Chapter 5: Direct Patient Care
Karen Piette and Kristen Hosey
According to the World Health Organization (WHO), nurses represent nearly 50% of the global healthcare workforce. Nursing is an in-demand career and one that will always be required making it a stable career to enter into. Essential qualities for the nursing role will include compassion, patience, communication skills, physical stamina and critical thinking and judgment.
In the United States, individuals who are interested in becoming nurses have many options. They can start in entry-level roles such as a nursing assistant and, if they desire, work their way through higher degree programs and certifications in order to gain additional responsibilities in the healthcare field. There are also multiple terminal, doctoral degrees and advanced practice areas in nursing, with many roles in between. This is often called the nursing ladder because many nurses will build on one step in their educational training, to the next and so on, in order to progress upward in the field. You also can have a very comfortable job without progressing if you find a specialty that fits best for you!
The job of a nurse can vary, so this section will focus on the three levels of nursing education you can get at the certificate, associate and bachelor degree levels. We will highlight the scopes of practice between Nursing Assistants (NAs), Licensed Practical Nurses (LPNs) and Registered Nurses (RNs).
Certified Nursing Assistants
Certified Nursing Assistants (CNA) complete training in order to provide basic care to patients, helping individuals with their activities of daily living (ADLs). ADLs are activities that we do everyday, and a CNA may support a patient in basic hygiene, eating, ambulation, exercise, getting dressed, going to the restroom, bathing, etc. A CNA can also collect a patients’ vital signs as well. Depending on the state requirements, they may also administer medications and perform other duties.
Licensed Practical Nurses
Licensed Practical Nurses (LPNs), also referred to in some settings as Licensed Vocational Nurses (LVNs) have a wider scope of practice than the CNA. The LPN, or LVN can monitor patient health, administer care (such as dressing changes, medication administration, inserting urinary catheters), and report patient status to providers. They may also reinforce plans of care or teaching that has already been completed by RNs, help collect laboratory samples, and depending on training they may be able to do additional tasks such as start intravenous (IV) medications. LPNs work under the supervision of other healthcare professionals such as RN’s, MD’s and NP’s.
Registered Nurses
The nursing scope of practice expands for Registered Nurses (RNs). They are responsible for physical assessments of patient conditions, and even can be responsible for triaging services. In addition to the skills listed above, they are responsible for developing plans of care for patients and families – this is different from prescribing or diagnosing patients – and this often includes teaching patients how to manage illnesses or injuries. Additional duties, titles, responsibilities, and skills will also depend on the location they work in, as well as additional certification and training post-RN licensure.
Employment Opportunities for Nurses
Employment opportunities for nurses are almost infinite. Nurses can work in hospitals, long-term care facilities, clinics, and even at employee offices, schools, jails, non-profit organizations, and in the community. As mentioned previously, the location and scope of practice for nurses will depend on the level of education, training, certification, and licensure of the nurse.
Employment opportunities for nurses look good at all levels. According to the U.S. Bureau of Labor Statistics Occupational Outlook Handbook, the job outlook for nursing careers sits between 5% (NAs) and 6% (LPNs and RNs).
As mentioned previously, education and scope of practice can determine where CNAs, LPNs and RNs will work. In the past, RN’s and CNAs were more commonly found in the hospital, or acute care settings, but in recent years LPNs are becoming a norm in acute care/hospital settings as well due to staffing shortages. CNAs are usually less seen in autonomous roles, like in home health or public health, but the reality is they could be anywhere there is a nurse if the organization is able to pay for them. Long term care facilities and assisted living facilities can employ any level of nurse, but a common trend is CNA and LPN nurses.
Nurses have additional opportunities available to them after earning higher level degree(s) if they choose. Education within the hospital setting and/or at the college level is an optional path down the road for RN’s. RN’s may also choose to further their career by entering hospital administration, conducting research, or avenues that measure the quality of hospital care to name a few.
Requirements and Qualifications
In most states, nursing education, certification and licensure is highly regulated by the department of health and/or the nursing commission of that state, as well as nationally by each educational pathway. Most states require pre-certification or pre-licensure training and examination. Below we will discuss the NA, LPN, and RN requirements.
Nursing Assistant Education Requirements and Qualifications
To become a nursing assistant, individuals often need to complete a course or program typically lasting one to three months. Nursing assistant programs include instruction on basic skills, and a lab and/or clinical work component. These programs can occur on the job at hospitals, nursing homes, at colleges and even in high school.
Depending on the state, there may be additional requirements, such as a state-issued certification that often includes a competency exam and skills exam. Often, individuals are called a Certified Nursing Assistant (CNA), or a Nursing Assistant Certified (NAC), and commonly the term CNA will be used informally to encompass all nursing assistants, even those without certification. Additional certifications may also be available on the job, or with continued training, that can allow for more skills on the job such as medication administration.
Licensed Practical/Vocational Nurse Requirements and Qualifications
To become a LPN, or LVN, one must complete an approved educational program that typically takes about 1 year to complete, although with prerequisites this could take longer. A LPN, or LVN, must have a license to practice, and upon completion of coursework they should be eligible to sit for the National Council Licensure Exam – Practical Nurse (NCLEX-PN). LPN/LVN programs will likely have prerequisite coursework in anatomy and physiology, nutrition and general education, and coursework within the program will include nursing, patient safety and pharmacology.
Registered Nurse Requirements and Qualifications
The pathway to earn licensure as an RN can be through diploma (hospital-based training), associate degree, and bachelor degree programs. Diploma programs are rare these days. Many states now require an associate or bachelor degree in nursing to practice.
An Associate Degree in Nursing (ADN) typically will be a two year program following one year of prerequisites, while the Bachelor’s Degree in Nursing (BSN) is a four year program that includes two years of prerequisites, and two years of nursing coursework. The biggest distinction between the BSN and ADN education is coursework in the BSN is focused in areas of research, public/community health, humanities, leadership and management as well as health policy and finance in addition to direct nursing care and clinical judgment. This additional training helps support BSN-prepared RNs in management, leadership, policy and public/community health roles.
Whatever the pathway to the RN, students should attend a college or university that is nationally accredited either by the Commission on Collegiate Nursing Education (CCNE), National League of Nurses Commission for Nursing Accreditation (CNEA) or Accreditation Commission for Education in Nursing (ACEN).
The RN programs are typically highly competitive as there are not enough nursing educators, or clinical sites, to meet the demand of student enrollment and RN job openings in the community. This does not mean you need a 4.0 Grade Point Average (GPA) to get into a RN program, but it does help. Once admitted into a RN program, coursework includes nursing concepts, pharmacology, clinical judgment as well as skills labs and clinical experiences, usually every quarter or semester.
Once the necessary coursework has been completed the student can sit for the National Council Licensure Exam – Registered Nurse (NCLEX-RN) examination. This is a computer adaptive examination that needs to be completed at a testing center. Once you complete and pass the NCLEX-RN you do not need to take this exam again even if you go on for more education or certification.
Continuing Medical Education
Licensed nurses must meet education and practice requirements yearly. These requirements vary slightly by state. In Washington state, RN and LPN’s must complete 8 continuing education hours per year. Practice hours are also required to remain licensed per state. Practice hours can be attained by working in the clinical environment.
Attributions
- Figure 5.6: image released under the Pexels License
- Figure 5.7: image released under the Pexels License
- Figure 5.8: Collaboration and best in class care: blood cancer by U.S. Department of Veterans Affairs in the Public Domain
- Figure 5.9: image released under the Pexels License
Activities that we do everyday such as basic hygiene, eating, ambulation, exercise, getting dressed, going to the restroom, bathing, etc.