“The rigor of the nursing major should be understood and appreciated by the nursing student" (Stabler-Haas, p. 17, 2012).
In this chapter, students will learn:
Educational Preparation and Career Choices
Nursing is an applied science and art which requires personal and professional growth and development (NLN, 2010). Knowledge, skills, and attitudes are learned through classroom, simulation, and clinical experience. Both theory and practice are necessary to develop competent nursing professionals as well as professional self-assessment skills. Maranon and Pera (2015) found that undergraduate students develop professional identities throughout nursing school and gain confidence in the ability to approach new situations. In this study, clinical mentors were crucial partners in the development of confidence and flexibility.
The National League for Nursing (NLN) (2010) recognized that “…it is no longer sufficient to launch a newly qualified nurse into the workforce armed only with mastery of a body of knowledge. We must instead prepare individuals grounded in values and ethics, with an understanding that knowledge is continually evolving, and with the skills to evaluate that knowledge and apply it in situations where nurses touch the lives of others.” This insight guides nurse educators to help students learn how to:
Christine Tanner’s (2006) model of clinical judgment in nursing is one way to understand the pre-licensure transformative journey. Nurses care for unique humans in varied settings under myriad conditions and must be able to adapt to individual patient needs at each moment of care. Students learn how to make sound clinical judgments, based on a relationship with the patient, and not blindly follow rules and procedures. Tanner describes four aspects of clinical judgment: Noticing, interpreting, responding, and reflecting. Students learn how and what to notice, how to accurately interpret findings based on patient-centered assessments, how to respond correctly in each situation and to reflect on what worked and what did not work (see image below). For a brief video on this model, go to Ian Camera’s Concept map of Tanner’s model (2012, April 26) at https://www.youtube.com/watch?v=odztmlPJoCM.
Image source: lafesolutionsacademy.com
Definitions and scopes of practice
Registered nurses have many roles: Caregiver, advocate, educator, communicator, and manager. Each role requires significant learning, which begins in formal education programs before entry to practice is granted. Nurses work in a myriad of practice settings, with persons across the lifespan, and at all levels of care: Acute, life-threatening, chronic, rehabilitation, wellness centers, and at the end of life where comfort care eases the transition to death. Nurses are expected to remain current with evolving practice guidelines and standards and maintain competence in skills and knowledge (ANA, 2010). The ANA (2010) practice standards also state that each nurse evaluates his/her own practice in relation to standards of practice, clinical practice guidelines, statutes, rules, and regulations.
The National League for Nursing (NLN) recommends that all levels of nursing - from LPN/LVN to doctorally prepared nurses - receive an education that includes the same core values and concepts (NLN, 2010). The core values are: Caring, diversity, ethics, excellence, holism, integrity, and patient-centeredness. In addition to these values, all nurses should learn integrating concepts: Knowledge/science, personal/professional development, quality/safety, context/environment, relationship-centered care, and teamwork. The recommended educational program outcomes include The recommended educational program outcomes at all levels of nursing are: Human flourishing, nursing judgment, professional identity, and spirit of inquiry (NLN, 2010). In other words, every nurse in every setting should practice with these values, concepts, and outcomes in mind.
This text introduces the student to each component of nursing education. For more information see the chapter indicated below:
Attributes, criteria, and context
Nursing education is a rigorous and life-changing process that prepares individuals for a rewarding professional career. The journey includes several steps: Becoming a successful student nurse, becoming a successful registered nurse, and advancing education and career opportunities.
Becoming a successful student nurse
A nursing major differs from other college majors with an additional dimension - patient care! Student nurses learn not only about nursing knowledge and skills, but they must also demonstrate the ability to safely care for diverse patients in a variety of settings with compassion and respect. Nurses interact with strangers every day in very intimate ways while they assess, plan, and care for physical, psychosocial, emotional, and spiritual needs. These therapeutic interactions are guided by a fund of nursing knowledge with skills in nurse-patient relationships. Therefore, becoming a nurse requires quite a few personal changes along the way and a commitment to becoming a responsible professional.
The application process to enter nursing school is also different from other majors and usually very competitive. Many schools of nursing admit only a fraction of applicants each year due to a national nursing faculty shortage and limited clinical experience opportunities. Therefore, most schools require an intriguing well-written essay about the candidate’s passion for the profession and caring for others. Sometimes a personal interview is required. The grade-point average (GPA) should be high, especially in the sciences. Pre-licensure student nurses must demonstrate beginning mastery in anatomy, physiology, microbiology, pharmacology, psychology, and emotional intelligence to adequately care for patients. Therefore, a well-rounded application would indicate qualities such as caring, compassion, empathy, and personal resilience.
Godfrey and Crigger (2017) encourage students to be accountable for their own learning, to engage in reflection, to build relationships, and to develop habitual self-care practices. Students must also take control of their lives through adjustments to work, social, leisure and study time with more focus on studies. The decision to work while in a rigorous program of study should be considered carefully. Professional education takes many more hours of preparation beyond the classroom and clinical hours (Stabler-Haas, 2012). Working as a nurse-tech where administrators are supportive of school hours could help increase confidence and build rapport with a future employer. Stabler-Haas (2012) recommends that the maximum amount of work per week for a student nurse should be 20 hours or less.
Family expectations usually need adjustment during nursing school due to the number of clinical, classroom, and study hours required for success. An honest conversation about this temporary “time away” can help prepare loved ones for added responsibilities, limited “together” time, and the change in relationship dynamics. The group can decide together how best to manage this commitment and plan for contingencies should crises emerge. Student nurses often expand their normal support group to include neighbors, friends and extended family members as back up for childcare, meals, and other duties.
Nursing school exams and success. One nurse educator reminds students that nursing school is different; memorization has its place but does not help a learner “figure things out,” solve problems, or make sound clinical decisions (Scott, p. 81, 2009). Students must learn how to think critically and use information to solve complex problems. Scott also tells students to fortify themselves for a nursing career where instant decisions must be made based on evidence, experience, and patient preferences (Scott, 2009). To do this well, students must learn in various ways, not just with memorization. The change in learning methods and exams can take students by surprise. In the first semester, students who achieved high grades on general education exams can be shocked by the different testing format in nursing school. Nurses use information to solve problems every day, so application and analysis questions test the student’s ability to use data, to think through problems, and make good clinical decisions in various settings.
Many students face feelings of inadequacy during the transition to a nursing student. Two forms of self-care can help: Use learning techniques that apply or analyze facts and keep a passionate statement visible on why nursing is a chosen career. Learning techniques should include asking questions that address dilemmas in patient-centered care, priorities, safety, and evidence-based clinical decisions:
Additionally, study groups can help with application-learning through discussion and questioning while working on clinical problems together. This form of education and ‘training the brain to think like a nurse’ becomes easier each semester and prepares nurse graduates for the licensure exam. A major goal of nursing faculty is to: Prepare graduates who can think critically, make sound clinical judgments, and integrate the best evidence into practice (NLN, pp. 67, 2010).
Preparation for clinical experiences. Student nurses learn nursing care at the bedside of patients in various settings with increasingly complex health conditions. Clinical facilities such as hospitals and nursing homes require clinical credentialing and verified skills demonstration to ensure patient safety. These facilities also require that anyone caring for their patients must have certain physical and psychosocial skills.
Clinical credentialing processes are the responsibility of the nursing program and each student must comply with requirements prior to caring for patients. Common items include annual drug screens, criminal background checks, health insurance, proof of immunization from communicable diseases, cardiopulmonary resuscitation (CPR) certification, signed confidentiality agreements, and successful completion of healthcare facility safety procedure quizzes (i.e., infection prevention, fire and disaster procedures, and healthy body mechanics). Additionally, clinical uniforms, shoes, and personal appearance standards must be met. Students are reminded that all school paperwork related to patients should omit identifier information such as age, ethnicity, name, etc. and that hallway and mealtime conversations must never violate confidentiality laws.
Skills verification sessions are held at the school prior to clinical experiences where the skills will be used. For example, students practice administering medications and injections, initiating intravenous infusions, and insertion of urinary catheters prior to performing these skills on patients. Additionally, students are monitored by an instructor or registered nurse during the performance of these tasks at the facility. Students must maintain skill in tasks previously verified and are required to prepare for each clinical experience through study, practice, and critical thinking before arrival. Instructors often quiz students about readiness to practice so that patients are safe and care standards are met.
Preparation for clinical education at clinical facilities requires certain physical and psychosocial skills (Stabler-Haas, 2012). Good assessment skills require the ability to see, hear, smell, and feel changes in the human body and in mental and emotional states that might not be expressed. Most nurses who work in hospitals and nursing homes need physical stamina to sit, stand, lift, move equipment, and assist others with eating, bathing, toileting, standing, walking, and transfers to and from the bed. They also need to hear and read prescriptions, medical records, procedure guidelines, and other communication to make good clinical decisions. Finally, healthcare workers are expected to possess a certain level of emotional intelligence, control over behavior and affect, and a professional restraint when stressful situations occur.
Student nurses learn two crucial personal and professional skills during school – flexibility and critical thinking. Every clinical instructor is different as is each clinical facility. How things are done at one facility and with one instructor, might not be how things are done at another facility or with another instructor. However, the principles of excellent nursing care guide each task and every patient-student nurse encounter. For additional thoughts on preparation for nursing school, go to:
Becoming a successful registered nurse
Pre-licensure graduates from an accredited nursing program are qualified to sit for the National Council Licensure Examination for Registered Nurses (NCLEX-RN) after completion of all requirements at the diploma, associate, or baccalaureate level. Many nursing schools provide preparation classes and several companies offer preparation courses for a fee. Students can purchase NCLEX-RN books and visit online test banks. Perhaps the best preparation advice is to practice as many test questions as possible throughout nursing school (Stabler-Haas, 2012; Scott, 2009). Through practice, students learn to discern which ‘right’ answer is the best answer for the patient and scenario in the test question. More information on the NCLEX-RN is located under the Licensure and Certification section. Read the exemplars to learn about pre-licensure programs.
Nurse Practice Acts. In the U.S., registered nurses are licensed to practice under a legal agreement within each state and territory. The Nurse Practice Act (NPA) is written by the state legislature and contains specific information about the scope of practice – what nurses can legally do and not do. This law establishes a board of nursing (BON) with the authority to develop rules and regulations that further guide nursing practice. The BON is also responsible for making decisions about disciplinary action and license renewal. Once licensed, registered nurses are required to remain current with all updates or changes to the NPA. For more information on NPAs, go to https://www.ncsbn.org/npa-toolkit.htm.
Career choices. During the pre-licensure educational journey, students perform a self-assessment to determine which nursing specialty and clinical setting would match their competencies (Burkhardt and Irwin, 2008). For example, a nurse who enjoys structure, timelines, and following strict procedures might flourish in an operating room. Another nurse might enjoy the freedom of home care hospice where care is continuously modified to meet patient and family needs. An interpersonal skills self-assessment is also needed. Some nurses enjoy plenty of time to talk with, listen, and learn about patients while others prefer to teach and coach toward structured goals. Nurses who enjoy listening might find behavioral health or counseling a good job fit and those who prefer to coach toward health goals would probably thrive in a rehabilitation setting.
Another consideration before employment is to work as a nurse-tech on a unit with nurses who enjoy mentoring student nurses. The on-the-job training helps with learning the scope of professional nursing, and the student can decide whether the unit is a “good fit” before graduation. Other students apply for nurse internship positions prior to graduation. These highly structured programs smooth the transition from student to the professional registered nurse after licensure is achieved.
Highly successful nurse graduates who take control of their career path learn as much as they can about the best "job fit" after graduation. Honest self-assessment is crucial and can lead to a satisfying career by understanding personal preferences, skills, and aptitudes (Stabler-Haas, 2012). Some questions to ask oneself include:
Nursing workforce trends wax and wane over time and new specialties develop with new technology. Studying the current situation can help a nurse graduate begin a career that matches interests, preferences, and competencies. The following actions should be taken during the last three months of school or before, and the student should ‘dress for success’ when interacting with potential employers.
Obtaining the first RN position. Final comments about finding the ‘perfect’ job include creating a professional portfolio. First on the list is a brief resume that highlights education, work, and volunteer service. Use an online format with instructions on how to create a professional resume. Obtain reference letters from nursing professors and clinical instructors. Write a cover letter that summarizes professional goals with an emphasis on knowledge, skills, and attitudes that match the job description and facility mission. Update this portfolio each year with new knowledge, skills, and abilities to be ready for the next career advancement.
Advancing education and career opportunities
Many registered nurses pursue a master's and/or doctoral degree in a chosen nursing specialty. There are several paths to higher education in nursing that deepen expertise in a selected area of interest: nursing administration, advanced practice, and nursing education (NLN, 2010). Currently, there are four advanced practice designations: nurse anesthetist (CRNA), clinical nurse specialist (CNS), nurse-midwife (CNM), and nurse practitioner (APRN) (AACN, n.d.). Nurses who practice in these advanced roles obtain additional education in pathophysiology, pharmacology, and physical assessment to practice at higher levels of independence (AACN, n.d.). Most advanced practice nurses can prescribe medication, perform minor procedures, and practice independently. For more information on graduate programs in nursing, go to the AACN website: https://www.aacnnursing.org/Nursing-Education-Programs/Masters-Education.
Some nurses prefer to specialize in nursing care for specific populations or conditions. For example, a clinical nurse specialist (CNS) might care for communities or persons with diabetes, heart failure, or mental illness. Most graduate programs in nursing require a BSN as part of the admissions process. Some bridge programs are available which teach the core BSN content prior to graduate school courses.
The application process is like other college admissions requirements and could include items from the professional portfolio (letters of recommendation, cover letter, and current resume). Applicants might also be required to take an entrance exam called the Graduate Record Exam (GRE). This exam tests skills and knowledge in writing, math, and verbal communication (Burckhardt and Irwin, 2008). For more information on the GRE go to Educational Testing Service (ETS), the organization that creates, proctors the exam: https://www.ets.org/gre/?WT.ac=etshome_gre_flagship_180417.
At the doctoral level, nurses can choose a practice-focused doctorate (DNP), a research doctorate (Ph.D., DNS, DSN, DNSc), or a doctorate in nursing education (EdD). The DNP has two possible tracks: Advanced practice for nurse practitioners or a population and systems focused degree; however, both tracks prepare nurses for doctoral-level evidence-based practice (American Association of Colleges of Nursing [AACN], 2006). Nurse scientists and scholars (Ph.D., DNS, DSN, DNSc) are prepared to conduct research and scholarly activities (AACN, 2006). The Ed.D. in nursing focuses on the art and science of nursing education, research, and scholarly endeavors.
Once a career path and degree are selected, the nurse chooses a nursing program that matches career goals and personal and professional interests. There are over 500 nursing schools nationwide and over 2,000 graduate programs. For help in determining a career path, go to the AACN website at https://www.aacnnursing.org/.
Continuing education requirements. Most professions require continuing education to ensure that current best practice is provided to the public. For example, a physician attends conferences to learn about updated treatments, and an engineer attends a continuing education workshop on how to use new technologies safely. The same is true for nurses. Each state board of nursing determines the number of continuing education units (CEU) that a nurse must complete prior to licensure renewal every two years. Additionally, hospital nurses are often required to participate in CEUs regularly. Most nurses focus on updating knowledge and skills in a chosen specialty, however, broadening interest in general nursing and other specialties can enhance nursing practice.
The following examples describe various paths from pre-licensure education to practice at entry and advanced levels of nursing practice. The stories are fictional but based on common facts.
Diploma program education
After three years of training in a diploma nursing program, Nancy was hired to work in a 100-bed rural hospital. Her education was from a hospital-based program that allowed much on-the-job training as she progressed through school. She would learn a skill and apply it that same week. Her fund of knowledge grew deeply because she was able to care for patients with the same conditions that she had learned each semester. Most of the nurses were graduates from the same program and helped her know what to expect next. They gave her assignments that matched what she was learning. These nurses told her to keep learning and to finish her core classes for the Bachelor of Science in Nursing (BSN) as soon as possible. The hospital was being purchased by a larger hospital system that required at least an ASN but preferred BSN nurses. They reminded her that a BSN was required, not a bachelor’s degree in another field.
Nancy realized this program had prepared her well for hospitalized patient care, but she eventually wanted to become a homecare nurse which required a BSN. Her diploma program was associated with a community college, so some of her courses counted toward a BSN degree. One year after graduation from the diploma program, she completed her core courses shopped around for an online RN-BSN program that matched her learning style and work/family schedule. Working full time and going to school full time for four years had taken a toll on her family, so she worked on her BSN part-time. After graduating from the BSN program, Nancy was hired as a home care nurse in her rural community to provide nursing care to persons she had known all her life. The job was immensely fulfilling, and she grew in knowledge, skills, and confidence while helping her community strive for better health.
Associate of Science in Nursing (ASN) education
After two years of pre-requisite courses in general education (English, math, history, and sciences), Gloria was admitted into the nursing program at her community college. She had gone to school part-time while she worked as a waitress. Her part-time status helped to keep her grade point average (GPA) high enough to qualify for entry into the nursing program. At her college, over 600 candidates applied to the nursing program, but only 60 students were admitted each year.
After admission to the program, she attended the orientation session where she learned the many rules and policies that are common in nursing programs across the nation. She was surprised to learn that nursing education is very different from a general college education. Attendance is mandatory and there are many other required experiences besides classroom learning. Gloria wrote the dates on her calendar for simulation labs, skills labs, classes, and tutoring sessions as well as writing the dates and directions to various clinical facilities. She took notes about the nursing school uniform (scrubs, lab coat, and clinical shoes) which must be the right type, color, and fit. The scrubs and lab coat must be ironed, and the shoes must be closed-toe and impermeable to fluids – no tennis shoes! She also decided to create a "clinical bag" where all her required nursing equipment, clinical facility badges, student ID, clinical facts book, notebook, and pen would stay throughout nursing school. That way, she would always be prepared and not turned away from a vital clinical experience. She learned that nursing school has strict rules because clinical facilities have very strict rules to protect patients and their loved ones from infection, errors, and other risks.
Once in the program, Gloria realized that the orientation faculty were right – nursing school is rigorous and that her waitress job was getting in the way of study time. Her family began to complain that she was never at home, but always at school studying or at work. Gloria made two smart moves: She quit her job as a waitress, applied for a nurse-tech position, and she joined a study group. The nurse-tech position supported her learning on the job, and the nurse manager was very supportive of schedule changes for school. The study group made learning fun and more efficient. She remembered more on tests without having to spend hours and hours studying alone. Her family began to understand that this two-year commitment belonged to them, too. So, after a family meeting, they agreed to do their share of housework and spend ‘potent’ time together in brief bursts on scheduled days. One of the children made a calendar to mark off each day toward graduation. They all realized this was hard work which would pay off in two years.
Gloria continued her nursing school program, learning more each day about the needs of patients, families, and communities. She began to see a difference in how she related to people – even her family. Although her self-confidence was challenged during the first semesters of school, in the last semester, she realized that school had prepared her for a nursing career, not just a job. Nursing education had transformed her into a professional with a large body of knowledge, specialized skills, and a new attitude about work, health, and life. She was ready to graduate and begin learning how to care for patients on her unit – where being a nurse tech had helped shape her philosophy of nursing.
Bachelor of Science in Nursing (BSN) education
George was a practical and goal-driven registered nurse and wanted to continue growing in his nursing career. As soon as he graduated from an ASN program, he applied and was accepted to an online RN-BSN program. His friend, Steve, had graduated with a BSN from a four-year university and was hired at a prestigious hospital with better pay. George wanted the same opportunity. The RN-BSN online format would work well with his work schedule and help him advance his career faster. The application process was similar to the ASN program which required school transcripts, standardized test scores, background checks, photo IDs, letters of reference, and application essays.
During the application process, George was told that BSN-level education requires scholarly writing and thinking. In the first class, he realized that writing skills and knowledge of the American Psychological Association (APA) scholarly paper format were crucial to success. George did not have the required writing skills to succeed but was very intelligent and understood the educational content. Even though he could pass a test with A's, he received a C on his first two papers. The grade was low because it did not meet scholarly paper format requirements. He decided to use the college writing tutorial service where he learned how to write scholarly papers quickly. His grades returned to A's and he graduated with honors.
George had heard that BSN programs were “loaded with papers to write” and he realized that writing in a scholarly fashion had changed how he thought about and talked about nursing. He felt, acted, and spoke more professionally which reflected his intelligence and passion for excellence in nursing practice. The process of BSN-level education had also prepared him for graduate school – where even more papers are required.
Master of Science in Nursing (MSN) education
Sally had worked as an RN in her hospital for three years. She had a BSN from a four-year college and was ready to advance her career. There were several role models on her unit who she admired but was unsure which path to take. After the BSN, nurses have many, many options for practice. Some nurses continue to work in hospitals after graduate school, others work in community agencies, start their own clinics, or teach in nursing programs. She talked with each of her role models and investigated several schools, specialties, and work settings.
After a self-assessment that included her strengths and weaknesses, family and social life and her career goals, Sally knew what she wanted to do. Her favorite type of patient was a person who needed acute care stabilization in the intensive care unit (ICU). And, she loved to teach other nurses how to best care for each patient. She had excellent scholarly writing skills and a 3.9 GPA. She also enjoyed working with and learning more from physicians, physical therapists, and pharmacists. Sally had a reputation for being one of the best ICU nurses and was admired by staff and other disciplines as a good leader, a great clinician, and a helpful teammate. To advance her career and better care for ICU patients, Sally decided to become an advanced practice registered nurse (APRN) with a specialty in acute care for adults. She researched schools and found the best fit for her work-life balance, location, educational rigor, and school mission. After two more years of full-time study (yes, the family took a back seat for another two years, but they cheered her on), Sally graduated from an accredited nurse practitioner program. She passed the national certification for her nurse practitioner (NP) specialty and applied to the state board of nursing for an NP license. The application process was like obtaining an RN license and renewal was set at every two years. She decided to keep her RN license, too, so she could work as an RN in other states that might not recognize her NP license.
Sally continued to work in the ICU but was now a nurse practitioner who worked alongside doctorally prepared physicians, nurses, pharmacists, and physical therapists to plan and direct care. She wrote prescriptions for medication and treatments and mentored RN's on best nursing practices. Sally felt fulfilled in her new position and reaped several other benefits. The pay was much better, she could make higher-level clinical decisions with her patients and their loved ones, and she was able to mentor other nurses toward career goals and best patient outcomes. The work had paid off. Sally had a job she enjoyed at a salary that reflected her level of expertise and in a setting where she thrived. She and her family agreed that school had been worth the effort.
Doctoral-level education: A DNP and Ph.D. comparison
At the doctoral level, nurses have several choices in career path and Justin and Anna were aware that it would be rigorous. Justin's main strength and joy in work came from finding out what worked best at the bedside for each patient on each unit. He was frustrated, however, with the lack of connection between new research and getting that evidence to the bedside in a timely manner. He knew that as a master's prepared clinical nurse specialist (CNS), his fund of knowledge was excellent, but he did not have the power to make changes to policies and procedures. He wanted to learn how changes are made in the healthcare system and have the authority to make that happen.
Anna wanted to teach nursing. She was already an adjunct clinical instructor who took pre-licensure BSN students to clinical facilities. There, she taught them the art and science of nursing care in her specialty – adult psychiatric nursing. She worked in a community crisis stabilization unit as an APRN and had enjoyed the work for many years. But lately, she knew that teaching was becoming her passion. She would end up taking a pay cut to teach but knew that it was the right move at this stage of her career. A Ph.D. in nursing would help her obtain a nurse faculty position at the university and it would help her advance through the promotion and tenure process. As an older nurse, Anna was interested in working as long as she could to influence nursing in the right direction. Research was going to be the way to demonstrate the evidence that nurses needed to make improvements in healthcare outcomes.
After interviewing several recruiters from doctor of nursing practice (DNP) and doctor of philosophy (Ph.D.) programs, Justin and Anna found the perfect fit for their career goals. Through several phone conversations, they learned that Ph.D. nursing programs take about four years to complete and Anna would have skills in conducting research. Justin knew that he enjoyed staying close to bedside nursing, so he chose to work on a DNP degree that prepared him to bring evidence-based practice to the bedside – in two years. He would also learn how healthcare systems work, how financial decisions are made, and how evidence-based changes can be implemented throughout a healthcare system. They also learned that nurses with a Doctor of Nursing Practice (DNP) degree focus on the clinical setting whereas nurses with a Doctor of Philosophy (Ph.D.) in nursing, focus on research. The Ph.D. nurse scientists and DNP nurses work together to bring evidence-based practice to the bedside (NLN, 2010).
Justin and Anna were taking different paths toward a doctoral degree in nursing to further advance their careers and the nursing profession. They would be joining other leaders in nursing to guide and direct the profession toward improved healthcare outcomes.
Licensure and Certification Requirements
The sense of achievement and joy that comes with obtaining a nursing license can be deeply satisfying. The registered nurse (RN) license requires hard work, dedicated study, and support from others but it opens doors to a wide array of career possibilities. RNs can also obtain an advanced practice registered nurse (APRN) license after additional education. This section describes the process for obtaining and maintaining an RN and APRN license and certifications that recognize specialty expertise.
Licensure for registered nurses
Graduates from diploma, associate, or baccalaureate nursing programs must apply for permission to take a national exam as part of the licensure process. The graduate chooses a state in which to sit for the National Council Licensure Examination for Registered Nurses (NCLEX-RN). This state becomes the "home" for the RN license and is granted by the state board of nursing (BON) which sets testing requirements. Candidates for the exam provide a background check, proof of identification, and professional name for the license. The nursing program director provides proof of completion from an accredited nursing program. Once all requirements are met, candidates sit for the exam at a proctored testing center.
After achieving a passing score, the nurse can use the RN designation and must provide each employer with proof of passing. RNs do not need to re-test periodically as some other healthcare professions require however, the home BON determines the number of continuing education credits and annual work hours required to renew the license every two years.
Nurses who practice in multiple states can opt for a multi-state license if the candidate tests in a 'compact' state. Compact states have a legal agreement to honor the home state license. For more information on compact licensure, go to https://www.ncsbn.org/compacts.htm. This link provides a map of compact states: https://www.ncsbn.org/nurse-licensure-compact.htm.
Licensure for advance practice registered nurses
After graduation from an accredited advanced practice nursing program, candidates sit for a national certification exam by an accredited organization. Nurse practitioner requirements are set by state legislatures and board of nursing, including which certification exams are accepted for licensure (Nursinglicensure.org, n.d.). However, a national model is emerging for information on the consensus model. For information on this change, go to https://ncsbn.org/campaign-for-consensus.htm. For more information on current nurse practitioner certification and licensure, go to https://www.nursinglicensure.org/articles/nurse-practitioner-license.html.
Most nurse practitioners will hold RN and APRN licenses simultaneously. These licenses do not need to be held in the same state. The “home” state board of nursing where the license is held determines renewal requirements such as continuing education units, ongoing work experience, and whether the licensee meets all other requirements for license renewal.
Certifications for nurse specialists
Thirty nursing specialties have been recognized and adopted by the American Nurses Association with published standards of practice for each area (American Nurses Association, n.d.). At the time of publication, specialties included: Addictions, AIDS care, ambulatory care, corrections, critical care, diabetes educator, faith community, forensic, holistic, hospice and palliative care, infusion, intellectual and developmental disabilities, medical/surgical, nephrology, neonatal, neuroscience, nurse anesthetists, nurse midwife, nursing informatics, occupational health, oncology, pediatric, preventive cardiovascular, psychiatric, perioperative, radiologic and imaging, rehabilitation, women’s health, wound, ostomy, and continence care, and veterans. For more information, go to https://www.nursingworld.org/ana/org-affiliates/. Many of these specialties offer continuing education and certification exams to demonstrate expertise in the field. To maintain a certification nurses must complete continuing education.
Other specialties include nurse educators, school nurses, and epidemiology, geriatric, organ donation, and transplant nurses. Future specialties could include aeronautics/space nurses, fitness, global health, and more.
NCLEX and NCSBN
The NCLEX-RN (National Council Licensure Exam) is created, managed, and proctored by the National Council for State Boards of Nursing (NCSBN). Registered nurses with test-writing skills in clinical specialties write the exam questions based on the knowledge and activities of entry-level nurses. The questions focus on patient needs and human responses to various health conditions – not the medical model which focuses on diseases. The test is designed to ensure the public that new nurses are competent to provide basic, safe nursing care in hospital and community settings (National Council for State Boards of Nursing [NCSBN], 2015).
NCLEX-RN questions are different from most college-level exam questions where memorized facts are recalled. This level of testing is called comprehension. Nurses, however, must be able to apply knowledge and skills in a variety of settings and situations that meet the unique needs of each patient (Burckhardt and Irwin, 2008). Therefore, NCLEX-RN questions are written at the application (doing) and analysis (thinking) level. For example, instead of being asked to recall the name of a medication, candidates might be asked to notice whether a medication is negatively affecting a patient and then what the best nursing action would be. Many questions ask which nursing action in the scenario has the highest priority to determine whether a candidate can make safe clinical judgments.
Many nursing programs use the NCLEX-RN test blueprint to prepare graduates for the national exam. Questions are categorized into four areas of patient needs with eight subcategories:
For more information on the NCLEX-RN, go to https://www.ncsbn.org/nclex.htm and click on the links for application, registration, testing locations, what to expect on exam day, and much more. Also check out these videos: https://www.ncsbn.org/8243.htm and https://www.ncsbn.org/356.htm for specific information about preparation and what to expect at the exam.
Nurses at any practice level (RN, Advanced Practice) or with any nursing degree (Diploma, ASN, BSN, MSN, DNP, DNS, Ph.D.) may choose to obtain a specialty certificate that indicates expertise in an area of nursing practice. For example, a nurse leader might become a
Certified Nurse Executive (NE-BC) or a nurse educator might achieve a Certified Nurse Educator (CNE). A nurse who has dedicated a career to mother/baby care would study for and pass the exam for Inpatient Obstetrics (RN-C).
As part of the application process, the professional portfolio will be updated to include a personal statement that highlights career goals, experiences, continuing education in the specialty, and philosophy or thoughts about nursing care. Letters of recommendation are needed and should come from nurses who completed the certification successfully.
Professional organizations offer support, guidance, policy statements, standards of practice, and networking opportunities that promote excellence in nursing practice. Nurses are often called to coordinate many aspects of patient care that lie outside the usual nurse responsibilities and membership in professional organizations fosters (NLN, 2010).
Student nurse organizations
The National Student Nurses Association (NSNA) was founded in 1952 to bring students together with mentors to prepare for initial licensure as registered nurses. The organization promotes the development of skills in advocacy, leadership, caring, and professionalism that convey the standards and ethics of the nursing professions. Memberships in NSNA prepares students to play active roles in the nursing profession and bridges the gap between education and practice. The networking opportunities equip future nurses with skills to serve as leaders within the profession.
Membership allows students an opportunity to participate at the local, state, and national levels. Each school of nursing has a local chapter that is part of the state organization. Members of the state organization are also members of the national organization. These organizations help students build knowledge, skills, and attitudes related to professionalism, leadership, service, diversity, and teamwork. Participation in conferences offers career development opportunities, scholarships, networking, and a look into the legislative process as it pertains to the nursing profession and nursing education. For more information on the national organization go to https://www.nsna.org/.
American Nurses Association and state associations
The professional organization for nurses is the American Nurses Association (ANA). When nurses join this organization, they are automatically enrolled as a member of their home state organization. The ANA improves patient care through the support of nurses and organizations to advance the nursing profession. Advocacy occurs through work with the federal and state legislatures and in collaboration with global and national healthcare organizations. For more information on the organization, resources, and membership go to:
Nurses who want to deepen specialized knowledge and skills often join a specialty organization. For example, a nurse-midwife might join the American College of Nurse-Midwives (https://www.midwife.org/) while a behavioral health nurse might join the American Psychiatric Nurses Association (https://www.apna.org/i4a/pages/index.cfm?pageid=1).
Nurses who work with special populations also join professional organizations to further the specialty and promote high-quality care. For example, nurses who work with veterans or persons with HIV/AIDS might join these organizations:
Some professional nurse organizations focus on skills such as infusion or wound care.
Other organizations support nurses who work in special settings.
These organizations usually offer evidence-based literature, conference discounts, continuing education units, certification preparation courses and exams, and networking opportunities. Over 40 organizations support professional growth and development within the nursing profession. For a list of organizations recognized by and partnering with the ANA, go to https://www.nursingworld.org/ana/org-affiliates/.
Sigma Theta Tau Nursing Honor Society
Sigma Theta Tau is an international organization of nurses who meet the criteria for excellence in academia and/or community service. These nurses are known for their efforts to change lives and advance healthcare for local, state, national, and global populations. The organization provides numerous resources to enhance and further nursing careers including opportunities for education, publication, and leadership. For more information, go to https://www.sigmanursing.org/.
In this chapter, students learned about: