Nurses


 * This article focuses on the training and regulation of nurses. See the article Nursing for more information on the practice of nursing.  For information on the television show Nurses, see Nurses (TV series).

A nurse is a health care professional who is engaged in the practice of nursing. Nurses are men and women who are responsible (along with other health care professionals) for the treatment, safety and recovery of acutely or chronically ill or injured people, health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings. Nurses may also be involved in medical and nursing research and perform a wide range of non-clinical functions necessary to the delivery of health care.

Overview
Nurses develop a plan of care, sometimes working collaboratively with physicians, therapists, the patient, the patient's family and other team members. In the US (and increasingly the United Kingdom), advanced practice nurses, such as clinical nurse specialists and nurse practitioners, diagnose health problems and prescribe medications and other therapies. Nurses may help coordinate the patient care performed by other members of a health care team such as therapists, medical practitioners, dietitians, etc. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.

According to the US Department of Labor's revised Occupational Outlook Handbook (2000), "Registered nurses (R.N.s) work to promote health, prevent disease, and help patients cope with illness. They are advocates and health educators for patients, families, and communities. When providing direct patient care, they observe, assess, and record symptoms, responses, and progress; assist physicians during treatments and examinations; administer medications; and assist in convalescence and rehabilitation. R.N.s also develop and manage nursing care plans; instruct patients and their families in proper care; and help individuals and groups take steps to improve or maintain their health."

The nursing career structure varies considerably throughout the world. Typically there are several distinct levels of nursing practitioner, distinguished by increasing education, responsibility and skills. The major distinction is between task-based nursing and professional nursing.

In various parts of the world, the educational background for nurses varies widely. In some parts of eastern Europe, nurses are high school graduates with twelve to eighteen months of training. In contrast, Chile requires any Registered Nurse to have at least a bachelor's degree.

At the top of the educational ladder is the doctoral-prepared nurse. Nurses may gain the PhD or another doctoral degree such as Doctor of Nursing Science (DNSc) or Doctor of Nursing Practice (DNP), specializing in research, clinical nursing, etc. These nurses practice nursing, teach nursing and carry out nursing research. As the science of nursing has advanced, so has the demand for doctoral-prepared nurses.

Legal regulation
The practice of nursing is governed by state and territorial nursing regulation authorities. The Australian Nursing and Midwifery Council (ANMC) was established in 1992 and works with these authorities to facilitate a national approach to nursing and midwifery regulation.

Types of nurses
In all states other than Victoria, nurses fall into the following major categories:
 * Nurse Practitioners (NP)
 * Registered Nurse (RN)
 * Enrolled Nurse (EN)

Victoria
Nurses and nursing were first regulated by statue in 1923 in Victoria. In 1993 the legislation was revised and all nurses are now termed Registered Nurse classified according to their educational preparation by the Nurses Board of Victoria.

RN Division 1 are first level nurses comprehensively trained with the potential ability to work in any branch of nursing.

RN Division 2 are second level nurses that work under the direction of a Division 1 or 3 Nurse, equivalent to an enrolled nurse in other Australian states.

RN Division 3 are nurses formally trained solely in psychiatric nursing. This is not to be confused with general nurses who undertook "post basic" training in psychiatric nursing and were thus able to work in both general and psychiatric nursing settings.

RN Division 4 nurses formally trained solely in institutions that cared for people with an intellectual disability. It was possible (but unusual) for general nurses to undertake post basic training to attain this as an additional qualification. Mental retardation nursing (as it was then known) is no longer considered the sole domain of nursing, and courses are available such as the Graduate Certificate of Disability Studies (Positive Behaviour Support) designed to meet the needs of practitioners in a variety of disciplines.

RN Division 5 are former Maternal and Child Welfare Nurses who had additional post basic training.

Divisions 3,4 and 5 are now closed to new applicants. The effect of this policy is that there will be, in time, only first and second level nurses, with a common foundation qualification to each type.

Midwifery
Unlike the United Kingdom, until relatively recently midwifery training required registration in nursing as a prerequisite. At least one course has been established that will qualify a person as a midwife, but not as a registered nurse.

Victoria ceased to list midwives in 1993 as a separate register on the presumption that all midwives were also registered nurses. However, in latter years Victoria now "recognises" additional qualifications provided they are Midwifery, Maternal & Child Health Nursing or Psychiatric qualifications.

There is a philosophical argument that child birth and reproduction are natural conditions and should not be treated as a disease or ailment, and that since the "disease model" permeates nursing, midwifery is and should be considered a separate discipline. Opponents to this argument counter that many other speciality areas in nursing support a natural process, e.g. palliative care.

Nevertheless, it is likely that independent practice midwives will continue to develop as a profession despite the current issues relating to the availability of malpractice insurance.

Nurse Practioners
Nurse Practitioners are being introduced into the Australian healthcare community.

In some instances it could be argued that this is as a natural professional evolution and recognition of the outstanding clinical expertise some nurses have attained over the course of their careers in areas such as wound management.

The formal recognition of nurse practitioners permits duly educated and credentialled health care nursing professionals with autonomous practice rights within their particular area of expertise. This may include (but not necessarily) drug prescription rights. The development of nurse practitioners is opposed by the | Australian Medical Association.

Education
Registration as a Registered Nurse now requires a Bachelor of Nursing, considered the foundation for any future specialisation within nursing. Postgraduate diplomas provide further vocational training for specialist areas. Masters level courses are available in both research and course work streams; a specialist course has been developed to provide preparation for registration as a Nurse Practitioner. Professional doctorates are also available (ND).

Australia has a long tradition of post basic courses, usually of a 6 month (minor) or 12 month (major) duration, which included Midwifery, Maternal and Child Welfare, Psychiatric, Perioperative ("Theatre Nursing"), Intensive Care, and Coronary Care in later years, as well as a myriad of other courses. There are now provided by the university sector as postgraduate diplomas or post graduate certificates, depending on the length and complexity.

There are options available for hospital trained nurses to upgrade their qualifications to a Bachelor of Nursing (post registration); however, most opt instead to undertake specialist courses such as a postgraduate diploma or certificate in the area of their clinical interest.

Enrolled nurses are trained in the TAFE sector of approximately 12 months duration. In some states the length has been increased to 18 moinths to include a module that permits enrolled nurses to dispense oral medications.

Historical
Prior to the transfer of nursing education to the university sector nurses were trained in a course of instruction in hospital nursing schools that awarded a certificate in General Nursing. These courses were generally for a three year period, and nurses were paid employees of the parent hospital. Hospitals awarded distinctive badges upon graduation. In addition, state registering authorities awarded a badge of registration. These were generally worn on the uniform collars.

It is interesting to note that as early as the 1930s, attempts were made to establish university credentialled nursing courses in Australia, most notably by then Director of Nursing at the Royal Melbourne Hospital and the University of Melbourne. As recently as the 1970s, Dr. Sandra Stacey, one of the first Australian nurses to attain a PhD enrolled in a school of anthropology to submit her thesis.

In the late 1970s, the Royal College of Nursing Australia pioneered a course that became the Diploma of Applied Science (Nursing) awarded by the Lincoln Institute in Melbourne and Cumberland College in Sydney. The transfer of nursing education to the university sector continued throughout the 1980s, and gradually hospital schools ceased operating. In the early 1990s universities finally granted nursing education the same status as allied health and granted bachelor degrees in nursing rather than diplomas for entry-level courses.

The first move towards baccalaurate recognition was the development of the Bachelor of Applied Science (Advanced Nursing), a post graduate degree that required registration as a Registered Nurse as a prerequisite to admission and the completion of 16 units. This course is no longer offered, having been superceded by the transition of "post basic courses" conducted by various hospitals as a form of inservice training to the tertiary sector (see above).

Historically, a "double" or "triple certificate(d) sister" would have been a registered nurse who held general, midwifery, psychiatric or other range of certificates. The post nominals RN(DC) or RN(TC) was used by some nurses to signify this attainment.

Professional Title
The professional courtesy title "Sister" has fallen into disuse and disapproval, even though it was formerly used by both male and female registered general nurses. The title "Nurse" was used when addressing enrolled nurses. The term "Matron" is inadvisable.

In keeping with the relaxed attitude to formalities in Australia, most nurses are happy to be addressed by their first name and describe themselves either as "an RN" or "an EN". In Victoria, an enrolled nurse will commonly describe themself as a "Div. 2".

Education
Most provinces in Canada prefer any Registered Nurse to have at least a bachelor's degree. Many practicing nurses are still college graduates but those entering nursing now are required or encouraged to enter at the university level.

Types of nurses
Registered Nurse (RN)

Licensed Practical Nurse (LPN), known as Registered Practical Nurse (RPN) in Ontario

Legal regulation
The profession of nursing is regulated at the provincial and territorial level in keeping with the priniciples of professional regulation endorsed by the International Council of Nurses. The College of Nurses of Ontario regulates both RNs and RPNs in contrast to the other provinces and territories where RNs and LPNs are regulated by separate bodies. In the western provinces, psychiatric nurses are governed by distinct legislation.......

Education
All Registered Nurses in the Philippines are required to have a Bachelor's Degree in Nursing.

Legal regulation
The Professional Regulation Commission oversees the licensing of Registered Nurses as authorized by the Philippine Nursing Act of 2002.

A Professional Regulatory Nursing Board implements and enforces the Nursing Act. The board is composed of a chairperson and six additional members, all of whom are nurses with at least a master's degree and ten years of nursing experience. The board inspects nursing schools, conducts licensure examinations, issues and monitors certificates of licensure, promulgates a code of ethics, participates in recognizing nursing specialty organizations, and prescribes guidelines and regulations governing the profession under the Nursing Act.

Education
In order to be examined to practice as an enrolled nurse, students must complete a two-year academic course which includes 2,000 hours of clinical practice.

Subjects studied in the first year include:
 * Nursing History and Ethics
 * Basic Nursing Care
 * Elementary Nutrition
 * First Aid
 * Elementary Anatomy and Physiology
 * Introduction to Comprehensive Health Care.

The second year includes study of sciences fundamental to basic nursing and, depending upon the area for which the nursing school has been approved, one of the following subjects:
 * General Nursing Care
 * Nursing Care of the Aged
 * Nursing Care of Mentally Retarded Persons
 * Community Nursing Care
 * Psychiatric Nursing Care

Legal regulation
The South African Nursing Council (SANC) was created by the Nursing Act of 1957. Currently it functions under the authority of the Nursing Act of 1978 and subsequent amendments. SANC inspects and approves nursing schools and education programs; examines, registers, and enrolls nurses, midwives, and nursing auxiliaries;  licenses nursing agencies;  and monitors nursing employers. Nurses and nursing auxiliaries are required to wear "distinguishing devices" consisting of pins and colored epaulettes to identify them as licensed professionals.

Education
Since the 1990s, UK nurses are now educated to diploma or bachelor's degree level. They undertake their training at universities and in placements in healthcare settings. Though the student will train in either adult, child, mental health or learning disabilities branch.

Titles
 * RGN - Registered General Nurse
 * RMN - Registered Mental Nurse
 * RSCN - Registered Sick Childrens' Nurse
 * (S)EN - (State) Enrolled Nurse
 * RN - Registered Nurse (Applies to adult, child, mental health or learning disability nurses) and ocassionally abbreviated to, for example, RN-C.

Pre-Project 2000
Student Nurses

Prior to the implementation of Project 2000, nurse education was the responsibility of teaching hospitals and local Schools of Nursing. Student nurses were salaried members of the health service during their training. For example, for student RGNs, this would involve what was known as "rotational" or "modular" training, where the student would rotate to different specialities (e.g. paediatrics, medical, surgical etc). At the end of their three (or two) years training, nurses were eligible to regsiter with the United Kingdom Central Council of Nursing and Midwifery (UKCC), and were then legally able to practice as a nurse within the United Kingdom.

Registered Nurses

There were (and still are) two levels of nurse; 1st levels are nurses trained for 3 years (RGN, RMN, RSCN, RN (all branches) whereas 2nd level nurses are the SENs, who trained for two years. Formerly, SENs worked under the direction of 1st level nurses, however the distiction is less clear, for example an experienced level 2 nurse taking 'charge' of a ward if the first level nurse is inexperienced.

Project 2000
Student Nurses

Under the Margaret Thatcher government a report by the UKCC was produced to radically change the face of nurse training within the United Kingdom. Students were to be given supernumerary status, and were no longer employed directly by the hospital trusts. The education was moved in to classroom, with colleges and "new" post-1992 universities training nurses. The diploma or degree in nursing, is the only way to register as a nurse in the UK. The three [or four] year full-time course is 50/50 theory and practice. The clinical practice is in local hospitals, community health centres etc. Students follow in their first year a "Common Foundation Programme" that is taught to all student nurses irrespective of their future branch. The next two years are the branch specific programme, where students are taught the skills for their chosen branch, be it adult, children's, mental health or learning disabilities. At the end of year 3, students can register with the NMC (which replaced the UKCC in 2001) and are legally able to practise as a nurse within the United Kingdom.

Registered Nurses

All nurses that qualify in Britain currently belong to one of the four branches of nursing. adult, children's, ,mental health, learning disabilities. All have an RN qualification within their specific branch and are registered as such on the NMC register.

Legal regulation
All UK nurses are listed on a register and are regulated by the Nursing & Midwifery Council (NMC). Nurses need to re-register every year from 1st January 2006 (formerly every three years) and are required to have demonstrated that they have kept up-to-date by undertaking at least 35 hours of professional development and nursing practice within 3 years.

There are approximately 673,000 registered nurses and midwives on the NMC's register, including non-practising nurses and midwives within the UK who have maintained their registration. Approximately 12% of registrants are male and the percentage is steadily increasing year on year. As of August 2005, the NMC register split into three distinct parts, nurses, midwives and specialist community public health nurses. There are 'sub-parts' that the nurse or midwife is registered to practice in, these are:

Pre-Project 2000 Nurses
 * 1 - First level nurses trained in general nursing [RGN]
 * 2 - Second level nurses trained in general nursing (EN(G)) (England and Wales)
 * 3 - First level nurses – mental illness [RMN]
 * 4 - Second level nurses – mental illness (EN(M)) (England and Wales)
 * 5 - First level nurses – learning disabilities [RNLD]
 * 6 - Second level nurses – learning disabilities (EN(LD)) (England and Wales)
 * 7 - Second level nurses (SEN) (Scotland and Northern Ireland)
 * 8 - Nurses – children [RSCN]
 * 9 - Fever nurses (RFN)[Obsolete]
 * 10 - Midwives [RM]
 * 11 - Health visitors [HV]

Project 2000 Nurses
 * 12 - First level nurses – adult nursing [RN]
 * 13 - First level nurses – mental health [RN]
 * 14 - First level nurses – learning disabilities [RN]
 * 15 - First level nurses – children [RN]

Nursing titles

 * Healthcare Assistant/Auxiliary Nurse/Nursing Assistant/Clinical Support Worker:- various titles exist to describe staff who, whilst not registered nurses, assist the nursing staff in the performing of roles which are part of the nursing scope of practice. Such workers may provide basic care to the patient, record and monitor vital signs, perform medical investigations for example, venepuncture or ECGs, and various other nursing tasks. They work under the direct and indirect supervision of a qualified nurse. There is no mandatory formal training required for these posts, though all NHS trusts must offer courses such as S/NVQ's (Scottish/National Vocational Qualifications) at level two and three which can satisfy the entry requirements for nurse training. Also many employers will insist that the worker attend various training courses such as moving and handling before they can care for patients.


 * Staff Nurse:- All newly qualified nurses begin at this level and the majority of the registered nursing staff. These nurses were previously graded "D" (on the A-I grade system, with A being the most junior), however under Agenda for Change (A of C), most nurses, depending on their roles and responsibilties will be on Band 5.


 * Senior Staff Nurse:- A senior staff nurse has more clinical experience and management responsibility than a staff nurse. They were employed as 'E' grade nurses under the clinical grading system. Under A of C, again depending on their roles and responsibilites, will probably be in Band 5 or 6.


 * Junior Sister/Junior Charge Nurse/Deputy Ward Manager:- Formerly an "F" grade under clinical grading. These nurses are deputy to the ward manager/charge nurse and as such have more of a managerial role. Banded in either 6 or 7 under A of C.


 * Sister/Charge Nurse/Ward Manager:- Responsible for the management of their ward/clinic/unit usually with budgetry control. Formerly grade "G", under A of C most likely band 7.


 * Clinical Nurse Manager:- Usually manages a specific area, for example Accident and Emergency. Previously, they were graded "H" grades, but likely to be banded 8 (although depending on scope of responsibilies possibly band 7).


 * Matron:- Usually manages an entire directorate, e.g. medical, surgical etc. Historically managed the entire hospital, although this role is obsolete.  Modern Matrons attracted an "I" grade under clinical grading.  Most likely band 8 under Agenda for Change.

There are various other higher managerial and specialist nurse roles, however these are less well defined on a national scale.

Education
Registered Nurses generally receive their basic preparation through one of three basic avenues:


 * 1) Graduation from an Associate of Science in Nursing degree-granting nursing program (two to three years of college level study with a strong emphasis on clinical knowledge and skills) earning the degree of ASN/AAS or ADN in Nursing.
 * 2) Graduation with a three-year (Diploma in Nursing) certificate from a hospital-based school of nursing (non-degree). Few of these programs remain in the U.S. and the proportion of nurses practicing with a diploma is rapidly decreasing.
 * 3) Graduation from a university with a Bachelor of Science in Nursing (a four - five year program conferring the BSN/BN degree with enhanced emphasis on leadership and research as well as clinically-focused courses).

There are also special programs for "LPN to RN", for people who hold undergraduate degrees in other disciplines, and for paramedics or military medics. Graduates of all programs, once licensed, are eligible for employment as entry-level staff nurses.

A typical course of study at any level typically includes such topics as:
 * Anatomy and physiology
 * Microbiology
 * Pharmacology and medication administration
 * Psychology
 * Nursing ethics
 * Nursing theory
 * Nursing practice
 * Legal issues in nursing practice

All pathways into practice require that the candidate undergo clinical training in nursing. Care is delivered by the student nurses under academic supervision in the hospital and in other practice settings. Clinical courses typically include:
 * Maternal-child nursing
 * Pediatric nursing
 * Adult medical-surgical nursing
 * Geriatric nursing
 * Psychiatric nursing

While in clinical training, student nurses are identified by a special uniform to distinguish them from licensed professionals.

It is common for RNs to seek additional education to earn a Master of Science in Nursing or Doctor of Nursing Science to prepare for leadership or advanced practice roles within nursing. Management and teaching positions increasingly require candidates to hold an advanced degree in nursing. Many hospitals offer tuition reimbursement or assistance to nurses who want to continue their education beyond their basic preparation.

Many nurses pursue voluntary specialty certification through professional organizations and certifying bodies in order to demonstrate advanced knowledge and skills in their area of expertise.

All U.S. states and territories require RNs to graduate from an accredited nursing program which allows the candidate to sit for the NCLEX-RN, a standardized examination administered through the National Council of State Nursing Boards. Successful completion of the NCLEX-RN is required for state licensure as an RN.

Nurses from other countries are required to be proficient in English and have their educational credentials evaluated by an association known as the Council of Graduates of Foreign Nursing Schools prior to being permitted to take the U.S. licensing exam.

Legal regulation
Government regulates the profession of nursing to protect the public.

In the U.S., the individual states have authority over nursing practice. The scope of practice is defined by legislative and regulatory laws which are administered by State Nursing Boards.

Many states have adopted the Model Nursing Practice Act and Model Nursing Administrative Rules created by the National Council of State Nursing Boards (NCSNB). In addition, many State Nursing Boards model their licensure requirements on the Uniform Core Licensure Requirements which set forth competency development and competency assessment principles.

Nurses may be licensed in more than one state, either by examination or endorsement of a license issued by another state. In addition, the states which have adopted the Nurse Licensure Compact allow nurses licensed in one of the states to practice in all of them through mutual recognition of licensure.

Licenses must be periodically renewed. Some states require continuing education in order to renew licenses.

Types of nurses
Licensed Practical Nurses (LPNs) are also known as Licensed Vocational Nurses (LVNs) in California and Texas. These individuals usually have eighteen months to two years of training in anatomy and physiology, medications, and practical patient care. They must pass state or national boards and renew their license periodically.

LPNs can perform simple as well as complex medical procedures but must operate under the supervision of either a Registered Nurse or a physician. They can administer most medications (usually with the exception of IV push medications), perform measurements (blood pressure, temperature, etc.), keep records, perform CPR, maintain sterile and isolation conditions, and administer basic care.

LPNs are often found working under the supervision of physicians in clinics. In long term care facilities, they sometimes supervise nursing assistants and orderlies.

The Bureau of Labor Statistics estimates that there were about 700,000(1) persons employed as Licensed Practical Nurses and Licensed Vocational Nurses in the U.S. in 2004.

Registered Nurses (RNs) are professional nurses who often supervise the tasks performed by LPNs, orderlies and nursing assistants. They provide direct care and make decisions regarding plans of care for individuals and groups of healthy, ill and injured people. They have a Diploma, Associate Degree, or Bachelors Degree in Nursing at entry level, and after passing state board examininations are granted the title Registered Nurse. Regardless of degree, RNs have many hours of clinical experience before they are graduated.

RNs are the largest group of healthcare workers in the U.S. The Bureau of Labor Statistics estimates that there were about 2.3 million (1) persons employed as Registered Nurses in the U.S. in 2004.

Research has shown that RNs are the first-line defense of hospitalized patients against disability or death from infection, cardiopulmonary arrest, and other serious complications. Higher ratios of registered nurses to patients have been shown to decrease certain complications of illness and mortality rates. Registered Nurses are educators, managers, executives, therapists, intensive care experts, symptom managers, professional mentors, researchers and community members. In hospitals, registered nurses perform diverse roles such as writing policies, responding to emergencies, managing professional, technical and ancillary staff, determining budgets, performing strategic planning, and supervising construction projects.

Advanced practice nurses (APNs) are Registered Nurses with advanced education, knowledge, skills, and scope of practice. APNs possess a master's or doctoral degree in nursing and may also sit for additional certification examinations. APNs may function as a Certified Nurse Midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS) or Certified Registered Nurse Anesthetist (CRNA). They perform primary health care, provide mental health services, diagnose and prescribe, carry out research, and educate the public and other professionals. Some APNs diagnose illness and prescribe medication.

All advanced practice credentials have requirements such as continuing education and periodic re-examination to maintain the credential.

Advanced Practice Nurses can expect to earn above-average salaries, especially as the population of ages and the demand for highly-skilled healthcare workers grows proportionally.

Other healthcare workers
Health care settings generally involve a wide range of health care workers other than nurses. Examples include:
 * Nursing assistants, orderlies, and patient care assistants are not nurses. In acute-care hospitals, their duties are limited to tasks delegated by the RN or LPN. Most orderlies are trained to perform heavy patient-movement or other muscular tasks. Certified nursing assistants assist nurses by taking vital signs, administering hygienic care, assisting with feeding, giving basic psychosocial care, and similar duties. See also candystriper and hospital volunteers.
 * Technicians may wear uniforms similar to those of nurses and perform some duties traditionally associated with nurses, but are not nurses. For example, certified medication aides are trained to administer medications in a long-term care setting, but have no training in nursing decision-making; thus, their use is controversial.  There are also phlebotomy technicians, who draw blood; surgical technologists, who are more or less equivalent to a Registered Nurse in the first scrub role during a surgery; and technicians trained to operate most kinds of diagnostic and laboratory equipment, such as X-ray machines, electrocardiographs, and so forth.
 * Medical practitioners (medical doctors) and allied health professionals (such as speech therapists, occupational therapists and physical therapists), are not nurses. Whilst they may work closely with nurses, they are members of their own separate professions, with distinct training, licensing, skills and roles.