Numbers

Registered nurses (RNs) are the largest group of health care providers in the United States. More than 3 million individuals held licenses as RNs in 2008, a 5.3% increase from the 2004 survey. Approximately 445,000 RNs received their first license to practice in the United States and 291,000 RNs allowed their licenses to expire, resulting in a net increase in RNs of 154,000 between 2004 to 2008 (U.S. Department of Health and Human Services, 2010). The retirement of the older generation of nurses has been long anticipated; these lapses in licensure may indicate that this wave of retirement is occurring.

An estimated 2.6 million (85% of) licensed RNs were actively working in nursing, 63% of them full-time. For nurses younger than 50 years old, 90% were employed in nursing either full- or part-time; fewer than half of the nurses older than 65 were working in nursing. A significant percentage of nurses hold two nursing positions. Among those working full-time in nursing, 12% have a second nursing position; 14% of those working part-time in nursing hold a second nursing position (U.S. Department of Health and Human Services, 2010).

Gender

Nursing remains a profession dominated by women; however, the percentage of men in nursing has increased by 50% since 2000 (U.S. Department of Health and Human Services, 2010). Overall, 7.1% of nurses are men, and 92.9% are women. However, among nurses licensed before 2000, 6.2% were men and 93.8% were women. Of those licensed in 2000 or later, 9.6% are men and 90.4% are women. Figure 1-1 gives a clear picture of the disparity between the overall percentages of women and men in nursing.

In 2010, 11.4% of students in entry-level bachelor of science in nursing (BSN) programs were men (American Association of Colleges of Nursing, 2012). Male and female RNs were equally likely to have a bachelor’s or higher degree in nursing or nursing-related fields (49.9% and 50.3%, respectively). Men, however, were more likely than women to have a bachelor’s or higher degree in nursing and any nonnursing field (62% vs. 55%). A higher percentage of the men work in hospitals (76% vs. 62%). At 41%, men are over-represented in the advanced practice role of certified registered nurse anesthetists. Among all other job titles held by men, staff nurse and administration have proportional representation, with about 7% of these positions held by men. Nurse practitioners and “other” positions (e.g., consultant, clinical nurse specialist, informatics, researcher) are slightly less proportional, with 6% of these positions held by men. Interestingly, only about 3.8% of instructor positions are held by men.

Age

The future of any profession depends on the infusion of youth, and the steady increase in the age of the nursing workforce has been a concern. For the first time in the past 30 years, however, the rate of aging of nurses in the workforce has slowed (U.S. Department of Health and Human Services, 2010). This is a result of the increased number of working RNs who are under age 30, which offsets the increasing number of nurses age 60 or older who continue to work. The rise in the number of nurses under age 30 is attributed to the increased number of graduates from bachelor of science in nursing (BSN programs, who tend to be younger than graduates from other types of nursing programs. Since 2005, the average age of graduates from all nursing programs has been 31 years old. BSN graduates, at an average age of 28 years old, are 5 years younger than graduates of associate-degree and diploma (hospital-based) programs, who are on average 33 years old.

The median age is that point at which half of the nurses are older and half are younger, and it provides a more useful metric of the workforce than does calculating a mean age. Since 1988, when the median age was 38, the median age of nurses rose by 2 years between each survey, so that by 2004, the median age was a worrisome 46 years old. The increasing number of nurses 60 and older who are still in the workforce is possibly a result of the recent economic downturn in which unemployment rates were high. Older nurses are more likely to remain in the workforce because the nursing field is reasonably protected from the layoffs and downsizing experienced in other professions.

This stabilization of the aging pattern seen in the 2008 survey is an optimistic sign that nursing is seen as an option for younger people entering the workforce, and that nursing will not face a shortage as older nurses age out of the workforce in a few years.

Race and ethnicity

Racial/ethnic minorities make up 34.4% of the population of the United States today but only 16.8% of the RN population, an underrepresentation by about 50% in 2008 (U.S. Department of Health and Human Services, 2010) (Figure 1-2). Although still troublesome, the number is an improvement from 2004, when only 12.2% of RNs had racial/ethnic minority backgrounds. The largest disparity between the U.S. general population and the RN population is seen with Hispanics/Latinos of any race. Although this group forms about 15.4% of the U.S. population, they make up only 3.6% of RNs. Black/African American, non-Hispanics also have a significant disparity; now constituting 12.2% of the U.S. population, this group makes up just 5.4% of RNs. The only group that exceeds its representational percentage in the general population is the Asian or Native Hawaiian/Pacific Islander, non-Hispanic group. Composing 4.5% of the general population, this group makes up 5.8% of the RN population, possibly because a substantial number of RNs practicing in the United States received their nursing education in India or the Philippines, thus contributing to their overrepresentation.

Despite efforts to recruit and retain racial/ethnic minority women and men in the nursing profession, nursing still has a long way to go before the racial/ethnic composition of the profession more accurately reflects that of the United States as a whole. This situation is slowly improving, however. In a recent report on enrollment and graduation in bachelor’s and graduate programs in nursing, the American Association of Colleges of Nursing (AACN, 2010) showed that 26.8% of nursing students in entry-level BSN programs were from minority backgrounds.

Education

The basic education to become a nurse is referred to as the entry level into practice. Successful completion of your basic education, however, does not qualify you to become a nurse. Once you have graduated from an accredited school of nursing, you are qualified to take the National Council Licensure Examination for Registered Nurses, known as the NCLEX-RN^®. Successfully passing the NCLEX-RN^® then qualifies you to be licensed as an RN.

Nursing has three mechanisms by which you can get basic nursing education to qualify to take the NCLEX^®: (1) 4-year education at a college or university conferring a BSN degree; (2) 2-year education at a community college or technical school conferring an associate degree in nursing (ADN); and (3) a diploma in nursing, awarded after the successful completion of a hospital-based program that typically takes 3 years to complete, including prerequisite courses that may be taken at another school. There are rare instances of initial qualification for licensure that occur through military training or master’s or doctoral degrees, but most of these basic nursing education programs are designed for students who have earned undergraduate or graduate degrees previously. Nursing education is discussed in greater detail in Chapter 7.

Diploma programs are gradually disappearing, many of which are now affiliated with local community colleges and confer the associate of science degree. Since 2004, only 3.1% of RNs reported receiving a diploma as their entry-level education. The majority of nurses in the United States get their initial nursing education in ADN programs; however, slightly more than 50% of nurses eventually earn a BSN or a master’s or doctoral degree. Many colleges and universities offer BSN programs, often online, to accommodate RNs in practice who want to work toward a BSN degree as a supplement to their basic nursing education at the ADN or diploma level. White, non-Hispanic nurses are less likely to get a BSN or higher degree than are Black/African American, non-Hispanics; Hispanic/Latino, any race; and Asian, non-Hispanic nurses. Figure 1-3 shows the distribution of RNs across levels of initial education.

Globalization and the international migration of nurses has resulted in an increase of internationally educated nurses practicing in the United States, up from 3.7% in 2004 to 5.6% in 2008 (Thekdi, Wilson, Xu, 2011). The recruitment of foreign-educated nurses to the United States has been a strategy to expand the nursing workforce in response to the recent nursing shortage. This strategy, however, has been criticized because recruitment of these nurses to the United States may result in shortages in their own countries. Foreign-educated nurses face challenges as they join the workforce in the United States, including speaking English as a second language and problems with their peers who may not perceive them as knowledgeable (Thekdi et al, 2011). Deep cultural differences may further separate the foreign-educated nurses from their American peers. Thekdi and colleagues (2011) noted that foreign-educated nurses may have very different views of gender, authority, power, and age that affect their communication styles. Furthermore, absolute respect for experts and teachers is common among foreign-educated nurses, creating a “permanent barrier” between nurse-managers and managers, and foreign-educated nurses.

Sigma Theta Tau International (STTI) (2005) published a position paper on international nurse migration, recognizing the autonomy of nurses in making decisions for themselves about where to live and work, and noting that “push/pull” factors shape nurse migration. Push factors include poor compensation and working conditions, political instability, and lack of opportunities for career development that drive (push) a nurse to seek employment in another country. Factors that pull nurses to emigrate include opportunities for a better quality of life, personal safety, and professional incentives such as increased pay, better working conditions, and career development. STTI called for further exploration of the issue with a focus on identifying “solutions that do not promote one nation’s health at the expense of another” (p. 2). Furthermore, STTI endorsed the International Council of Nurses position in calling for a regulated recruitment process based on ethical principles that deter exploitation of foreign-educated nurses and reinforce sound employment policies (p. 4).

Employment opportunities for nurses

As members of the largest health care profession in the United States, nurses practice in a wide variety of settings. The most common setting is the hospital, and many new nurses seek employment there to strengthen their clinical and assessment skills. Nurses practice in clinics, physician offices, skilled nursing facilities, and other long-term settings. Nurses also provide care in places where people spend much of their time: homes, schools, and workplaces. In communities, nurses can be found in the military, community and senior centers, children’s camps, homeless shelters, and, recently, in retail clinics found in some pharmacies. Increasingly, nurses with advanced degrees, training, and certification are working in private practice or in partnership with a physician or other provider. This expansion of practice holds promise for nurses to widen their roles in health care, especially as the transformation of the health care system continues to evolve.

In 2008, hospitals remained the primary work site for RNs, with 62.2% of nurses employed by hospitals. This is up from 56.2% in 2004. Most of these nurses (39.6%) work in inpatient units in community hospitals, whereas others work in specialty hospitals, long-term hospitals, and psychiatric units. The federal government employs nurses, generally in the U.S. Department of Veterans Affairs (VA) hospitals, where 1.1% of RNs work.

Ambulatory care settings, such as physician-based practices, nurse-based practices, and free-standing emergency and surgical centers accounted for 10.5%, the second largest segment of the nurse workforce. Public and community health accounted for 7.8% of employed nurses, and an additional 6.4% worked in home health. Nursing homes or extended care facilities employed 5.3% of nurses in the workforce. The remainder of employed RNs worked in settings such as schools of nursing; nursing associations; local, state, or federal governmental agencies; state boards of nursing; or insurance companies (U.S. Department of Health and Human Services, 2010, pp. 3-9).

Not all nurses provide direct patient care as their primary role. A small but important group of nurses spend the majority of their time conducting research, teaching undergraduate and graduate students, managing companies as chief executives, and consulting with health care organizations. Nurses who have advanced levels of education, such as master’s and doctoral degrees, are prepared to become researchers, educators, and administrators. Nurses can practice as advanced practice nurses (APNs), including a variety of types of nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs). These advanced practice roles are described later in this chapter.

Nurses have much to consider in deciding where to practice. Some settings will not be immediately open to new nurses because they require additional educational preparation. Importantly, nurses entering the workforce need to consider their special talents, likes, and dislikes—neither the nurse nor patients benefit when a nurse is working with a population for which he or she has little affinity. A nurse who loves children may not feel at ease in caring for elderly patients; a nurse with excellent communication skills may find that a postanesthesia care unit does not allow the formation of professional relationships with patients that this nurse might enjoy in a psychiatric setting. Nursing school offers the chance to experience a wide variety of settings with diverse patient populations. At the end of your studies, you may be surprised at the skills you have developed and by which populations appeal to you (Figure 1-4).

Health care reform and the push to transform the health care system are moving nurses into new territory. Numerous new opportunities and roles are being developed that use nurses’ skills in different and exciting ways. In the following section, you will be introduced to a range of settings in which nurses practice. In some instances, nurses are interviewed. These settings areas are only a sampling of the growing variety of opportunities available to nurses entering practice today.

Hospital-based nursing

Nursing care originated and was practiced informally in home and community settings and moved into hospitals only within the last 150 years. Hospitals vary widely in size and services. Certain hospitals are referred to as medical centers and offer comprehensive specialty services, such as cancer centers, maternal-fetal medicine services, and heart centers. Medical centers are usually associated with university medical schools and have a complex array of providers. Medical centers can have 1000 or more beds and have a huge nursing workforce. Medical centers are often designated as “Level 1 Trauma Centers” because they offer highly specialized surgical and supportive care for the most severely injured patients. The patients at community-based hospitals usually are less severely ill than those needing comprehensive care or trauma care at a medical center. However, if a patient becomes highly unstable or if the patient’s condition warrants, he or she can be transferred to a larger hospital or a medical center. Nurses play an important role in identifying very sick patients and preparing them for transport.

In general, nurses in hospitals care for patients who have medical or surgical conditions (e.g., those with cancer or diabetes, those in need of postoperative care), children and their families on pediatric units, women and their newborns, and patients who have had severe trauma or burns. Specialty areas are referred to as “units,” such as operating suites or emergency departments, coronary and other special care units, and step-down or progressive care units, among others. In addition to providing direct patient care, nurses are educators, managers, and administrators who teach or supervise others and establish the direction of nursing on a hospital-wide basis.

Various generalist and specialist certification opportunities are appropriate for hospital-based nurses, including medical-surgical nurse, pediatric nurse, perinatal nurse, acute care NP, gerontological nurse, psychiatric and mental health nurse, nursing administration, nursing administration—advanced, nursing continuing education or staff development nurse, and informatics nurse. There is perhaps no other single work setting that offers so much employment variety to nurses as do hospitals.

The educational credentials required of RNs practicing in hospitals can range from associate degrees and diplomas to doctoral degrees. In general, entry-level positions require only RN licensure. Many hospitals require nurses to hold bachelor’s degrees to advance on the clinical ladder or to assume management positions. A clinical ladder is a multiple-step program that begins with entry-level staff nurse positions. As nurses gain experience, participate in continuing education, demonstrate clinical competence, pursue formal education, and become certified, they are eligible to move up the rungs of the ladder. A clinical coordinator, who is responsible for the management of more than one unit, is generally expected to have a master’s degree.

Most new nurses choose to work in hospitals initially to gain experience in organizing and delivering patient care to multiple patients. For many, staff nursing is extremely gratifying, and they continue in this role for their entire careers. Others pursue additional education, sometimes provided by the hospital, to work in specialty units such as neonatal intensive care or cardiac care. Although specialty units often require clinical experience and additional training, some hospitals allow new graduates to work in these units.

Some nurses find that management is their strength. Nurse managers are in charge of all activities on their units, including patient care, continuous quality improvement, personnel selection and evaluation, and resource management. Being a nurse manager in a hospital today requires business acumen and knowledge of business and financial principles to be most effective in this role. Nurse managers typically assume 24-hour accountability for the units they manage.

Most nurses in hospitals provide direct patient care. In the past, it was necessary for nurses to assume administrative or management roles to be promoted or receive salary increases. Such positions removed them from bedside care. Today, in hospitals with clinical ladder programs, nurses no longer must make that choice; clinical ladder programs allow nurses to progress while staying in direct patient care roles.

At the top of most clinical ladders are clinical nurse specialists (CNSs), who are nurses with master’s degrees in specialized areas of nursing, such as oncology (cancer) or diabetes care. The role varies but generally includes responsibility for serving as a clinical mentor and role model for other nurses, as well as setting standards for nursing care on one or more particular units. The oncology clinical specialist, for example, works with the nurses on the oncology unit to help them stay informed regarding the latest research and skills useful in the care of patients with cancer. The clinical specialist is a resource person for the unit and may provide direct care to patients or families with particularly difficult or complex problems, establish nursing protocols, and be responsible for ensuring that nurses adhere to high standards of care.

Salaries and responsibilities increase at the upper levels of the clinical ladder. The clinical ladder concept benefits nurses by allowing them to advance while still working directly with patients. Hospitals also benefit by retaining experienced clinical nurses in direct patient care, thus improving the quality of nursing care throughout the hospital. Research has demonstrated that patient outcomes are more positive for patients cared for by bachelor’s- or higher- degree–prepared RNs. Linda Aiken, PhD, RN, FAAN is a leader in nursing who has conducted important research documenting the positive impact of adequate RN staffing on patient outcomes. A decade ago, Aiken, Clarke, Cheung, and others (2003) published a groundbreaking study in which they found that patients on surgical units with more BSN-prepared nurses had fewer complications than patients on units with fewer BSN nurses. Aiken has published widely on nurse staffing and safety since publishing this landmark study. More recently, Aiken, Sloane, Cimiotti, and colleagues (2010) reported on a comparison of nurse and patient outcomes among hospitals in California, which has state-mandated nurse-to-patient ratios, and in Pennsylvania and New Jersey, neither of which has state-mandated nurse-to-patient ratios. See the Evidence-Based Practice Note for a description of these studies.

EVIDENCE-BASED PRACTICE NOTE

Linda Aiken, PhD, RN, FAAN, Professor of Nursing and Professor of Sociology at the University of Pennsylvania School of Nursing, is the director of the Center for Health Outcomes and Policy Research. She is an authority on causes, consequences, and solutions for nursing shortages both in the United States and worldwide. Dr. Aiken has published extensively. She and her colleagues (2003) noted growing evidence suggesting “that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes.” They wondered whether the proportion of a hospital’s staff of bachelor’s or higher degree–prepared RNs contributed to improved patient outcomes. To answer this question, they undertook a large analysis of outcome data for 232,342 general, orthopedic, and vascular surgery patients discharged from 168 Pennsylvania hospitals over a 19-month period. They used statistical methods to control for risk factors such as age, sex, emergency or routine surgeries, type of surgery, preexisting conditions, surgeon qualifications, size of hospital, and other factors. Their findings were very important:

“To our knowledge, this study provides the first empirical evidence that hospitals’ employment of nurses with BSN and higher degrees is associated with improved patient outcomes. Our findings indicate that surgical patients cared for in hospitals in which higher proportions of direct-care RNs held bachelor’s degrees experienced a substantial survival advantage over those treated in hospitals in which fewer staff nurses had BSN or higher degrees. Similarly, surgical patients experiencing serious complications during hospitalization were significantly more likely to survive in hospitals with a higher proportion of nurses with baccalaureate education” (p. 1621).

Noting that fewer than half of all hospital staff nurses nationally are prepared at the bachelor’s or higher level, and citing a shortage of nurses as a complicating factor, this group of researchers recommended “placing greater emphasis in national nurse workforce planning on policies to alter the educational composition of the future nurse workforce toward a greater proportion with bachelor’s or higher education as well as ensuring the adequacy of the overall supply” (p. 1623). They concluded that improved public financing of nursing education and increased employers’ efforts to recruit and retain highly prepared bedside nurses could lead to substantial improvements in quality of care.

More recently, California became the first state to enforce state-mandated minimum nurse-to-patient ratios. Much commentary about the pros and cons of these types of mandates has been generated. To determine whether nurse and patient outcomes were different in California than in two states without mandated staffing, Aiken and colleagues analyzed survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey, as well as state hospital discharge databases. From this highly complex analysis they determined the following:

When we use the predicted probabilities of dying from our adjusted models to estimate how many fewer deaths would have occurred in New Jersey and Pennsylvania hospitals if the average patient-to-nurse ratios in those hospitals had been equivalent to the average ratio across the California hospitals, we get 13.9% (222/1598) fewer surgical deaths in New Jersey and 10.6% (264/2479) fewer surgical deaths in Pennsylvania.

In addition, the nurses in California experienced lower levels of burnout (a condition associated with intense and prolonged stress in work settings) and were less likely to report being dissatisfied with their jobs. These important findings can inform ongoing debates in other states regarding nurse-patient ratio legislation or mandatory reporting of nurse staffing. Aiken and colleagues (2010) concluded, “Improved nurse staffing, however it is achieved, is associated with better outcomes for nurses and patients” (p. 918).

Aiken LH, Clarke SP, Cheung RB, Sloane D, Silber JH: Educational levels of hospital nurses and surgical patient mortality, JAMA 290(12):1617–1623, 2003.Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, Seago JA, et al.: Implications of the California nurse staffing mandate for other states, Health Serv Res 45(4):904–921, 2010.

One of the greatest drawbacks to hospital nursing in the past was the necessity for nurses to work rigid schedules, which usually included evenings, nights, weekends, and holidays. Although hospital nurses still must work a fair share of undesirable times, flexible staffing is becoming the norm. Today, nurses on a particular unit often negotiate with one another and establish their own schedules to meet personal needs while still ensuring that appropriate patient care is provided.

Each hospital nursing role has its own unique characteristics. In the following profile, an RN discusses his role as a bedside nurse in a burn unit:

A burn nurse has to be gentle, strong, and patient enough to go slow. You must be confident enough to work alone; you must believe that what you’re doing is in the patient’s best interest, because some of the procedures hurt far worse than anyone can imagine. Each burn is unique and a challenge. Years ago, the prognosis for surviving an extensive burn was not good, but with today’s techniques for fluid replacement and the development of effective antibiotics, many patients are surviving the first few critical days. During the long hours of one-on-one care, you really get to know your patient. There is nothing more rewarding.

When the “fit” between nurses and their role requirements is good, nursing is a gratifying profession, as an oncology nurse demonstrates in discussing her role:

Being an oncology nurse and working with people with potentially terminal illnesses brings you close to patients and their families. The family room for our patients and their families is very homelike. Families bring food in and have dinner with their loved one right here. Working with dying patients is a tall order. You must be able to support the family and the patient through many stages of the dying process, including anger and depression. Experiencing cancer is always traumatic, with the diagnosis, the treatment, and the struggle to cope. But today’s statistics show that more people survive cancer. Because of research and early detection, being diagnosed with cancer is no longer the automatic death sentence it used to be. I love getting involved with patients and their families and feel that I can contribute to their positive mental attitude, which can have an impact on their disease process, or hold their hand and help them to die with dignity. They cry, I cry—it is part of my nursing, and I would have it no other way.

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