monitoring and emergency care services, and help employers implement health and safety standards. Perianesthesia nurses provide preoperative and postoperative care to patients undergoing anesthesia during surgery or other procedure. Perioperative nurses assist surgeons by selecting and handling instruments, controlling bleeding, and suturing incisions. Some of these nurses also can specialize in plastic and reconstructive surgery. Psychiatric-mental health nurses treat patients with personality and mood disorders. Radiology nurses provide care to patients undergoing diagnostic radiation procedures such as ultrasounds, magnetic resonance imaging, and radiation therapy for oncology diagnoses. Rehabilitation nurses care for patients with temporary and permanent disabilities. Transplant nurses care for both transplant recipients and living donors and monitor signs of organ rejection.

RNs specializing in a particular disease, ailment, or health care condition are employed in virtually all work settings, including physicians' offices, outpatient treatment facilities, home health care agencies, and hospitals. Addictions nurses care for patients seeking help with alcohol, drug, tobacco, and other addictions. Intellectual and developmental disabilities nurses provide care for patients with physical, mental, or behavioral disabilities; care may include help with feeding, controlling bodily functions, sitting or standing independently, and speaking or other communication. Diabetes management nurses help diabetics to manage their disease by teaching them proper nutrition and showing them how to test blood sugar levels and administer insulin injections. Genetics nurses provide early detection screenings, counseling, and treatment of patients with genetic disorders, including cystic fibrosis and Huntington's disease. HIV/AIDS nurses care for patients diagnosed with HIV and AIDS. Oncology nurses care for patients with various types of cancer and may assist in the administration of radiation and chemotherapies and follow-up monitoring. Wound, ostomy, and continence nurses treat patients with wounds caused by traumatic injury, ulcers, or arterial disease; provide postoperative care for patients with openings that allow for alternative methods of bodily waste elimination; and treat patients with urinary and fecal incontinence.

RNs specializing in treatment of a particular organ or body system usually are employed in hospital specialty or critical care units, specialty clinics, and outpatient care facilities. Cardiovascular nurses treat patients with coronary heart disease and those who have had heart surgery, providing services such as postoperative rehabilitation. Dermatology nurses treat patients with disorders of the skin, such as skin cancer and psoriasis. Gastroenterology nurses treat patients with digestive and intestinal disorders, including ulcers, acid reflux disease, and abdominal bleeding. Some nurses in this field also assist in specialized procedures such as endoscopies, which look inside the gastrointestinal tract using a tube equipped with a light and a camera that can capture images of diseased tissue. Gynecology nurses provide care to women with disorders of the reproductive system, including endometriosis, cancer, and sexually transmitted diseases. Nephrology nurses care for patients with kidney disease caused by diabetes, hypertension, or substance abuse. Neuroscience nurses care for patients with dysfunctions of the nervous system, including brain and spinal cord injuries and seizures. Ophthalmic nurses provide care to patients with disorders of the eyes, including blindness and glaucoma, and to patients undergoing eye surgery. Orthopedic nurses care for patients with muscular and skeletal problems, including arthritis, bone fractures, and muscular dystrophy. Otorhinolaryngology nurses care for patients with ear, nose, and throat disorders, such as cleft palates, allergies, and sinus disorders. Respiratory nurses provide care to patients with respiratory disorders such as asthma, tuberculosis, and cystic fibrosis. Urology nurses care for patients with disorders of the kidneys, urinary tract, and male reproductive organs, including infections, kidney and bladder stones, and cancers.

RNs who specialize by population provide preventive and acute care in all health care settings to the segment of the population in which they specialize, including newborns (neonatology), children and adolescents (pediatrics), adults, and the elderly (gerontology or geriatrics). RNs also may provide basic health care to patients outside of health care settings in such venues as including correctional facilities, schools, summer camps, and the military. Some RNs travel around the United States and abroad providing care to patients in areas with shortages of health care workers.

Most RNs work as staff nurses as members of a team providing critical health care . However, some RNs choose to become advanced practice nurses, who work independently or in collaboration with physicians, and may focus on the provision of primary care services. Clinical nurse specialists provide direct patient care and expert consultations in one of many nursing specialties, such as psychiatric-mental health. Nurse anesthetists provide anesthesia and related care before and after surgical, therapeutic, diagnostic and obstetrical procedures. They also provide pain management and emergency services, such as airway management. Nurse-midwives provide primary care to women, including gynecological exams, family planning advice, prenatal care, assistance in labor and delivery, and neonatal care. Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing and health care services to patients and families. The most common specialty areas for nurse practitioners are family practice, adult practice, women's health, pediatrics, acute care, and geriatrics. However, there are a variety of other specialties that nurse practitioners can choose, including neonatology and mental health. Advanced practice nurses can prescribe medications in all States and in the District of Columbia.

Some nurses have jobs that require little or no direct patient care, but still require an active RN license. Case managers ensure that all of the medical needs of patients with severe injuries and severe or chronic illnesses are met. Forensics nurses participate in the scientific investigation and treatment of abuse victims, violence, criminal activity, and traumatic accident. Infection control nurses identify, track, and control infectious outbreaks in health care facilities and develop programs for outbreak prevention and response to biological terrorism. Legal nurse consultants assist lawyers in medical cases by interviewing patients and witnesses, organizing medical records, determining damages and costs, locating evidence, and educating lawyers about medical issues. Nurse administrators supervise nursing staff, establish work schedules and budgets, maintain medical supply inventories, and manage resources to ensure high-quality care. Nurse educators plan, develop, implement, and evaluate educational programs and curricula for the professional development of student nurses and RNs. Nurse informaticists manage and communicate nursing data and information to improve decision making by consumers, patients, nurses, and other health care providers. RNs also may work as health care consultants, public policy advisors, pharmaceutical and medical supply researchers and salespersons, and medical writers and editors.

Work environment. Most RNs work in well-lighted, comfortable health care facilities. Home health and public health nurses travel to patients' homes, schools, community centers, and other sites. RNs may spend considerable time walking, bending, stretching, and standing. Patients in hospitals and nursing care facilities require 24-hour care; consequently, nurses in these institutions may work nights, weekends, and holidays. RNs also may be on call—available to work on short notice. Nurses who work in offices, schools, and other settings that do not provide 24-hour care are more likely to work regular business hours. About 20 percent of RNs worked part time in 2008.

RNs may be in close contact with individuals who have infectious diseases and with toxic, harmful, or potentially hazardous compounds, solutions, and medications. RNs must observe rigid, standardized guidelines to guard against disease and other dangers, such as those posed by radiation, accidental needle sticks, chemicals used to sterilize instruments, and anesthetics. In addition, they are vulnerable to back injury when moving patients.



Training, Other Qualifications, and Advancement

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The three major educational paths to registered nursing are a bachelor's degree, an associate degree, and a diploma from an approved nursing program. Nurses most commonly enter the occupation by completing an associate degree or bachelor's degree program. Individuals then must complete a national licensing examination in order to obtain a nursing license. Further training or education can qualify nurses to work in specialty areas, and may help improve advancement opportunities.

Education and training. There are three typical educational paths to registered nursing—a bachelor's of science degree in nursing (BSN), an associate degree in nursing (ADN), and a diploma. BSN programs, offered by colleges and universities, take about 4 years to complete. ADN programs, offered by community and junior colleges, take about 2 to 3 years to complete. Diploma programs, administered in hospitals, last about 3 years. Generally, licensed graduates of any of the three types of educational programs qualify for entry-level positions as a staff nurse. There are hundreds of registered nursing programs that result in ADN or BSN; however, there are relatively few diploma programs.

Individuals considering a career in nursing should carefully weigh the advantages and disadvantages of enrolling each type of education program. Advancement opportunities may be more limited for ADN and diploma holders compared to RNs who obtain a BSN or higher. Individuals who complete a bachelor's degree receive more training in areas such as communication, leadership, and critical thinking, all of which are becoming more important as nursing practice becomes more complex. Additionally, bachelor's degree programs offer more clinical experience in nonhospital settings. A bachelor's or higher degree is often necessary for administrative positions, research, consulting, and teaching

Many RNs with an ADN or diploma later enter bachelor's degree programs to prepare for a broader scope of nursing practice. Often, they can find an entry-level position and then take advantage of tuition reimbursement benefits to work toward a BSN by completing an RN-to-BSN program. Accelerated master's degree in nursing (MSN) programs also are available. They typically take 3-4 years to complete full time and result in the award of both the BSN and MSN.

There are education programs available for people interested in switching to a career in nursing as well. Individuals who already hold a bachelor’s degree in another field may enroll in an accelerated BSN program. Accelerated BSN programs last 12 to 18 months and provide the fastest route to a BSN for individuals who already hold a degree. MSN programs also are available for individuals who hold a bachelor's or higher degree in another field; master’s degree programs usually last 2 years.

All nursing education programs include classroom instruction and supervised clinical experience in hospitals and other healthcare facilities. Students take courses in anatomy, physiology, microbiology, chemistry, nutrition, psychology and other behavioral sciences, and nursing. Coursework also includes the liberal arts for ADN and BSN students.

Supervised clinical experience is provided in hospital departments such as pediatrics, psychiatry, maternity, and surgery. A number of programs include clinical experience in nursing care facilities, public health departments, home health agencies, and ambulatory clinics.

Licensure and certification. In all States, the District of Columbia, and U.S. territories, students must graduate from an approved nursing program and pass a national licensing examination, known as the National Council Licensure Examination, or NCLEX-RN, in order to obtain a nursing license. Other eligibility requirements for licensure vary by State. Contact your State’s board of nursing for details.

Other qualifications. Nurses should be caring, sympathetic, responsible, and detail oriented. They must be able to direct or supervise others, correctly assess patients' conditions, and determine when consultation is required. They need emotional stability to cope with human suffering, emergencies, and other stresses.

RNs should enjoy learning because continuing education credits are required by some States and/or employers at regular intervals. Career-long learning is a distinct reality for RNs.

Some nurses may become credentialed in specialties such as ambulatory care, gerontology, informatics, pediatrics, and many others. Credentialing for RNs is available from the American Nursing Credentialing Center, the National League for Nursing, and many others. Although credentialing is usually voluntary, it demonstrates adherence to a higher standard and some employers may require it.

Advancement. Most RNs begin as staff nurses in hospitals and, with experience and good performance, often move to other settings or are promoted to positions with more responsibility. In management, nurses can advance from assistant unit manager or head nurse to more senior-level administrative roles of assistant director, director, vice president, or chief of nursing. Increasingly, management-level nursing positions require a graduate or an advanced degree in nursing or health services administration. Administrative positions require leadership, communication and negotiation skills, and good judgment.

Some RNs choose to become advanced practice nurses, who work independently or in collaboration with physicians, and may focus on providing primary care services. There are four types of advanced practice nurses: clinical nurse specialists, nurse anesthetists, nurse-midwives, and nurse practitioners. Clinical nurse specialists provide direct patient care and expert consultations in one of many nursing specialties, such as psychiatric-mental health. Nurse anesthetists provide anesthesia and related care before and after surgical, therapeutic, diagnostic, and obstetrical procedures. They also provide pain management and emergency services, such as airway management. Nurse-midwives provide primary care to women, including gynecological exams, family planning advice, prenatal care, assistance in labor and delivery, and neonatal care. Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing and healthcare services to patients and families.

All four types of advanced practice nurses require at least a master's degree. In addition, all States specifically define requirements for registered nurses in advanced practice roles. Advanced practice nurses may prescribe medicine, but the authority to prescribe varies by State. Contact your State’s board of nursing for specific regulations regarding advanced practice nurses.

Some nurses move into the business side of healthcare. Their nursing expertise and experience on a healthcare team equip them to manage ambulatory, acute, home-based, and chronic care businesses. Employers—including hospitals, insurance companies, pharmaceutical manufacturers, and managed care organizations, among others—need RNs for health planning and development, marketing, consulting, policy development, and quality assurance. Other nurses work as college and university faculty or conduct research.



Employment

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As the largest healthcare occupation, registered nurses held about 2.6 million jobs in 2008. Hospitals employed the majority of RNs, with 60 percent of such jobs. About 8 percent of jobs were in offices of physicians, 5 percent in home healthcare services, 5 percent in nursing care facilities, and 3 percent in employment services. The remainder worked mostly in government agencies, social assistance agencies, and educational services.



Job Outlook

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Overall job opportunities for registered nurses are expected to be excellent, but may vary by employment and geographic setting. Some employers report difficulty in attracting and retaining an adequate number of RNs. Employment of RNs is expected to grow much faster than the average and, because the occupation is very large, 581,500 new jobs will result, among the largest number of new jobs for any occupation. Additionally, hundreds of thousands of job openings will result from the need to replace experienced nurses who leave the occupation.

Employment change. Employment of registered nurses is expected to grow by 22 percent from 2008 to 2018, much faster than the average for all occupations. Growth will be driven by technological advances in patient care, which permit a greater number of health problems to be treated, and by an increasing emphasis on preventive care. In addition, the number of older people, who are much more likely than younger people to need nursing care, is projected to grow rapidly.

However, employment of RNs will not grow at the same rate in every industry. The projected growth rates for RNs in the industries with the highest employment of these workers are:

Offices of physicians 48%
Home health care services 33
Nursing Care Facilities 25
Employment services 24
Hospitals, public and private 17

Employment is expected to grow more slowly in hospitals—health care's largest industry—than in most other health care industries. While the intensity of nursing care is likely to increase, requiring more nurses per patient, the number of inpatients (those who remain in the hospital for more than 24 hours) is not likely to grow by much. Patients are being discharged earlier, and more procedures are being done on an outpatient basis, both inside and outside hospitals. Rapid growth is expected in hospital outpatient facilities, such as those providing same-day surgery, rehabilitation, and chemotherapy.

More and more sophisticated procedures, once performed only in hospitals, are being performed in physicians' offices and in outpatient care centers, such as freestanding ambulatory surgical and emergency centers. Accordingly, employment is expected to grow very fast in these places as health care in general expands.

Employment in nursing care facilities is expected to grow because of increases in the number of elderly, many of whom require long-term care. However, this growth will be relatively slower than in other health care industries because of the desire of patients to be treated at home or in residential care facilities, and the increasing availability of that type of care. The financial pressure on hospitals to discharge patients as soon as possible should produce more admissions to nursing and residential care facilities and to home health care. Job growth also is expected in units that provide specialized long-term rehabilitation for stroke and head injury patients, as well as units that treat Alzheimer's victims.

Employment in home health care is expected to increase rapidly in response to the growing number of older persons with functional disabilities, consumer preference for care in the home, and technological advances that make it possible to bring increasingly complex treatments into the home. The type of care demanded will require nurses who are able to perform complex procedures.

Rapid employment growth in employment services industry is expected as hospitals, physician's offices, and other health care establishments utilize temporary workers to fill short-term staffing needs. And as the demand for nurses grows, temporary nurses will be needed more often, further contributing to employment growth in this industry.

Job prospects. Overall job opportunities are expected to be excellent for registered nurses. Employers in some parts of the country and in certain employment settings report difficulty in attracting and retaining an adequate number of RNs, primarily because of an aging RN workforce and a lack of younger workers to fill positions. Qualified applicants to nursing schools are being turned away because of a shortage of nursing faculty. The need for nursing faculty will only increase as many instructors near retirement. Despite the slower employment growth in hospitals, job opportunities should still be excellent because of the relatively high turnover of hospital nurses. To attract and retain qualified nurses, hospitals may offer signing bonuses, family-friendly work schedules, or subsidized training. Although faster employment growth is projected in physicians' offices and outpatient care centers, RNs may face greater competition for these positions because they generally offer regular working hours and more comfortable working environments. Generally, RNs with at least a bachelor's degree will have better job prospects than those without a bachelor's. In addition, all four advanced practice specialties—clinical nurse specialists, nurse practitioners, nurse-midwives, and nurse anesthetists—will be in high demand, particularly in medically underserved areas such as inner cities and rural areas. Relative to physicians, these RNs increasingly serve as lower-cost primary care providers.



Earnings

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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.

Source: Bureau of Labor Statistics


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