Contemporary Nursing Roles and Career Opportunities



Contemporary Nursing Roles and Career Opportunities


Robert W. Koch, DNS, RN




Key Terms



Advanced practice nursing


Based on knowledge and skills acquired through basic nursing education, with licensure as a registered nurse (RN) and graduate education and experience that includes advanced nursing theory, physical assessment, psychosocial assessment, and treatment of illness. Includes nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs).


Clinical nurse leader (CNL)


The CNL is a master’s degree–prepared generalist who oversees the care coordination of a distinct group of patients in any setting. The CNL actively provides direct patient care in complex situations, evaluates patient outcomes, and has the decision-making authority to change care plans when necessary. This clinician puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery and is envisioned as a leader in the health care delivery system.


Doctor of nursing practice (DNP)


The DNP is an expert in advanced nursing practice who has an earned clinically focused doctorate degree in nursing.


Interprofessional team


Health care team composed of professionals from different disciplines including chaplains, nurses, dietitians, pharmacists, physical therapists, physicians, respiratory therapists, social workers, and speech-language pathologists who cooperate, collaborate, communicate, and integrate care to ensure that care is continuous and reliable.


Nursing roles


(1) Traditional duties and responsibilities of the professional nurse, regardless of practice area or setting, such as the roles of care provider, educator, counselor, client advocate, change agent, leader and manager, researcher, and coordinator of the interprofessional health care team. (2) Duties and responsibilities of the professional nurse that are guided by specific professional standards of practice and usually carried out in a distinct practice area (e.g., flight nurse, forensic nurse, occupational nurse).





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Additional resources are available online at:


http://evolve.elsevier.com/Cherry/


VIGNETTE


When Eric Sanders graduated 15 years ago, he thought he would work in the hospital his entire career. However, with so many changes in the economic forces affecting health care and the resulting shift of clients outside acute care, more opportunities exist for him. Eric can take his skills and seek new ones to have a choice of practice roles and settings. Being a registered nurse now gives him more options for practice than he ever thought possible.




Chapter Overview


The health care system continues to change as social and economic factors create a state of constant evolution. Professional nurses respond by creating innovative alternatives to traditional nursing practice to meet these new challenges. As nurses proactively define solutions to today’s health care dilemmas, multiple career opportunities emerge.


In the past, most nurses considered acute care hospitals the main practice setting available upon graduation. Few other career choices were available. Public health nursing was one of the exceptions, providing variety in the nursing job market. As health care moves from inpatient treatment to outpatient and home care, and acute care shifts to health promotion and disease prevention, the U.S. culture seeks alternative options to meet this growing need. This shift in health care settings creates a variety of choices for nurses exploring career opportunities.


Nurses today have more liberty to explore and even create job opportunities. Nurses may continue to select the hospital acute care setting or venture into less traditional nursing roles. Nurses must claim ownership of nontraditional roles as they emerge in the health care job market. As professionals, they should exercise their influence to develop and support new nursing roles.


This chapter presents an overview of some key opportunities available for RNs today in the United States. Included are demographics of today’s nurses, in addition to implications for the future. This chapter examines the traditional and less traditional options available and the current and future issues for roles in professional practice.



Nursing—Much the Same, but Bigger and Better


In the past, describing the role of the RN was simple because there were few opportunities for variation. Today exploring job opportunities for RNs is more complicated because nurses can practice in literally hundreds of diverse settings with a broad variety of clients. The proliferation of career opportunities for nurses is growing. Although nursing roles have expanded, the traditional functions of the nurse remain intact. Box 26-1 summarizes the roles nurses assume in any employment role or setting.








Leader and Manager


The leadership role of the professional nurse is paramount to the health care system. Nursing leadership varies according to the level of application and includes the following:



There is little doubt that the management role of the nurse has become more important. Nursing management includes planning, giving direction, and monitoring and evaluating nursing care of individuals, groups, families, and communities.




Coordinator of the Interprofessional Health Care Team


Interprofessional teams consist of collaborative practice relationships among several disciplines of health care professionals. These disciplines may include nursing, medicine, pharmacy, nutrition, social work, case management, and other allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, and speech therapists. Chaplains or pastoral care representatives also serve a valuable role on the interprofessional health care team. These teams are found in all health care delivery settings and function most effectively when their focus revolves around the needs of the client.


Interprofessional teams are valuable because professional members bring in-depth and specialized knowledge and skills to the interaction process. In an age of exploding information, the roles of interprofessional team members complement one another. Through the formal and informal communication of ideas and opinions of team members, health care plans are determined. A plan of care developed by the interprofessional team is considered a valuable health management tool.


Interprofessional teams refer to coordination between and among disciplines involved in providing client care. The collaborative process involved in interprofessional health care transcends a single health profession to create comprehensive work outcomes. This team process can improve the quality of care, enhance client satisfaction, strengthen nursing satisfaction, and reduce hospital cost by decreasing hospital length of stay and increasing nurse retention.


Successful health care team models that use concepts related to interprofessional health care include pain management, nutritional support, skin care, rehabilitation, mental health, and hospice. Discharge planning, which emerged as a major focus of health care delivery in the 1980s, involves developing a plan of treatment that ultimately results in the discharge of the client from the health care facility. This practice is built on the concept of interprofessional care, with each discipline involved in providing care included in developing the discharge plan.


Client education is another area in which collaboration of disciplines is absolutely essential. Health care professionals must understand one another’s contributions to client education and ensure that the information clients and families receive is consistent and complete. This will produce the best possible health outcomes for clients and families.


Box 26-2 lists some common roles of interprofessional health care team members with the website of their associated professional organization. These team members are involved in client care to varying degrees, depending on client needs for the specific talents and knowledge of each team member. This list contains selected professional roles contributing to the interprofessional health care team approach, but there may be more in a given team.



BOX 26-2   INTERPROFESSIONAL HEALTH CARE TEAM MEMBERS




Nurse (RN): Often the coordinator of the team. RNs take licensure examinations after completing associate degree, diploma, or baccalaureate degree preparation from an accredited school of nursing. RNs are able to obtain specialty certification for advanced skills and/or advanced degrees. RNs use the nursing process in client care in any health care setting.



Physician (MD or DO): Often the leader of the team, the physician diagnoses and prescribes treatment interventions for clients. Medical doctors (MDs) or doctors of osteopathy (DOs) complete 4 years of medical school and board examinations. Physicians can complete postgraduate training, including internship, residency, and fellowship training in a specialty area. Physicians also complete state licensing examinations and function in all health care arenas.



Pharmacist (RPh or PharmD): Responsible for providing drug therapy for positive client outcomes; activities include drug information services, client and health care staff education, dispensing medications and client monitoring, adverse drug reaction reporting, research, concurrent drug use evaluation, and consultative services in areas such as pain management and nutritional support. Pharmacists complete baccalaureate preparation, an internship period, and licensing board examinations. Pharmacists can complete additional specialized training, certifications, and/or advanced degrees. In some states, the PharmD, or doctor of pharmacy degree, is now the educational requirement for entering practice.



Physician assistant (PA): Works under the supervision of the MD or DO and performs assessments, procedures, or protocols approved by the physician. PAs complete a baccalaureate degree with specialized PA training (usually 2 years) and state licensure.



Dietitian (RD or LD): Provides nutritional therapy and support to ensure that the nutritional needs of the client are met. Activities include involving both client and family in dietary assessment and teaching, identifying resources for food purchase and preparation, and identifying areas of food-drug interactions. Dietitians complete a baccalaureate degree from an accredited nutrition or food service administration program and national board examinations and may also complete state licensure and advanced educational preparation.



Physical therapist (PT): Attends to the client’s needs for movement. Activities include assessing physical strength and mobility needs and developing a plan of strengthening exercises for the client with movement dysfunction, maintaining range of motion and muscle tone, and identifying assistive devices that may be needed. A physical therapist may also be expert in the area of wound care. The basic educational requirement is a baccalaureate degree in a physical therapy program and completion of a national certifying examination. Advanced degrees are available.



Speech-language pathologist (SLP): Assists clients who are communicatively impaired by intervening in speech, language, and/or swallowing disorders related to receptive language, expressive language, speech intelligibility, voice disorders, alaryngeal speech, or prosody and cognitive impairments; plays an important role in evaluation and treatment of swallowing disorders. Therapists complete a master’s degree from an accredited school, a 1-year fellowship, and a national certifying examination.



Occupational therapist (OT): Plans activities that assist and teach clients with physical disabilities to become independent in activities of daily living, such as dressing, grooming, bathing, and eating. Once self-care goals have been met, the OT can help the client perform daily responsibilities of caring for a home and/or returning to work. Educational requirements include completion of an occupational therapy program of study at the baccalaureate, graduate certification, or master’s degree level. Graduates must complete a period of supervised clinical experience and state licensure examinations.



Respiratory therapist (RT): Responsible for assessment and maintenance of the client’s airway and respiratory equipment used for diagnosis and therapy of respiratory disorders. Activities include client assessment, aerosolized medication administration, sputum sampling, arterial and mixed venous blood sampling, pulmonary function testing, cardiopulmonary stress testing, and sleep studies; may also be involved in conducting pulmonary rehabilitation programs. RTs complete a program of study and take a national certifying examination. If the program of study is completed in an associate or bachelor’s degree program, the level of credentialing examination is different.



Social worker: Uses skills to help clients, families, and communities address psychosocial needs. Activities include educating clients, families, and staff about community resources; discharge planning; financial counseling and identifying financial resources; crisis intervention; referring to community resources; abuse and neglect reporting; completing advanced directives; assisting with resolving ethical dilemmas; evaluating behavior and mental disorders; and conducting support groups. Social workers complete a minimum of baccalaureate preparation in the field and may pursue advanced degrees.



Chaplain or pastoral representative: Attends to the spiritual and emotional needs of the client and family. Activities include providing pastoral counseling and support and sacramental ministry and liturgical celebrations; not all pastoral representatives share the same religion as the client or family members but must be able to acknowledge the differences among religions and help assist the person with spiritual needs. Basic education requirements vary based on the setting and religious affiliation. The Association for Clinical Pastoral Education is a multicultural, multifaith organization devoted to improving the quality of ministry and pastoral care offered by spiritual caregivers of all faiths.




CASE STUDY 26-1


John was discussing a problem with a coworker over his cell phone as he approached the intersection. He did not notice the truck approaching on his left side, so he did not see the STOP sign. After evaluation in the emergency department, John was diagnosed as post–motor vehicle accident with multiple trauma, closed head injury, several rib and leg fractures, lacerations, and internal injuries. His physician ordered multiple diagnostic tests, laboratory tests, medications, and treatments. John’s nurse monitored his physical status and carried out the orders written by the physician. The nurse organized the tests and procedures and managed his pain. The pharmacist reviewed and supplied the medications ordered and analyzed potential interaction effects of the multiple pharmaceutical agents. A respiratory therapist was consulted to perform breathing treatments to facilitate lung expansion and prevent respiratory complications. After surgical repair of his fractured leg, physical therapy was consulted to assess John’s condition and his need for physical reconditioning. A plan of care was determined to enhance his mobility. His long recuperation led to mild depression and spiritual distress. The nurse who assessed these symptoms made arrangements for the chaplain to visit John and discussed the possibility of pharmacotherapy for depression with the physician and pharmacist. Throughout John’s period of care, all involved practitioners communicated their assessments and worked together to provide collaborative interventions for holistic care. In addition, all interprofessional team members collaborated in medical rounds and discharge planning meetings to plan and coordinate John’s care.


Case Study 26-1 provides an excellent example of the role of various members of the interprofessional health care team. Multiple professional caregivers provide health care within the limits of each provider’s expertise. The joint efforts of all professionals provide the opportunity for a better overall outcome.



Nurses today: who are they, and what are they doing?


The phrase “a typical nurse” became a misnomer as the profession entered the twenty-first century. Nursing roles are so diverse that no typical role or practice setting exists. Nurses are the largest occupation in health care with a total of more than 3 million, with 62.2% working in a hospital setting. Projections state that nursing will create the largest number of new jobs of all occupations in the future as more specialties and diverse work options emerge. Overall jobs for nurses are projected to expand 22% between 2008 and 2018, with some specialties such as home care services and physician offices growing up to 48%. Nurses can specialize in basically four ways: work or treatment setting, disease category or condition, organ or body system, or population. Some nurses specialize in more than one of these (U.S. Department of Labor, 2011).


Examples of specialization in work or treatment settings include ambulatory care nurses, critical care nurses, trauma or emergency nurses, home care nurses, holistic care nurses, medical-surgical nurses, hospice nurses, perioperative nurses, transplant nurses, psychiatric nurses, and rehabilitation nurses. Examples of nurses who specialize in disease category or condition are oncology nurses, addictions nurses, ostomy and wound care nurses, developmental disabilities nurses, diabetes management nurses, HIV-AIDS nurses, and genetics nurses. Organ or body systems can differentiate nurses as cardiovascular nurses, dermatology nurses, urology nurses, orthopedic nurses, nephrology nurses, gastroenterology nurses, gynecology nurses, ophthalmic nurses, or respiratory nurses. Nurses can be recognized by the population they serve, such as neonatology nurses, pediatric nurses, or gerontology nurses. Nurses such as CNSs, nurse anesthetists, nurse-midwives, and NPs have more direct patient contact, whereas case management nurses, infection control nurses, forensic nurses, legal nurses, nurse educators, nurse administrators, and nurse informaticists have little or no contact with patients. Truly these diverse opportunities are increasing in the world of health care.



Demographics for Registered Nurses


Preliminary findings indicated that there were an estimated 3 million RNs in the United States as of 2008. Of this total nursing population, 80% were employed in nursing, whereas 12.38% were not. Approximately 63.2% of this group was employed full time in the profession. In 2008, half of the RN population was 46.8 years of age, compared with 45.2 years of age in the 2000 survey report. In 2004, the largest group was 45 to 49 years of age.


Although the nursing profession continues to be mostly female, the number of men working as RNs significantly increased in the past decade. The 2004 report indicates that the number of male RNs increased to 6.2% who were licensed prior to 2000 and 9.6% of those licensed in or after that time (Bureau of Health Professions, 2010).


Changes in racial or ethnic backgrounds were reported as well. The 2008 survey reports that 83.2% of RNs were white or non-Hispanic, whereas 16.8% reported being from one or more racial and/or ethnic backgrounds. Some did not specify this information on the survey (http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf).


Changes also are occurring in the educational preparation of RNs. There has been a substantial increase in the number of nurses graduating from associate degree nursing programs over the past decade. Although not as dramatic an increase, baccalaureate-prepared nurses also are increasing in number. In 2008, nurses reported their highest degree as 20.4% diploma, 45.4% associate degree, and 34.2% baccalaureate degree or higher (Bureau of Health Professions, 2010).


In 2008, advanced practice nurses numbered 250,527. NPs lead this group in numbers, followed by CNSs, nurse anesthetists, and nurse-midwives (Bureau of Health Professions, 2010). Acute care hospitals remain the common worksite for RNs, although there has been a trend toward outpatient settings. In 2008, 62.2% of RNs reported working in hospitals, an increase from the 57.4% in 2004.


The next largest area of employment was in community, public health settings, and school nursing—a total of 13.4%. About 12.3% work in ambulatory care settings such as physician-based practices, nurse-based practices, surgical centers, or insurance claims organizations. Other worksites include occupational health settings, policy or regulatory agencies, telehealth, pharmaceuticals, adult/senior centers, and flight nurse/medical air transport (Bureau of Health Professions, 2010).


The Health Resources and Services Administration (HRSA) is part of the U.S. Department of Health and Human Services. The Bureau of Health Professions, a division of the HRSA, provides national information on the health professions workforce in this country. You can explore demographic changes in nursing online at http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf.



Hospital Opportunities


Despite enormous changes in hospital care, jobs in the hospital environment will be available for a long time. In the hospital, a nurse provides direct care for people who are ill and unable to care for themselves. Another function of the direct-care role is to help the client and family in managing the illness event. Hospital positions can range from staff nurse to administrator and may entail any of the clinical specialties and most of the target populations identified in Table 26-1. Determining the area of clinical interest depends mainly on personal preferences.


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Nov 6, 2016 | Posted by in NURSING | Comments Off on Contemporary Nursing Roles and Career Opportunities

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