A British nurse caring for a baby
|Competencies||Caring for general well-being of patients|
|Qualifications in terms of statutory regulations according to national, state, or provincial legislation in each country|
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 many specialties with differing levels of prescription authority. Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the 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 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 multidisciplinary health care team such as therapists, medical practitioners and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.
Nursing historians face the challenge of determining whether care provided to the sick or injured in antiquity was nursing care. In the fifth century BC, for example, the Hippocratic Collection in places describes skilled care and observation of patients by male "attendants", who may have been early nurses. Around 600 BC in India, it is recorded in Sushruta Samhita, Book 3, Chapter V about the role of nurse as "the different parts or members of the body as mentioned before including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, any one desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully, observe, by dissecting it, and examine its different parts."
Before the foundation of modern nursing, members of religious orders such as nuns and monks often provided nursing-like care. Examples exist in Christian, Islamic and Buddhist traditions amongst others. Phoebe, mentioned in Romans 16 has been described in many sources as "the first visiting nurse". These traditions were influential in the development of the ethos of modern nursing. The religious roots of modern nursing remain in evidence today in many countries. One example in the United Kingdom is the use of the honorific "sister" to refer to a senior nurse.
During the Reformation of the 16th century, Protestant reformers shut down the monasteries and convents, allowing a few hundred municipal hospices to remain in operation in northern Europe. Those nuns who had been serving as nurses were given pensions or told to get married and stay home. Nursing care went to the inexperienced as traditional caretakers, rooted in the Roman Catholic Church, were removed from their positions. The nursing profession suffered a major setback for approximately 200 years.
Florence Nightingale laid the foundations of professional nursing during the Crimean War. Her Notes on Nursing became popular. The Nightingale model of professional education, having set up the first school of nursing that is connected to a continuously operating hospital and medical school, spread widely in Europe and North America after 1870.
Other important nurses in the development of the profession include:
- Agnes Hunt from Shropshire was the first orthopedic nurse and was pivotal in the emergence of the orthopedic hospital The Robert Jones & Agnes Hunt Hospital in Oswestry, Shropshire.
- Agnes Jones, who established a nurse training regime at the Brownlow Hill infirmary, Liverpool, in 1865.
- Linda Richards, who established quality nursing schools in the United States and Japan, and was officially the first professionally trained nurse in the US, 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.
Catholic orders such as Little Sisters of the Poor, Sisters of Mercy, Sisters of St. Mary, St. Francis Health Services, Inc. and Sisters of Charity built hospitals and provided nursing services during this period. In turn, the modern deaconess movement began in Germany in 1836. Within a half century, there were over 5,000 deaconesses in Europe.
Formal use of nurses in the modern military began in the latter half of the nineteenth century. Nurses saw active duty in the First Boer War, the Egyptian Campaign (1882) and the Sudan Campaign (1883).
Hospital-based training came to the fore in the early 1900s, with an emphasis on practical experience. The Nightingale-style school began to disappear. Hospitals and physicians saw women in nursing as a source of free or inexpensive labor. Exploitation of nurses was not uncommon by employers, physicians and educational providers.
Many nurses saw active duty in World War I, but the profession was transformed during the second World War. British nurses of the Army Nursing Service were part of every overseas campaign. More nurses volunteered for service in the US Army and Navy than any other occupation. The Nazis had their own Brown Nurses, 40,000 strong. Two dozen German Red Cross nurses were awarded the Iron Cross for heroism under fire.
The modern era saw the development of undergraduate and post-graduate nursing degrees. Advancement of nursing research and a desire for association and organization led to the formation of a wide variety of professional organizations and academic journals. Growing recognition of nursing as a distinct academic discipline was accompanied by an awareness of the need to define the theoretical basis for practice.
In the 19th and early 20th century, nursing was considered a women's profession, just as doctoring was a men's profession. With increasing expectations of workplace equality during the late 20th century, nursing became an officially gender-neutral profession, though in practice the percentage of male nurses remains well below that of female physicians in the early 21st century.
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 judgment 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 (2003)
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.
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. 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 bachelor's degree for the RN and a two-year diploma for the LPN. A registered nurse 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 United States, 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. It is also referred to as Associate in Nursing (AN), Associate of Applied Science in Nursing (AAS), or Associate of Science in Nursing (ASN). The Bachelor of Science in Nursing (BScN) 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 United States, graduates are eligible to sit for a licensing examination to become a nurse, the passing of which is required for the nursing license. The National Licensure Examination (NCLEX) test is a multiple choice exam nurses take to become licensed. It costs two-hundred dollars to take the NCLEX. It examines a nurses ability to properly care for a client. Study books and practice tests are available for purchase.
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. Other options include: Pediatrics, Neonatal, Maternity, OBGYN, Geriatrics, Ambulatory, or Nurse Anesthetists. There are many other options nurses can explore depending on the type of degree and education acquired. RNs may also pursue different roles as advanced practice registered nurses.
Nurses are not truly doctor's assistants. This is possible in certain situations, but nurses more often are independently caring for their patients or assisting other nurses. Registered Nurses treat patients, record their medical history, provide emotional support, and provide follow-up care. Nurses also help doctors perform diagnostic tests. Nurses are almost always working on their own or with other nurses. Nurses will assist doctors in the emergency room or in trauma care when help is needed.
Despite equal opportunity legislation, nursing has continued to be a female-dominated profession. For instance, the male-to-female ratio of nurses is approximately 1:19 in Canada and the United States. 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. In Europe, in countries such as Spain, Portugal, Czech Republic and Italy, over 20% of nurses are male. The number of male-registered nurses in the United States between 1980 and 2000s doubled.
There are many myths about nursing, including the profession and the people that work as a nurse. One of the most common myths is that all nurses are females. The nursing industry is dominated by females, but there are male nurses in the profession as well. A study in 2011 shows that 91% of all nurses in the United States were female, and 9% were male. Although females are more common, male nurses receive more pay. In the same survey, male nurses average $60,700 per year and female nurses average $51,100 per year. Male nurses have the highest percentage as nurse anesthetists, rating at 41%.
Theory and 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.
Scope of activities
Activities of daily living assistance
Assisting in activities of daily living (ADL) are skills required in nursing as well as other professions such as nursing assistants. This includes assisting in patient mobility, such as moving an activity intolerant patient within bed. For hygiene, this often involves bed baths and assisting with urinary and bowel elimination.
Nurses do not have the authority to prescribe medications, with few exceptions. All medications administered by nurses must be from a medication prescription from a licensed practitioner. Nurses are legally responsible for the drugs they administer and there may be legal implications when there is an error in a prescription and the nurse could be expected to have noted and reported error. In the United States, nurses have the right to refuse any medication administration that they deem to be harmful to the patient. In the United Kingdom there are some nurses who have taken additional specialist training that allows them to prescribe certain medications.
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:
- family/individual across the lifespan
- women's health/gender-related
- psych/mental health
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 (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. 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. 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. Some countries and states have passed legislation regarding acceptable nurse-to-patient ratios.
The fast-paced and unpredictable nature of health care places nurses at risk for injuries and illnesses, including high occupational stress. Nursing is a particularly stressful profession, and nurses consistently identify stress as a major work-related concern and have among the highest levels of occupational stress when compared to other professions. This stress is caused by the environment, psychosocial stressors, and the demands of nursing, including new technology that must be mastered, the emotional labor involved in nursing, physical labor, shift work, and high workload. This stress puts nurses at risk for short-term and long-term health problems, including sleep disorders, depression, mortality, psychiatric disorders, stress-related illnesses, and illness in general. Nurses are at risk of developing compassion fatigue and moral distress, which can worsen mental health. They also have very high rates of occupational burnout (40%) and emotional exhaustion (43.2%). Burnout and exhaustion increase the risk for illness, medical error, and suboptimal care provision.
In the United States, the Occupational Health Safety Network (OHSN) is an 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. It focuses on three high risk and preventable events:
- Musculoskeletal injuries from patient handling activities;
- Slips, trips, and falls
- Workplace violence
Hospitals and other healthcare facilities can upload the occupational injury data they already collect for analysis and benchmarking with other de-identified facilities, in order to identify and implement timely and targeted interventions.
Nurses are also at risk for violence and abuse in the workplace. Violence is typically perpetrated by non-staff (e.g. patients or family), whereas abuse is typically perpetrated by other hospital personnel. 57% of American nurses reported in 2011 that they had been threatened at work; 17% were physically assaulted.
There are a number of interventions that can mitigate the occupational hazards of nursing. They can be individual-focused or organization-focused. Individual-focused interventions include stress management programs, which can be customized to individuals. Stress management programs can reduce anxiety, sleep disorders, and other symptoms of stress. Organizational interventions focus on reducing stressful aspects of the work environment by defining stressful characteristics and developing solutions to them. Using organizational and individual interventions together is most effective at reducing stress on nurses.
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.
The state nursing licensing bodies amalgamated in Australia in 2011 under the 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 (enrolled nurses can progress to registered nurse status and do get credit for previous study)
- Nurse practitioners have started emerging from postgraduate programs and work in private practice.
- 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. 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 specialization.
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' favor
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 in the EU member states, EEA countries and Switzerland. This list is covered by the Directive 2005/36/EC .
Nursing educational program in Iran is similar to the nursing educational program in other countries from some aspects. Holding secondary school diploma and passing the entrance exam is necessary for the admission in this course. Entrance exam to governmental universities and Azad University is held on separate basis. Duration of associate degree course of operating room and anesthesia is 2 years, bachelor's degree in nursing is 4 years and master's degree in nursing is 2- 2.5 years and PhD degree in nursing is 4–5 years.
In the beginning, nursing educational program was the part of medical educational program. On the basis of this structure, the nurse follows the instruction of physician without any question. Nowadays, nursing educational program in Iran has been progressed and after the year 1992 considering the community base care, the nursing educational program also has changed. At present nursing education is held in 43 governmental nursing colleges and 63 nursing colleges of Azad University. Governmental universities' students do not have to pay tuition fee, but in Azad University, which is a private university, the students must pay necessary expenses. The PhD degree program is held only in governmental universities under the supervision of Ministry of Health and Ministry of Sciences.
In bachelor's degree program, nursing students start the clinical work from 2nd term and pass till the completion of 6th term simultaneously with theoretical subjects. 7th and 8th terms are allocated for training program. At present nursing educational program in throughout Iran is the same and is compiled under the supervision of Supreme Council of Ministry of Health, Treatment and Medical Education. Nursing students take the theoretical subjects, training and internship courses in various sections of educational hospitals and hospitals that affiliated to universities. Students' learning, in clinical sections is performed under the direct supervision and guidance of nursing instructors, but in the final year, activities of students mainly performs under the supervision of nursing personnel and alternate supervision of nursing instructors.
Students, during the years of study have opportunity to create relation with patients in the various sections especially intensive care units and to achieve experiences. Students' progress in clinical environments is from simple issues toward harder issues. At present practical nursing degree and associate degree Nursing Program has been canceled and Iranian nurses must hold bachelor's degree to work in Iran from accredited universities confirmed by the Ministry of Health.
Nursing Groups in Iran
Nurse is a person who is holding four years university degree and executes works relating to nursing profession including taking care of patients, perform health and medical services, educational, research and managerial affairs. At present annually 6000 persons are graduated in the bachelor's degree program in nursing.
- Practical Nurse
A person who is holding secondary school diploma in nursing and have completed 2 years program in nursing and cooperate in activities of nurses in medical sections under the supervision of nurses.
- Nursing Assistant
A person who is holding secondary school diploma and passing short term program for the execution of initial cares of patients under the supervision of nurses.
- Operating Room Technician
These persons after obtaining secondary school diploma and passing university's entrance exam and completing 2 years program are in charge of performing professional duties in operation room for preparing patients for surgery and necessary cooperation with surgeons at the time of surgery. These persons by passing the exam are eligible to continue uncontinuous bachelor's degree course in nursing.
- Anesthesia Technician
These persons after obtaining secondary school diploma and passing university's entrance exam and completing 2 years program in Anesthesia, are in charge of performing profession duties in the operating room in the field of anesthesia including preparing the patients for anesthesia and necessary cooperation with anesthesiologists at the time of operation. These persons by passing exam are eligible to continue uncontinuous bachelor's degree course in nursing.
- Emergency medical technician
These persons after obtaining secondary school diploma and passing entrance exam of university and obtaining technician diploma are in change of performing affairs including rendering first aid services to the patients and emergency victims resulting from accidents with motor vehicles, explosion, debris, falling from height, fractures, burns, poisonings, cuts, drowning, industrial accidents (cutting of limbs), patients with heart diseases and baby delivering.
- Master in Nursing
Nurses after obtaining bachelor's degree and passing the entrance exam are eligible to continue their study in geriatric nursing, pediatric nursing, medical surgical nursing, community health nursing, psychiatric nursing and nursing education. These persons after graduation mainly become in charge of nurses' education or management of medical sections. Duration of this program is 2.5 years. At present annually 150 persons are graduated in master's degree program in nursing.
- PhD in Nursing
Nurses by holding master's degree after passing entrance exam, are eligible to continue their study in PhD in the field of Nursing. Duration of this program is 4 years and the graduates mainly will work in educational and research sections. At present annually 20 persons are graduated in this program.
Nursing jobs in Iran
According to the censes at present approximately 120,000 nurses are working in Iran in various sections. Most of them are working in hospitals and health centers belong to Ministry of Health, Treatment & Medical Education. Also, nurses are working in the hospitals affiliated to social security organization, armed forces, private sector and charity sector.
Within the last years of independence, nurses' activities are established in offices of consultancy and rendering nursing services at home. Nurses by establishment these centers can render consultant and care services to the client.
At present to work as a nurse only holding accredited academic degree is sufficient, but there are programs for nurses to take RN examination after graduation.
Also, upon the approval and execution of continuous educational act, the Iranian nurses should obtain score of 15 every year in various educational courses held by the Ministry of Health of Universities, Scientific Associations and Nursing organization.
Iranian Nursing Organization (INO)
Having an independent organization that defends the rights of nurses and to follow up nurses' problems was the long time wishes of Iranian nurses. Before Islamic revolution in 1979, efforts in this respect finally led to the establishment of the Iranian Nurses Association and activities were taken in this respect. After the victory of Islamic revolution, this association also canceled its activities and after that, number of associations mainly with political and professional formation was established, but the main problem of nurses was still present. Gradually in the year 1994 with the efforts of numbers of persons mostly nursing students and faculty member, the preliminary step was taken for the establishment of nursing organization. This preliminary nucleus started its work in the name of Nursing Coordination council with the instruction of students.
This council had correspondences with the president, speaker of parliament, ministry of health, treatment and medical education in connection with problems of nursing society. Also this organization had correspondence with nursing colleges for unity throughout the country.
After this date till March 2001, a number of state seminars were held in various cities and finally on March 5.2001, generalities of formation of Nursing Organization was entered in the agenda of the Islamic Consultative Assembly, and finally approved in an open session on Aug.12.2001. Finally with the procurement of comments of Guardian's Organization in Jan.2002, Establishment Act of Nursing Organization was approved by the parliament.
The first election of board of directors throughout the country was performed on Sept.20.2002 and members of 85 boards of directors of districts were elected throughout the country with the direct vote of nurses. The board of directors of the first Supreme of Organization, was elected on Dec.8.2002.
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. From April 2016, nurses in the United Kingdom are expected to revalidate every three years which involves providing evidence of further development and active practice.
First and second level
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).
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.
- Nurse practitioners – Most of these nurses obtain a minimum of a master's 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 NPs 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.
Nursing in the United Kingdom
To become a registered nurse, one must complete a program recognised by the Nursing and Midwifery Council (NMC) . Currently, this involves completing a degree, 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, assignments 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. Skills included in the CFP may include communication, taking observations, administering medication and providing personal care to patients. 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 the UK to hold a degree qualification. However, those nurses who hold a diploma, or even a certificate in nursing are still able to legally practice in the UK, although they are able to undertake university modules to obtain enough credits to top up to a degree.
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) programs 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.
As of 2016 student nurses in the UK can apply a bursary from the government to support them during their nurse training, and may also be eligible for a student loan, although there has been speculation that this will not be available in the future.
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.
There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venipuncture, intravenous drug therapy and male catheterization are the most common, although there are many others (such as advanced life support), which some nurses 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 was 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.
To become specialist nurses (such as nurse consultants, nurse practitioners etc.) or nurse educators, some nurses undertake further training above bachelor's degree level. Master's 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 to become such they must undertake specialist training. This is a one-year full-time degree.
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.
Canadian nursing dates back to 1639 in Quebec with the Augustine nuns. 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. 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.
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 him or her more of an edge in the field. This ultimately saves the hospital money because they deal with less problematic incidents. All Canadian provinces and territories except for the Yukon and Quebec require that all nurses must have a baccalaureate degree. 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.
Nursing specialty certification is available through the Canadian Nurses Association in nineteen practice areas. Some of those specialties are cardiovascular nursing, community health nursing, critical care nursing, emergency nursing, gerontological nursing, medical-surgical nursing, neuroscience nursing, oncology nursing, orthopedic nursing, psychiatric/mental health nursing, and rehabilitation nursing. Certification requires practice experience and passing a test that is based on competencies for that specialty.
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".
Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance. 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. 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. 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
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 labour 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. 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 Bachelor's 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's degree, go to a junior nursing college for three years or go to a nursing school for three years. 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. 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. Japanese nurses never have to renew their licenses. Once they have passed their exam, they have their license for life.
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. 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. 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. The JNA is 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. It is a union that includes physicians as well as nurses. This organization was involved with the Nursing Human Resource Law.
- In Taiwan, the Ministry of Health and Welfare is in charge of the regulation of nursing. The Taiwan Union of Nurses Association (TUNA) is the union unit in Taiwan, fighting for nurses on payment and working time issues.
In the US, scope of practice is determined by the state or territory in which a nurse 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, licenses nurses and nursing assistants, and makes decisions on nursing issues. 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).
In the hospital setting, registered nurses often delegate tasks to LPNs and unlicensed assistive personnel.
RNs are not limited to employment as bedside nurses. They 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.
Nursing is the nation's largest health care profession, with more than 3.1 million registered nurses nationwide. Of all licensed RNs, 2.6 million or 84.8% are employed in nursing. Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation's long-term care. The primary pathway to professional nursing, as compared to technical-level practice, is the four-year Bachelor of Science in Nursing (BSN) degree . Registered nurses are prepared either through a BSN program; a three-year associate degree in nursing; or a three-year hospital training program, receiving a hospital diploma. All take the same state licensing exam. (The number of diploma programs has declined steadily—to less than 10 percent of all basic RN education programs—as nursing education has shifted from hospital-operated instruction into the college and university system.)
Educational and licensure requirements
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. 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.
Associate Degree 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 prerequisite and corequisite courses (which may include English, Math and Human Anatomy and Physiology) and ultimately stretch out the degree-acquiring process to about three years or greater.
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. In some new programs the first two years can be substituted for an active LPN license along with the required general studies. 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. Nursing schools may be accredited by either the Accreditation Commission for Education in Nursing (ACEN) 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. 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).
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 and CNSs 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, additionally, a CNS usually works for a facility to improve patient care, do research, or as a staff educator.
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.
Shortage in the United States
RNs are the largest group of health care workers in the United States, with about 2.7 million employed in 2011. 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. The Bureau of Labor Statistics reported that 296,900 healthcare jobs were created in 2011. RNs 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).
The International Council Of Nursing (ICN), the largest international health professional organization in the world, recognizes the shortage of nurses as a growing crisis in the world. This shortage impacts the healthcare of everyone worldwide. One of the many reasons is that nurses who pursue to become nurses do so very late in their lives. This leads to a non-lengthy employment time. 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. Approximately 29.8 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. 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.
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.
Furthermore, there is a shortage of academically qualified instructors to teach at schools of nursing worldwide. The serious need for educational capacity is not being met, which is the underlying most important preparation resource for the nurses of tomorrow. The decrease in faculty everywhere is due to many factors including decrease in satisfaction with the workforce, poor salaries, and reduction in full-time equivalent. Throughout the span of 6 years the nursing faculty shortage has been written about an increasing amount. Unfortunately, there is no clear consensus or an organized plan on how to fix the ongoing issue.
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 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.
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.
The Nursing education is governed in India by the central body Indian Nursing Council and its norms are implemented through respective State Nursing council such as Kerala Nurses and Midwives Council.
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- International Council of Nurses
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