Nurses in the United States exist on several distinct levels, distinguished by increasing education, responsibility and skills. The major distinction is between task-based nursing and professional nursing.
Nursing assistants and orderlies are not nurses. In acute-care hospitals, their duties are limited to simpler tasks delgated by the registered nurse. Most orderlies are trained to perform heavy patient-movement or other muscular tasks. Orderlies were originally the "police" of hospitals, to keep the patients "orderly." Certified nursing assistants assist nurses by taking vital signs, administering hygienic care, assessing patients' well-being, assisting with feeding, giving basic psychosocial care, and similar duties.
Technicians and specialized therapists may wear uniforms similar to those of nurses, but are not considered nurses. For example, certified medication aides are trained to administer medications but have no training in nursing decision-making. There are also blood collection technicians, and technicians trained to operate most kinds of diagnostic and laboratory equipment. Respiratory and physical therapists perform only specific procedures. The salaries of technicians and therapists vary wildly depending on their skills and demand for their services.
Licensed practical nurses (LPN; they are known as Licensed vocational nurses, LVN, in California and Texas) exist in some states. These usually have two years of training, in body function & structure, drugs and practical patient care. They can perform simple medical procedures and usually operate under the supervision of professional registered nurses (RNs). They can administer medication, perform measurements (blood pressure, temperature, etc), record-keeping, help with patient-care planning, first aid, CPR, sterile and isolation procedure and basic care and house-keeping. In long term care facilities, they sometimes supervise nursing assistants and orderlies.
Registered Nurses are professional nurses who often supervise the task-based LVNs, orderlies and nursing assitants. They provide direct care and make decisions regarding plans of care for groups of healthy, ill and injured people. They typically complete 3 to 5 years of college, including many hours of clinical experience. They are the largest group of healthcare workers in the United States, with over 2.6 million RNs. It is estimated that an additional 750,000 RNs will be needed by 2005. Many years of research has shown that RNs are the first-line defense of hospitalized patients against disability or death from infection, cardiopulmonary arrest, and other complications. Registered nurses are patient educators, family therapists, intensive care nurses, symptom managers, organizational experts, professional mentors and community members. In hospitals, registered nurses perform diverse roles such as writing policies, responding to emergencies, managing professional and non-professional staff, determining budgets, performing strategic planning, and supervising construction projects.
Advanced Practice Nurses perform primary health care, mental health services, diagnosis and prescribing, carry out research, and educate the public and other professionals. Some APNs diagnose illness and prescribe drugs. APNs possess a Masters' Degree or higher in Nursing, and may sit for additional certification examinations. These exams allow an APN to practice at a more advanced (sometimes independent) level in a specialty. They may operate as a Certified Nurse Midwife (CNM), Nurse-Practitioner (NP), Clinical Nurse Specialist (CNS) or Certified Registered Nurse Anesthetist (CRNA).
All advanced practice certifications require continuing education and other requirements (such as periodic reexamination) to maintain the credential. Advanced practice nurses can expect to earn above-average salaries, especially as the population of the US ages and the demand for highly-skilled healthcare workers grows proportionally.
At the top of the educational ladder is the doctorally-prepared nurse. Nurses may gain the PhD or another doctoral degree (Doctor of Nursing Science, Nursing Doctor), specializing in research and/or clinical nursing treatment. These nurses practice nursing, teach nursing and carry out nursing research. As the science of nursing has advanced, so has the demand for doctorally-prepared nurses.
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."
All US states and territories require RNs to graduate from an accredited nursing program which allows the candidate to sit for the NCLEX examination, a standardized examination administered through the National Council of State Boards of Nursing. Successful completion of the NCLEX examination confers state licensure as an RN. Nurses may be licensed in more than one state, either by examination or endorsement of a license issued by another state. Licenses must be periodically renewed. Some states require continuing education in order to renew licenses.
Nurses may receive their basic preparation for Registered Nursing through one of three avenues:
All pathways into practice require that the candidate complete some clinical training in nursing. While in clinical training, student nurses are identified by a special uniform. Graduates of all programs, once licensed, are generally eligible for employment as entry-level staff nurses.
It is common for RNs to seek additional education to prepare themselves to assume leadership or advanced practice roles within nursing. Management positions increasingly require candidates to hold an advanced degree in nursing. Many hospitals offer tuition remission or assistance to nurses who want to continue their education beyond their basic preparation.
Most RNs work in a hospital. A registered nurse has a very portable job skill. In many cities, RNs can enter their names in a "registry" and work a wide variety of temporary jobs. Beside hospitals, RNs work in schools, home health care, in office and occupational or industrial health settings, free-standing clinics and physician offices, long-term care facilities, camps, and as advisors and consultants to the healthcare and insurance industries. Some RNs work with attorneys as Legal Nurse Consultants, reviewing patient records to assure that adequate care was provided.
There are many different nursing specialties, encompassing care throughout the human lifespan and based upon patient needs. Many nurses who choose a specialty become certified in that specialty, signifying that they possess expert knowledge of the specialty. There are over 200 nursing specialties and sub-specialties. Certified nurses often earn a salary differential over their non-certified colleagues, and studies from the Institute of Medicine have demonstrated that specialty certified nurses have higher rates of patient satisfaction, as well as lower rates of work-related errors in patient care.
In premodern times, nuns and the military often provided nursing services. the religious and military roots of modern nursing remain in evidence today. For example, in Great Birtain nurses are known as "sisters." Florence Nightingale is regarded as the founder of modern nursing, which flourished in response to the World Wars[?].