Significant points
- Registered nurses constitute the largest health care occupation, with 2.4 million jobs.
- About 3 out of 5 jobs are in hospitals.
- The three major educational paths to registered nursing are a bachelor's degree, an associate degree, and a diploma from an approved nursing program.
- Registered nurses are projected to create the second largest number of new jobs among all occupations; job opportunities in most specialties and employment settings are expected to be excellent, with some employers reporting difficulty in attracting and retaining enough RNs.
Nature of the work
Registered nurses (RNs), regardless of specialty or work setting, perform basic duties that include treating patients, educating patients and the public about various medical conditions, and providing advice and emotional support to patients' family members. RNs record patients' medical histories and symptoms, help to 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, including post-treatment home care needs, diet and exercise programs, and self-administration of medication and physical therapy. Some RNs also are trained to provide grief counseling to family members of critically ill patients. RNs work to promote general health by educating the public on various warning signs and symptoms of disease and where to go for help. RNs also might run general health screening or immunization clinics, blood drives, and public seminars on various conditions.
RNs can specialize in one or more patient care specialties. The most common specialties can be divided into roughly four categories-by work setting or type of treatment; disease, ailment, or condition; organ or body system type; or population. RNs may combine specialties from more than one area-for example, pediatric oncology or cardiac emergency-depending on personal interest and employer needs.
RNs may specialize by work setting or by type of care provided. For example, ambulatory care nurses treat patients with a variety of illnesses and injuries on an outpatient basis, either 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 or the Internet. Critical care nurses work in critical or intensive care hospital units and provide care to patients with cardiovascular, respiratory, or pulmonary failure. Emergency, or trauma, nurses work in hospital emergency departments and treat patients with life-threatening conditions caused by accidents, heart attacks, and strokes. Some emergency nurses are flight nurses, who provide medical care to patients who must be flown by helicopter 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 care for patients who are recovering from surgery, accidents, and childbirth. Hospice and palliative care nursesprovide care for, and help ease the pain of, terminally ill patients outside of hospitals. Infusion nurses administer medications, fluids, and blood to patients through injections into patients' veins. Long- term care nurses provide medical services on a recurring basis to patients with chronic physical or mental disorders. Medical-surgical nurses provide basic medical care to a variety of patients in all health settings. Occupational health nursesprovide treatment for job-related injuries and illnesses and help employers to detect workplace hazards and implement health and safety standards. Perianesthesia nurses provide preoperative and postoperative care to patients undergoing anesthesia during surgery. 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 nurses treat patients with personality and mood disorders. Radiologic nurses provide care to patients undergoing diagnostic radiation procedures such as ultrasounds and magnetic resonance imaging. 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 condition are employed in virtually all work settings, including physicians' offices, outpatient treatment facilities, home health care agencies, and hospitals. For instance, addictions nurses treat patients seeking help with alcohol, drug, and tobacco addictions. Developmental disabilities nurses provide care for patients with physical, mental, or behavioral disabilities; care may include help with feeding, controlling bodily functions, and sitting or standing independently. 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 nursesprovide early detection screenings 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 nursescare for patients with various types of cancer and may administer radiation and chemotherapies. Finally, 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 specialty physicians' offices or outpatient care facilities, although some are employed in hospital specialty or critical care units. For example, cardiac and vascular 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 specialize in endoscopic procedures, 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.
Finally, RNs may specialize by providing preventive and acute care in all health care settings to various segments of the population, 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 medical professionals.
Most RNs work as staff nurses, providing critical health care services along with physicians, surgeons, and other health care practitioners. However, some RNs choose to become advanced practice nurses, who often are considered primary health care practitioners and work independently or in collaboration with physicians. For example, clinical nurse specialists provide direct patient care and expert consultations in one of many of the nursing specialties listed above. Nurse anesthetists administer anesthesia, monitor patient's vital signs during surgery, and provide post-anesthesia care. 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 provide basic preventive health care to patients, and increasingly serve as primary and specialty care providers in mainly medically underserved areas. The most common areas of specialty for nurse practitioners are family practice, adult practice, women's health, pediatrics, acute care, and gerontology; however, there are many other specialties. In most States, advanced practice nurses can prescribe medications.
Some nurses have jobs that require little or no direct patient contact. Most of these positions still require an active RN license. Case managers ensure that all of the medical needs of patients with severe injuries and illnesses are met, including the type, location, and duration of treatment. Forensics nurses combine nursing with law enforcement by treating and investigating victims of sexual assault, child abuse, or accidental death. Infection control nurses identify, track, and control infectious outbreaks in health care facilities; develop methods of outbreak prevention and biological terrorism responses; and staff immunization clinics. 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, and maintain medical supply inventories. Nurse educators teach student nurses and also provide continuing education for RNs. Nurse informaticists collect, store, and analyze nursing data in order to improve efficiency, reduce risk, and improve patient care. RNs also may work as health care consultants, public policy advisors, pharmaceutical and medical supply researchers and salespersons, and medical writers and editors.
Working conditions
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 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 office settings are more likely to work regular business hours. About 23 percent of RNs worked part time in 2004, and 7 percent held more than one job.
Nursing has its hazards, especially in hospitals, nursing care facilities, and clinics, where nurses may care for individuals with infectious diseases. 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, shocks from electrical equipment, and hazards posed by compressed gases. RNs who work with critically ill patients also may suffer emotional strain from observing patient suffering and from close personal contact with patients' families.
Training
In all States and the District of Columbia, students must graduate from an approved nursing program and pass a national licensing examination, known as the NCLEX-RN, in order to obtain a nursing license. Nurses may be licensed in more than one State, either by examination or by the endorsement of a license issued by another State. Currently 18 States participate in the Nurse Licensure Compact Agreement, which allows nurses to practice in member States without recertifying. All States require periodic renewal of licenses, which may involve continuing education.
There are three major 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. In 2004, 674 nursing programs offered degrees at the bachelor's level. ADN programs, offered by community and junior colleges, take about 2 to 3 years to complete. About 846 RN programs in 2004 granted associate degrees. Diploma programs, administered in hospitals, last about 3 years. Only 69 programs offered diplomas in 2004. Generally, licensed graduates of any of the three types of educational programs qualify for entry-level positions as staff nurses.
Many RNs with an ADN or diploma later enter bachelor's programs to prepare for a broader scope of nursing practice. Often, they can find a staff nurse position and then take advantage of tuition reimbursement benefits to work toward a BSN by completing an RN-to-BSN program. In 2004, there were 600 RN-to-BSN programs in the United States. Accelerated master's degree programs in nursing also are available. These programs combine 1 year of an accelerated BSN program with 2 years of graduate study. In 2004, there were 137 RN-to-MSN programs.
Accelerated BSN programs also are available for individuals who have a bachelor's or higher degree in another field and who are interested in moving into nursing. In 2004, more than 165 of these programs were available. Accelerated BSN programs last 12 to 18 months and provide the fastest route to a BSN for individuals who already hold a degree.
Individuals considering nursing should carefully weigh the advantages and disadvantages of enrolling in a BSN program, because, if they do, their advancement opportunities usually are broader. In fact, some career paths are open only to nurses with a bachelor's or master's degree. A bachelor's degree often is necessary for administrative positions and is a prerequisite for admission to graduate nursing programs in research, consulting, and teaching, and all four advanced practice nursing specialties-clinical nurse specialists, nurse anesthetists, nurse midwives, and nurse practitioners. Individuals who complete a bachelor's receive more training in areas such as communication, leadership, and critical thinking, all of which are becoming more important as nursing care becomes more complex. Additionally, bachelor's degree programs offer more clinical experience in nonhospital settings. In 2004, 417 nursing schools offered master's degrees, 93 offered doctoral degrees, and 46 offered accelerated BSN-to-doctoral programs.
All four advanced practice nursing specialties require at least a master's degree. Most programs last about 2 years and require a BSN degree and some programs require at least 1 to 2 years of clinical experience as an RN for admission. In 2004, there were 329 master's and post-master's programs offered for nurse practitioners, 218 master's and post-master's programs for clinical nurse specialists, 92 programs for nurse anesthetists, and 45 programs for nurse midwives. Upon completion of a program, most advanced practice nurses become nationally certified in their area of specialty. In some States, certification in a specialty is required in order to practice that specialty.
All nursing education programs include classroom instruction and supervised clinical experience in hospitals and other health care 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 growing number of programs include clinical experience in nursing care facilities, public health departments, home health agencies, and ambulatory clinics.
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.
Some RNs start their careers as licensed practical nurses or nursing aides, and then go back to school to receive their RN degree. Most RNs begin as staff nurses, and with experience and good performance often are promoted to more responsible positions. In management, nurses can advance to assistant head nurse or head nurse and, from there, to assistant director, director, and vice president. Increasingly, management-level nursing positions require a graduate or an advanced degree in nursing or health services administration. They also require leadership, negotiation skills, and good judgment.
Some nurses move into the business side of health care. Their nursing expertise and experience on a health care team equip them to manage ambulatory, acute, home-based, and chronic care. 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.
Foreign-educated nurses wishing to work in the United States must obtain a work visa. Applicants are required to undergo a review of their education and licensing credentials and pass a nursing certification and English proficiency exam, both conducted by the Commission on Graduates of Foreign Nursing Schools. (The commission is an immigration-neutral, nonprofit organization that is recognized internationally as an authority on credentials evaluation in the health care field.) Applicants from Australia, Canada (except Quebec), Ireland, New Zealand, and the United Kingdom are exempt from the language proficiency exam. In addition to these national requirements, most States have their own requirements.
Employment
As the largest health care occupation, registered nurses held about 2.4 million jobs in 2004. About 3 out of 5 jobs were in hospitals, in inpatient and outpatient departments. Others worked in offices of physicians, nursing care facilities, home health care services, employment services, government agencies, and outpatient care centers. The remainder worked mostly in social assistance agencies and educational services, public and private. About 1 in 4 RNs worked part time.
Job outlook
Job opportunities for RNs in all specialties are expected to be excellent. Employment of registered nurses is expected to grow much faster than average for all occupations through 2014, and, because the occupation is very large, many new jobs will result. In fact, registered nurses are projected to create the second largest number of new jobs among all occupations. Thousands of job openings also will result from the need to replace experienced nurses who leave the occupation, especially as the median age of the registered nurse population continues to rise.
Much faster-than-average growth will be driven by technological advances in patient care, which permit a greater number of medical 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.
Employers in some parts of the country and in certain employment settings are reporting 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. Enrollments in nursing programs at all levels have increased more rapidly in the past couple of years as students seek jobs with stable employment. However, many qualified applicants are being turned away because of a shortage of nursing faculty to teach classes. The need for nursing faculty will only increase as a large number of instructors nears retirement. Many employers also are relying on foreign-educated nurses to fill open positions.
Even though employment opportunities for all nursing specialties are expected to be excellent, they can vary by employment setting. For example, employment is expected to grow more slowly in hospitals-which comprise 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.
Despite the slower employment growth in hospitals, job opportunities should still be excellent because of the relatively high turnover of hospital nurses. RNs working in hospitals frequently work overtime and night and weekend shifts and also treat seriously ill and injured patients, all of which can contribute to stress and burnout. Hospital departments in which these working conditions occur most frequently-critical care units, emergency departments, and operating rooms-generally will have more job openings than other departments.
To attract and retain qualified nurses, hospitals may offer signing bonuses, family-friendly work schedules, or subsidized training. A growing number of hospitals also are experimenting with online bidding to fill open shifts, in which nurses can volunteer to fill open shifts at premium wages. This can decrease the amount of mandatory overtime that nurses are required to work.
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 much faster than average in these places as health care in general expands. However, RNs may face greater competition for these positions because they generally offer regular working hours and more comfortable working environments.
Employment in nursing care facilities is expected to grow faster than average because of increases in the number of elderly, many of whom require long-term care. In addition, the financial pressure on hospitals to discharge patients as soon as possible should produce more admissions to nursing care facilities. 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. 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, midwives, and 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
Median annual earnings of registered nurses were $52,330 in May 2004. The middle 50 percent earned between $43,370 and $63,360. The lowest 10 percent earned less than $37,300, and the highest 10 percent earned more than $74,760. Median annual earnings in the industries employing the largest numbers of registered nurses in May 2004 were as follows:
- Employment services $63,170
- General medical and surgical hospitals 53,450
- Home health care services 48,990
- Offices of physicians 48,250
- Nursing care facilities 48,220
Related occupations
Workers in other health care occupations with responsibilities and duties related to those of registered nurses are cardiovascular technologists and technicians; diagnostic medical sonographers; dietitians and nutritionists; emergency medical technicians and paramedics; licensed practical and licensed vocational nurses; massage therapists; medical and health services managers; nursing, psychiatric, and home health aides; occupational therapists; physical therapists; physician assistants; physicians and surgeons; radiologic technologists and technicians; respiratory therapists; and surgical technologists.
Suggested citation
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2006-07 Edition, Registered Nurses, on the Internet at http://www.bls.gov/oco/ocos083.htm (visited July 18, 2007).
